Quantitative Modeling of External Ventricular Drain Output to Predict Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage: Cohort Study

  
NCJ_cover.jpgBy A. Perry, C. S. Graffeo, G. Kleinstern, L. P. Carlstrom, M. J. Link, A. A. Rabinstein

First Online: 09 December 2019

Background
Acute hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH); however, attempts to predict shunt-dependent chronic hydrocephalus using clinical parameters have been equivocal.

Methods
Cohort study of aSAH is treated with external ventricular drainage (EVD) placement at our institution, 2001–2016, via logistic regression. EVD-related parameters included mean/total EVD output (days 0–2), EVD days, EVD days ≤ 5 mmHg, and wean/clamp fails. aSAH outcomes assessed included ventriculoperitoneal shunt (VPS) placement, delayed cerebral ischemia (DCI), radiographic infarction (RI), symptomatic vasospasm (SV), age, and aSAH grades.

Results
Two hundred and ten aSAH patients underwent EVD treatment for a median 12 days (range 1–54); 85 required VPS (40%). On univariate analysis, EVD output, total EVD days, EVD days ≤ 5 mmHg, and wean/clamp trial failures were significantly associated with VPS placement (p < 0.01 for all parameters). No EVD output parameter demonstrated a significant association with DCI, RI, or SV. On multivariate analysis, EVD output was a significant predictor of VPS placement, after adjusting for age and clinical and radiological grades; the optimal threshold for predicting VPS placement was mean daily output > 204 ml on days 0–2 (OR 2.59, 95% CI 1.31–5.07). Multiple wean failures were associated with unfavorable functional outcome, after adjusting for age, grade, and VPS placement (OR 1.65, 95% CI 1.10–2.47). We developed a score incorporating age, grade and EVD parameters (MAGE) for predicting VPS placement after aSAH.

Conclusions
EVD output parameters and wean/clamp trial failures predicted shunt dependence in an age- and grade-adjusted multivariable model. Early VPS placement may be warranted in patients with MAGE score ≥ 4, particularly following 2 failed wean trials.

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