title: Ventriculoperitoneal shunting after aneurysmal subarachnoid hemorrhage: analysis of the indications, complications, and outcome with a focus on patients with borderline ventriculomegaly.
abstract: OBJECTIVE
  The goals of this study were to investigate the risk factors, indications, complications, and outcome for patients with ventriculoperitoneal shunts (VPSs) after subarachnoid hemorrhage and to define a subgroup eligible for future prospective studies designed to clarify indications for placement of a VPS.
  
  
  METHODS
  Clinical characteristics of 236 prospectively evaluated patients with subarachnoid hemorrhage and 6 months of follow-up were analyzed. Hydrocephalus was estimated by the relative bicaudate index (RBCI) measured on computed tomographic scans at the time of shunting. Patients were divided into three groups by ventricle size: Group 1 included 121 patients with small ventricles (RBCI <1.0), Group 2 included 88 patients with borderline ventricle size (RBCI 1.0-1.4), and Group 3 included 27 patients with markedly enlarged ventricles (RBCI >1.4).
  
  
  RESULTS
  Initially, 86 patients (36%) underwent ventriculoperitoneal shunting: 19 in Group 1 (16%), 43 in Group 2 (49%), and 24 in Group 3 (90%). Indications for placement of a VPS, risk factors, and outcome differed markedly by group. Four patients (3% of those not initially shunted) developed delayed hydrocephalus requiring a VPS, including one in Group 2 (2%). The 6-month shunt complication rate was 13%. Evaluation of patients in Group 2 indicated that functional status was an important factor in selecting candidates for shunting, and that patients receiving shunts and shunt-free patients demonstrated improvement in functional status during follow-up.
  
  
  CONCLUSIONS
  Although we currently use a proactive shunting paradigm for posthemorrhagic hydrocephalus, this report demonstrates that a conservative approach to patients with borderline ventricle size (i.e., RBCI of 1.0-1.4) and normal intracranial pressure should be evaluated in a prospective randomized trial.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona 85013, USA.
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Little
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Zabramski
authors.forename: Madelon
authors.initials: M
authors.lastname: Peterson
authors.forename: Pamela W
authors.initials: PW
authors.lastname: Goslar
authors.forename: Scott D
authors.initials: SD
authors.lastname: Wait
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
mesh_terms: D001130:Arizona / Q000453:epidemiology; D002552:Cerebral Ventricles / Q000002:abnormalities*; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000453:epidemiology* / Q000517:prevention & control*; D015994:Incidence; D008297:Male; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000453:epidemiology* / Q000601:surgery*; D016896:Treatment Outcome; D017287:Ventriculoperitoneal Shunt