Healthcare Economics of Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage in the United States

April 13, 2019 – American Association of Neurological Surgeons, San Diego, CA, Syed M. Adil, Beiyu Liu, et al

Syed M. Adil, BSa; Beiyu Liu, PhDb; Lefko T. Charalambous, BSa; Musa Kiyani, BSa; Robert Gramer, BSa; Christa B. Swisher, MDc; Laura Zitella Verbick, PhDd; Aaron McCabe, PhDd; Beth A. Parente, PA-Ca; Promila Pagadala, PhDa; Shivanand P. Lad MD, PhDa


  • Aneurysmal subarachnoid hemorrhage (aSAH) is a common but devastating condition, with fatality rates of 8-61% in the 1-month after diagnosis.1
  • Hydrocephalus is one of the most common sequelae after aSAH, with its incidence ranging from 15-58.4% in the acute stage (48-72 hours after SAH) to 4.3-37% in the chronic stage (>14 days after SAH).2
  • Management of hydrocephalus involves longer lengths of stay3 and requires placing extraventricular drains, sometimes followed by conversion to ventriculoperitoneal (VP) shunts or endoscopic third ventriculostomy (ETV).
  • Though post-aSAH hydrocephalus is recognized as a common and significant concern, there is scarce literature determining its actual monetary or resource cost.


  • Quantify the healthcare resource utilization (HCRU) and health economic burden incurred by the US health system due to post-aSAH hydrocephalus.
  • Perform a preliminary analysis regarding the effect of timing of permanent CSF diversion procedure (i.e. VP shunt or ETV) on cost.

Methods (Figure 1)

  • The Truven MarketScan® Research database was used to retrospectively quantify the prevalence and HCRU associated with hydrocephalus in aSAH patients undergoing surgical clipping or endovascular coiling from 2008-2015.
  • Multivariable longitudinal analysis was conducted across 5 years to model the relationship between total annual cost (hospital service cost + medication cost) and hydrocephalus status, controlling for Charlson Comorbidity Index, clipping vs. coiling treatment, sex, and insurance status.
  • Performed a non-multivariable analysis across 2 years comparing HCRU for patients undergoing early (≤21 days after admission) vs. late (22-90 days after admission) CSF diversion procedures.

Results (Figures 2-4)

  • In total, 2374 patients were included; hydrocephalus was diagnosed in 959 (40.4%).
  • In the preliminary HCRU analysis of early vs. late CSF diversion procedures, 306 patients were included.


  • Our study characterizes one of the largest cohorts of aSAH patients in the United States.
  • The healthcare resource utilization due to post-aSAH hydrocephalus in the United States is substantial, resulting in cost increase of nearly $70,000 in first 90 days and $55,000 at 5 years.
  • Future research should further quantify the potential resources that could be saved with early intervention for post-aSAH hydrocephalus.


1. Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol.2009;8(7):635-42. doi:10.1016/S1474-4422(09)70126-7.

2. Xie Z, Hu X, Zan X, Lin S, Li H, You C. Predictors of Shunt-dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage? A Systematic Review and Meta-Analysis. World Neurosurg. 2017;106:844-60 e6. doi:10.1016/j.wneu.2017.06.119.

3. Rumalla K, Smith KA, Arnold PM, Mittal MK. Subarachnoid Hemorrhage and Readmissions: National Rates, Causes, Risk Factors, and Outcomes in 16,001 Hospitalized Patients. World Neurosurg. 2018;110:e100-e11. doi:10.1016/j.wneu.2017.10.089.5

Author Organization Key

a. Duke University Medical Center, Department of Neurosurgery
b. Duke University Medical Center, Department of Biostatistics and Bioinformatics
c. Duke University Medical Center, Department of Neurology
d. Minnetronix, Inc, St. Paul, MN, USA