Early Ventriculo-peritoneal Shunt in Subarachnoid Patients With External Ventricular Drainage
Early Ventriculo-peritoneal Shunt in Subarachnoid Patients With External Ventricular Drainage
Acute hydrocephalus is a common complication following subarachnoid hemorrhage (SAH). Early
 and emergency insertion of external ventricular drain (EVD) is standard treatment of acute
 post-SAH hydrocephalus. According to the high risk of infection associated with EVD, the
 study evaluates the outcome of early EVD conversion to ventriculoperitoneal shunt (VPS) in
 poor-grade SAH patients.
This study was performed on patients diagnosed with high grade SAH (WFNS 4-5) who undergo EVD
 within 24 hours of their admission. The conversion of EVD to VPS is performed within 7-10
 days of EVD insertion, defined as early VPS group. The ventricular catheter is inserted in
 lateral ventricle using the same burr hole of EVD or the contralateral Kocher's point. All
 ruptured aneurysms could be closed by endovascular techniques or surgery.

 The goal is to discontinuing EVD or its conversion to VPS within 7 to 10 days of insertion.
 At day 5-7 of EVD insertion, the EVD level is elevated from 15 cmH2O to 25 centimeter of
 water (cmH2O) gradually. The patients is evaluated during the 48 hours for cerebrospinal
 fluid (CSF) volume discharge, neurological consciousness, and hydrocephalus within brain CT
 scan acquired at the end of 48 hours of observation. If the daily CSF fluid discharge will be
 greater than 100 ml, brain CT scan shows evidence of HCP, there is any CSF leak from around
 the catheter, or the patient experiences GCS drop for 2 points or more, EVD is converted to
 VPS.

 EVD conversion to VPS is postponed if there is any evidence of CSF infection within the last
 CSF analysis obtained 48 hours before VPS placement, patient experiences fever (>38.5° C)
 without any other source, or there is any evidence of severe vasospasm in transcranial
 Doppler (TCD) imaging or brain CT angiography. Otherwise, The EVD is discontinued.

 For all patients, a brain CT scan is taken to evaluate the location of shunt 24 hours after
 VPS placement. Forty-eight hours after VPS placement, lumbar puncture (LP) is performed to
 collect CSF for ruling out the possibility of shunt infection or ventriculitis. Shunt
 malfunction (approved by imaging or signs of HCP) is reported if it occurred within 3 months
 of VPS placement.

 When VPS malfunction is diagnosed it is revised. CSF infection is considered if there is a
 positive culture or ratio of CSF white blood cell count (WBC)/ red blood cell count (RBC) to
 blood WBC/RBC was more than 3. All patients is evaluated for clinical condition using
 modified Rankin scale (mRs) at discharge and 6 months later.
Inclusion Criteria:

 -  patients with SAH and World Federation of Neurosurgeon (WFNS) Grade 4 or 5 and

 -  patient who underwent ventriculostomy (EVD insertion) within 24 hours of SAH onset.

 Exclusion Criteria:

 -  patients with Glasgow Coma Scale of (GCS) 3 and fixed non-reactive pupils,

 -  patients in whom EVD was inserted in the other hospital,

 -  patients were successfully weaned from EVD with 7-10 days of EVD insertion

 -  patients who died during hospitalization.