Complications in Patients Undergoing Microsurgical Clipping of Intracranial Aneurysms with Pre-existing Ventriculoperitoneal Shunts Following a Cranial Procedure
Introduction
Ventricular shunting is a routine neurosurgical procedure for conditions that require cerebrospinal fluid (CSF) diversion, including congenital hydrocephalus, normal pressure hydrocephalus, pseudotumor cerebri, and acquired hydrocephalus, secondary to conditions such as subarachnoid hemorrhage (SAH), trauma, infection, and mass occupying lesions.1, 2 The most common type of ventricular shunt placed is a ventriculoperitoneal (VP) shunt. Although commonly performed, VP shunting is not without complications. In fact, single-center studies investigating shunt-related complications have reported a major complication rate of 17.1%, overall complication rate of 58%, and shunt reoperation rates ranging from 17% to 69%.3, 4, 5 Examples of complications include intracerebral hemorrhage, mechanical dysfunction, and shunt infection.
VP shunt-related CSF diversion alters pressure and fluid dynamics within the brain.6, 7, 8 These alterations have the potential to complicate future cranial operations, a not uncommon occurrence for patients harboring vascular or tumor-associated pathologies. We postulated that the alteration of pressure and fluid dynamics from CSF diversion could potentially put patients undergoing subsequent cranial operations at higher risk of complications.
The purpose of this study was to determine whether patients with VP shunts are at increased risk of complications in subsequent neurosurgical cranial operations. To standardize the cohort, we chose to examine patients whose initial cranial operation was for the management of a cerebral aneurysm. We hypothesized that such patients may be at an increased risk of developing symptomatic hemorrhages, hygromas, or infections due to enlargement of epidural and subdural potential spaces initially created during the cranial procedure.9
Section snippets
Study Design
We performed a retrospective cohort study of all patients undergoing a cranial operation for management of cerebral aneurysms. Patient medical record numbers were collected through the University of Michigan Data Office for Clinical and Translational Research. Approval for this study was obtained from the University of Michigan Institutional Review Board.
Patient Selection
Adult patients (≥18 years old) who presented for cerebral aneurysm clipping from January 1, 2005 through December 31, 2014 with Current
Results
Of the 818 patients who underwent cranial operations for aneurysm clipping, 71.8% were females and the average age was 52.7 ± 10.8 years old. Twenty-eight (3.4%) of the patients with a cranial procedure had a VP shunt already in place at the time of their cranial operation. Over 98% of clipped aneurysms were anterior circulation aneurysms; aneurysm location was not associated with the presence of a postoperative complication. Additional demographic and clinical data are given in Table 1.
In
Discussion
The placement of a VP shunt is a common neurosurgical procedure for the treatment of hydrocephalus and other CSF-related pathologies. Placement of a VP shunt has been shown to alter intracranial fluid dynamics, leading to potential collections within the epidural and subdural spaces.11 When comparing outcomes for cranial operations in patients with and without a previously placed VP shunt, we demonstrate a nonsignificant trend toward increased postoperative complications in shunted patients
Conclusion
We found a nonsignificant trend toward an increase in postoperative complications in patients with a VP shunt who underwent subsequent cranial procedures when compared to patients without a VP shunt.
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