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Ventriculopleural shunt dysfunction as the first sign of a hidden aneurysmal Subarachnoid Hemorrhage: A case report.

ABSTRACT: Introduction:Subarachnoid Hemorrhage (SAH) is caused by an aneurysmatic origin in 80% of cases. In the adult population, the risk of shunt dysfunction is about 16% in the first year, with proximal mechanical obstruction being the most frequent cause. Case report:An 81-year-old man with a history of shunt system placement presented among clinical data of shunt dysfunction. The brain Computed Tomography (CT) showed dilation of the ventricular system, with no other associated injury. The cause of the dysfunction was a SAH determined by a lumbar puncture (LP) study. We performed an angiography reporting 3 aneurysms. Discussion:The risk of shunt dysfunction at one year is 40% and at two years, the risk ups to 53% with obstruction of the system and infection being the two principal causes. The usefulness of a lumbar puncture for late detection of SAH lies in the red cells in the Cerebrospinal Fluid (CSF). When the CT is negative and the clinical suspicion remains, the lumbar puncture (LP) continues with higher sensitivity despite is over 12 hours of the onset clinic symptoms. Conclusion:This case encourages to follow a rigorous protocol study for patients with multiple shunt dysfunction and chronic hydrocephalus. Also, this case invites to consider a hidden SAH secondary to a vascular pathology as a differential diagnosis for a multiple shunt dysfunction.

SUBMITTER: Vega-Moreno DA

PROVIDER: S-EPMC7484500 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Ventriculopleural shunt dysfunction as the first sign of a hidden aneurysmal Subarachnoid Hemorrhage: A case report.

Vega-Moreno Daniel Alejandro DA Córdoba-Mosqueda María Elena ME Aguilar-Calderón José Ramón JR Hernández-Resendiz Rodrigo Efraín RE Valdivia-Chiñas Heberseleth H Castañeda-Ramírez Erick Alberto EA Medina-Carrillo Óscar Ó Sánchez-Mata Rafael R

Annals of medicine and surgery (2012) 20200821

<h4>Introduction</h4>Subarachnoid Hemorrhage (SAH) is caused by an aneurysmatic origin in 80% of cases. In the adult population, the risk of shunt dysfunction is about 16% in the first year, with proximal mechanical obstruction being the most frequent cause.<h4>Case report</h4>An 81-year-old man with a history of shunt system placement presented among clinical data of shunt dysfunction. The brain Computed Tomography (CT) showed dilation of the ventricular system, with no other associated injury. ...[more]

PMID: 32953100

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Project description:Background and purposeCurrent guidelines do not support the routine use of corticosteroids in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, corticosteroids use in aSAH has been practiced at some centers by convention. The aim of the study was to determine the incidence of hydrocephalus requiring ventriculoperitoneal shunt (VPS) placement as well as functional outcome on discharge and adverse events attributed to corticosteroids in patients with aSAH treated with different dexamethasone (DXM) treatment schemes.MethodsWe retrospectively analyzed 206 patients with aSAH stratified to three groups based on the DXM treatment scheme: no corticosteroids, short course of DXM (S-DXM; 4 mg every 6 h for 1 day followed by a daily total dose reduction by 25% and then by 50% on last day), and long course of DXM (L-DXM; 4 mg every 6 h for 5-7 days followed by reduction by 50% every other day). The primary outcome measure was the placement of a VPS, and the secondary outcome was a good functional outcome [modified Rankin Scale (mRS) 0-3] at hospital discharge. Safety measures were the incidence of infection (pneumonia, urinary tract infection, ventriculitis, meningitis), presence of delirium, and hyperglycemia.ResultsThere was no difference in the rate of external ventricular drain (EVD) (p = 0.164) and VPS placement (p = 0.792), nor in the rate of good outcome (p = 0.928) among three defined treatment regimens. Moreover, the median duration of treatment with EVD did not differ between subjects treated with no corticosteroids, S-DXM, and L-DXM (p = 0.905), and the probability of EVD removal was similar when stratified according to treatment regimens (log-rank; p = 0.256). Patients who received L-DXM had significantly more complications as compared to patients, who received no corticosteroids or S-DXM (78.4% vs. 58.6%; p = 0.005). After adjustment, L-DXM remained independently associated with increased risk of combined adverse events (OR = 2.72; 95%CI, 1.30-5.72; p = 0.008), infection (OR = 3.45; 95%CI, 1.63-7.30; p = 0.001) and hyperglycemia (OR = 2.05; 95%CI, 1.04-4.04; p = 0.039).ConclusionsDXM use among patients with aSAH did not relate to the rate of EVD and VPS placement, duration of EVD treatment, and functional disability at discharge but increased the risk of medical complications.

Project description:BackgroundShunt-dependent hydrocephalus significantly complicates subarachnoid hemorrhage (SAH), and reliable prognosis methods have been sought in recent years to reduce morbidity and costs associated with delayed treatment or neglected onset. Machine learning (ML) defines modern data analysis techniques allowing accurate subject-based risk stratifications. We aimed at developing and testing different ML models to predict shunt-dependent hydrocephalus after aneurysmal SAH.MethodsWe consulted electronic records of patients with aneurysmal SAH treated at our institution between January 2013 and March 2019. We selected variables for the models according to the results of the previous works on this topic. We trained and tested four ML algorithms on three datasets: one containing binary variables, one considering variables associated with shunt-dependency after an explorative analysis, and one including all variables. For each model, we calculated AUROC, specificity, sensitivity, accuracy, PPV, and also, on the validation set, the NPV and the Matthews correlation coefficient (ϕ).ResultsThree hundred eighty-six patients were included. Fifty patients (12.9%) developed shunt-dependency after a mean follow-up of 19.7 (± 12.6) months. Complete information was retrieved for 32 variables, used to train the models. The best models were selected based on the performances on the validation set and were achieved with a distributed random forest model considering 21 variables, with a ϕ = 0.59, AUC = 0.88; sensitivity and specificity of 0.73 (C.I.: 0.39-0.94) and 0.92 (C.I.: 0.84-0.97), respectively; PPV = 0.59 (0.38-0.77); and NPV = 0.96 (0.90-0.98). Accuracy was 0.90 (0.82-0.95).ConclusionsMachine learning prognostic models allow accurate predictions with a large number of variables and a more subject-oriented prognosis. We identified a single best distributed random forest model, with an excellent prognostic capacity (ϕ = 0.58), which could be especially helpful in identifying low-risk patients for shunt-dependency.

Project description:BackgroundDisease progression and delayed neurological complications are common after aneurysmal subarachnoid hemorrhage (aSAH). We explored the potential of quantitative blood-brain barrier (BBB) imaging to predict disease progression and neurological outcome.MethodsData were collected as part of the Co-Operative Studies of Brain Injury Depolarizations (COSBID). We analyzed retrospectively, blinded and semi-automatically magnetic resonance images from 124 aSAH patients scanned at 4 time points (24-48 h, 6-8 days, 12-15 days and 6-12 months) after the initial hemorrhage. Volume of brain with apparent pathology and/or BBB dysfunction (BBBD), subarachnoid space and lateral ventricles were measured. Neurological status on admission was assessed using the World Federation of Neurosurgical Societies and Rosen-Macdonald scores. Outcome at ≥6 months was assessed using the extended Glasgow outcome scale and disease course (progressive or non-progressive based on imaging-detected loss of normal brain tissue in consecutive scans). Logistic regression was used to define biomarkers that best predict outcomes. Receiver operating characteristic analysis was performed to assess accuracy of outcome prediction models.FindingsIn the present cohort, 63% of patients had progressive and 37% non-progressive disease course. Progressive course was associated with worse outcome at ≥6 months (sensitivity of 98% and specificity of 97%). Brain volume with BBBD was significantly larger in patients with progressive course already 24-48 h after admission (2.23 (1.23-3.17) folds, median with 95%CI), and persisted at all time points. The highest probability of a BBB-disrupted voxel to become pathological was found at a distance of ≤1 cm from the brain with apparent pathology (0·284 (0·122-0·594), p < 0·001, median with 95%CI). A multivariate logistic regression model revealed power for BBBD in combination with RMS at 24-48 h in predicting outcome (ROC area under the curve = 0·829, p < 0·001).InterpretationWe suggest that early identification of BBBD may serve as a key predictive biomarker for neurological outcome in aSAH. FUND: Dr. Dreier was supported by grants from the Deutsche Forschungsgemeinschaft (DFG) (DFG DR 323/5-1 and DFG DR 323/10-1), the Bundesministerium für Bildung und Forschung (BMBF) Center for Stroke Research Berlin 01 EO 0801 and FP7 no 602150 CENTER-TBI. Dr. Friedman was supported by grants from Israel Science Foundation and Canada Institute for Health Research (CIHR). Dr. Friedman was supported by grants from European Union's Seventh Framework Program (FP7/2007-2013; grant #602102).

Dataset Information

Ventriculopleural shunt dysfunction as the first sign of a hidden aneurysmal Subarachnoid Hemorrhage: A case report.

Publications

Ventriculopleural shunt dysfunction as the first sign of a hidden aneurysmal Subarachnoid Hemorrhage: A case report.

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