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A Report of the Cooperative Aneurysm Study

Neill R. Graff-Radford, MB, BCh, MRCP; James Torner, PhD; Harold P. Adams, Jr, MD; Neal F. Kassell, MD

Arch Neurol. 1989;46(7):744-752.

Abstract
• Hydrocephalus is an important complication of subarachnoid hemorrhage (SAH). We analyzed several factors possibly related to hydrocephalus following SAH in 3521 patients from the International Study on the Timing of Aneurysm Surgery. Hydrocephalus was diagnosed on admission computed tomographic (CT) scans in 15% of patients and was thought to be clinically symptomatic in 13.2% of patients. There was a 5.9% overlap between these groups. Using contingency table analysis, we found the following were significantly related to clinical hydrocephalus: increasing age; preexisting hypertension; admission blood pressure measurements; postoperative hypertension; admission CT findings of intraventricular hemorrhage, a diffuse collection of subarachnoid blood, and a thick focal collection of subarachnoid blood; posterior circulation site of aneurysm; focal ischemic deficits; use of antifibrinolytic drugs preoperatively; hyponatremia; admission level of consciousness; and a low score on the Glasgow outcome scale. Using discriminate factor analysis to predict clinical hydrocephalus, the most important variables in order were the following: CT hydrocephalus, intraventricular hemorrhage, admission level of consciousness, presubarachnoid hypertension, increasing age, subarachnoid blood noted on CT scan, posterior circulation aneurysm site, and hypertension postoperatively (canonical correlation =.399). We conclude that the development of hydrocephalus after SAH is multifactorial. Factors that compromise cerebrospinal fluid circulation acutely (eg, intraventricular hemorrhage, hemorrhage from a posterior circulation site of aneurysm, and diffuse spread of subarachnoid blood) contribute to the development of acute hydrocephalus. These same factors, plus the use of antifibrinolytic drugs preoperatively, are also important in the pathogenesis of clinical hydrocephalus, perhaps by promoting subarachnoid fibrosis. Older patients, those with preexisting hypertension, hypertension on admission, and hypertension post-operatively, and those who develop focal ischemic deficits or have hyponatremia are all more likely to have acute and clinical hydrocephalus. Patients with hydrocephalus following SAH have a worse prognosis.

Author Affiliations
From the Department of Neurology, University of Iowa College of Medicine, Iowa City (Drs Graff-Radford and Adams), and Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville (Drs Torner and Kassell).

Footnotes
Accepted for publication March 8, 1989.

Reprint requests to Department of Neurology, University of Iowa Hospital and Clinics, Iowa City, IA 52242 (Dr Graff-Radford).

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