Incidence of Ventricular Shunt Placement for Hydrocephalus with Clipping versus Coiling for Ruptured and Unruptured Cerebral Aneurysms in the Nationwide Inpatient Sample Database: 2002 to 2007

doi:10.1016/j.wneu.2011.05.054

World Neurosurgery

Volume 76, Issue 6, December 2011, Pages 548-554

https://doi.org/10.1016/j.wneu.2011.05.054 Get rights and content

Background

Few studies have compared the incidence of ventricular shunt placement for hydrocephalus after clipping versus coiling of cerebral aneurysms.

Objective

The Nationwide Inpatient Sample (NIS) database was used to compare, on a national level, the incidence of ventricular shunt placement after clipping versus coiling of ruptured and unruptured aneurysms.

Methods

Hospitalizations for clipping and coiling of ruptured and unruptured aneurysms from 2002 to 2007 were collected from the NIS by cross-matching International Classification of Diseases–9 codes for diagnoses of subarachnoid hemorrhage or unruptured cerebral aneurysm with procedure codes for clipping or coiling. The incidence of ventricular shunt placement for hydrocephalus after clipping and coiling was compared using generalized linear models with generalized estimating equations (GEE) to adjust for patient- and hospital-specific factors and correlation between admissions.

Results

Of 10,899 ruptured aneurysm patients (6593 clipping, 4306 coiling), clipping had a similar incidence of ventricular shunt placement (9.3%) compared to coiling (10.5%) (odds ratio = 0.984; 95% confidence interval = 0.85, −1.14; P value = 0.833 after adjustment for patient-specific and hospital-specific factors). Likewise, of 9686 unruptured aneurysm patients (4483 clipping, 5203 coiling), clipping had similar incidence of ventricular shunt placement (0.4%) compared to coiling (0.5%) (odds ratio = 0.763; 95% confidence interval = 0.37, −1.58; P value = 0.465 after adjustment for patient-specific and hospital-specific factors). Predictors of shunt placement in ruptured aneurysm patients were age, comorbidity score, admission type, payer, and hospital aneurysm volume. Predictors of shunt placement in unruptured aneurysm patients were comorbidity score and admission type.

Conclusions

In an observational study, clipping and coiling of ruptured and unruptured cerebral aneurysms are associated with similar incidences of ventricular shunt placement for hydrocephalus.

Introduction

Few studies have compared the incidence of ventricular shunt placement for hydrocephalus after clipping versus coiling of cerebral aneurysms, all in single-center series, and all in patients with ruptured aneurysms, none with unruptured aneurysms (9, 10, 15, 20, 31, 41). Hydrocephalus requiring ventricular shunt placement after aneurysmal subarachnoid hemorrhage is reported to occur over a wide range, from 2.3% to 63.4% of patients (9, 10, 12, 15, 17, 20, 22, 24, 31, 39, 41), reflecting a significant variation in practices among different neurosurgeons and institutions. This wide variation necessitates a larger, multicenter study with larger numbers of patients. The research question of this study was to use the Nationwide Inpatient Sample (NIS) database to compare, on a national multicenter level, the incidence of ventricular shunt placement after clipping and coiling of ruptured and unruptured cerebral aneurysms. A secondary objective was to use the NIS to identify the patient-specific and hospital-specific factors that are independent predictors of ventricular shunt placement after cerebral aneurysm treatment.

Section snippets

Patients and Methods

We obtained the NIS database from the Agency for Healthcare Quality and Research's Healthcare Cost and Utilization Project (Rockville, Maryland, USA). The NIS is the largest all-payer hospital inpatient database in the United States and contains data approximating a 20% stratified sample of US hospitals. For each sampled hospital, all inpatient admissions for the year are contained in the NIS, so annual case volumes for hospitals can be calculated. The NIS includes data for approximately 8

Comparison of Clipping versus Coiling

A search in the NIS database, years 2002 to 2007, for cross-matches of the ICD-9 diagnosis codes for subarachnoid hemorrhage (430) or unruptured cerebral aneurysm (437.3) with procedure codes for clipping (39.51) or coiling (39.79, 39.72, or 39.52) of cerebral aneurysms yielded 10,899 hospitalizations for ruptured aneurysms (6593 clipping, 4306 coiling); and 9686 hospitalizations for unruptured aneurysms (4483 clipping, 5203 coiling). The patient demographic and hospital characteristics of the

Discussion

Hydrocephalus is a known occurrence in patients with aneurysmal subarachnoid hemorrhage (9, 10, 12, 15, 17, 20, 22, 24, 31, 39, 41). Hydrocephalus after treatment of unruptured cerebral aneurysms is very rare, but does occur (6, 13, 21, 26, 27). The incidence of hydrocephalus requiring ventricular shunt placement after cerebral aneurysm treatment is important to investigate because it is associated with poor neurological outcomes, cognitive deficits, and longer hospital length of stay (9, 12, 14

Conclusions

The results of this nationwide analysis demonstrate that clipping and coiling of ruptured and unruptured cerebral aneurysms are associated with similar incidences of ventricular shunt placement. However, age, comorbidity score, admission type, payer, and hospital aneurysm volume are independent predictors of ventricular shunt placement after treatment of ruptured cerebral aneurysms. Furthermore, comorbidity score and admission type are independent predictors of ventricular shunt placement after

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Cited by (62)

Effect of combined fenestration of lamina terminalis and Liliequist membrane during surgical clipping on the incidence of chronic hydrocephalus in patients with anterior circulation ruptured aneurysms
2023, Clinical Neurology and Neurosurgery
To explore the effects of combined fenestration of lamina terminalis and Liliequist membrane during surgical clipping on the occurrence of chronic hydrocephalus in patients with ruptured anterior circulation aneurysm.
Clinical data of 78 patients with anterior circulation ruptured aneurysms who were treated between June 2018 and January 2021 were retrospectively analyzed. Based on the surgical treatment, patients were divided into 3 groups: clipping group (26 cases); fenestration group (lamina terminalis fenestration combined with clipping, 28 cases); and combination group (lamina terminalis fenestration and Liliequist membrane opening combined with clipping, 24 cases). The incidence of postoperative chronic hydrocephalus, the postoperative hydrocephalus shunt rate, and the Glasgow prognostic score (GOS) were evaluated.
The incidence of postoperative chronic hydrocephalus in the combined group (16.6 %, 4/24) was significantly lower than that in the clipping group (46.1 %, 12/26) and the fenestration group (35.7 %, 10/28; P < 0.05). The shunt rate of chronic hydrocephalus in the combined group (4.1 %, 1/24) was significantly lower than that in the clipping group (30.7 %, 8/26) and the fenestration group (17.8 %, 5/28; P < 0.05). The rate of postoperative GOS score of 5 in the combined group (75.0 %, 18/24) was significantly higher than that in the clipping group (23.0 %, 6/26) and the fenestration group (57.1 %, 16/28; P < 0.05).
Aneurysm clipping combined with lamina terminalis fenestration and Liliequist membrane opening can reduce the occurrence of chronic hydrocephalus and the rate of chronic hydrocephalus shunt surgery, thereby improving the prognosis of patients.
Safety and efficacy of intrathecal nicardipine for aneurysmal subarachnoid hemorrhage induced vasospasm
2021, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Citation Excerpt :
In a National Inpatient Sample analysis of 10,899 ruptured aneurysms by Hoh et al. [29] ventricular shunts were placed in 9.3% of patients after clipping and 10.8% after coiling. In our series, hydrocephalus requiring a VP shunt occurred in only 6% of patients, which interestingly is lower than reported by Hoh et al. [29] though this is likely multifactorial. Favorable outcomes (GOS 4 or 5) were achieved in 56% of our patients and mortality occurred in 20.8%.
Cerebral vasospasm (CV) is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality.
To report our institutional experience with intrathecal (IT) nicardipine for treatment of moderate to severe CV.
A retrospective study was performed for all patients treated with intrathecal nicardipine from October 2014-May 2017. The primary goal was to evaluate the safety of IT nicardipine to treat subarachnoid induced CV. Results.
48 patients with aSAH were treated with IT nicardipine for moderate or severe CV. The average age of patients was 49.6 years (range 14–77 years) with mean Hunt Hess of 3.2 and mean Fisher scores of 3.1. Patients were treated with different dosing regiments ranging from 2 mg q12 to 4 mg q8hr. The average total dose was 35.1 mg (range 6 to 112 mg). The average initiation of treatment was post bleed day 6 (range day 2–15) and length of treatment was 5.9 days (range 1–15 days.) 10/48 (20.8%) patients underwent TBA with only 4/48 (8.3%) treated after initiation of IT nicardipine. Three patients (6.3%) developed meningitis/ventriculitis. Three (6.3%) patients required ventriculoperitoneal shunt. Favorable outcome (Glasgow Outcome Scale 4 or 5) was achieved in 56.3% of patients.
The use of intrathecal nicardipine should be considered a safe option in the treatment of moderate to severe cerebral vasospasm. The use of intrathecal nicardipine has resulted in a near discontinuation of balloon angioplasty in our institution. Randomized trials to identify the optimal dosing, timing, and length of treatment is warranted.
III. Ventricle diameter increase during ventricular drainage challenge – A predictor of shunt dependency after subarachnoid hemorrhage
2020, Journal of Clinical Neuroscience
Hydrocephalus with the need for shunt placement is a common sequela after aneurysmal subarachnoid hemorrhage (aSAH). In 2009 Chan et al. published a formula to predict shunt dependency in SAH patients, the failure risk index (FRI).
We reevaluated the FRI within the aSAH population in our hospital and wanted to identify easier measurements forecast shunt dependency.
We retrospectively analyzed data from patients with aSAH treated in our neuro-intensive care unit and calculated the FRI according to the paper by Chan et al. 2013 and data were compared to the results of Chan et al.
38 patients were included in this study, 24 female and 14 male. 38% suffered a SAH WFNS I, 19% WFNS II, 24% WFNS III, 5% WFNS IV and 14% WFNS V. 17 patients underwent a shunt implantation (group 1), 21 patients did not (group 2). The calculated FRI Index did not correlate with the expectancy of shunt implantation in 22% of the cases (group 1). In group 2 the FRI index and the prediction of shunt dependency did not match in 33% of the cases. Furthermore, we found the increase of the third ventricle diameter to be predictive in 67% for failed EVD challenge and the decrease of the third ventricle diameter predictive in 67% for successful EVD challenge.
In this study, we were not able to confirm the results of the FRI designed by Chan et al within our patient population. Furthermore, we consider the increase of the third ventricle diameter to be a simpler and more reliable predictor of shunt dependency.
Prognostic Model for Chronic Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage
2019, World Neurosurgery
Citation Excerpt :
However, others have concluded that the risk of chronic hydrocephalus is greater with endovascular coiling than with clipping procedures.2 Our results are consistent with the reported data showing that the treatment modality is not a prognostic variable for the development of chronic hydrocephalus.6,8,10,19 Our explorative analysis has shown that the duration required for blood clearance in the basal cisterns was not modified by microsurgical clipping in which we used ≥2–4 L of nimodipine dissolved in isotonic NaCl solution (1:1) for intraoperative irrigation.
Patients with aneurysmal subarachnoid hemorrhage (aSAH) are at risk of the development of chronic shunt-dependent hydrocephalus. However, identification of shunt-dependent patients remains challenging. We sought to develop a prognostic model to identify patients with aSAH at risk of chronic shunt-dependent hydrocephalus. In addition to the well-known prognostic variables, blood clearance in the cerebrospinal fluid (CSF) spaces was considered.
We retrospectively analyzed the data from 227 patients treated at our institution from January 2012 to January 2016. The outcome was ventriculoperitoneal shunt placement within 30 days after aSAH. The candidate prognostic variables were patient age, World Federation of Neurological Surgeons grade and Fisher grade, external ventricular drainage, ventricular and intracerebral hemorrhage, and interval to blood clearance in the peripheral/basal CSF spaces. Adjustment for multiple testing was performed. Multivariable logistic regression analysis was used for model development. Bootstrapping was applied for internal validation. The model performance measures included indexes for explained variance (R²), calibration (graphic plot, Hosmer-Lemeshow test), and discrimination (c-statistic).
Of the 227 patients, 90 (39.6%) required a ventriculoperitoneal shunt. The constructed prognostic model combined external ventricular drainage placement, the presence of ventricular blood, and the duration of blood clearance in the basal cisterns. The model performance was promising, with an R² of 33% (20% after bootstrapping), the calibration plot was adequate, the Hosmer-Lemeshow test result was not significant, and the c-statistic was 0.85 (0.84 as assessed after bootstrapping) indicating a good discriminating prognostic model.
Our prognostic model could help identify patients requiring permanent CSF diversion after aSAH, although additional modification and external validation are needed. Interventions aimed at accelerating the clearance of blood in the basal cisterns might have the potential to prevent the development of chronic hydrocephalus after aSAH.
Comparing the Risk of Shunt-Dependent Hydrocephalus in Patients with Ruptured Intracranial Aneurysms Treated by Endovascular Coiling or Surgical Clipping: An Updated Meta-Analysis
2019, World Neurosurgery
This meta-analysis aimed to evaluate the risk of shunt-dependent hydrocephalus among patients with ruptured intracranial aneurysms treated with either coil placement or clipping.
A systematic literature search of Embase, PubMed, Web of Science, and the Cochrane Library was performed to confirm relevant studies. The scientific literature was screened in accordance with the predetermined inclusion and exclusion criteria. After quality assessment and data extraction from the eligible studies, a meta-analysis was conducted using the STATA 12.0 software (Stata corporation, College Station, Texas, USA).
Thirteen studies met all inclusion criteria and were included in the analysis. In total, these studies included 13,751 patients. Of the patients, 8444 of them underwent neurosurgical clipping, and 5307 underwent endovascular coiling. The overall result of a pooled estimate revealed there was no statistically significant risk of shunt dependency difference between the clipping and coiling groups (11.4% vs. 12.0%, respectively; relative risk [RR], 0.92; 95% confidence interval [CI], 0.84–1.01). Six prospective studies (n = 1373) reported shunt-dependent hydrocephalus revealed no significant difference between clipping and coiling (23.3% vs. 20.1%, respectively; RR, 1.12; 95% CI, 0.91–1.38). Seven retrospective studies (n = 12,378) reported shunt-dependent hydrocephalus found statistical significance between the surgical and endovascular treatment groups (10.0% vs. 11.1%, respectively; RR, 0.88; 95% CI, 0.79–0.98).
Microsurgical clipping and endovascular coiling of ruptured cerebral aneurysms are associated with similar incidences of ventricular shunt placement for hydrocephalus. The risk of shunt-dependent hydrocephalus is not higher after coiling than after clipping of ruptured intracranial aneurysms.
Predictors of Shunt-dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage? A Systematic Review and Meta-Analysis
2017, World Neurosurgery
Citation Excerpt :
Furthermore, the treatment modality (coiling vs. clipping), as one of the most manageable predictors, has not been systematically reviewed since De Oliveira et al. (2007).12 Eleven eligible studies addressing this issue have been reported since then, including 3 cohort studies and 1 clinical trial.14,28,32,36 A total of 14 potential predictors were analyzed in our study.
Hydrocephalus is a well-recognized complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to identify predictors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis.
A systematic search was conducted using the Embase, MEDLINE, and Web of Science databases for studies pertaining to aSAH and SDHC. Risk factors were assessed by meta-analysis when they were reported by at least 2 studies. The results were presented as odd ratios or risk ratios according to the study design with the corresponding 95% confidence intervals (CI).
Twenty-five studies were included. In primary analysis of 14 potential risk factors, 12 were identified as predictors of SDHC after aSAH including age ≥50 years, female gender, high Hunt-Hess grade, Glasgow Coma Scale ≤8, Fisher grade ≥3, acute hydrocephalus, external ventricular drainage insertion, intraventricular hemorrhage, postcirculation aneurysm, anterior communicating artery aneurysm, meningitis, and rebleeding. The meta-analysis based on cohort studies found a significantly increased risk for SDHC in patients with aSAH treated by coiling (risk ratio, 1.16; 95% CI, 1.05–1.29), while the meta-analysis based on case-controlled studies failed to replicate this finding (odds ratio, 1.27; 95% CI, 0.95–1.71).
Several new predictors of SDHC after aSAH were identified that may assist with the early recognition and prevention of SDHC. The controversial evidence found in this study was insufficient to support the potential of neurosurgical clipping for reducing the risk of shunt dependency. Further well-designed studies are warranted to explore the effect of treatment modality on SDHC risk.

View all citing articles on Scopus

: Conflict of interest statement: B.L.H. has received an honorarium from Codman Neurovascular. J.M. has received an unrestricted educational grant from Boston Scientific; an unrestricted educational grant from and is a consultant for Codman Neurovascular; is a consultant for Actelion Pharmaceuticals, Nfocus, and Lazarus Effect; and has received an honorarium from Edge Therapeutics.

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Peer-Review ReportIncidence of Ventricular Shunt Placement for Hydrocephalus with Clipping versus Coiling for Ruptured and Unruptured Cerebral Aneurysms in the Nationwide Inpatient Sample Database: 2002 to 2007

Background

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients and Methods

Comparison of Clipping versus Coiling

Discussion

Conclusions

Surg Neurol

The effects of fenestration of the interpeduncular cistern membrane arousted to the opening of lamina terminalis in patients with ruptured ACoA aneurysms: a prospective, comparative study

Acta Neurochir (Wien)

Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database

J Neurosurg

Disturbed cerebrospinal fluid circulation after subarachnoid hemorrhage and acute aneurysm surgery

Neurosurgery

Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000

Neurosurgery

Patient and aneurysm characteristics in multiple intracranial aneurysms

Acta Neurochir

Treatment of cerebral aneurysms with hydrogel-coated platinum coils (HydroCoil): early single-center experience

AJNR Am J Neuroradiol

Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms

J Neurosurg

Influence of weekend versus weekday hospital admission on mortality after subarachnoid hemorrhage

J Neurosurg

Risk of shunt-dependent hydrocephalus after occlusion of ruptured intracranial aneurysms by surgical clipping or endovascular coiling: a single-institution series and meta-analysis

Neurosurgery

Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality

J Neurosurg

Factors leading to hydrocephalus after aneurysmal subarachnoid hemorrhage

Minim Invasive Neurosurg

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage

Neurosurgery

Wall enhancement, edema, and hydrocephalus after endovascular coil occlusion of intradural cerebral aneurysms

J Neurosurg

Factors associated with hydrocephalus after subarachnoid hemorrhageA report of the Cooperative Aneurysm Study

Arch Neurol

Chronic shunt-dependent hydrocephalus after early surgical and early endovascular treatment of ruptured intracranial aneurysms

Neurosurgery

Length of stay and total hospital charges of clipping versus coiling for ruptured and unruptured adult cerebral aneurysms in the Nationwide Inpatient Sample database 2002 to 2006

Stroke

Lower incidence of reoperation and longer shunt survival for adult ventriculoperitoneal shunts placed for hemorrhage-related hydrocephalus

Neurosurgery

In-hospital morbidity and mortality after endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000: effect of hospital and physician volume

AJNR Am J Neuroradiol

Cognitive deficits in the acute stage after subarachnoid hemorrhage

Neurosurgery

Chronic hydrocephalus after neurosurgical and endovascular treatment of ruptured intracranial aneurysms

Acta Radiol

Embolization of intracranial aneurysms with hydrogel-coated coils: result of a Korean multicenter trial

Neurosurgery

Peer-Review Report
Incidence of Ventricular Shunt Placement for Hydrocephalus with Clipping versus Coiling for Ruptured and Unruptured Cerebral Aneurysms in the Nationwide Inpatient Sample Database: 2002 to 2007