Background: Intraventricular hemorrhage requiring ventriculostomy (EVD) placement is a frequent complication of spontaneous intracerebral hemorrhage (ICH). Urgent EVD may be warranted for management of acute hydrocephalus, and a subset of these patients will require permanent ventricular shunt (VS) placement. In contrast to hydrocephalus following sub-arachnoid hemorrhage, less is known about the frequency and timing of EVD and VS placement after ICH.
Methods: Using the 2010-2012 National Inpatient Sample, we selected patients with ICD-9 codes for ICH, excluded secondary causes, and examined procedure dates for EVD and VS placement.
Results: Of 35,991 primary ICH patients, 2,392 (6.7%) received an EVD, 89% within the first 3 days of admission and 64% within the first day. Placement of a VS occurred in 268 patients (0.7%) overall. VS placement occurred in 143 of 2,129 (6.7%) of those receiving an EVD in the first 72 hours and 34 of 263 (12.9%) receiving an EVD after 72 hours (p<0.001). Median time to shunt placement following EVD was 15 days (IQR 11-21) vs 16.5 (IQR 13-21) for those with EVD within vs after 72 hours (p=0.2). 82 (0.2%) received a VS without an initial EVD at a median of 14 days (IQR 9-18). Kaplan-Meier analysis revealed that among those remaining alive and in hospital at 14 and 21 days, 5% and 11%, respectively, underwent shunt placement following EVD.
To analyze the effect of VS timing following EVD, we compared those undergoing VS in the first two weeks versus later than two weeks. Following multivariate logistic regression, only age 70 -80 was associated with early shunt placement (OR 4.8, 95%CI 1.2-19). No effect on mortality or rate of home discharge was seen. Length of stay was shorter in those with early versus later VS (20 vs 32 days, p<0.001)
Conclusion: Persistent hydrocephalus following EVD placement for ICH is rare overall but VS is required in up to 12% of a subset of patients. EVD placement after the initial 72 hours was associated with an increased rate of VS, while older age was associated with earlier VS placement after EVD. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.