- Department of Neurosurgery, International University of Health and Welfare Narita Hospital, Narita, Chiba, Japan
- Department of Neurology, Imari Arita Kyoritsu Hospital, Arita, Saga, Japan
- Department of Neurosurgery, Imari Arita Kyoritsu Hospital, Arita, Saga, Japan
- Department of Neurosurgery, Shiroishi Kyoritsu Hospital, Shiroishi, Japan
Correspondence Address:
Tatsuya Tanaka, Department of Neurosurgery, International University of Health and Welfare Narita Hospital, Narita, Chiba, Japan.
DOI:10.25259/SNI_411_2024
Copyright: © 2024 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Tatsuya Tanaka1, Hirofumi Goto2, Nobuaki Momozaki3, Eiichiro Honda4, Eiichi Suehiro1, Akira Matsuno1. Optimizing shunt integrity during acute subdural hematoma evacuation. 27-Sep-2024;15:354
How to cite this URL: Tatsuya Tanaka1, Hirofumi Goto2, Nobuaki Momozaki3, Eiichiro Honda4, Eiichi Suehiro1, Akira Matsuno1. Optimizing shunt integrity during acute subdural hematoma evacuation. 27-Sep-2024;15:354. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=13113
Abstract
Background:Even mild head trauma can cause severe intracranial hemorrhage in patients with cerebrospinal fluid (CSF) shunts for hydrocephalus. CSF shunts are considered a risk factor for subdural hematoma (SDH). The management of acute SDH (ASDH) in shunted patients with normal pressure hydrocephalus can be challenging. Addressing the hematoma and the draining function of the shunt is important. To preserve the shunt, we set the shunt valve pressure to the highest and perform hematoma evacuation for ASDH. In this study, we report the surgical cases of ASDH in patients with shunts.
Methods:Between 2013 and 2019, five patients with ASDH and CSF shunts underwent hematoma evacuation at our hospital. We retrospectively analyzed data regarding their clinical and radiological presentation, hospitalization course, the use of antithrombotic medications, and response to different treatment regimens.
Results:The patients presented with scores of 5–14 in the Glasgow coma scale and severe neurological signs, consciousness disturbance, and hemiparesis. Most patients were elderly, taking antithrombotic medications (four of five cases), and had experienced falls (4 of 5 cases). All patients underwent hematoma evacuation following resetting their programmable shunt valves to their maximal pressure setting and shunt preservation. ASDH enlargement was observed in only one patient who underwent burr-hole drainage. Glasgow outcome scale scores at discharge were 1 and 3, respectively.
Conclusion:In hematoma evacuation, increasing the valve pressure may reduce the bleeding recurrence. To preserve the shunt, setting the shunt valve pressure to the highest level and performing endoscopic hematoma evacuation with a small craniotomy could be useful.
Keywords: Acute subdural hematoma, Intracranial pressure, Normal pressure hydrocephalus, Shunt, Traumatic brain injury
INTRODUCTION
Even mild head trauma can cause severe intracranial hemorrhage in patients with cerebrospinal fluid (CSF) shunts for hydrocephalus. CSF shunts are considered a risk factor for subdural hematoma (SDH), which can occur in 2–17% of patients with CSF shunts.[
The management of acute SDH (ASDH) in patients with shunted normal pressure hydrocephalus (NPH) can be challenging. If the hematoma volume is small, treating the shunt by increasing the valve pressure or ligating the shunt could reduce recurrent bleeding.[
To preserve the shunt, we set the shunt valve pressure to the highest and perform hematoma evacuation for ASDH. In this study, we report a series of surgical cases of five patients with ASDH occurring in shunt patients.
MATERIALS AND METHODS
We retrospectively reviewed the hospitalization records of patients with ASDH and CSF shunts who underwent hematoma evacuation surgery between 2013 and 2019.
Five patients with ASDH were identified and analyzed for the following details: age, sex, modified Ranking scale (mRS) score before onset, cause of hydrocephalus, pressure level of the shunt valve at the time of head trauma, and use of antiplatelet medications or anticoagulant medications before injury.
The interval until ASDH from CSF shunt, cause of head injury, Glasgow coma scale (GCS) score on admission, and neurological deficits were documented. The maximal width of the hematomas and midline shift were measured.
Treatments and their timing during hospitalization were recorded, including changes in the shunt valve pressure setting, shunt ligation or externalization, addition of shunt assist devices, surgical procedures for evacuation of the hematomas, operation duration, and measurement of intracranial pressure (ICP).
Outcomes included the length of hospitalization, and Glasgow outcome scale (GOS) scores at discharge. Furthermore, chronic SDH (CSDH) after the procedure and outcome-affecting complications were recorded.
RESULTS
The results are summarized in
Patient background
The average age at presentation was 84.4 years (range, 77–95 years). Of the patients, three were male, and two were female. Pre-trauma mRS scores were four in four patients and three in one patient. During their injuries, two were hospitalized, and three were in nursing homes.
All patients had ventriculoperitoneal shunt (VPS) or lumboperitoneal shunt inserted for 26.6 months (range, 5–96 months) before their current presentation. The cause of hydrocephalus was secondary in four cases and idiopathic in one case. Three types of shunt valves were used: CodmanHakim programmable valves with SiphonGuard (Codman, Raynham, Massachusetts) programed to 200 mmH2O (two cases), Polaris programmable valve (Sophysa Ltd, Orsay, France) programed to 110–150 mmH2O (two cases), and Strata valve (Medtronic Inc., Minneapolis, MN, USA) programed at 2.5 (one case).
Four patients received pretreatment with antiplatelet or anticoagulant medications. This included one patient on aspirin, one on clopidogrel, one on warfarin, and one on a combination of aspirin and warfarin.
Presentation on admission
Initial head computed tomography (CT) revealed ASDH in all cases. The hematomas were located on the left side in two cases, on the right side in two cases, and bilateral in one case. The causes of ASDH included falls in four patients and unknown in one patient. The patients’ preoperative GCS scores ranged from 5 to 14 (average, 9.8), and the symptoms included headache, vomiting, hemiparesis, and consciousness disturbances.
Hematomas were located on the shunt side in two patients. The average maximal hematoma width was 23.6 mm, ranging from 19 mm to 30 mm, and the average midline shift was 10.2 mm, ranging from 0 mm to 17 mm.
Treatment
All urgent surgeries for ASDH were performed with the shunt preserved. The pressure setting on the shunt valve was set to its maximal pressure before the evacuation of the hematoma. Two patients underwent small craniotomy and endoscopic hematoma evacuation for ASDH, one patient underwent craniotomy, another patient underwent large decompressive craniectomy, and the remaining patient underwent burr-hole evacuation followed by craniotomy on day 4. A drainage tube and an ICP sensor were inserted into the subdural space. The operation time was 32–202 min (average, 91.2 min). No increased ICP (<25 mmHg) was observed. One patient had clinical deterioration due to CSDH under conservative treatment and, thus, had the hematoma drained.
Outcome
The mean hospitalization period was 30–119 days (median, 38 days; average, 55.6 days). The GOS scores at discharge were three in four patients and one in one patient. Four patients were discharged to a rehabilitation hospital. Three patients presented with symptomatic cerebral infarction at the ASDH side, and one patient had a lower extremity embolism.
Illustrative cases
An 85-year-old female presented to our hospital with consciousness disorder after a fall at a nursing home. On admission, the patient’s level of consciousness was 9 points on the GCS. Initial head CT revealed an inserted VPS and a right ASDH without contusion or other intracranial hematomas [
Therefore, the shunt valve pressure was set to the maximum valve pressure of 200 mmH2O. To preserve the shunt catheter, a small craniotomy with endoscopy for ASDH was performed. A 10-cm linear skin incision was made parallel to the shunt catheter, and a small craniotomy with a diameter of 7 × 4 cm was performed [
DISCUSSION
Therapy for SDH in patients with shunts is extremely challenging due to heterogeneous treatment options, such as programmable shunt valve function restriction, shunt ligation, hematoma evacuation, and a combination of these techniques.
This study reports on five cases of ASDH in patients shunted for NPH. The typical patient is elderly, taking antithrombotic medication caused by a fall. The pressure of the shunt valve was consistently set to the highest level in all cases, and the patients with symptoms related to mass effect underwent urgent hematoma evacuation with a craniotomy.
In the literature, 12 cases have been reported regarding urgent surgical treatment of CSF shunt patients presenting with ASDH.[
Shunt management
Programmable shunt valves include a nonoperative treatment option for conservative management of ASDH in patients with ventricular shunts.[
This report suggests that increasing the shunt pressure settings prevents hematoma expansion even in ASDH, which requires emergency surgery. Thus, we recommend preserving the shunt function by increasing the shunt pressure settings.
ASDH treatment
The first choice of treatment for ASDH is a large craniotomy under general anesthesia. However, increasing age or the comorbid burden of patients may render invasive treatment strategies inappropriate. There have been increasing reports of the use of endoscopic hematoma evacuation for ASDH in the elderly.[
Treatment strategy for ASDH in shunt patients
Whenever possible, we recommend preserving the shunt function during ASDH treatment in patients with CSF shunts [
Limitation
The limitations of this study include the small number of cases and its retrospective design conducted at a single institution. Further, research with larger sample sizes and prospective randomized trials is necessary to establish the safety and efficacy of our treatment strategy.
CONCLUSION
ASDH in CSF shunt patients who required hematoma removal was common in the elderly, in those taking antithrombotic medications, and in those that were caused by falls.
To preserve the shunt, it may be useful to set the shunt valve pressure to the highest level and perform endoscopic hematoma evacuation with a small craniotomy.
Ethical approval
The authors declare that this work complies the guidelines for human studies, and the research was conducted ethicallly in accordance with the World Medical Association Declaration of Helsinki.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
References
1. Aoki N. Acute subdural hematoma of arterial origin in a patient with a lumboperitoneal shunt. Neurol Med Chir (Tokyo). 1987. 27: 60-2
2. Berger A, Constantini S, Ram Z, Roth J. Acute subdural hematomas in shunted normal-pressure hydrocephalus patients-Management options and literature review: A case-based series. Surg Neurol Int. 2018. 9: 238
3. Birkeland P, Lauritsen J, Poulsen FR. Aspirin is associated with an increased risk of subdural hematoma in normal-pressure hydrocephalus patients following shunt implantation. J Neurosurg. 2015. 123: 423-6
4. Feletti A, d’Avella D, Wikkelsø C, Klinge P, Hellström P, Tans J. Ventriculoperitoneal shunt complications in the European idiopathic normal pressure hydrocephalus multicenter study. Oper Neurosurg (Hagerstown). 2019. 17: 97-102
5. Goodwin CR, Kharkar S, Wang P, Pujari S, Rigamonti D, Williams MA. Evaluation and treatment of patients with suspected normal pressure hydrocephalus on long-term warfarin anticoagulation therapy. Neurosurgery. 2007. 60: 497-501
6. Hayes J, Roguski M, Riesenburger RI. Rapid resolution of an acute subdural hematoma by increasing the shunt valve pressure in a 63-year-old man with normal-pressure hydrocephalus with a ventriculoperitoneal shunt: A case report and literature review. J Med Case Rep. 2012. 6: 393
7. Hoya K, Tanaka Y, Uchida T, Takano I, Nagaishi M, Kowata K. Treatment of traumatic acute subdural hematoma in adult hydrocephalus patients with cerebrospinal fluid shunt. Clin Neurol Neurosurg. 2012. 114: 211-6
8. Huang PK, Sun YZ, Xie XL, Kang DZ, Zheng SF, Yao PS. Twist drill craniostomy for traumatic acute subdural hematoma in the elderly: Case series and literature review. Chin Neurosurg J. 2019. 5: 10
9. Ichimura S, Takahara K, Nakaya M, Yoshida K, Mochizuki Y, Fukuchi M. Neuroendoscopic hematoma removal with a small craniotomy for acute subdural hematoma. J Clin Neurosci. 2019. 61: 311-4
10. Kamiryo T, Hamada J, Fuwa I, Ushio Y. Acute subdural hematoma after lumboperitoneal shunt placement in patients with normal pressure hydrocephalus. Neurol Med Chir (Tokyo). 2003. 43: 197-200
11. Katsuki M, Kakizawa Y, Nishikawa A, Kunitoki K, Yamamoto Y, Wada N. Fifteen cases of endoscopic treatment of acute subdural hematoma with small craniotomy under local anesthesia: Endoscopic hematoma removal reduces the intraoperative bleeding amount and the operative time compared with craniotomy in patients aged 70 or older. Neurol Med Chir (Tokyo). 2020. 60: 439-49
12. Khan QU, Wharen RE, Grewal SS, Thomas CS, Deen HG, Reimer R. Overdrainage shunt complications in idiopathic normal-pressure hydrocephalus and lumbar puncture opening pressure. J Neurosurg. 2013. 119: 1498-502
13. Kon H, Saito A, Uchida H, Inoue M, Sasaki T, Nishijima M. Endoscopic surgery for traumatic acute subdural hematoma. Case Rep Neurol. 2013. 5: 208-13
14. Mahaney KB, Chalouhi N, Viljoen S, Smietana J, Kung DK, Jabbour P. Risk of hemorrhagic complication associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy. J Neurosurg. 2013. 119: 937-42
15. Miki K, Nonaka M, Kobayashi H, Horio Y, Abe H, Morishita T. Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience. Neurosurg Rev. 2021. 44: 1635-43
16. Sila D, Morsi K, Lenski M, Rath S. Intraoperative ventricular volume restoration by intraventricular Ringer solution injection in a normal-pressure hydrocephalus patient with traumatic bilateral acute subdural hematoma and ventricular system collapse caused by cerebrospinal fluid shunt overdrainage: Illustrative case. J Neurosurg Case Lessons. 2021. 1: CASE21188
17. Sundström N, Lagebrant M, Eklund A, Koskinen LD, Malm J. Subdural hematomas in 1846 patients with shunted idiopathic normal pressure hydrocephalus: Treatment and long-term survival. J Neurosurg. 2018. 129: 797-804
18. Tamaki N, Suyama T, Shirakuni T, Matsumoto S. Acute subdural hematoma of arterial origin following ventriculoperitoneal shunting--report of two cases. Neurol Med Chir (Tokyo). 1987. 27: 643-6
19. Tanaka T, Goto H, Momozaki N, Honda E. Endoscopic hematoma evacuation for acute subdural hematoma with improvement of the visibility of the subdural space and postoperative management using an intracranial pressure sensor. Surg Neurol Int. 2023. 14: 1
20. Yamada SM, Tomia Y, Murakami H, Nakane M. Management for traumatic chronic subdural hematoma patients with well-controlled shunt system for hydrocephalus. Clin Case Rep. 2015. 3: 548-50