Predisposing Factors And Prognosis Of Chronic Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage Treated By Guglielmi Detachable Coils Endovascular Embolization Treatment

Predisposing factors of chronic hydrocephalus following aneurysmal subarachnoid hemorrhage treated by Guglielmi detachable coils endovascular embolization treatmentBackground Hydrocephalus is one of the complications of aneurysmal subarachnoid hemorrhage(aSAH), including acute hydrocephalus which occurs within 7days after aS AH and chronic hydrocephalus which occurs in 7～10 days after aSAH. Generally speaking the course of chronic hydrocephalus is more than 1 month and patients with severe chronic hydrocephalus suffer from disturbance of consciousness, incontinence, progressive dementia and gait instability. The incidence of chronic hydrocephalus due to ruptured aneurysms are very different in some study. surgical treatment with aSAH has the risks of trauma and infection, especially intraoperative aneurysm rupture, brain tissue retraction, postoperative aggravated brain edema and infection being likely to affect the incidence of chronic hydrocephalus and further affect the prognosis of patients. Tapaninaho studied the relationship between surgical complications and the incidence of chronic hydrocephalus, showing there was significant relationship between complications of bleeding and infection and the incidence of chronic hydrocephalus. GDC endovascular embolization of aSAH being with minimally invasive procedures and less pain, After endovascular embolization treatment ventricular drainage was conventionally performed in patients who occurred intraventricular hemorrhage resulting in obstruction of the ventricular system,while cerebrospinal fluid permutation was performed in other patients,but chronic hydrocephalus being still appear in GDC embolization treatment of some patients. because the risks of traumableeding and infection caused by GDC embolization basically does not exist,It could be better to exclude interference of confounding factors caused by procedure and find a true reflection of the occurrence and development of chronic hydrocephalus which being not subject to confounding factors. To find the relationship between predisposing factors and the occurrence of chronic hydrocephalus being our goal, large data sample of a single center through GDC endovascular embolization treatment of aSAH could explain the relationship between predisposing factors and the occurrence of chronic hydrocephalus, which will help to resolve some questions of clinical work in order to improve clinical work and reduce the occurrence of chronic hydrocephalus after endovascular embolization treatment of aSAH.Timely to find the patients who could suffer from chronic hydrocephalus and take the necessary and diagnosis and treatment measures for these patients will help to improve the quality of life of these patients patients,reduce morbidity and mortality rates, and reduce the burden on society and family.Objective To explore the relationship between predisposing factors and the occurrence of chronic hydrocephalus chronic hydrocephalus following aneurysmal subarachnoid hemorrhage treated by Guglielmi detachable coils endovascular embolization treatmentMethods The selection criteria for this study was the patient who suffered aneurysmal subarachnoid hemorrhage diagnosed with cerebral panangiography and treated by the Guglielmi detachable coils (GDC) endovascular embolization treatment After endovascular embolization treatment ventricular drainage was conventionally performed in patients who occurred intraventricular hemorrhage resulting in obstruction of the ventricular system,while cerebrospinal fluid permutation was performed in other patients. The patient survived for at least 1 month after aSAH in order to evaluate the occurrence of chronic hydrocephalus. The exclusion criteria for this study was subarachnoid hemorrhage caused by cerebral arteriovenous malformation, moyamoya disease, brain tumor; death within 1 month after aSAH and patients lost to follow-up; patients with hydrocephalus before aSAH.137 cases of patients with aneurysmal subarachnoid hemorrhage were treated at the neurosurgery center of Zhujiang hospital from January 2005 to June 2008, of whom five cases due to brain herniation died within 1 month after aSAH, and therefore a total of 132 cases in the group of patients met the inclusion criteria in the study, of whom 54 cases were male and 78 cases were female aged 26-78 years, with an average of 49.92 years of age.Patient characteristics, such as age, sex, size of aneurysm,aneurysm location, preoperative neurological grade according to Hunt and Hess and Fisher grade, the presence of symptomatic cerebral vasospasm,treatment day and acute hydrocephalus classification were collected from the database established at the neurosurgery center of Zhujiang hospital. To find the significant predisposing factors affecting the occurrence of chronic hydrocephalus following aneurysmal subarachnoid hemorrhage treated by Guglielmi detachable coils endovascular embolization treatmentIn the study we defined chronic hydrocephalus as ventricular expansion 1 month after aSAH. According to the standard made by vassilouthis and Richardson in 1979. None of the patient with chronic hydrocephalus was defined Ventricle-cranial ratio (VCR)< 0.15 and mild was defined Ventricle-cranial ratio (VCR) range between0.15 and 0.25, while VCR of severe degree was>0.25 by CT expression one month after aSAH.132 cases of patients according to age were divided into three age groups:young adults 26 to 39 years old; middle-aged adults 40 to 59 years old; and senior adults 60 to 78 years old. Size of aneurysm according to maximal diameter was divided into four groups:small(< 0.5 cm), medium(0.6cm～1.5cm),large (1.6 cm～ 2.5 cm),giant (>2.5 cm). Aneurysms based on the location under the DSA angiography was divided into five groups:internal carotid artery, anterior cerebral artery, middle cerebral artery, anterior communicating artery and vertebral-basilar-posterior cerebral artery. Preoperative Hunt-Hess grade was made by Hunt and Hess in 1968,while preoperative Fisher grade was made by Fisher in 1980. Patients with symptomatic cerebral vasospasm were diagnosed by clinical manifestations, cerebral panangiography,transcranial Doppler ultrasound brain CT and MRI examination. Because rebleeding of ruptured aneurysm occured in some patients and the peak period for cerebral vasospasm is 4～14 d after hemorrhage,treatment day was grouped three periods:earl y(0-3days),middle (4-14days), later (>14days) after the first SAH. Acute hydrocephalus which occurred within 7days after aSAH was diagnosed by brain CT and it was defined in the same degree standards with chronic hydrocephalus.All statistical analyses were carried out using the SPSS for windows version 13.0 software package, Univariate statistical analysis used to determine predisposing factors that were statistically significant (p<0.05) affecting the occurrence of chronic hydrocephalus. All independent variables with p< 0.05 from the univariate analysis were entered into binary logistic regression analysis to explain the role of statistic variables.Results In the study, chronic hydrocephalus following aneurysmal subarachnoid hemorrhage got the overall incidence rate of 12.12% and univariate statistical analysis showed age, preoperative Fisher grade and preoperative Hunt and Hess grade were significantly associated with the occurrence of chronic hydrocephalus. Binary logistic regression analysis showed that age was the primary predisposing factor associated with severe chronic hydrocephalusConclusions Not a single predisposing factor related to the occurrence of chronic hydrocephalus following aneurysmal subarachnoid hemorrhage treated by the Guglielmi detachable coils (GDC) embolization treatment. Age, Fisher grade and Hunt-Hess grade were significantly predisposing factors affecting the occurrence of chronic hydrocephalus and age was the primary factor affecting the occurrence of severe chronic hydrocephalus.prognosis of the patients with chronic hydrocephalus following aneurysmal subarachnoid hemorrhage treated by Guglielmi detachable coils endovascular embolization treatmentObjective To explore prognosis of the patients with chronic hydrocephalus following aneurysmal subarachnoid hemorrhage treated by Guglielmi detachable coils endovascular embolization treatmentMethods 137 cases of patients with aneurysmal subarachnoid hemorrhage were treated by Guglielmi detachable coils endovascular embolization treatment at the neurosurgery center of Zhujiang hospital from January 2005 to June 2008, of whom five cases due to brain herniation died within 1 month after aSAH, and therefore a total of 132 cases in the group of patients met the inclusion criteria in the study. After endovascular embolization treatment ventricular drainage was conventionally performed in patients who occurred intraventricular hemorrhage resulting in obstruction of the ventricular system,while cerebrospinal fluid permutation was performed in other patients. The occurrence of chronic hydrocephalus was evaluated by CT expression one month after SAH. Ventricle-peritoneal shunt was carried out for severe chronic hydrocephalus while clinical observation for mild chronic hydrocephalus.Clinical follow-up for all the patients included in the study was carried out six months or more after endovascular embolization treatment by phone follow-up or outpatient follow-up to evaluate the clinical prognosis of the patients without chronic hydrocephalus,the patients with mild chronic hydrocephalus and the patients undergoing ventriculoperitoneal shunt with severe chronic hydrocephalus. The clinical outcomes were classified according to the modified Rankin scale (mRS) score, in which a score of 0 indicates that the patient has no symptoms at all, a score of 1 that the patient has no marked disability despite symptoms, a score of 2 that the patient has slight disability but is able to look after his or her own affairs, a score of 3 that the patient has moderate disability and requires some help but is able to walk without assistance, a score of 4 that the patient has moderately severe disability, is unable to walk without assistance, and is unable to attend to his or her own bodily needs without assistance, a score of 5 that the patient has severe disability and is bed-ridden, incontinent, and requires constant nursing care and attention, and a score of 6 that the patient is dead.In the statistical analysis mRS scores were grouped as favorable (mRS≤1), moderate disabled(2≤mRS≤3) and severe disabled or poor (mRS≥4). Kruskal-Wallis test was used in order to find the relationship between the degree of chronic hydrocephalus and clinical outcome.Statistical analysis was carried out using the SPSS for windows version 13.0 software package, P<0.05 indicating significant difference.Results In the study, chronic hydrocephalus occurred in 16 (12.12%)out of 132 patients with aneurysmal subarachnoid hemorrhage, including short-term clinical observations of 10 patients with mild chronic hydrocephalus,5 patients undergoing ventriculo-peritoneal shunt with severe chronic hydrocephalus and one patient without ventriculo-peritoneal shunt with severe chronic hydrocephalus. The outcome of 132 patients showed mRS≤1 in 84 patients,2≤mRS≤3 in 40 patients and mRS≥4 in 8 patients.10 patients with mild chronic hydrocephalus do not presented disturbance of consciousness, incontinence, progressive dementia and gait instability in clinical follow-up.4 out of 6 patients with severe chronic hydrocephalus undergoing ventriculo-peritoneal shunt got relatively high quality of daily life in clinical follow-up, symptoms of hydrocephalus being disappear within 6 months after endovascular embolization treatment; one patient who was pre-operative persistent vegetative state with severe chronic hydrocephalus underwent ventriculo-peritoneal shunt 15 months after endovascular embolization, the patient still showing vegetative state after aperation in clinical follow-up; the other patient without ventriculo-peritoneal shunt with severe chronic hydrocephalus presented with urinary incontinence without dementia and gait instability six months after endovascular embolization treatment, but the patient without urinary incontinence, dementia and gait instability for unclear reasons refuse brain CT check one and a half years after endovascular embolization treatment. Clinical follow-up outcome 6 months after GDC endovascular embolization treatment showed the patients with severe chronic hydrocephalus, mild chronic hydrocephalus hydrocephalus and without chronic hydrocephalus were not significantly associated with mRS score.Conclusion The patients who suffered aneurysmal subarachnoid hemorrhage with severe chronic hydrocephalus undergoing ventriculo-peritoneal shunt, mild chronic hydrocephalus and without chronic hydrocephalus were not significantly associated with clinical prognosis after GDC endovascular embolization treatment. The patients with severe chronic hydrocephalus treated by promptly ventricle-peritoneal shunt could get the same clinical prognosis as mild chronic hydrocephalus or not.