190

Treatment of Acute Hydrocephalus After

Subarachnoid Hemorrhage With
Serial Lumbar Puncture
Djo Hasan, MD; Kenneth W. Lindsay, PhD, FRCS; and Marinus Vermeulen, MD

Computed tomography demonstrated acute hydrocephalus 72 hours after subarachnoid

hemorrhage in 24 (23%) of 104 patients. Of these 24 patients, six (25%) had no impairment of
consciousness. In nine (11%) of the remaining 80 patients, acute hydrocephalus developed
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within 1 week after subarachnoid hemorrhage. With the exception of three patients, all 104
patients received antifibrinolytic treatment Delayed clinical deterioration from acute hydro-
cephalus occurred in seven (29%) of the 24 patients with acute hydrocephalus on admission and
in six (8%) of the remaining 80 patients. Serial lumbar puncture was performed in 17 patients.
Twelve (71%) of the 17 patients treated with serial lumbar puncture, including 10 (77%) of the
13 patients with delayed deterioration from acute hydrocephalus after admission, achieved
improvement in the level of consciousness. Four of these 17 patients (4% of all 104 patients)
required an internal shunt. No patient deteriorated from coning following serial lumbar
puncture. The rebleeding rate within 12 days after subarachnoid hemorrhage in hydrocephalic
patients with serial lumbar puncture was not higher than the rate in those without hydroceph-
alus (two [12%] of 17 versus nine [13%] of 71). Neither meningitis nor ventriculitis was
observed. We conclude that if neither a hematoma with a mass effect nor an obstructive element
exists, cerebrospinal fluid drainage with serial lumbar puncture is a good alternative to
ventricular drainage in patients with acute hydrocephalus after subarachnoid hemorrhage.
(Stroke 1991^2:190-194)

A cute hydrocephalus is a frequent complication

following subarachnoid hemorrhage.1-2 In a
series of 473 patients with subarachnoid
hemorrhage admitted ^72 hours after the initial hem-
orrhage, hydrocephalus, defined as a bicaudate index
on a computed tomogram (CT scan) exceeding the
95th percentile for age, occurred in 20%.2 Manage-
ment of these patients presents problems. Not all
patients with acute hydrocephalus and a decreased
level of consciousness on admission require treatment,
and approximately 40% improve spontaneously within
24 hours.2 However, in some patients a delay in
reducing the high intracranial pressure could produce
deleterious effects, resulting in irreversible brain dam-
age or death from cerebral ischemia.1 On the other
hand, external ventricular drainage carries a risk of
ventriculitis and rebleeding2 although in a recent
editorial Heros3 recommended "immediate ventricu-
From the Department of Neurology (D.H., M.V.), University
Hospital Dijkzigt, Rotterdam, The Netherlands, and the Institute
of Neurological Sciences (K.W.L.), Southern General Hospital,
Glasgow, Scotland.
Address for correspondence: Djo Hasan, Department of Neu-
rology, University Hospital Dijkzigt Rotterdam, 40 Dr Molewater-
plein, 3015 GD Rotterdam, The Netherlands.
Received March 22, 1990; accepted October 4, 1990.
lar drainage" in patients with significant hydrocepha-
lus and a decreased level of consciousness. Serial
lumbar puncture provides an alternative and simpler
approach.4'5 We investigated the effectiveness of serial
lumbar puncture in restoring the level of conscious-
ness in patients with acute hydrocephalus and as-
sessed the complications of this treatment.
Subjects and Methods
We entered 104 consecutive patients with sub-
arachnoid hemorrhage admitted <, 72 hours after the
initial hemorrhage into this study. Twenty-six pa-
tients were admitted to the Department of Neuro-
surgery of the Royal Free Hospital, London and the
other 78 to the Department of Neurology of the
University Hospital Dijkzigt, Rotterdam. All patients
had clinical signs of subarachnoid hemorrhage and
abnormalities suggesting a ruptured aneurysm on a
CT scan.6 Patients with a perimesencephalic hemor-
rhage7 or a negative angiogram and patients who
were moribund on admission were excluded.
Events were prospectively recorded during 28 days
after the initial subarachnoid hemorrhage or until
death or surgical treatment of the aneurysm. An
initial CT examination was carried out on admission,

and CT was repeated after any clinical deterioration.
The amount of cisternal blood on the initial CT scan
was graded on a scale of 0 to 3 separately for each of
the 10 cisterns (maximum score of 30).8-9 Similarly,
the amount of intraventricular blood was graded
separately for each of the four ventricles (maximum
score of 12).8-9 Because an intraventricular score of 1
reflects sedimentation of blood in the ventricle, we
defined intraventricular blood to be present if at least
one of the four ventricles had a score of >1. We
assessed the level of consciousness with the 14-point
Glasgow Coma Scale (GCS).10'11 A decreased level of
consciousness was defined as a reduction of at least 1
point in the motor or verbal score on the GCS. We
defined events as probable delayed cerebral isch-
emia: gradual development of focal neurologic signs,
with or without deterioration in the level of con-
sciousness, without confirmation by CT or autopsy;
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definite delayed cerebral ischemia: deterioration in
the level of consciousness or development of focal
signs, or both, with CT or autopsy confirmation of
cerebral infarction; probable rebleeding: sudden de-
terioration and death, without the possibility of proof
by CT or if autopsy was refused; definite rebleeding:
sudden deterioration with an increased amount of
blood on a repeat CT scan or at autopsy compared
with a previous CT scan; and acute hydrocephalus:
increase in the bicaudate index beyond the upper
limit (95th percentile for age) measured on the initial
CT scan or on a CT scan repeated : 1 week after the
initial subarachnoid hemorrhage.1'2 The upper limits
were <36 years of age, 0.16; 36-45 years, 0.17; 46-55
years, 0.18; 56-65 years, 0.19; 66-75 years, 0.20; and
76-85 years, 0.21.iAi2,i3 Deterioration from hydro-
cephalus was defined as deterioration in the level of
consciousness with no detectable cause other than
hydrocephalus, confirmed by repeat CT.
Serial lumbar puncture was performed when acute
hydrocephalus appeared to cause impairment of con-
sciousness in the absence of a hematoma with a mass
effect and provided that blood did not completely fill
the third or fourth ventricle, obstructing the ventricle
system.14 If such an obstructing element exists, lum-
bar puncture is contraindicated and ventricular
drainage should be performed. Each time a maxi-
mum of approximately 20 ml cerebrospinal fluid
(CSF) was removed, we aimed at a closing pressure
of 15 cm H2O.
Of the 104 patients, 101 received tranexamic acid.
Fluid intake was maintained at 3 I/day in all patients;
fluid restriction and diuretic medication after admis-
sion were avoided. Patients receiving antihypertensive
therapy on admission continued to receive treatment;
otherwise none was given. Cerebral angiography and
aneurysm operation were performed according to the
patient's clinical condition. Aneurysm operation was
usually planned between days 7 and 10 in London and
on day 12 in Rotterdam. All survivors were followed
up at 3 months and graded according to the five-point
Glasgow Outcome Scale.15
Hasan et al Serial Lumbar Puncture After SAH 191
The fourfold tables were analyzed with the two-
sided Fisher's exact probability test.
Results
Measurement of the initial CT scan indicated
acute hydrocephalus in 24 (23%) of the 104 patients.
Of these 24 patients, six (25%) had no impairment of
consciousness on admission (a total score on the GCS
of 14), five (21%) had a GCS score of 13, and the
remaining 13 (54%) had a GCS score of <13. In
another nine patients (11% of the 80 patients without
hydrocephalus on admission), repeat CT l week
after the initial hemorrhage demonstrated delayed
ventricular enlargement.
Patients with acute hydrocephalus had a higher
incidence of impaired consciousness on admission, a
higher score for cistemal blood, and a higher fre-
quency of ventricular blood than those with normal-
sized ventricles (Table 1). Clinical deterioration oc-
curred after admission in seven (29%) of the 24
patients with acute hydrocephalus on the initial CT
scan and in six of the nine patients who had delayed
ventricular enlargement (i.e., in 8% of the 80 patients
without acute hydrocephalus on the initial CT scan).
Serial lumbar puncture was performed in 17 pa-
tients, immediately in five of them because they had
a decreased level of consciousness on admission. In
the remaining 13 of the total 18 hydrocephalic pa-
tients with a decreased level of consciousness on
admission (GCS score of < 14), lumbar puncture was
not performed. Six of the 13 improved spontaneously
after admission; in four patients there was doubt as
to whether the decreased level of consciousness was
caused by hydrocephalus, and three patients died
<24 hours after admission, one with a massive ven-
tricular clot and two with early rebleeding. One of
these latter two patients had a hematoma with a mass
effect. In the remaining 12 of the 17 patients who
underwent serial lumbar puncture, this treatment
was started ^ 1 week after admission. In 11 of these
12 patients without a decreased level of conscious-
ness on admission, lumbar puncture was not per-
formed until clinical deterioration from acute hydro-
cephalus had developed. The twelfth patient had
hydrocephalus and a decreased level of conscious-
ness on admission, but lumbar puncture was delayed
because of fluctuation in the level of consciousness.
Figure 1 summarizes the period during which lumbar
punctures were required and the number of punc-
tures performed in each patient.
If analysis is restricted to the 13 patients who
showed clinical deterioration from acute hydrocepha-
lus, serial lumbar puncture improved the level of
consciousness in 10 (77%). If analysis includes all 17
patients who underwent lumbar puncture, the level of
consciousness improved in 12 (71%) (within 1 day in
10 patients and within 6 days in two); six patients
recovered fully (GCS score of 14) and the other six did
not improve beyond a GCS score of 13 (disoriented).
In two of these latter six patients, an internal shunt
was inserted, followed by sustained improvement in
 192 Stroke Vol 22, No 2, February 1991

TABLE 1. Entry CharacttrisHcs of 104 Patients With Aneurjsmal Subarachnoid Hemorrhage by Presence of Acute
Hydrocephalns and by Treatment With Serial Lumbar Puncture
Serial lumbar puncture
No Yes
No hydrocephalus Hydrocephalus Hydrocephalus
(n=71) (n=16) (n=17)
Characteristic No. % No. % No. %
GCS on admission
S12 20 28 8 50 9 53
13 16 23 2 13 5 29
14 35 49 6 38 3 18
Cistemal blood
0-6 11 15 2 13 1 6
7-12 10 14 2 13 1 6
13-18 26 37 7 44 6 35
19-24 14 20 2 13 5 29
25-30 6 8 3 19 4 24
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Not scored 4 6 0 0 0 0
Ventricular blood 7 10 7 44 7 41
GCS, total score on 14-point Glasgow Coma Scale.

the level of consciousness (GCS score of 14), and the
remaining four patients died of other complications
several days after serial lumbar puncture was started.
In five (29%) of the 17 patients, serial lumbar punc-
ture had no effect; two of these patients received an
internal shunt followed by sustained improvement
period of LP's required (days) number of LP's
25 r
20
15
10
FIGURE 1. Scatter plot of period during which lumbar
punctures (LP's) were required (left) and number of LP's
performed (right) in each patient.
(GCS score of 14), and the other three patients died of
other complications several days after the commence-
ment of serial lumbar puncture. In summary, four
(12%) of the 33 patients with acute hydrocephalus
received an internal shunt (4% of all patients). No
patient who underwent serial lumbar puncture or who
received an internal shunt developed clinical signs of
meningitis or ventriculitis. Although five patients
failed to improve after lumbar puncture, none deteri-
orated from transtentorial herniation during the days
following serial lumbar puncture.
Analysis of probable and definite rebleeding was
restricted to the first 12 days. The incidence of
rebleeding in hydrocephalic patients treated with
serial lumbar puncture was not higher than that in
patients without acute hydrocephalus (two [12%] of
17 versus nine [13%] of 71 patients, Table 2). Re-
bleeding occurred more frequently in hydrocephalic
patients who were not treated with serial lumbar
puncture than in those without acute hydrocephalus
(Table 2), but this difference was not significant
(p=0.999).
The incidence of definite and probable cerebral
ischemia in patients with acute hydrocephalus was no
higher than that in those without hydrocephalus (9
[27%] of 33 versus 22 [31%] of 71 patients). The
frequency of cerebral ischemia in hydrocephalic pa-
tients treated with serial lumbar puncture was similar
to that of patients without acute hydrocephalus (6
[35%] of 17 versus 22 [31%] of 71 patients, Table 2).
Cerebral ischemia in patients with acute hydroceph-
alus treated with serial lumbar puncture was more
often fatal (four [67%] of six patients) than in
patients without hydrocephalus (seven [32%] of 22
patients), but the number of patients was small and
the difference was not significant (p=0.141).
 Hasan et al Serial Lumbar Puncture After SAH 193

TABLE 2. Rebleeding and Cerebral Ischemia in Relation to Acute Hydrocephalus and Serial Lumbar Puncture in 104
Patients With Aneurysmal Subarachnoid Hemorrhage
Serial lumbar puncture
No Yes
No hydrocephaJus Hydrocephalus Hydrocephalus
(=71) (n = 16) (n = 17)
No. % No. % No. %
Rebleeding by day 12 9 13 4 25 2 12
Cerebral ischemia 22 31 3 19 6 35
Definite and probable events.

Only 24% of the hydrocephalic patients (compared
with 62% of those without acute hydrocephalus) had
their aneurysms clipped by day 28. The proportion
with independent outcome at 3 months in patients
without acute hydrocephalus was significantly higher
than that in hydrocephalic patients treated with
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is not feasible. It is likely that serial lumbar puncture
is carried out more readily and with less delay than is
external ventricular drainage in hydrocephalic pa-
tients with an impaired level of consciousness, but it
is also likely that some of these patients might have
improved spontaneously if treatment had been de-

serial lumbar puncture (/>=0.033, Table 3). layed. However, the beneficial effect of lumbar punc-
ture cannot be attributed to spontaneous improve-
Discussion ment in all patients since progressive deterioration in
In patients with a hematoma occluding the third, the level of consciousness from acute hydrocephalus
fourth, or lateral ventricles, an obstructive element halted and improved in 77% of the patients shortly
exists, contraindicating lumbar puncture and making after lumbar puncture.
ventricular drainage necessary. In our series of 104 In the series of patients treated with ventricular
consecutive patients with aneurysmal subarachnoid drainage, the risk of rebleeding was significantly
hemorrhage, serial lumbar puncture performed in 17 increased during the first 12 days.2 Several factors
with acute hydrocephalus resulted in an improve- may play a role: rapid decreases in CSF pressure and
ment in the level of consciousness in 12 (71%). Half ventricular size may displace the aneurysm clot;
of the patients recovered fully and the other half insertion of the ventricular catheter may induce
improved, but not beyond a GCS score of 13. Of all intracranial fibrinolytic activity, resulting in lysis of
104 patients, only 4% required internal shunting. the aneurysm clot; and there maybe a difference in
The frequency of acute hydrocephalus in this se- neurologic grade between the treated and the un-
ries matches that in other recent studies.116 The treated groups.3-17-18 On the other hand, in a large
extent to which acute hydrocephalus on admission series of patients in which the occurrence of rebleed-
affected the level of consciousness closely approxi- ing was studied prospectively with clearly defined
mated that of a previous series.2 The proportion of criteria, no association between rebleeding and the
patients with acute hydrocephalus who improved initial condition could be demonstrated.19 We ob-
after lumbar puncture is similar to that in previous served no such difference in the rebleeding rate
series who improved after ventricular drainage.2 A between patients who underwent lumbar puncture
direct comparison of treatment with external ventric- and those who did not. A possible explanation for
ular drainage versus treatment with lumbar puncture this is that the drop in CSF pressure after lumbar
puncture is more gradual than that after insertion of
TABLE 3. Outcome in 104 Patients With Aneurysmal Subarach-
a ventricular catheter or that lumbar puncture does
noid Hemorrhage Related to Acute Hydrocephalus and Treatment not induce intracranial fibrinolytic activity. However,
With Serial Lumbar Puncture this cannot be concluded with certainty since there is
Serial lumbar puncture an important difference between this study and the
previous study.2 In the previous study analysis of
No Yes
patients treated with ventricular drainage was re-
No hydro- Hydro- Hydro- stricted to those not receiving antifibrinolytic treat-
cephalus cephalus cephalus ment, whereas in this study nearly all patients re-
(n-71)
ceived tranexamic acid.
Outcome No. % No. % No. %
A high CSF pressure in patients with acute hydro-
Dead 21 30 8 50 10 59 cephalus after subarachnoid hemorrhage may reduce
Dependent 7 10 0 0 2 12 cerebral perfusion and theoretically contribute to
Independent 42 59< 8 SOt 5 29 ischemic complications. Continuous ventricular
Missing 1 1 0 0 0 0 drainage should ensure a constant reduction in CSF
*tp=0.033, 0.296, respectively, different from hydrocephalic
pressure, even though the small defect in the dura
patients treated with serial lumbar puncture by Fisher's enact after lumbar puncture may not be large enough to
probability test. prevent fluctuations in CSF pressure. However, in
 194 Stroke Vol 22, No 2, February 1991
this series, the incidence of cerebral ischemia was not
different between patients with and without acute
hydrocephalus despite a higher rate of risk factors for
cerebral ischemia in the former group.1920 On the
other hand, when cerebral ischemia did develop, it
was more often fatal among patients with acute
hydrocephalus.1
In conclusion, ventricular drainage produces a
significant risk of ventriculitis and may increase the
risk of rebleeding.2 In contrast, none of our patients
developed ventriculitis or meningitis and the inci-
dence of rebleeding was not increased after serial
lumbar puncture. No patient deteriorated from con-
ing resulting from lumbar puncture. Serial lumbar
puncture is therefore a simple, safe, and effective way
of treating acute hydrocephalus. This "conservative"
treatment readily identifies those patients in whom
the hydrocephalus will spontaneously regress and
those who will require an internal shunt.
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Acknowledgments
We thank Dr. R.S. Maurice-Williams for allowing
his patients to be included in this study and Betty
Mast for her excellent secretarial help.
References
1. Van Gijn J, Hijdra A, Wijdicks EFM, Vermeulen M, van
Crevel H: Acute hydrocephalus after aneurysmal subarach-
noid hemorrhage. J Neurosurg 1985;63:355-362
2. Hasan D, Vermeulen M, Wijdicks EFM, Hijdra A, van Gijn J:
Management problems in acute hydrocephalus after subarach-
noid hemorrhage. Stroke 1989;20:747-753
3. Heros RC: Acute hydrocephalus after subarachnoid hemor-
rhage. Stroke 1989;20:715-717
4. Foltz EL, Ward AA Jr: Communicating hydrocephalus from
subarachnoid hemorrhage. J Neurosurg 1956;13:546-566
5. Raimondi AJ, Torres H: Acute hydrocephalus as a complica-
tion of subarachnoid hemorrhage. Surg Neurol 1973;l:23-26
6. Van Gijn J, van Dongen KJ: Computerized tomography in
subarachnoid hemorrhage: Difference between patients with
and without an aneurysm on angiography. Neurology 1980;30:
538-539
7. Van Gijn J, van Dongen KJ, Vermeulen M, Hijdra A: Peri-
mesencephalic hemorrhage: A nonaneurysmal and benign form
of subarachnoid hemorrhage. Neurology 1985;35:493-497
8. Hasan D, Vermeulen M, Wijdicks EFM, Hijdra A, van Gijn J:
Effect of fluid intake and antihypertensive treatment on
cerebral ischemia after subarachnoid hemorrhage. Stroke
1989;20:1511-1515
9. Hijdra A, Brouwers PJAM, Vermeulen M, van Gijn J: Grading
the amount of blood on computed tomograms after subarach-
noid hemorrhage. Stroke 1990;20:1156-1161
10. Teasdale GM, Jennett B: Assessment of coma and impaired
consciousness: A practical scale. Lancet 1974;2:81-84
11. Lindsay KW, Teasdale GM, Knill-Jones RP: Observer vari-
ability in assessing the clinical features of subarachnoid hem-
orrhage. / Neurosurg 1983;58:57-62
12. Earnest MP, Heaton RK, Wilkinson WE, Manke WF: Cortical
atrophy, ventricular enlargement and intellectual impairment
in the aged. Neurology 1979;29:1138-1143
13. Meese W, Kluge W, Grumme T, Hopfenmiiller W: CT eval-
uation of the CSF spaces of healthy persons. Neuroradiology
1980;19:131-136
14. Duffy GP: Lumbar puncture in spontaneous subarachnoid
hemorrhage. Br Med J 1982;285:1163-1164
15. Jennett B, Bond M: Assessment of outcome after severe brain
damage: A practical scale. Lancet 1975;l:480-484
16. Milhorat TH: Acute hydrocephalus after aneurysmal sub-
arachnoid hemorrhage. Neurosurgery 1987;20:15-20
17. Richardson AE, Jane JA, Payne PM: Assessment of the
natural history of anterior communicating aneurysms. J Neu-
rosurg 1964;21:266-274
18. Adams HP, Kassell NF, Tomer JC: Early management of
aneurysmal subarachnoid hemorrhage: A report of the Coop-
erative Aneurysm Study. J Neurosurg 1981;54:141-145
19. Hijdra A, van Gijn J, Nagelkerke NJD, Vermeulen M, van
Crevel H: Prediction of delayed cerebral ischemia, rebleeding,
and outcome after aneurysmal subarachnoid hemorrhage.
Stroke 1988;19:1250-1256
20. Adams HP, Kassell NF, Tomer JC, Haley EC: Predicting
cerebral ischemia after aneurysmal subarachnoid hemorrhage:
Influences of clinical condition, CT results, and antifibrinolytic
therapy. A report of the Cooperative Aneurysm Study. Neu-
rology 1987;37:1586-1591
KEY WORDS spinal puncture subarachnoid hemorrhage
 Treatment of acute hydrocephalus after subarachnoid hemorrhage with serial lumbar
puncture.
D Hasan, K W Lindsay and M Vermeulen

Stroke. 1991;22:190-194
doi: 10.1161/01.STR.22.2.190
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
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