title: Permanent cerebrospinal fluid diversion in subarachnoid hemorrhage: Influence of physician practice style.
abstract: BACKGROUND
  Acute hydrocephalus (HCP) after aneurysmal subarachnoid hemorrhage (SAH) often persists. Our previous study described factors that singly and combined in a formula correlate with permanent CSF diversion. We now aimed to determine whether the same parameters are applicable at an institution with different HCP management practice.
  
  
  METHODS
  We reviewed records of 181 consecutive patients who presented with SAH and received an external ventricular drain (EVD) for acute HCP. After exclusion and inclusion criteria were met, 71 patients were analyzed. Data included admission Fisher and Hunt and Hess grades, aneurysm location, treatment modality, ventricle size, CSF cell counts and protein levels, length of stay (LOS) in the hospital, and the presence of craniectomy. Outcome measures were: (1) initial EVD challenge outcome; (2) shunting within 3 months; and (3) LOS.
  
  
  RESULTS
  Shunting correlated with Hunt and Hess grade, CSF protein, and the presence of craniectomy. The formula derived in our previous study demonstrated a weaker correlation with initial EVD challenge failure. Several parameters that correlated with shunting in the previous study were instead associated with LOS in this study.
  
  
  CONCLUSIONS
  The decision to shunt depends on management choices in the context of a disease process that may improve over time. Based on the treatment strategy, the shunting rate may be lowered but LOS increased. Markers of disease severity in patients with HCP after SAH correlate with both shunt placement and LOS. This is the first study to directly evaluate the effect of different practice styles on the shunting rate. Differences in HCP management practices should inform the design of prospective studies.
authors.affiliation: Section of Neurosurgery, Department of Surgery, The University of Chicago Medical Center, Chicago, IL, USA.
authors.forename: Domenic P
authors.initials: DP
authors.lastname: Esposito
authors.forename: Fernando D
authors.initials: FD
authors.lastname: Goldenberg
authors.forename: Jeffrey I
authors.initials: JI
authors.lastname: Frank
authors.forename: Agnieszka A
authors.initials: AA
authors.lastname: Ardelt
authors.forename: Ben Z
authors.initials: BZ
authors.lastname: Roitberg