Predictors of Long-Term Shunt-Dependent Hydrocephalus in Patients With Intracerebral Hemorrhage Requiring Emergency Cerebrospinal Fluid Diversion

Brad E. Zacharia, M.D.; Kerry A. Vaughan, B.A.; Zachary L. Hickman, M.D.; Samuel S. Bruce, B.A.; Amanda M. Carpenter, B.A.; Nils H. Petersen, M.D.; Stacie Deiner, M.D.; Neeraj Badjatia, M.D.; E. Sander Connolly Jr., M.D.


Neurosurg Focus. 2012;32(4):e5 

In This Article

Abstract and Introduction


Object Intracerebral hemorrhage (ICH) is frequently complicated by acute hydrocephalus, necessitating emergency CSF diversion with a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. It is unclear what factors may predict the need for ventricular shunt placement in this patient population.
Methods The authors performed a retrospective analysis of a prospective database (ICH Outcomes Project) containing patients with nontraumatic ICH admitted to the neurological ICU at Columbia University Medical Center between January 2009 and September 2011. A multiple logistic regression model was developed to identify independent predictors of shunt-dependent hydrocephalus after ICH. The following variables were included: patient age, admission Glasgow Coma Scale score, temporal horn diameter on admission CT imaging, bicaudate index, admission ICH volume and location, intraventricular hemorrhage volume, Graeb score, LeRoux score, third or fourth ventricle hemorrhage, and intracranial pressure (ICP) and ventriculitis during hospital stay.
Results Of 210 patients prospectively enrolled in the ICH Outcomes Project, 64 required emergency CSF diversion via placement of an external ventricular drain and were included in the final cohort. Thirteen of these patients underwent permanent ventricular CSF shunting prior to discharge. In univariate analysis, only thalamic hemorrhage and elevated ICP were significantly associated with the requirement for permanent CSF diversion, with p values of 0.008 and 0.033, respectively. Each remained significant in a multiple logistic regression model in which both variables were present.
Conclusions Of patients with ICH requiring emergency CSF diversion, those with persistently elevated ICP and thalamic location of their hemorrhage are at increased odds of developing persistent hydrocephalus, necessitating permanent ventricular shunt placement. These factors may assist in predicting which patients will require permanent CSF diversion and could ultimately lead to improvements in the management of this disorder and the outcome in patients with ICH.


Acute hydrocephalus is a common complication of ICH, with an incidence of 40%–50%, and is an independent predictor of poor outcome in this population.[3,6,28] In patients with ICH, acute hydrocephalus generally develops as a consequence of intraventricular extension of the hematoma, resulting in IVH and impairment of CSF drainage and reabsorption.[20] Intraventricular hemorrhage is observed in 45% of patients with ICH, which in and of itself also independently predicts poor outcome.[11,13] Standard treatment of acute hydrocephalus in patients with ICH in whom IVH is present typically involves emergency CSF diversion via placement of an EVD.

Placement of an EVD also affords the opportunity for intraventricular thrombolysis through the administration of compounds such as rtPA into the CSF, which may accelerate clot resolution and decrease the risk of chronic hydrocephalus.[12] In fact, patients with significant IVH, defined as a Graeb score of ≥ 6, have 24 times the odds of developing acute hydrocephalus compared with patients who have minimal or no IVH.[17] This acute CSF flow obstruction can evolve into persistent communicating hydrocephalus despite intraventricular clot resolution, and may necessitate the placement of a VP shunt for permanent CSF diversion.

Little is known about the progression from acute to chronic hydrocephalus and what factors are involved in the process. Few studies have focused specifically on hydrocephalus following ICH; one prior study at a tertiary care center identified thalamic location and elevated ICP as independent predictors of the need for VP shunt placement in patients with ICH admitted for acute hydrocephalus.[14] We sought to identify early predictors of long-term shunt dependency in a prospectively studied cohort of patients with ICH who had undergone EVD placement for emergency CSF diversion.


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