Risk factors for shunt dependency in patients suffering from spontaneous, non-aneurysmal subarachnoid hemorrhage

  • Patrick Schuss
  • Alexis Hadjiathanasiou
  • Simon Brandecker
  • Christian Wispel
  • Valeri Borger
  • Ági Güresir
  • Hartmut Vatter
  • Erdem Güresir
Original Article


Patients presenting with spontaneous, non-aneurysmal subarachnoid hemorrhage (SAH) achieve better outcomes compared to patients with aneurysmal SAH. Nevertheless, some patients develop shunt-dependent hydrocephalus during treatment course. We therefore analyzed our neurovascular database to identify factors determining shunt dependency after non-aneurysmal SAH. From 2006 to 2016, 131 patients suffering from spontaneous, non-aneurysmal SAH were admitted to our department. Patients were stratified according to the distribution of cisternal blood into patients with perimesencephalic SAH (pSAH) versus non-perimesencephalic SAH (npSAH). Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months and stratified into favorable (mRS 0–2) versus unfavorable (mRS 3–6). A multivariate analysis was performed to identify predictors of shunt dependency in patients suffering from non-aneurysmal SAH. Overall, 18 of 131 patients suffering from non-aneurysmal SAH developed shunt dependency (14%). In detail, patients with npSAH developed significantly more often shunt dependency during treatment course, when compared to patients with pSAH (p = 0.02). Furthermore, patients with acute hydrocephalus, presence of intraventricular hemorrhage, presence of clinical vasospasm, and anticoagulation medication prior SAH developed significantly more often shunt dependency, when compared to patients without (p < 0.0001). However, “acute hydrocephalus” was the only significant and independent predictor for shunt dependency in all patients with non-aneurysmal SAH in the multivariate analysis (p < 0.0001). The present study identified acute hydrocephalus with the necessity of CSF diversion as significant and independent risk factor for the development of shunt dependency during treatment course in patients suffering from non-aneurysmal SAH.


Non-aneurysmal subarachnoid hemorrhage Shunt dependency Perimesencephalic 


Compliance with ethical standards

Ethical approval

The present study was approved by the local ethics committee.

Informed consent

Informed consent was not sought as a retrospective study design was used.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Adams H, Ban VS, Leinonen V, Aoun SG, Huttunen J, Saavalainen T, Lindgren A, Frosen J, Fraunberg M, Koivisto T, Hernesniemi J, Welch BG, Jaaskelainen JE, Huttunen TJ (2016) Risk of shunting after aneurysmal subarachnoid hemorrhage: a collaborative study and initiation of a consortium. Stroke 47:2488–2496. CrossRefPubMedGoogle Scholar
  2. 2.
    Beseoglu K, Pannes S, Steiger HJ, Hanggi D (2010) Long-term outcome and quality of life after nonaneurysmal subarachnoid hemorrhage. Acta Neurochir 152:409–416. CrossRefPubMedGoogle Scholar
  3. 3.
    Boswell S, Thorell W, Gogela S, Lyden E, Surdell D (2013) Angiogram-negative subarachnoid hemorrhage: outcomes data and review of the literature. J Stroke Cerebrovasc Dis 22:750–757. CrossRefPubMedGoogle Scholar
  4. 4.
    de Oliveira JG, Beck J, Setzer M, Gerlach R, Vatter H, Seifert V, Raabe A (2007) 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 61:924–933; discussion 933–924. CrossRefPubMedGoogle Scholar
  5. 5.
    Diesing D, Wolf S, Sommerfeld J, Sarrafzadeh A, Vajkoczy P, Dengler NF (2017) A novel score to predict shunt dependency after aneurysmal subarachnoid hemorrhage. J Neurosurg 1–7. doi:
  6. 6.
    Dorai Z, Hynan LS, Kopitnik TA, Samson D (2003) Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 52:763–769 discussion 769–771CrossRefPubMedGoogle Scholar
  7. 7.
    Duong H, Melancon D, Tampieri D, Ethier R (1996) The negative angiogram in subarachnoid haemorrhage. Neuroradiology 38:15–19CrossRefPubMedGoogle Scholar
  8. 8.
    Elhadi AM, Zabramski JM, Almefty KK, Mendes GA, Nakaji P, McDougall CG, Albuquerque FC, Preul MC, Spetzler RF (2015) Spontaneous subarachnoid hemorrhage of unknown origin: hospital course and long-term clinical and angiographic follow-up. J Neurosurg 122:663–670. CrossRefPubMedGoogle Scholar
  9. 9.
    Gupta SK, Gupta R, Khosla VK, Mohindra S, Chhabra R, Khandelwal N, Gupta V, Mukherjee KK, Tewari MK, Pathak A, Mathuriya SN (2009) Nonaneurysmal nonperimesencephalic subarachnoid hemorrhage: is it a benign entity? Surg Neurol 71:566–571; discussion 571,571-562,572. CrossRefPubMedGoogle Scholar
  10. 10.
    Jabbarli R, Bohrer AM, Pierscianek D, Muller D, Wrede KH, Dammann P, El Hindy N, Ozkan N, Sure U, Muller O (2016) The CHESS score: a simple tool for early prediction of shunt dependency after aneurysmal subarachnoid hemorrhage. Eur J Neurol 23:912–918. CrossRefPubMedGoogle Scholar
  11. 11.
    Kang P, Raya A, Zipfel GJ, Dhar R (2016) Factors associated with acute and chronic hydrocephalus in nonaneurysmal subarachnoid hemorrhage. Neurocrit Care 24:104–109. CrossRefPubMedGoogle Scholar
  12. 12.
    Konczalla J, Kashefiolasl S, Brawanski N, Lescher S, Senft C, Platz J, Seifert V (2016) Cerebral vasospasm and delayed cerebral infarctions in 225 patients with non-aneurysmal subarachnoid hemorrhage: the underestimated risk of Fisher 3 blood distribution. J Neurointerv Surg 8:1247–1252. CrossRefGoogle Scholar
  13. 13.
    Konczalla J, Platz J, Schuss P, Vatter H, Seifert V, Güresir E (2014) Non-aneurysmal non-traumatic subarachnoid hemorrhage: patient characteristics, clinical outcome and prognostic factors based on a single-center experience in 125 patients. BMC Neurol 14:140. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Konczalla J, Schmitz J, Kashefiolasl S, Senft C, Platz J, Seifert V (2016) Non-aneurysmal non-perimesencephalic subarachnoid hemorrhage: effect of rehabilitation at short-term and in a prospective study of long-term follow-up. Top Stroke Rehabil 23:261–268. CrossRefPubMedGoogle Scholar
  15. 15.
    Konczalla J, Schmitz J, Kashefiolasl S, Senft C, Seifert V, Platz J (2015) Non-aneurysmal subarachnoid hemorrhage in 173 patients: a prospective study of long-term outcome. Eur J Neurol 22:1329–1336. CrossRefPubMedGoogle Scholar
  16. 16.
    Raabe A, Beck J, Keller M, Vatter H, Zimmermann M, Seifert V (2005) Relative importance of hypertension compared with hypervolemia for increasing cerebral oxygenation in patients with cerebral vasospasm after subarachnoid hemorrhage. J Neurosurg 103:974–981. CrossRefPubMedGoogle Scholar
  17. 17.
    Rinkel GJ, Wijdicks EF, Hasan D, Kienstra GE, Franke CL, Hageman LM, Vermeulen M, van Gijn J (1991) Outcome in patients with subarachnoid haemorrhage and negative angiography according to pattern of haemorrhage on computed tomography. Lancet 338:964–968CrossRefPubMedGoogle Scholar
  18. 18.
    Rinkel GJ, Wijdicks EF, Vermeulen M, Hasan D, Brouwers PJ, van Gijn J (1991) The clinical course of perimesencephalic nonaneurysmal subarachnoid hemorrhage. Ann Neurol 29:463–468. CrossRefPubMedGoogle Scholar
  19. 19.
    Rosen DS, Macdonald RL (2004) Grading of subarachnoid hemorrhage: modification of the World Federation of Neurosurgical Societies scale on the basis of data for a large series of patients. Neurosurgery 54:566–575 discussion 575-566CrossRefGoogle Scholar
  20. 20.
    Schuss P, Borger V, Güresir Á, Vatter H, Güresir E (2015) Cranioplasty and ventriculoperitoneal shunt placement after decompressive craniectomy: staged surgery is associated with fewer postoperative complications. World Neurosurg 84:1051–1054. CrossRefPubMedGoogle Scholar
  21. 21.
    Schuss P, Wispel C, Borger V, Güresir Á, Vatter H, Güresir E (2017) Accuracy and safety of ventriculostomy using two different procedures of external ventricular drainage: a single-center series. J Neurol Surg Part A, Central Eur Neurosurg.
  22. 22.
    Teasdale GM, Drake CG, Hunt W, Kassell N, Sano K, Pertuiset B, De Villiers JC (1988) A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. J Neurol Neurosurg Psychiatry 51:1457CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Tso MK, Ibrahim GM, Macdonald RL (2016) Predictors of shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage. World Neurosurg 86:226–232. CrossRefPubMedGoogle Scholar
  24. 24.
    van Gijn J, van Dongen KJ, Vermeulen M, Hijdra A (1985) Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage. Neurology 35:493–497CrossRefPubMedGoogle Scholar
  25. 25.
    Whiting J, Reavey-Cantwell J, Velat G, Fautheree G, Firment C, Lewis S, Hoh B (2009) Clinical course of nontraumatic, nonaneurysmal subarachnoid hemorrhage: a single-institution experience. Neurosurg Focus 26:E21. CrossRefPubMedGoogle Scholar
  26. 26.
    Wilson CD, Safavi-Abbasi S, Sun H, Kalani MY, Zhao YD, Levitt MR, Hanel RA, Sauvageau E, Mapstone TB, Albuquerque FC, McDougall CG, Nakaji P, Spetzler RF (2017) Meta-analysis and systematic review of risk factors for shunt dependency after aneurysmal subarachnoid hemorrhage. J Neurosurg 126:586–595. CrossRefPubMedGoogle Scholar
  27. 27.
    Wilson DA, Nakaji P, Abla AA, Uschold TD, Fusco DJ, Oppenlander ME, Albuquerque FC, McDougall CG, Zabramski JM, Spetzler RF (2012) A simple and quantitative method to predict symptomatic vasospasm after subarachnoid hemorrhage based on computed tomography: beyond the Fisher scale. Neurosurgery 71:869–875. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryRheinische Friedrich-Wilhelms-University BonnBonnGermany

Personalised recommendations