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with an incidence of up to 22&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In total&#44; 8&#8211;63&#37; of patients with SAH due to aneurysmal rupture develop chronic hydrocephalus leading to CSF shunt dependency&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Its onset can range from days to weeks after SAH and is suspected in patients with good initial recovery and subsequent deterioration&#44; appearance of characteristic clinical features or inability to remove the EVD already in place at the critical moment&#44; either due to clinical worsening or secondary ventricular dilation&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> VPS are also not without risk&#46; There may be valve failure secondary to infection&#44; proximal or distal catheter obstruction&#44; system disconnection or drainage-related problems&#44; either due to overdrainage &#40;hyperdrainage&#41; or underdrainage &#40;hypodrainage&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This means an increase in length of hospital stay for these patients&#44; as well as an increase in surgical procedures for VPS replacement or revision&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Several studies have attempted to predict which factors are associated with shunt dependency in the treatment of post-SAH hydrocephalus&#46; Decreasing the time with EVD and therefore early placement of a VPS in patients who require it could decrease drainage-associated complications&#44; VPS complications and length of hospital stay&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objectives of this study are&#58; <ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0030" class="elsevierStylePara elsevierViewall">To identify and analyse clinical and radiological factors that help predict which patients with spontaneous SAH are most likely to require permanent VPS placement due to hydrocephalus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0035" class="elsevierStylePara elsevierViewall">To quantify and describe complications associated with VPS placed in this period and to analyse whether they are related to the time interval between EVD placement and VPS placement&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0040" class="elsevierStylePara elsevierViewall">To evaluate the data obtained to help us make decisions and improve our clinical practice&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">This was a retrospective&#44; observational analytical study including all patients with spontaneous SAH referred to Hospital Miguel Servet in Zaragoza from 2017 to 2022&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The database was created with the CT reports and images available in the Electronic Medical Records&#46; Excel was used to create the database and SPSS Statistics software was used for the statistical analysis&#46; Authorisation was obtained from both the Hospital Miguel Servet Archives and Clinical Documentation Service and the Research Ethics Committee of Aragon&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The minimum follow-up period was one year&#44; sufficient to assess the need for fluid diversion&#46; There is no strict protocol at our centre for defining the need for VPS placement after SAH&#58; surgery is indicated if the patient does not tolerate drain closure for a period of 48&#8722;72&#8239;h based on clinical or radiological criteria &#40;control CT scan 48&#8239;h after closure&#41; or an increase in intracranial pressure &#40;ICP&#41; &#62;25&#8239;mmHg&#46; One&#44; two or three closure attempts were made depending on multiple factors such as&#58; the volume drained per day&#59; the patient&#39;s characteristics&#59; the severity of the clinical signs and symptoms&#59; the degree of dilation&#59; or the ease of follow-up should the patient develop chronic hydrocephalus&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A statistical analysis of the most relevant variables was performed to check for an association between these variables and the need for VPS placement&#46; We used the Kolmogorov-Smirnov test to calculate the normality of the variables&#46; To test for a statistically significant relationship&#44; Student&#39;s <span class="elsevierStyleItalic">t</span>-test was used for normal quantitative independent variables and the chi-square test for qualitative variables&#46; Variables with p-values &#60;0&#46;05 were considered statistically significant&#46; To assess the degree of association between qualitative variables&#44; the Phi and Cramer&#39;s V coefficients were used&#46; For variables that reached statistical significance&#44; a multivariate comparative study such as logistic regression was performed and the Odds Ratio &#40;OR&#41; was applied as a measure of association&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Subsequently&#44; the results obtained were compared with existing results in the literature&#46; This entailed a review and analysis of the literature available in PubMed and Cochrane&#46; The search strategies were&#58; subarachnoid haemorrhage AND aneurysm&#59; subarachnoid haemorrhage AND diagnosis&#59; shunt dependent hydrocephalus AND subarachnoid haemorrhage AND complications&#59; subarachnoid haemorrhage AND early shunting&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">General characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">In the period 2017&#8211;2022&#44; we collected data from a total of 359 patients referred to Hospital Universitario Miguel Servet &#91;Miguel Servet University Hospital&#93; with a diagnosis of spontaneous SAH&#59; 128 males &#40;35&#46;7&#37;&#41; and 231 females &#40;64&#46;3&#37;&#41;&#46; The mean age was 58&#46; Overall&#44; 63 patients had a history of HTN &#40;45&#46;4&#37;&#41;&#44; 125 DLP &#40;34&#46;8&#37;&#41;&#44; 44 DM &#40;12&#46;3&#37;&#41; and 35 obesity &#40;9&#46;7&#37;&#41;&#46; In total&#44; 104 patients were smokers &#40;29&#37;&#41;&#44; 19 were regular alcohol users &#40;5&#46;3&#37;&#41; and 10 patients used other drugs &#40;2&#46;8&#37;&#41;&#46; Only 17 patients had a family or personal history of aneurysms &#40;4&#46;7&#37; of the total&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A ruptured aneurysm was diagnosed in 238 cases&#44; accounting for 66&#46;3&#37; of the total&#46; The most common location was the anterior circulation &#40;87&#37;&#41;&#58; AcomA and MCA&#46; Overall&#44; 56 patients had multiple aneurysms&#44; accounting for 23&#46;5&#37; of the total&#46; Regarding SAH of non-aneurysmal aetiology&#44; 45 cases were pre-truncal SAH &#40;12&#46;5&#37;&#41;&#44; 15 cases secondary to AVM rupture &#40;4&#46;1&#37;&#41; and four secondary to AVF &#40;1&#46;4&#37;&#41;&#46; In the remaining cases&#44; no further tests were performed due to poor clinical condition or they were SAH with an aneurysmal pattern but with negative studies&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Arteriography was performed in 261 patients within 24&#8239;h &#40;72&#46;7&#37;&#41; and in 16 patients within 48&#8239;h of arrival at Accident and Emergency &#40;4&#46;4&#37;&#41;&#46; Of the 238 aneurysmal SAH&#44; 166 were treated within 24&#8239;h &#40;69&#46;7&#37;&#41;&#44; 28 &#40;11&#46;8&#37;&#41; within 48&#8239;h and the remainder &#40;18&#46;5&#37;&#41; within 72&#8239;h of arrival at Accident and Emergency&#44; the majority being late diagnosed cases&#46; Endovascular treatment was performed in 71&#46;1&#37; of cases&#44; surgical in 24&#46;1&#37; and mixed in 4&#46;8&#37;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The in-hospital mortality rate was 25&#46;3&#37;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Hydrocephalus</span><p id="par0090" class="elsevierStylePara elsevierViewall">Some 117 patients had acute hydrocephalus &#40;32&#46;9&#37;&#41; and 33 patients had shunt-dependent hydrocephalus &#40;9&#37;&#41;&#44; the latter defined as the need for VPS placement&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Of all patients with spontaneous SAH&#44; 131 &#40;36&#46;4&#37;&#41; required EVD&#46; Of these&#44; 30 patients required a permanent shunt&#46; Of the 228 patients who did not have EVD&#44; three still required VPS placement&#46; Of the 238 patients with aneurysmal SAH&#44; 108 required EVD &#40;45&#46;3&#37;&#41; and&#44; of those&#44; 25 required VPS &#40;23&#46;1&#37;&#41;&#46; Three patients underwent direct VPS placement without prior EVD&#44; so the rate of VPS among patients with aneurysmal SAH was 11&#46;7&#37;&#46; A statistically significant&#44; albeit moderate &#40;Phi and Cramer&#39;s <span class="elsevierStyleItalic">V</span>&#8239;&#61;&#8239;0&#46;322&#41; association was found between EVD placement and VPS &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#60;&#8239;0&#46;001&#41; in patients with aneurysmal SAH&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Risk factors for VPS placement in aneurysmal SAH</span><p id="par0100" class="elsevierStylePara elsevierViewall">A statistically significant relationship was found between the aetiology of SAH &#40;aneurysmal or non-aneurysmal&#41; and patients who have required VPS &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;018&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> show the possible risk factors for VPS placement in patients with aneurysmal SAH&#58;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">It was found that neither gender&#44; age&#44; presence of multiple aneurysms&#44; WFNS nor type of treatment were statistically related to VPS placement&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Statistically significant differences were identified between the modified Fisher scale and the need for VPS placement &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;009&#41;&#46; Although no statistically significant differences were found when analysing each Fisher scale score separately as opposed to when they were compared overall&#44; this may be due to insufficient sample size&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">According to the HH score&#44; there are statistically significant differences for VPS placement&#44; such that patients arriving at the accident and emergency department with an HH score of 1&#8211;2 are more likely to have a long-term VPS placement &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;012 and <span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;026 respectively&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">For the EVD variable&#44; statistically significant differences were observed for VPS placement &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#60;&#8239;0&#46;001&#41;&#44; such that patients who have had drainage are 93&#46;3&#37; more likely to have VPS placement&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Complications of shunt systems in aneurysmal SAH</span><p id="par0130" class="elsevierStylePara elsevierViewall">EVD infection prior to VPS placement is not statistically associated with subsequent VPS infection &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;156&#41;&#46; There is also no statistically significant association between VPS infection and the number of VPS re-interventions &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;183&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The minimum time from EVD placement to VPS placement was 10 days&#44; while the maximum time was 317 and 364 days&#46; VPS was placed directly in three patients&#44; classed as &#34;0 days&#34;&#46; The mean time to VPS placement during admission in patients who have had an EVD in our centre was 26&#46;1 days &#40;95&#37; CI&#44; 17&#8211;35&#46;1&#41;&#44; excluding three patients who had a VPS placed months later due to late hydrocephalus&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The number of days from EVD placement to VPS did not follow a normal distribution according to the Kolmogorov-Smirnov analysis&#46; The Mann-Whitney <span class="elsevierStyleItalic">U</span> test was performed to compare non-parametric samples&#46; It can be concluded that there is a statistically significant association between days with EVD and EVD infection &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;001&#41;&#44; but not between time with EVD and VPS infection &#40;<span class="elsevierStyleItalic">p</span>&#8239;&#61;&#8239;0&#46;312&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Of the patients with EVD who subsequently required VPS &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;25&#41;&#44; six patients &#40;24&#37;&#41; were diagnosed with EVD infection &#40;two positive cultures or one culture with biochemical or clinical involvement&#41;&#46; Four patients with VPS developed a VPS infection &#40;14&#46;2&#37;&#41;&#46; The reoperation rate for VPS was 17&#46;7&#37;&#58; four patients were re-operated on twice&#44; all of them for infection&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">Hydrocephalus is associated with higher morbidity and mortality rates in patients with spontaneous SAH&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> VPS placement is not without risk&#44; as it leads to an increase in surgical procedures&#44; hospitalisation time and complications&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> To optimise the management of this condition&#44; the factors that increase the risk of VPS placement in patients with SAH and hydrocephalus must be identified&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The incidence of VPS-dependent hydrocephalus secondary to SAH has been reported to vary from 9&#37; to 35&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In this study&#44; permanent CSF diversion was performed in 11&#46;7&#37; of patients&#46; These results are similar to those of the study by Adams et al&#40;17&#46;7&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Tso et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> &#40;17&#46;1&#37;&#41; and Paisan et al&#46; &#40;13&#46;1&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Although factors that may predict the risk of VPS placement after SAH are not precisely defined&#44; intraventricular haemorrhage and high scores on the HH and modified Fisher scale are predominant&#46; Our study found no statistically significant association between age&#47;gender and VPS placement&#46; In contrast&#44; in other studies&#44; such as those published by Wilson&#44; Tso and Hao et al&#46;&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7&#44;10</span></a> patients over 60 years of age were found to be at higher risk for VPS placement&#46; The meta-analysis by Wilson<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> identified no statistically significant association between gender and VPS placement&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The HH scale also appears to be useful in predicting the need for VPS&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10&#44;11</span></a> Patients with an HH of 3&#8211;5 on arrival are three times more at risk of VPS placement than patients with an HH of 1&#8211;2&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8&#44;10</span></a> However&#44; this study demonstrates a higher likelihood of shunt dependency in SAH patients with low HH&#46; With a much higher mortality rate among patients with high HH and a high EVD time rate&#44; it can be assumed that our results have a survival bias&#58; more shunts are placed for patients who survive the first few weeks&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">With regards to the WFNS scale&#44; consistent with our study&#44; the study by Tso et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> also found a significant association in the univariate analysis&#44; but not in the multivariate analysis&#46; This difference in results may be due to insufficient sample size&#44; which is why the results in the multivariate analysis do not reach statistical significance&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In the meta-analysis by Wilson et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> a score of 3&#8211;4 on the Fisher scale was the most important risk factor for VPS placement in patients with SAH&#44; with a 4&#8211;8 fold increased risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8</span></a> In addition&#44; patients with IVH have an almost four-fold greater risk of VPS placement&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Paisan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> describe intraventricular blood as the most important predictive factor for VPS placement&#44; with an OR of 5&#46; These results are consistent with those of this study&#44; which were statistically significant&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The location of the aneurysm in our study was not related to VPS placement&#44; in contrast to the findings published by Wilson&#44; Adams and Hao&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6&#44;10</span></a> in which patients with posterior circulation aneurysms are at higher risk&#46; It should be noted that this association is not clinically relevant&#46; First of all&#44; in the meta-analysis by Wilson&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> the association between these two variables is weak or insignificant&#46; Furthermore&#44; the division between anterior and posterior circulation is not specific for predicting the risk of shunt&#59; each artery would have to be analysed separately&#46; However&#44; posterior circulation aneurysms usually cause a greater amount of blood in the basal cisterns and ventricles&#44; and this may be the factor that correlates them to the placement of a VPS&#44; since&#44; as mentioned above&#44; the greater the amount of intraventricular blood&#44; the greater the likelihood of VPS placement&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In our study&#44; consistent with the findings of Hao et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> no association was found between the type of treatment received and VPS placement&#46; This was not the case in the studies by Adams and Xie et al&#46;&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8</span></a> where the univariate analysis did show an association between the two variables&#46; According to the meta-analysis by Xie&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> there is a higher risk of VPS placement in patients who have received endovascular treatment&#44; although selection bias cannot be ruled out&#46; In contrast&#44; Paisan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> report that surgical treatment is a predictor for VPS placement after aneurysmal SAH&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The strongest predictor for VPS placement is previously having an EVD&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;10</span></a> In contrast&#44; according to Hao&#44; EVD can reduce VPS rates&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Although the pathophysiology is not discussed in detail&#44; it is reported that EVD can restore normal CSF circulation and therefore decrease rates of shunt-dependent hydrocephalus&#46; According to Tso et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> patients who drain more than 78&#8239;mL per day through the EVD are more likely to require a valve in the future&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Several studies have shown a statistically significant association between the amount of volume drained through the EVD and shunt dependency&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15</span></a> The study by Zolal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> found that patients with CSF volumes greater than 130&#8239;mL&#47;day drained at &#43;15 cmH2O are more likely to be CSF shunt-dependent&#46; In contrast&#44; other studies&#44; such as the one published by Garc&#237;a Armengol et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> report this limit at volumes greater than 214&#8239;mL&#47;day&#44; especially in the first 72&#8239;h&#44; with a sensitivity of 93&#46;5&#37; and a specificity of 89&#46;4&#37;&#46; This value is similar to that reported in the study by Perry et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> where a mean CSF of 204&#8239;mL per day drained in the first 72&#8239;h was considered to be the optimal point for predicting patients who would require a VPS&#46; According to the study&#44; another predictor for VPS placement is the length of time the patient has had the EVD and the number of failed EVD closure attempts&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Liang et al&#46; analysed the risk factors associated with VPS placement after aneurysmal SAH and created a score called the MAI score&#44; which attempts to unify these factors&#46; The initials of MAI stand for the Modified Fisher Scale equal to or greater than 3 points&#44; Acute Hydrocephalus and Intraventricular Haemorrhage &#40;IVH&#41;&#46; Each of the variables is given one point and it was found that patients with scores of 2 and 3 on this scale are 10 times more likely to need VPS than patients with scores of 0 and 1&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> According to this study&#44; the MAI score is superior in predicting VPS placement&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> with an AUC of 0&#46;773&#46; In the internal validation of this score&#44; the MAI score had an AUC of 0&#46;950&#44; while the AFA and SDASH scores had AUC of 0&#46;691 and 0&#46;689 respectively&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">There are other scales designed to predict the risk of needing a VPS&#44; such as the Barrow Neurological Institute &#40;BNI&#41; Score&#44; Shunt Dependency in Subarachnoid Hemorrhage &#40;SDASH&#41; Score&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> AFA risk scoring system&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Chronic Hydrocephalus ensuing from SAH Score &#40;CHESS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> PostSubarachnoid Shunt Scoring System &#40;PS3&#41; Score&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> modified Graeb score<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and Hijdra sum score&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> This last one &#40;Hijdra sum score&#41; more accurately captures the amount of blood in the subarachnoid space&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The BNI Score is a score described by Wilson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> which classifies SAH according to the thickness of the haemorrhage measured in millimetres at the fissures or cisterns&#46; The following parameters are included in the AFA score&#44; with one point awarded for each&#58; acute hydrocephalus&#59; modified Fisher grade 4&#59; and age over 50&#46; The SDASH scale includes three items&#58; acute hydrocephalus&#59; HH score greater than or equal to 4&#59; and BNI Score&#46; According to the study carried out by Garc&#237;a-Armengol et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> which compared this score &#40;SDASH score&#41; with the other scores mentioned&#44; clinical-radiological scores such as the SDASH score are more accurate than radiological scores such as the BNI score&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In the Perry et al&#46; study&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> the authors develop the MAGE Score&#44; which aims to predict which patients will be CSF shunt-dependent&#46; This score incorporates for the first time the volume of CSF drained through the EVD as a predictor&#46; Although VPS placement must be individualised for each patient&#44; volumes greater than 200&#8239;mL&#47;day make this decision more consistent&#46; MAGE scores greater than or equal to 4 make the need for VPS placement more likely&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The data provided by this study yield results comparable to the literature and help to define which patients are most at risk of shunt dependency in our setting&#58; those with previous EVD and a high score on the modified Fisher scale&#46; These factors are the same as those used by the MAI score&#44; which is why&#44; in addition to its simplicity&#44; we have considered its use in patients with spontaneous SAH in our setting&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Complications of shunt dependency and the importance of EVD time</span><p id="par0225" class="elsevierStylePara elsevierViewall">The incidence of EVD infection in patients who required VPS was 24&#37;&#46; The mean time to VPS placement after EVD was 26&#46;1 days&#46; Statistical significance was found between the length of time the patient had the EVD and EVD infection&#44; but it was not associated with VPS infection&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">The relationship between EVD duration and device infections is subject to much debate&#46; In the article by Lozier et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> the length of time the patient has had the EVD is considered a risk factor for EVD infection&#46; According to the study by Adams&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the mean time to valve placement is 33 days&#44; which is similar to the results of our study&#46; In the meta-analysis by Xie&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> the mean time to VPS placement is 17&#8211;44 days&#46; Kang et al&#46; found that early VPS placement &#40;6&#46;4 days on average&#41; in patients with EVD was associated with a lower infection rate&#44; earlier patient mobilisation and shorter hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Patients with VPS have an incidence of complications of 18&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our study&#44; the percentage of complications and need for reoperation in patients with VPS secondary to aneurysmal SAH was 17&#46;7&#37; &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;5&#41;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Kang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> re-operated on 6&#46;1&#37; of patients for valve malfunction and 0&#37; for infection&#46; This percentage difference may be due to early VPS placement&#44; with a higher likelihood of obstruction and malfunction in exchange for a zero infection rate&#46; The results in the literature&#44; however&#44; are very mixed&#46; According to the study by Tso et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> 35&#8211;50&#37; of patients require VPS revision in the first year after valve placement&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The results obtained in our study and the methodology used preclude us from defining whether early VPS placement is beneficial for our patients&#44; let alone the best time to perform it&#46; We can&#44; however&#44; draw the following conclusions&#58; 1&#41; the risk factors for VPS placement are modified Fisher 3&#8211;4 and the need for ventricular drainage&#59; 2&#41; the greater the number of days with external ventricular drainage&#44; the greater the likelihood of EVD infection&#59; 3&#41; the mean external drainage time at our centre is high&#59; and 4&#41; the most prevalent complication after VPS placement at our centre is infection&#46; Although the literature review also fails to provide strong evidence on the approach to be taken&#44; we consider that decreasing ventricular drainage time at our centre is a priority&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">While the indication for shunt depends on multiple factors and is difficult to strictly protocolise&#44; we have added three factors that we believe can reduce drainage time&#58; 1&#41; direct closure of the EVD without progressive pressure rise&#59; 2&#41; use of the MAI score in order to be more aggressive when indicating shunts in patients who are more likely to need them&#59; and 3&#41; use of the volume drained in the first 72&#8239;h as a risk factor&#46; The protocol is set out in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#58;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0255" class="elsevierStylePara elsevierViewall">A high score on the modified Fisher scale and the need for EVD for acute hydrocephalus are risk factors for VPS placement in patients with aneurysmal SAH&#46; There is a statistically significant relationship between the length of time a patient has had an EVD and EVD infection&#44; but it is not associated with VPS infection&#46; We believe that early VPS placement in at-risk patients could reduce complications and improve the prognosis of these patients&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Declaration of conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that they have no financial or personal interests that might have influenced the work carried out&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "titulo" => "Abbreviations"
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        3 => array:3 [
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          "titulo" => "Resumen"
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            0 => array:2 [
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          "titulo" => "Introduction"
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            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "General characteristics"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Hydrocephalus"
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            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Risk factors for VPS placement in aneurysmal SAH"
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              "identificador" => "sec0035"
              "titulo" => "Complications of shunt systems in aneurysmal SAH"
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          "titulo" => "Discussion"
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              "identificador" => "sec0045"
              "titulo" => "Complications of shunt dependency and the importance of EVD time"
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          "titulo" => "Conclusions"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2023-09-24"
    "fechaAceptado" => "2024-01-28"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1845018"
          "palabras" => array:4 [
            0 => "Subarachnoid haemorrhage"
            1 => "Intracranial aneurysm"
            2 => "Hydrocephalus"
            3 => "Ventriculoperitoneal shunt"
          ]
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        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1845019"
          "palabras" => array:16 [
            0 => "SAH"
            1 => "EVD"
            2 => "ELD"
            3 => "CSF"
            4 => "VPS"
            5 => "HTN"
            6 => "DLP"
            7 => "DM"
            8 => "AComA"
            9 => "MCA"
            10 => "AVM"
            11 => "AVF"
            12 => "HH"
            13 => "WFNS"
            14 => "IVH"
            15 => "BNI"
          ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1845017"
          "palabras" => array:4 [
            0 => "Hemorragia subaracnoidea"
            1 => "Aneurisma intracraneal"
            2 => "Hidrocefalia"
            3 => "Derivaci&#243;n ventr&#237;culoperitoneal"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Subarachnoid haemorrhage &#40;SAH&#41; is one of the most frequent neurosurgical emergencies&#44; most of them due to intracranial aneurysm rupture&#46; Hydrocephalus is a prevalent complication with a high rate of complications&#46; The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022&#46; Patients&#8217; clinical and radiological characteristics&#44; type of treatment&#44; diagnoses and treatment of hydrocephalus&#44; complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study&#46; A descriptive study of these variables has been done and&#44; subsequently&#44; the most relevant variables have been statistically analysed to identify patients with increasing risk of shunting for hydrocephalus&#46; This study was authorized by the Ethics Committee prior to its elaboration&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022&#44; with an intrahospitalary death rate of 25&#46;3&#37;&#46; 66&#46;3&#37; of the total of patients with SAH were due to intracranial aneurysm rupture &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;238&#41;&#46; 45&#46;3&#37; of the patients with aneurysmal SAH required an external ventricular drain &#40;EVD&#41; to treat acute hydrocephalus&#46; 11&#46;7&#37; &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;28&#41; developed a shunt-dependent hydrocephalus&#46; Statistical significance was found between shunt-dependent hydrocephalus and the following&#58; high score in modified Fisher scale and placement of EVD&#46; The mean interval from EVD to ventriculoperitoneal shunt placement was 26&#46;1 days&#46; The mean rate of reoperation of patients after shunt was 17&#46;7&#37;&#44; mostly due to infection&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD&#46; Shunt infections is the main cause of shunt reoperation&#46; Early shunt placement in selected patients might reduce the rate of infectious complications&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La hemorragia subaracnoidea es una de las urgencias neuroquir&#250;rgicas m&#225;s frecuentes&#44; siendo la ruptura de un aneurisma intracraneal la principal causa&#46; La hidrocefalia es un complicaci&#243;n neurol&#243;gica prevalente y presenta una elevada tasa de complicaciones y necesidad de reintervenciones&#46; Los objetivos de este trabajo son identificar los factores predictores de colocaci&#243;n de derivaci&#243;n ventr&#237;culoperitoneal y conocer la tasa de complicaciones asociadas a estos dispositivos en nuestro centro&#46; Con ello&#44; se pretende seleccionar los pacientes a los que colocar una derivaci&#243;n de manera temprana para reducir las complicaciones&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se trata de un estudio observacional retrospectivo anali&#769;tico de los pacientes con HSA esponta&#769;nea derivados al Hospital Universitario Miguel Servet de Zaragoza entre 2017 y 2022&#46; Se han recogido diversas variables como caracter&#237;sticas cli&#769;nicas y radiolo&#769;gicas&#44; tipo de tratamiento&#44; diagn&#243;stico y tratamiento de la hidrocefalia&#44; tiempo hasta la colocaci&#243;n de la derivaci&#243;n ventriculoperitoneal &#40;DVP&#41;&#44; complicaciones de la DVP y mortalidad global de la HSA&#46; Se ha realizado un ana&#769;lisis estadi&#769;stico para comprobar si existe asociacio&#769;n entre estas variables y la necesidad de colocacio&#769;n de v&#225;lvula&#46; Posteriormente se comparan los resultados obtenidos con los existentes en la literatura&#46; Este estudio ha sido aprobado por el Comite&#769; de E&#769;tica de Investigacio&#769;n Cli&#769;nica de Arago&#769;n &#40;CEICA&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Entre 2017 y 2022 se recogieron un total de 359 pacientes con HSA esponta&#769;nea derivados a nuestro centro&#44; presentando una mortalidad intrahospitalaria del 25&#44;3&#37;&#46; El 66&#44;3&#37; &#40;n&#8239;&#61;&#8239;238&#41; de las HSA fueron secundarias a la ruptura de un aneurisma&#46; El 45&#44;3&#37; de los pacientes con HSA aneurisma&#769;tica requirieron la colocacio&#769;n de un drenaje ventricular externo &#40;DVE&#41; y el 11&#44;7&#37; &#40;n&#8239;&#61;&#8239;28&#41; necesitaron la colocacio&#769;n de una DVP por hidrocefalia permanente&#46; Existe relacio&#769;n estadi&#769;stica entre la colocacio&#769;n de DVP y una puntuaci&#243;n alta en la escala de Fisher modificada y la colocacio&#769;n previa de DVE&#46; El tiempo medio hasta la colocacio&#769;n de la DVP fue de 26&#44;1 di&#769;as&#44; encontr&#225;ndose diferencias significativas entre el tiempo de DVE y la infecci&#243;n del mismo&#44; pero no con la infecci&#243;n de la derivaci&#243;n definitiva&#46; La tasa de reintervenci&#243;n de v&#225;lvulas fue del 17&#44;7&#37;&#44; principalmente por infecci&#243;n del sistema&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Los factores de riesgo que permiten predecir la colocaci&#243;n de DVP son una puntuaci&#243;n alta en la escala de Fisher modificada y la colocaci&#243;n previa de DVE&#46; La infecci&#243;n valvular es la complicaci&#243;n m&#225;s frecuentemente asociada a reintervenci&#243;n quir&#250;rgica&#46; Consideramos que una actitud m&#225;s proactiva a la hora de la colocaci&#243;n de DVP en estos pacientes podr&#237;a disminuir la tasa de complicaciones&#46;</p></span>"
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            "titulo" => "Material y m&#233;todo"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
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            "titulo" => "Conclusiones"
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Decision algorithm for VPS placement after SAH in our department&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The main limitation of this study is that the data collection was retrospective and that the volume of fluid drained by ventricular drainage was not used as a variable&#46; Therefore&#44; we propose the need for a new prospective study applying the algorithm suggested in this paper in order to compare clinical outcomes in patients who undergo early shunt placement and those who undergo late shunt placement&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Bold value signifies values are statistically significant&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total <span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;238 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">VPS yes <span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;28 &#40;11&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">58 &#40;49&#8722;69&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>30&#8211;65&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">144 &#40;91&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;65&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">75 &#40;31&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14 &#40;18&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">61 &#40;81&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Gender</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;304&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">158 &#40;66&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;13&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">137 &#40;86&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;8&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">73 &#40;91&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Multiple aneurysms</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;465&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55 &#40;23&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;14&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Aneurysm location</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;419&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anterior circ&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">207 &#40;87&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;11&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">184 &#40;88&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Posterior circ&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;13&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;16&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  """
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Vol. 35. Núm. 4.
Páginas 196-204 (julio - agosto 2024)
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Vol. 35. Núm. 4.
Páginas 196-204 (julio - agosto 2024)
Clinical Research
Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage
Factores de riesgo para la colocación de derivación ventriculoperitoneal en hidrocefalia secundaria a hemorragia subaracnoidea espontánea
Loreto Esteban Estallo
Autor para correspondencia
loretoestebanestallo@gmail.com

Corresponding author.
, Juan Casado Pellejero, Silvia Vázquez Sufuentes, Laura Beatriz López López, David Fustero de Miguel, Luis Manuel González Martínez
Hospital Universitario Miguel Servet, Zaragoza, Spain
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Table 1. Variables analysed in patients with spontaneous SAH due to aneurysmal rupture in relation to the need for VPS.
Table 2. Multivariate analysis of the most important variables and their association with VPS placement.
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Abstract
Introduction

Subarachnoid haemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts.

Methods

This study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients’ clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analysed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration.

Results

A total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25.3%. 66.3% of the total of patients with SAH were due to intracranial aneurysm rupture (n = 238). 45.3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11.7% (n = 28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26.1 days. The mean rate of reoperation of patients after shunt was 17.7%, mostly due to infection.

Conclusions

The most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Keywords:
Subarachnoid haemorrhage
Intracranial aneurysm
Hydrocephalus
Ventriculoperitoneal shunt
Abbreviations:
SAH
EVD
ELD
CSF
VPS
HTN
DLP
DM
AComA
MCA
AVM
AVF
HH
WFNS
IVH
BNI
Resumen
Introducción

La hemorragia subaracnoidea es una de las urgencias neuroquirúrgicas más frecuentes, siendo la ruptura de un aneurisma intracraneal la principal causa. La hidrocefalia es un complicación neurológica prevalente y presenta una elevada tasa de complicaciones y necesidad de reintervenciones. Los objetivos de este trabajo son identificar los factores predictores de colocación de derivación ventrículoperitoneal y conocer la tasa de complicaciones asociadas a estos dispositivos en nuestro centro. Con ello, se pretende seleccionar los pacientes a los que colocar una derivación de manera temprana para reducir las complicaciones.

Material y método

Se trata de un estudio observacional retrospectivo analítico de los pacientes con HSA espontánea derivados al Hospital Universitario Miguel Servet de Zaragoza entre 2017 y 2022. Se han recogido diversas variables como características clínicas y radiológicas, tipo de tratamiento, diagnóstico y tratamiento de la hidrocefalia, tiempo hasta la colocación de la derivación ventriculoperitoneal (DVP), complicaciones de la DVP y mortalidad global de la HSA. Se ha realizado un análisis estadístico para comprobar si existe asociación entre estas variables y la necesidad de colocación de válvula. Posteriormente se comparan los resultados obtenidos con los existentes en la literatura. Este estudio ha sido aprobado por el Comité de Ética de Investigación Clínica de Aragón (CEICA).

Resultados

Entre 2017 y 2022 se recogieron un total de 359 pacientes con HSA espontánea derivados a nuestro centro, presentando una mortalidad intrahospitalaria del 25,3%. El 66,3% (n = 238) de las HSA fueron secundarias a la ruptura de un aneurisma. El 45,3% de los pacientes con HSA aneurismática requirieron la colocación de un drenaje ventricular externo (DVE) y el 11,7% (n = 28) necesitaron la colocación de una DVP por hidrocefalia permanente. Existe relación estadística entre la colocación de DVP y una puntuación alta en la escala de Fisher modificada y la colocación previa de DVE. El tiempo medio hasta la colocación de la DVP fue de 26,1 días, encontrándose diferencias significativas entre el tiempo de DVE y la infección del mismo, pero no con la infección de la derivación definitiva. La tasa de reintervención de válvulas fue del 17,7%, principalmente por infección del sistema.

Conclusiones

Los factores de riesgo que permiten predecir la colocación de DVP son una puntuación alta en la escala de Fisher modificada y la colocación previa de DVE. La infección valvular es la complicación más frecuentemente asociada a reintervención quirúrgica. Consideramos que una actitud más proactiva a la hora de la colocación de DVP en estos pacientes podría disminuir la tasa de complicaciones.

Palabras clave:
Hemorragia subaracnoidea
Aneurisma intracraneal
Hidrocefalia
Derivación ventrículoperitoneal

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