Predicting the Need for a Shunt after a Brain Bleed

Tags: , , , , , , , , ,

Shunt to treat hydrocephalus on glass model skullPredictors for delayed ventriculoperitoneal shunt placement after external ventricular drain removal in patients with subarachnoid hemorrhage

By Ariane Lewis, MD
Assistant Professor, Department of Neurology (Division of Neurocritical Care)
NYU Langone Medical Center

Subarachnoid hemorrhage (SAH) is a type of bleed that can occur in the spaces surrounding the brain spontaneously or after an aneurysm ruptures. Patients with SAH often develop hydrocephalus and require placement of an external ventricular drain (EVD) to temporarily drain cerebrospinal fluid (CSF) and decrease intracranial pressure (ICP).  The drain generally remains in place throughout the period of time after a SAH when the blood vessels in the brain are at risk for narrowing which leads to reduced blood flow to the brain (the vasospasm period).  Once this period has ended, the EVD is clamped to stop external drainage of CSF.  Once CSF drainage has stopped, doctors determine if the hydrocephalus has improved and if the patient can tolerate removal of the drain. This is called a clamp trial. If the hydrocephalus is not improved or gets worse after the EVD has been clamped, the patient will require placement of a permanent ventriculoperitoneal (VP) shunt.

In some cases, a patient passes the clamp trial, the EVD is removed, and no VP shunt is placed, but later, the patient suffers from delayed cognitive and motor recovery, such as continued memory problems and trouble walking. If the doctors believe that hydrocephalus is causing the delay in recovery, they may decide that a VP shunt is required. This is termed delayed VP shunt placement. Little is known about the risk factors for delayed VP shunt placement in patients who pass a clamp trial and have their EVD removed.  In order to explore the risk factors associated with delayed VP shunt placement, we studied a retrospective cohort of SAH patients who required EVD placement during their hospitalization and then had their EVDs removed.

Of 91 patients who passed a clamp trial and had their EVD removed, 12 (13%) required delayed VP shunt placement at a median of 54 days (interquartile range 15-75 days) after EVD removal.  Eight of these patients (67%) had documented clinical changes, such as headaches and trouble walking, and nine of these patients (75%) had enlarged ventricles on brain imaging that prompted delayed VP shunt placement.  We examined many possible risk factors for delayed VP shunt placement including:

  • age
  • sex
  • severity of the SAH (Hunt Hess and Fisher scores)
  • neurologic exam on admission (Glasgow Coma Scale)
  • presence of an aneurysm as well as its location/size/treatment method
  • length of stay in the intensive care unit
  • initial and final CSF red blood cell count
  • initial and final CSF protein levels
  • ventricular size prior to EVD removal
  • presence of blood in the ventricles (intraventricular hemorrhage)
  • idevelopment of infection of the ventricles (ventriculitis)

We found that two factors increased the risk for delayed VP shunt placement.  These factors were: increased CSF protein within the first seven days of EVD placement and increased third ventricular size prior to EVD removal.  Nine of the twelve patients (75%) who had delayed VP shunt placement were noted to have subjective clinical improvement at a follow-up appointment.

Delayed hydrocephalus after SAH is associated with delayed cognitive and motor recovery and delayed transition to independent activities of daily living.  If we can diagnose delayed hydrocephalus early, we may be able to prevent additional neurological deterioration, but this diagnosis is difficult.

_____________________________________________

Dr. Ariane Lewis, MD

Assistant Professor, Department of Neurology (Division of Neurocritical Care)
NYU Langone Medical Center
Dr. Ariane Lewis is a neurointensivist at NYU Langone Medical Center.  She obtained her Bachelor’s Degree in Psychology at Johns Hopkins University and did her medical school training at Tulane University School of Medicine.  She then completed a residency in neurology at New York Presbyterian-Weill Cornell Medical Center and a fellowship in neurocritical care at Massachusetts General Hospital.  She is interested in management of hydrocephalus after acute brain injury.
11 Comments for : Predicting the Need for a Shunt after a Brain Bleed
    • Jill Collison
    • November 12, 2018
    Reply

    I had a grade 5 brain hemmerage in 2003 and it affected my left hand side badley still having problems but im lucky to be a live Addenbrookes hospital in cambrigde saved my life

    • Jill Collison
    • November 12, 2018
    Reply

    I had a grade 5 brain hemmerage in 2003 and i am still having problems cause it cause problems on my left hand side Dr Kirkpatrick at addenbrooks hospital saved my life i still had bad days but i am still alive

      • Melanie
      • December 9, 2018
      Reply

      Hey Jill just wondering how long it took you to get back on track my MIL just suffered a grade 5 bleed to the right side of the brain on the 19th of Oct a week later due to vasospasams she also had a stroke to the left parietal lobe to start either lost movement to her right side but is gradually getting that back she spent 5 weeks in icu 1 week in high care in the Neuro ward and is now moved to a lower care she still has a feed tube but every day is eating more and more in the way of jelly she seems like she is trying to.commincate with us but we arent 100% sure she tolerated the removal of the EVD but is now going in tomorrow to have a shunt put in still scary times for us just wondering on how it recovery went in a time frame i do realise everyone recovers different but you survived to tell your story all we get is i dont knows or we can’t say sorry.. tia

    • Phindile Mangwana
    • July 11, 2018
    Reply

    My 57 yo Mother has suffered a severe hemorrhagic stroke on June 12th 2018 and spent 27 days in ICU. She was on ventilation during this time and fed via PEG tube. She only shows small signs of response like blinking eyes but cannot speak, she is now only starting to show small movements in limbs. Doctors are saying that the scans are showing that she has had a bleed in a very important part of the brain and there is nothing that can be done and a shunt cannot be performed if she is not awake. I am worried that if this bleeding is not drained it may cause further damages. Her GCS scale we have been told that its 5/15. I am asking for help and would appreciate if you could leave contacts of people I can contact to seek help from or any information on whether EVD has been used on patients with little response. I can share scan report/results should that be required. Any help please. I am based in Port Elizabeth South Africa.

    • Marlene Amey
    • May 30, 2018
    Reply

    This procedure was performed on my mother in 1972. She was 36 at that time. I remember my grandmother was hysterical because it was a new procedure that was being tested. The surgeons came to Atlanta from Ohio to perform the surgery. They saved her life. Mom just recently passed at the age of 80.

    • Samone Scott
    • May 14, 2018
    Reply

    My mother is 57 y/0 hypertensive and she had an aneurysm rupture on April 25 2018 , she has been in icu since that day , she has had an evd since that day as well . She has a tracheotomy and feeding tube inserted and she is still barely conscious. Week 2 of her recovery she was showing signs of improvement with doing a thumbs up and wiggling her toes on her right side but now she isn’t doing any of that and we were told she has had additional strokes on her brain . I just want to know if she will ever fully regain consciousness??

  1. Reply

    My 52 yr old daughter has a rupture, EVD wouldn’t pass clamp, permanent shunt put in. 32 days in ICU another 7 on recovery ward then 2 weeks in rehab. Short term memory loss only residual but constant severe headaches cause hospitalization several times in past year. CT scans show excess fluid removal so has had shunt turned magnetically 3x. Fluid is cerebral fluid, not blood? How common is need to turn shunt? Amazing recovery but anxiety about shunt/rerupture a problem.

    • Nancy Paulk
    • March 28, 2018
    Reply

    My daughter was 6 days with an EVD for subdural hematoma with SAH when Neurosurgeon removed at 2am without explaining procedure to mom. Nine hours prior to removal she was comatose, on Ventilator, failed CPAP, seizures. CPAP continued, developed herniation. We were told quality of life zero, Any comments?

  2. Reply

    My fiancé had a shunt put in November 15th after a subcranial anuesym. In the past 2 months his short term memory is greatly being affected adversely. Could his shunt be blocked with drainage residue. Please help me help him. Thank you.

    • Dr Abidi
    • February 5, 2017
    Reply

    my sister 62 yrs old. H/O Hypertension. had brain hemorrhage on jan 15th and EVD inserted. yesterday after EVD Challenged scan showed no blood no hydrocephallus and drain removed.
    My concern is she is her GCS that is between 6-7. open her eys and moves all four limbs during phyical therapy. GCS is fluctuating.
    Can u please tell me when she will regain consciousness.
    Dr Abidi

      • Nancy Paulk
      • March 28, 2018
      Reply

      How is your sister doing?

Leave a Comment

Change this in Theme Options
Change this in Theme Options