Disturbances of cerebrospinal fluid dynamics as a complication of aneurysmal subarachnoid hemorrhage: predictors of development and influence of aneurysm occlusion method on the development of shunt-dependent hydrocephalus
Objective ‒ to study the effect of ruptured aneurysm localization, severity of hemorrhage and aneurysm occlusion method on the probability of developing shunt-dependent hydrocephalus (SDH) and to assess the prognostic sensitivity of clinical and radiological scales.
Materials and methods. The results of treatment of 597 patients with aneurysmal subarachnoid hemorrhage (SAH) of varying severity were analyzed. In 282 cases endovascular occlusion of the aneurysm was performed, in 315 ‒ microsurgical clipping. A group of 63 patients who required implantation of the ventriculoperitoneal shunt system within 3 to 15 weeks after aneurysm rupture was selected.
Results. Of the patients who underwent coiling of the ruptured aneurysm, 22 (7.8 %) required implantation of the cerebrospinal fluid shunt system, and 41 (13.0 %) of the patients who underwent microsurgery. The mean age of patients in the endovascular occlusion group was 64.28 years, in the microsurgical clipping group ‒ 50.64 years. The localization was dominated by aneurysms of the anterior communicating artery (ACA) complex ‒ 37 (58.7 %) observations, internal carotid artery ‒ 15 (23.8 %), vertebrobasilar basin (VBB) ‒ 9 (14.3 %) and the middle cerebral artery ‒ 2 (3.2 %). The predominance of aneurysms of the ACA complex among those operated by microsurgical method (29 (70.7 %)) and VBB aneurysms among those operated on endovascularly (9 (40.9 %)) was revealed. Rupture of the aneurysm was complicated by massive SAH in 20 (31.7 %) cases, subarachnoid-parenchymal hemorrhage ‒ in 7 (11.1 %), subarachnoid-ventricular ‒ in 4 (6.4 %), subarachnoid-parenchymal-ventricular ‒ in 32 (50.8 %). The distribution by severity of hemorrhage on the Hunt‒Hess scale was as follows: grade II ‒ 10 (15.9 %) cases, grade III ‒ 26 (34.9 %), grade IV ‒ 27 (49.2 %). According to the Fisher radiological scale, grade III hemorrhage was noted in 20 (31.7 %) cases, IV ‒ in 43 (68.3 %) cases. Analysis using the Graeb scale showed the absence of blood in the ventricular system in 27 (42.9 %) cases, 1‒3 points ‒ in 9 (14.3 %), 4‒6 points ‒ in 12 (19.0 %), 7–12 points ‒ in 15 (28.8 %).
Conclusions. Rupture of aneurysms of the ACA complex, accompanied by severe complicated SAH in patients operated on by microsurgery, and aneurysms of the VBB in persons operated on endovascularly, increases the risk of SDH. Endovascular occlusion of ruptured aneurysms does not increase the risk of SDH. The severity of hemorrhages of III–IV degree on the Hunt‒Hess scale and III–IV degree on the Fisher scale are predictors of SDH development.
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