RESEARCH—HUMAN—CLINICAL STUDIES

TOPIC Research—Human—Clinical Studies

Risk Factors for Conversion to Permanent Ventricular Shunt in Patients Receiving Therapeutic Ventriculostomy for Traumatic Brain Injury
David F. Bauer, MD* Gerald McGwin, Jr, MS, PhD†‡ Sherry M. Melton, MD† Richard L. George, MD, MSPH† James M. Markert, MD, MPH*
*Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama; †Section of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; ‡Department of Epidemiology, School of Public Health; University of Alabama at Birmingham, Birmingham, Alabama Correspondence: James M. Markert, MD, MPH Division Director, Neurosurgery, James Garber Galbraith Professor, Neurosurgery, Physiology and Pediatrics, and Cell Biology, University of Alabama, Birmingham, FOT No. 1060, 1530 3rd Ave S, Birmingham, AL 35294-3410. E-mail: markert@uab.edu Received, September 16, 2009. Accepted, June 7, 2010. Copyright ª 2010 by the Congress of Neurological Surgeons

BACKGROUND: Intracranial pressure is routinely monitored in patients with severe traumatic brain injury (TBI). Patients with TBI sometimes develop hydrocephalus, requiring permanent cerebrospinal fluid (CSF) diversion. OBJECTIVE: To quantify the need for permanent CSF diversion in patients with TBI. METHODS: Patients who received a ventriculostomy after TBI between June 2007 and July 2008 were identified, and their medical records were abstracted to a database. RESULTS: Sixteen of 71 patients (22.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. The average number of days between ventriculostomy and shunt was 18.3. Characteristics that predispose these patients to require permanent CSF diversion include the need for craniotomy within 48 hours of admission (odds ratio, 5.20; 95% confidence interval, 1.48-18.35) and history of culture-positive CSF (odds ratio, 5.52; 95% confidence interval, 1.19-25.52). Length of stay was increased in patients receiving permanent CSF diversion (average length of stay, 61 vs 31 days; P = .04). Patient discharge disposition was similar between shunted and nonshunted patients. CONCLUSION: In this retrospective study, 22% of TBI patients who required a ventriculostomy eventually needed permanent CSF diversion. Patients with TBI should be assessed for the need for permanent CSF diversion before discharge from the hospital. Care must be taken to prevent ventriculitis. Future studies are needed to evaluate more thoroughly the risk factors for the need for permanent CSF diversion in this patient population.
KEY WORDS: Hemorrhage, Shunt, Trauma, Ventriculostomy
Neurosurgery 68:85–88, 2011
DOI: 10.1227/NEU.0b013e3181fd85f4

www.neurosurgery-online.com

ntracranial pressure (ICP) is routinely monitored in patients presenting with a poor neurological examination after traumatic brain injury (TBI).1,2 Current guidelines provide Level 2 evidence that ICP monitoring is beneficial in patients with imaging-evident TBI and a Glasgow Coma Scale between 3 and 8.3-5 Devices such as a fiberoptic intraparenchymal monitor and a ventriculostomy drain are routinely used. Ventriculostomy offers the added advantage
ABBREVIATIONS: ICP, intracranial pressure; NICU, neurological intensive care unit; TBI, traumatic brain injury

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of therapeutic cerebrospinal fluid (CSF) diversion to decrease ICP. Patients with TBI sometimes develop hydrocephalus with increased ICP requiring permanent CSF diversion. Previous retrospective studies and case series have found the overall rate of posttraumatic hydrocephalus in patients with TBI to be between 0.7 and 45%.6-12 No study has looked at the rate of posttraumatic hydrocephalus in patients with severe TBI requiring ICP monitoring. This study sought to quantify the absolute risk for the need for permanent CSF diversion in this patient population, in addition to determining the risk factors that may predispose these patients to the need for permanent CSF diversion.

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mechanism of injury. Patients were included if they received the ventriculostomy for a Glasgow Coma Scale # 8 with radiographically confirmed TBI. intraparenchymal hemorrhage. These 4 patients received noncontrast head CT scans with the initial unsuccessful ventriculostomy in place. 3 (33%) had a ventriculostomy placed in the operating room and 6 patients (66%) had a ventriculostomy placed in the neurological intensive care unit (NICU). Ten patients required placement of a second ventriculostomy. After analysis of the CT scan. Three of these patients had unintended early removal of their ventriculostomy as a result of patient manipulation of catheter.19-25. respectively. Six of 21 patients who had a craniotomy within 48 hours of admission had removal of the bone flap at the time of surgery. time between the ventriculostomy and permanent CSF diversion. 5. In univariate analysis. 9 required craniotomy within 48 hours of admission to evacuate a hematoma or for cerebral decompression. RESULTS Of the 71 patients. only craniotomy (odds ratio. All patients had either a contusion or a discrete intracerebral hemorrhage on admission CT scan.neurosurgery-online. or skull fracture). time of postventriculostomy cranial imaging. Our hospital billing database was queried for all patients billed for a ventriculostomy at the University of Alabama Hospital between June 2007 and July 2008. 95% confidence interval. need for permanent CSF diversion.52. skull fracture.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. and 4 patients had unsuccessful initial placement of ventriculostomy. and 14 had a skull fracture. intraventricular hemorrhage. 1. 81 ventriculostomies were placed with an average of 1. complete hospital records and preprocedural and postprocedural imaging studies were available for 71 patients. and 3 of these 6 patients (50%) required a shunt. Unauthorized reproduction of this article is prohibited. mechanism of injury. patients receiving permanent CSF 86 | VOLUME 68 | NUMBER 1 | JANUARY 2011 www. . hemorrhage from ventriculostomy placement. Six of the 15 patients who had the bone flap replaced at surgery (40%) required a shunt. A stepwise logistic regression model was used to determine which demographic and clinical characteristics demonstrated significant. The charts of these 71 patients were retrospectively reviewed. patient medical history.48-18. contusion. 11 were male and 5 were female. time of ventriculostomy placement. subarachnoid hemorrhage. presence of other intracranial pathology (intraventricular hemorrhage. intraparenchymal hemorrhage). 3 patients had initially functioning ventriculostomies that stopped functioning. The average time between placement of the ventriculostomy and permanent CSF diversion was 18. evidence of culture-positive CSF (defined as having at least 1 positive CSF culture found on routine specimens sampled 3 times weekly in all patients with ventriculostomies). 95% confidence interval. independent associations with the need for permanent CSF diversion. and time to postprocedural imaging.20. This patient eventually required permanent cerebrospinal fluid diversion. These groups were compared with respect to demographic and clinical characteristics using analysis of variance and x2 tests for continuous and categorical variables. combined acute injury scores. and 3 had epidural hematomas. Of these patients. 5. number of passes needed to place the ventriculostomy. There were no differences with respect to sex.5 passes attempted per successful placement. place of patient discharge. A database was compiled containing the following information: time of admission.05 (2 sided) were considered statistically significant. Of the patients receiving permanent CSF diversion.52) demonstrated significant independent relationships with the need for permanent CSF diversion. 1. and total length of hospital stay. With respect to outcomes. mean Glasgow Coma Score. Patients were categorized according to their need for permanent CSF diversion placed at some time during their initial hospital admission. type of injury on initial head computed tomography (CT.com Copyright © Congress of Neurological Surgeons.3 days. FIGURE . and history of culture-positive CSF were associated with the need for permanent CSF diversion (Table). Twelve patients had subarachnoid hemorrhage. evidence of hemorrhage on postprocedural imaging. all 4 patients received successful placement of a subsequent ventriculostomy. mean injury severity score. A noncontrast head computed tomography obtained at hospital admission of a patient with a traumatic brain injury requiring ventriculostomy placement. Stereotaxis was not used (Figure).BAUER ET AL PATIENTS AND METHODS This study was undertaken with the approval of the University of Alabama at Birmingham Institutional Review Board. 3 had intraventricular hemorrhage on admission. increased age.35) and culture-positive CSF (odds ratio. Sixteen of 71 patients (22. Nine of 16 patients (56%) who underwent craniotomy eventually required a shunt before discharge from the hospital. Values of P # . One patient had a small hemorrhage with the placement of ventriculostomy. time to ventriculostomy placement. In a multivariable logistic regression model. need for craniotomy within 48 hours of admission. Of the 82 patients identified. laboratory data on admission and at ventriculostomy placement.

mean.7 27. diversion had an increased mean length of hospitalization (61 vs 31 days) but no difference in discharge disposition. y Male. The number of patients who received a ventriculostomy in the operating room was so small that no conclusion can be made from this analysis.8 6. Many articles have been written regarding the rate of conversion from ventriculostomy to permanent shunt in patients with aneurysmal subarachnoid hemorrhage.8 37. motor vehicle collision. % Skull fracture.8 7. Our practice is to drain CSF from patients acutely at a pop-off of 10 cm water.3 61. the average duration of external ventricular drainage was 18. once the ICP normalizes.2 14. conditions in the operating room may offer superior sterility than the bedside in the NICU. MVC. only 3 had a ventriculostomy placed in the operating room. % Intraparenchymal hemorrhage. mean Injury severity score. an attempt is made to wean the ventriculostomy by requiring increased ICP before CSF drainage occurs.6 78. we try to decide to shunt or to remove the ventriculostomy after the ICP has stabilized at . but we believe that this information cannot be extrapolated to the TBI population. At our institution.3 P .8 68.3 9.7 18.04 . these data may not be applicable in all instances.4 37.20 CSF.40 41.3 7. . % Craniotomy. whereas 6 of the 15 patients who had replacement of the bone flap required a shunt.6 18.7 61.0 58.5 6. mean Intraventricular hemorrhage.15 It is routine practice for neurosurgeons to place an ICP monitoring device in a patient with a TBI if the patient has a poor neurological examination. Some authors have postulated that intraventricular hemorrhage increases the need for permanent NEUROSURGERY VOLUME 68 | NUMBER 1 | JANUARY 2011 | 87 Copyright © Congress of Neurological Surgeons.5 87. If the ICP climbs or if CSF output remains substantial. We also looked at patients who received a craniotomy within 48 hours of admission to see if leaving the bone flap off at the time of surgery increased the need for permanent CSF diversion. Of the 21 patients who had a craniotomy.SHUNT AFTER VENTRICULOSTOMY TABLE.19 .8 31. % Infection Hemorrhage Outcome Length of stay.3 31. and Outcome Characteristics According to Need for Permanent Cerebrospinal Fluid Diversiona Need for Permanent CSF Diversion Yes Demographic Age.8 83. Other groups have found a correlation between decompressive craniectomy and need for permanent CSF diversion. 7–28 days).3 7.8 12.0 12. a shunt is placed.3 31. % # 24 h . % MVC Fall Other Clinical Glasgow Coma Scale score.76 . Three of these 6 patients required a shunt. Because practice patterns vary for conversion from ventriculostomy to a shunt.11 A few studies have looked at the rate of hydrocephalus after TBI in an attempt to differentiate between hydrocephalus ex vacuo and communicating hydrocephalus.3 25.17-19 A future study is planned to evaluate more thoroughly the risk factors for permanent CSF diversion after TBI requiring ventriculostomy.13. This study did not specifically address this question because of the relatively low number of decompressive craniotomies performed at our institution.5 56. The neurological rehabilitation literature is flush with articles detailing patient outcome after mild or severe TBI.14 According to procedural data published by the American Association of Neurological Surgeons.2 7.2 32. 20 cm water.2-5.2 68. We also sought to determine whether placing the ventriculostomy in the operating room made a difference in the need for permanent CSF diversion. then. Subgroup analysis found no correlation between placement of the ventriculostomy in the operating room and the need for permanent CSF diversion. Demographic.3 6. The other 6 patients had ventriculostomy placed in the NICU. d Discharge disposition.3 20.0 7.6 7. DISCUSSION Ventriculostomy placement is an important diagnostic and therapeutic tool in the treatment of TBI.6 72. There was no statistically significant difference between these 2 groups.10. % Inpatient rehabilitation hospital Home Dead Nursing home Other a No 32.9 38. excluding 2 outliers with positive CSF cultures who had ventriculostomies for 54 and 100 days.03 .1 7. h Time to postprocedural imaging. 42 446 ICP monitoring procedures were performed during 2006.74 . cerebrospinal fluid.3 days (range.16 There is no published literature regarding the need for permanent CSF diversion in patients initially requiring ventriculostomy for poor neurological examination after TBI. Nine of 16 patients who underwent craniotomy eventually required a shunt.00 . Intuitively.03 1. Clinical. and further study of this question is warranted because infection plays a role in the eventual need for permanent CSF diversion.008 . Interestingly.3 .3 5.96 . 24 h Ventriculostomy complication. and of these 9 patients.05 . % Time to ventriculostomy. intraventricular hemorrhage was not a risk factor for permanent CSF diversion.8 68. mean.8 21.5 18. % Mechanism of injury. we weigh the infectious risk of keeping a ventriculostomy in for extended periods against the risks inherent in shunt placement.40 . mean. In general.0 6.72 .64 . Unauthorized reproduction of this article is prohibited. In this series. 6 had the bone flap removed at the time of surgery.0 50.

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