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Abstract BACKGROUND: Acute hydrocephalus is a well-known sequela of aneurysmal subarachnoid hemorrhage (SAH). Controversy exists about whether open microsurgical methods serve to reduce shunt dependency compared with endovascular techniques. OBJECTIVE: To determine predictors of shunt-dependent hydrocephalus and functional outcomes after aneurysmal SAH. METHODS: A total of 471 patients who were part of a prospective, randomized, controlled trial from 2003 to 2007 were retrospectively reviewed. All variables including demographic data, medical history, treatment, imaging, and functional outcomes were included as part of the trial. No additional variables were retrospectively collected. RESULTS: Ultimately, 147 patients (31.2%) required a ventriculoperitoneal shunt (VPS) in our series. Age, dissecting aneurysm type, ruptured vertebrobasilar aneurysm, Fisher grade, Hunt and Hess grade, admission intraventricular hemorrhage, admission intraparenchymal hemorrhage, blood in the fourth ventricle on admission, perioperative ventriculostomy, and hemicraniectomy were significant risk factors (P < .05) associated with shunt-dependent hydrocephalus on univariate analysis. On multivariate analysis, intraventricular hemorrhage and intraparenchymal hemorrhage were independent risk factors for shunt dependency (P < .05). Clipping vs coiling treatment was not statistically associated with VPS after SAH on both univariate and multivariate analyses. Patients who did not receive a VPS at discharge had higher Glasgow Outcome Scale and Barthel Index scores and were more likely to be functionally independent and to return to work 72 months after surgery (P < .05). CONCLUSION: There is no difference in shunt dependency after SAH among patients treated by endovascular or microsurgical means. Patients in whom shunt-dependent hydrocephalus does not develop after SAH tend to have improved long-term functional outcomes.

BACKGROUND:Acute hydrocephalus is a well-known sequela of aneurysmal subarachnoid hemorrhage (SAH). Controversy exists about whether open microsurgical methods serve to reduce shunt dependency compared with endovascular techniques. OBJECTIVE:To determine predictors of shunt-dependent hydrocephalus and functional outcomes after aneurysmal SAH. METHODS:A total of 471 patients who were part of a prospective, randomized, controlled trial from 2003 to 2007 were retrospectively reviewed. All variables including demographic data, medical history, treatment, imaging, and functional outcomes were included as part of the trial. No additional variables were retrospectively collected. RESULTS:Ultimately, 147 patients (31.2%) required a ventriculoperitoneal shunt (VPS) in our series. Age, dissecting aneurysm type, ruptured vertebrobasilar aneurysm, Fisher grade, Hunt and Hess grade, admission intraventricular hemorrhage, admission intraparenchymal hemorrhage, blood in the fourth ventricle on admission, perioperative ventriculostomy, and hemicraniectomy were significant risk factors (P < .05) associated with shunt-dependent hydrocephalus on univariate analysis. On multivariate analysis, intraventricular hemorrhage and intraparenchymal hemorrhage were independent risk factors for shunt dependency (P < .05). Clipping vs coiling treatment was not statistically associated with VPS after SAH on both univariate and multivariate analyses. Patients who did not receive a VPS at discharge had higher Glasgow Outcome Scale and Barthel Index scores and were more likely to be functionally independent and to return to work 72 months after surgery (P < .05). CONCLUSION:There is no difference in shunt dependency after SAH among patients treated by endovascular or microsurgical means. Patients in whom shunt-dependent hydrocephalus does not develop after SAH tend to have improved long-term functional outcomes. ABBREVIATIONS:aSAH, aneurysmal subarachnoid hemorrhageBRAT, Barrow Ruptured Aneurysm TrialGOS, Glasgow Outcome ScaleSAH, subarachnoid hemorrhageVPS, ventriculoperitoneal shunt

The gunshot wound to the head (GSWH) is associated with a mortality rate of 20–90% in adults and 20–65% in the pediatric population. Due to the high rates of mortality and morbidity, the management of these patients has been a topic of high interest in the neurosurgical community. We present an 18-year-old male suffering a GSWH with the bullet following a transventricular trajectory and crossing the midsagittal plane, creating extensive intracranial injuries. Despite a calculated mortality rate of >97% from these devastating injuries, the patient survived the GSWH and made a remarkable recovery. The young adult brain still maintains a high potential for neurological plasticity. This may partially explain why the young adult population with a severe GSWH can have a better than expected recovery course. Bifrontal GSW injuries may have much better outcomes than more posterior injuries as has been demonstrated in this patient in this case.

New radiation delivery modalities have recently challenged Gamma Knife surgery as the historic gold standard in the treatment of trigeminal neuralgia (TN). TomoTherapy, a relative newcomer, has been approved by the U.S. FDA for various intracranial pathologies but is currently off label for the treatment of TN. A 73-year-old female presented with gait instability, intermittent headaches, and confusion. She was treated with TomoTherapy for refractory TN at an outside facility, which failed to reduce her symptoms. Magnetic resonance imaging demonstrated a lesion in the right mesial temporal lobe. A standard right anterior temporal lobectomy was performed and the final pathological report was notable for necrosis, gliosis, and edema consistent with a remote radiation injury. The patient improved postoperatively, but at her two-year follow up, she continued to have persistent bilateral TN and new onset seizures. Imaging revealed no new mass in the resection field. Stereotactic radiosurgery (SRS) is an evolving field with broadening indications, which makes it ever more important for physicians to be aware of differences between various SRS modalities. This case report highlights a cautionary example, and emphasizes the need for a more systematic evaluation of novel SRS methods before clinical application.

The gunshot wound to the head (GSWH) is associated with a mortality rate of 20-90% in adults and 20-65% in the pediatric population. Due to the high rates of mortality and morbidity, the management of these patients has been a topic of high interest in the neurosurgical community. We present an 18-year-old male suffering a GSWH with the bullet following a transventricular trajectory and crossing the midsagittal plane, creating extensive intracranial injuries. Despite a calculated mortality rate of >97% from these devastating injuries, the patient survived the GSWH and made a remarkable recovery. The young adult brain still maintains a high potential for neurological plasticity. This may partially explain why the young adult population with a severe GSWH can have a better than expected recovery course. Bifrontal GSW injuries may have much better outcomes than more posterior injuries as has been demonstrated in this patient in this case.