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  • Long-Term Functional Outcomes and Predictors of Shunt Dependent Hydrocephalus after Treatment of Ruptured Intracranial Aneurysms in the BRAT Trial: Another piece in the Clip versus Coil Puzzle

    Final Number:

    Hasan Zaidi BS MD; Ali M. Elhadi MD; Peter Nakaji MD; Cameron G. McDougall MD; Felipe Albuquerque MD; Robert F. Spetzler MD; Joseph M. Zabramski MD

    Study Design:
    Clinical trial

    Subject Category:
    Aneurysm/Subarachnoid Hemorrhage

    Meeting: AANS/CNS Cerebrovascular Section 2015 Annual Meeting

    Introduction: Acute Hydrocephalus is a well-known sequela of aneurysmal subarachnoid hemorrhage (SAH). Controversy exists on whether open microsurgical methods serve to reduce shunt dependency when compared to endovascular techniques. Furthermore, long-term functional outcomes of shunt dependent patients are unknown.

    Methods: Four hundred seventy one patients who were part of a prospective randomized controlled trial from 2003-2007 were retrospectively reviewed. All variables including demographic data, medical history, treatment, imaging and functional outcomes were included as part of the prospective randomized controlled trial. No additional variables were retrospectively collected.

    Results: 147 (31.2%) patients ultimately required a Ventriculoperitoneal Shunt (VPS) in our series. Age, dissecting aneurysm type, ruptured vertebrobasilar aneurysm, Fisher Grade, Hunt-Hess Grade, admission Intraventricular Hemorrhage (IVH), admission Intraparenchymal Hemorrhage (IPH), admission fourth-ventricular blood, perioperative ventriculostomy and hemicraniectomy were significant risk factors (P < 0.05) associated with shunt dependent hydrocephalus on univariate analysis. On multivariate analysis, IVH and IPH were independent risk factors for shunt dependency (P < 0.05). Clipping versus coiling treatment was not statistically associated with VPS after SAH on both univariate or multivariate analysis. At 6-years, 17% of shunted patients experienced at least one shunt infection/failure. Patients who did not received a VPS at discharge had a higher Glasgow Outcome Scale (GOS) Score and Barthel Index at 3-years, and were more likely to be independent at home and returned to work at 6-, 12-, 36-, 72-months after surgery (P < 0.05).

    Conclusions: There is no difference in shunt dependency after SAH among patients treated by endovascular or microsurgical means. Patients who do not develop shunt dependent hydrocephalus after SAH tend to have improved long term functional outcomes.

    Patient Care: Our results can help shape the subsequent discussion, providing statistically significant evidence on long-term functional status and outlook of shunted patients after subarachnoid hemorrhage.

    Learning Objectives: 1. Open microsurgical techniques do not reduce the incidence of postoperative shunt dependent hydrocephalus 2. Shunt dependent patients after aneurysmal Subarachnoid Hemorrhage have worse functional outcomes when compared to patients without shunt dependency.

    References: 1. Auer, L.M., M. Mokry. Disturbed Cerebrospinal Fluid Circulation After Subarachnoid Hemorrhage and Acute Aneurysm Surgery. Neurosurgery, 1990. 26: p.804-09. 2. Black, P.M. Hydrocephalus and Vasospasm After Subarachnoid Hemorrhage from Ruptured Intracranial Aneurysms. Neurosurgery, 1986.18: p.12-16. 3. 6. De Oliveira, J.G., J. Beck, M. Setzer, et al. Risk of Shunt-Dependent Hydrocephalus After Occlusion of Ruptured Intracranial Aneurysms by Surgical Clipping or Endovascular Coiling: A Single-Institution Series and Meta-Analysis. Neurosurgery, 2007. 65(5): p.924-34.

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