Insights in Neurosurgery

The Efficacy of Clipping over Endovascular Coiling In Reducing Shunt Dependent Hydrocephalus after Rupture of Intracranial Aneurysms, an Institutional Experience

Objectives: Clipping and Endovascular Therapy (EVT) have a variable benefit in reducing Shunt Dependence Hydrocephalus (SDHC) following an aneurysm bleed. We compared clipping over endovascular treatment in reducing such dependence. Additionally, we tried to assess the effect of lesser-studied modifiable risk factors such as External Ventricular Drainage (EVD), Ommaya reservoir placement, CSF protein, cisternostomy and vasospasm.

Materials and methods: We retrospectively analyzed 67 out of 300 patients treated between July 2018 and December 2021 at our center for ruptured aneurysms who developed hydrocephalus following an aneurysmal bleed. We divided the patients into two groups, one undergoing clipping other EVT.

Results: Of 67 patients, 33 were treated by clipping and 34 by coiling. Compared to clipping, coiling could not significantly reduce shunt dependence (p=0.66). On stepwise logistic regression analysis of risk factors for SDHC, the timing of EVD (p=0.05) and CSF protein on day 7 (p=0.01) was a significant risk factor. Ommaya reservoir placement following EVD was found to reduce shunt dependence (p=0.0001), together with patients responding to spasmolysis following vasospasm (p=0.001) and fenestration of lamina terminalis (p=0.017), while clipping.

Conclusion: We did not find any significant advantage of clipping over endovascular therapy in reducing shuntdependent hydrocephalus following aneurysmal rupture. The duration taken to put EVD after the onset of hydrocephalus and CSF protein on the seventh day, reflecting persistent infection or higher blood degradation, can also influence shunt dependence. Ommaya reservoir placement can reduce shunt dependence in patients who underwent EVD earlier and can substitute it, requiring further prospective study to comment certainly the use of Ommaya reservoir as a substitute for EVD for external CSF drainage in hydrocephalus induced by aneurysmal bleed.

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