Risk factor and Operation Influence of intracranial hemorrhage following ventriculoperitoneal shunt

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This study aimed to identify and assess the risk factors associated with intracranial hemorrhage in patients undergoing VP shunt surgery. Methods This retrospective study included patients who underwent a VP shunt surgery between January 2021 and July 2023. The patients were stratified into two groups based on whether they had a history of prior neurosurgical procedures. Demographic and clinical variables were analyzed for their correlation with postoperative hemorrhage risk. Postoperative CT confirmed hemorrhage. Univariate and logistic regression analyses were performed. Results Among the 838 patients, 49 (5.85%) developed intracranial hemorrhage. In the overall cohort, preoperative (P = 0.037) and postoperative anticoagulant or antiplatelet use (P = 0.001), left-sided catheter placement (P = 0.026), and pericardial edema (P = 0.052) were associated with hemorrhage. In patients without prior neurosurgery, independent predictors included pericatheter edema (P = 0.009), postoperative seizures (P < 0.001), shorter catheter depth (P = 0.022), and left-sided placement (P < 0.001). Postoperative anticoagulant use was significant in patients with prior neurosurgery (P = 0.004). Conclusion Perioperative anticoagulant and antiplatelet use, left-sided catheter placement, and pericatheter edema are critical risk factors for intracranial hemorrhage after VP shunt surgery. Surgical planning should prioritize the vascular anatomy and minimize anticoagulant exposure. Biological sciences/Neuroscience/Diseases of the nervous system Health sciences/Medical research Health sciences/Neurology Health sciences/Risk factors Intracranial hemorrhage ventriculoperitoneal shunt complication hydrocephalus Figures Figure 1 Introduction VP shunt surgery is a well-established neurosurgical procedure primarily used to treat hydrocephalus by diverting cerebrospinal fluid (CSF) from the brain ventricles into the peritoneal cavity[ 1 ]. Despite its efficacy, it can lead to various complications, including infections, shunt malfunction, and rarely, intracranial hemorrhage[ 2 ][ 3 ][ 4 ][ 5 ]. Although uncommon, intracranial hemorrhage following VP shunt surgery may result in severe neurological deterioration, seizures, or mortality[ 6 ][ 7 ]. Identifying the predisposing factors for intracranial hemorrhage is essential for optimizing surgical techniques and postoperative management. Previous studies have suggested that mechanical factors (e.g., catheter misplacement) and perioperative anticoagulation may contribute to intracranial hemorrhage[ 8 ][ 9 ][ 10 ][ 11 ], but comprehensive evidence remains limited. This study aimed to systematically evaluate the risk factors of intracranial hemorrhage following VP shunt surgery. This study aimed to investigate the risk factors that may contribute to cerebral hemorrhage following VP shunt surgery. By identifying these factors, we aimed to provide a comprehensive guide for clinicians to reduce the incidence of this complication and enhance the overall safety of VP shunt surgeries. Materials and Methods Patients This retrospective cohort study included 838 patients who underwent VP shunt surgery at the Second Affiliated Hospital of the Zhejiang University School of Medicine between January 2021 and July 2023. The inclusion criteria were first-time VP shunt placement and postoperative CT imaging within 24 hours. The patients were divided into two groups: no prior neurosurgery and prior neurosurgery (e.g., craniotomy or decompressive craniectomy). As Fig. 1 shows, we divided all patients into two groups according to whether they had a history of other neurosurgical procedures before undergoing VP shunt: no prior surgery and prior surgery. Neurosurgical history was defined as any intracranial procedure before VP shunt placement, including craniotomy, burr hole drainage, decompressive craniectomy, or skull reconstruction. Patients with endovascular interventions (e.g., coiling or embolization) were excluded. No cerebrovascular interventional surgery was performed. This information can be distinguished by medical history or imaging findings prior to surgery. Following surgery, the patients were further divided into two groups based on whether they experienced cerebral hemorrhage, as confirmed by CT imaging: a hemorrhage group and a non-hemorrhage group. Anticoagulant/antiplatelet agents were discontinued 7 days preoperatively. For patients at high thrombotic risk (e.g., mechanical heart valves), bridging therapy with low molecular weight heparin was administered until 24 hours before surgery. The Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine approved the study protocol, and all patients provided informed consent. All data were collected in accordance with the Declaration of Helsinki. Variables and Definitions Several clinical and demographic variables were recorded for each patient, including age, sex, and length of hospital stay. Medical history factors, such as hypertension, diabetes, smoking, alcohol consumption, history of craniotomy, and use of antiplatelet or anticoagulant medications, were also collected. Preoperative intracranial pressure was assessed using lumbar puncture. Other preoperative data, including preoperative GCS score, were also recorded. Postoperative data included the extent of pericatheter edema, seizures, fever, and intracranial infection. Meanwhile, we collected and measured operation-related data based on postoperative CT images, as follows: Puncture laterality (left/right): The puncture point of the VP shunt was located on the left or right side. Catheter depth Depth of the catheter through the brain parenchyma, excluding the part that passes through the skull and into the ventricle. Distance from the puncture point to the coronal suture The projected distance between the puncture point and coronal suture in the horizontal plane. Positive if the puncture point was in front of the coronal suture and negative behind the coronal suture. Pericatheter edema Determine the presence of edema around the catheter according to the CT images. All statistical analyses were performed using SPSS version 22.0 (IBM Corp.). Continuous variables were compared using Student’s t-test or the Mann-Whitney U test, depending on the data distribution. Categorical variables were analyzed using the chi-squared test or Fisher’s exact test. Univariate analysis was conducted, and variables with a P value < 0.1 were included in a binary logistic regression to identify independent risk factors associated with cerebral hemorrhage. Statistical significance was set at P < 0.05. Results Patient and Treatment Demographics A total of 838 patients participated in this study from January 2021 to July 2023. The age of the patients was 63 ± 17 years (median ± IQR), with a range of 18 to 87 years. The median length of hospital stay was 12 ± 8 days (range: 3–409 days). Of the 838 samples, 789 patients did not develop cerebral hemorrhage after VP shunt placement and 49 patients developed cerebral or ventricular hemorrhage after surgery. The proportion of patients with postoperative cerebral hemorrhage was 5.85%. Among those who experienced hemorrhage, 21 had no history of surgery. 17 had a history of craniotomy, eight underwent decompressive craniectomy, and three underwent cranioplasty. All patients with a history of surgery were included in the group. In terms of craniotomy history, the rate of cerebral hemorrhage varied: 6.65% in patients with no craniotomy history, 6.94% in those with craniotomy, 5.75% in patients with an open skull, and 3.37% in patients with cranioplasty. Univariate and Logistic Regression Analysis As Table 1 shows, in all samples, factors such as preoperative (P = 0.037) and postoperative(P = 0.001) use of anticoagulants or antiplatelets, catheter placement location(P = 0.026), and the distance between the puncture site and the coronal suture(P < 0.001) were significantly associated with cerebral hemorrhage. After excluding patients with a history of neurosurgery, we further analyzed the remaining patients. Pre-(P = 0.042) and postoperative(P = 0.030) GCS scores, depth of catheter passage through the brain parenchyma(P = 0.012), location of the puncture point(P < 0.001), distance between the puncture point and coronary suture(P = 0.039), pericardial edema(P = 0.009), and postoperative seizure(P < 0.001) were correlated with cerebral hemorrhage after VP shunting. Table 1 Univariate analysis of variables associated withVP-shunt and ICH Included patients No prior surgery group Prior surgery group Variables Non-hemorrhage (n = 789 ) Hemorrhage (n = 49 ) P Non-hemorrhage (n = 316 ) Hemorrhage (n = 21 ) P Non-hemorrhage (n = 473 ) Hemorrhage (n = 28) P Demographics Sex (Male/Female) 465/324 28/21 0.805 175/141 13/8 0.560 290/15 183/13 0.415 Age, years (Median ± IQR) 63.00 ± 16.00 59.00 ± 17.00 0.153 67.00 ± 16.00 66.00 ± 26.00 0.129 60.00 ± 18.00 55.00 ± 9.00 0.481 Past history Hypertension 346 26 0.208 155 10 0.899 191 16 0.080 Diabetes 124 10 0.385 61 7 0.121 63 3 0.692 Smoking history 257 13 0.380 100 6 0.769 157 7 0.369 Drinking history 260 13 0.352 108 5 0.330 152 8 0.694 Preoperative antiplatelet or anticoagulant use 73 9 0.037 21 3 0.187 52 6 0.094 Preoperative GCS 11.78 ± 0.14 10.88 ± 0.55 0.124 13.75 ± 0.15 11.90 ± 0.84 0.042 10.457 ± 4.164 10.107 ± 3.775 0.665 Image characteristics Puncture laterality(Left/Right) 207/582 20/29 0.026 22/294 7/14 < 0.001 185/288 13/15 0.442 The distance from the puncture point to the coronal suture (mm) 8.306 ± 6.266 12.036 ± 5.927 < 0.001 8.15 ± 7.23 11.40 ± 5.72 0.039 8.078 ± 6.361 12.445 ± 6.068 < 0.001 Pericatheter edema 293 25 0.052 107 13 0.009 186 12 0.710 Catheter depth(mm) 31.32 ± 8.13 29.00 ± 11.12 0.161 30.81 ± 7.70 26.57 ± 11.63 0.012 32.001 ± 7.081 31.449 ± 9.396 0.759 Postop. clinical characteristics Postoperative GCS 11.39 ± 0.15 10.490 ± 0.57 0.138 13.44 ± 0.16 11.28 ± 0.92 0.030 10.011 ± 4.205 9.893 ± 3.804 0.885 Postoperative anticoagulant use 47 9 0.001 15 3 0.060 32 6 0.004 Postoperative seizure 42 5 0.150 10 4 < 0.001 32 1 0.508 Intracranial infection 76 4 0.734 7 1 0.458 69 3 0.570 Logistic regression(Table 2 ) identified preoperative anticoagulant or antiplatelet use, pericatheter edema, and postoperative seizures as independent predictors of cerebral hemorrhage in the group with no history of surgery. Notably, left-sided placement of the shunt (P < 0.001, OR = 0.150) and the short length of the catheter passing through the brain parenchyma(P = 0.022, OR = 0.925) increased the risk of hemorrhage. Table 2 Logistic regression analysis identifying independent predictive factors of VP shunt and ICH Variables No prior surgery group OR 95%CI P Puncture site(Left/Right) 0.150 0.052–0.4432 < 0.001 Catheter depth 0.925 0.865–0.989 0.022 Discussion VP shunt surgery is an essential treatment for hydrocephalus, but it carries the risk of various complications[ 12 ]. Infections, shunt obstructions, and subdural hematomas are more commonly reported complications, but cerebral hemorrhage, while rare, poses a serious risk[ 13 ][ 14 ]. The incidence of cerebral hemorrhage in our study (5.85%) is consistent with previous findings, but slightly higher than earlier reports, such as the 4% rate of delayed hemorrhage reported by Savitz and Bobroff[ 15 ]. The differences in incidence rates may be due to differences in surgical techniques, patient selection, or postoperative monitoring protocols. The mechanism of cerebral hemorrhage after VP shunting has not yet been fully elucidated. Khandelwal et al. suggested that diffuse endovascular coagulation may be the cause of cerebral hemorrhage after VP shunt[ 16 ]. Okazaki et al. suggested that congenital CNS abnormalities and respiratory problems cause cerebral hemorrhage after a VP shunt[ 17 ]. However, our findings revealed that the choice of puncture site significantly affected postoperative cerebral hemorrhage. First, we confirmed that performing VP shunting (VPS) on the left side was a risk factor for delayed postoperative hemorrhage. This may be because performing VPS on the patient’s dominant hemisphere increases the risk of cerebral hemorrhage[ 18 ]. Second, the distance between the puncture site and coronal suture is also an important factor influencing the risk of postoperative cerebral hemorrhage. Specifically, in reference to the coronal suture, the probability of hemorrhage was lower for puncture sites located farther from the suture, suggesting that we need to improve the accuracy of catheter puncture to avoid regions with a high density of blood vessels. Selecting a more anterior puncture site may increase the distance to the ventricle, which could explain why the risk of hemorrhage is lower in patients without surgical history when the puncture path through the brain parenchyma is longer. Our findings corroborate previous reports indicating that left-sided shunt placement significantly increases the risk of hemorrhage. Cui Y et al. consider that there is a correlation between lateralization of cerebral basal ganglia hemorrhage and handedness. This means that right-handers are more likely to have a hemorrhage on the left side of the brain and vice versa[ 18 ]. They also found that the mean blood flow velocity in the right middle cerebral arteries of most left-handed individuals was relatively higher, and the mean blood flow velocity in the left middle cerebral arteries of most right-handed individuals was relatively higher. This is consistent with our findings. We believe that the difference in the bilateral bleeding risk during VP shunt surgery is due to the same reason. Left-sided catheter trajectories may traverse regions with higher vascular density (e.g., perisylvian arteries) in the dominant hemisphere, thereby increasing the risk of inadvertent vessel injury. In conventional surgery, the right side is always selected as the surgical approach for VP shunting. However, in some cases, a left VP shunt is chosen because it has left non-communicating hydrocephalus or lesions on the right side that are deemed unsuitable for surgery. Surgeons must carefully weigh the risk of bleeding. Additionally, the proximity of the puncture site to the coronal suture also appears to influence the hemorrhage risk, with more anterior placements associated with higher rates of ICH. Yamada et al. recommended using the right parieto-occipital approach for VP shunt placement to reduce the risk of hemorrhage[ 19 ]. Although we did not find enough literature to support the advantages of selecting the later location of the puncture site, we suspect that the parieto-occipital approach may also reduce the risk of hemorrhage after the VP shunt because it will reduce head rotation. Therefore, we suggest that, when selecting the puncture point during surgery, the catheter should not be too close to the frontal lobe. Coronal suture is an important sign of the skull, but it cannot be located by the naked eye before surgery because of scalp obstruction. Therefore, it is recommended that the surgeon first locate the location using imaging, such as CT, before the operation. Pericatheter edema, another independent risk factor, may be related to increased intracranial venous pressure or direct damage to the small vessels during catheter placement. Edema around the catheter may exacerbate the risk of ICH, particularly in patients with fragile vascular structures. Chen JC et al. have proposed that catheter insertion may lead to a disturbance in venous return or hemostasis of a cortical vein and then contribute to subcortical hemorrhage[ 20 ]. Brain edema around the catheter is regarded as a radiographic sign of vascular erosion and can be used to predict ICH. Our results are consistent with those of previous studies. We also considered that as the water around the catheter recedes, bleeding occurs in some of the damaged vessels that were originally compressed. However, studies have shown that postoperative intracranial hemorrhage correlates with the distance of the catheter through the brain parenchyma. Catheters in the ICH group had a shorter distance through the brain parenchyma than those without ICH. We consider this to be due to different degrees of hydrocephalus pressing on the brain parenchyma. As with ICH due to pericatheter edema, highly compressed brain parenchyma is released after surgery due to pressure, increasing the risk of bleeding. The greater the degree of compression of the brain parenchyma, the shorter the distance of the catheter through the brain parenchyma. Surgeons need to carefully assess the degree of compression of the brain parenchyma before surgery to avoid ICH. One of the most significant findings of our study was the strong association between perioperative anticoagulant or antiplatelet use and postoperative hemorrhage. While anticoagulant therapy is necessary for patients with comorbid conditions, such as atrial fibrillation or a history of thromboembolism, our results suggest that the use of these medications increases the likelihood of hemorrhage. Kandula V et al. study found no significant association between low molecular weight heparin use and deep vein thrombosis in patients after surgery[ 21 ]. However, our study found an association between anticoagulant use after surgery and ICH after VP shunt placement. Therefore, more attention should be paid to the risk of bleeding caused by anticoagulants after surgery. Careful perioperative management, including timely discontinuation of anticoagulants and close monitoring of coagulation status, is essential to mitigate this risk. Postoperative seizures were also strongly correlated with hemorrhage, suggesting that seizures may be both a consequence and a cause of hemorrhage. Seizures can lead to sudden increases in intracranial pressure, causing vascular rupture and hemorrhage, particularly in patients with preexisting vascular fragility. The results of this study provide valuable insights into the management of patients who undergo VP shunt surgery. Surgeons should carefully evaluate the risk of hemorrhage, particularly in patients with a history of anticoagulant or antiplatelet use. In addition, selecting the puncture site based on anatomical considerations, such as avoiding the dominant hemisphere and minimizing the distance from the coronal suture, may reduce the risk of postoperative hemorrhage. Postoperative monitoring should be particularly vigilant in patients who experience seizures or present with pericatheter edema. The present study has several limitations. First, this was a retrospective study that used multivariate analysis to minimize patient selection bias. Second, the inclusion criteria of the samples in this study were relatively lenient, and patients with different surgical histories were not analyzed in more detail. Third, the prognosis and long-term follow-up of patients should be studied. Conclusion Intracranial hemorrhage following VP shunt surgery is multifactorial, with key modifiable risks, including anticoagulant use and catheter placement strategies. Future studies should focus on vascular mapping to optimize the surgical trajectories. Declarations Disclosure of Conflicts of Interest None of the authors has any conflicts of interest to disclose. Author Contribution W.W. contributed to the study design and data collection. J.L. contributed to the study design, data collection and analysis, and manuscript drafting. X.G. and S.G. collected data. Y.H. and J.Z. designed the study and revised the manuscript critically. All authors have contributed to the manuscript and approved the submitted version. Data Availability The raw data supporting the conclusions of this article will be made available by the authors without undue reservation. One can contact J.L. to request the data from this study. References Tsakanikas D, Relkin N. Normal pressure hydrocephalus. Semin Neurol. 2007 Feb;27(1):58-65. doi: 10.1055/s-2006-956756. Katiyar V, Sharma R, Tandon V, Garg K, Narwal P, Chandra PS, Suri A, Kale SS. Comparison of Programmable and Non-Programmable Shunts for Normal Pressure Hydrocephalus: A Meta-Analysis and Trial Sequential Analysis. Neurol India. 2021 Nov-Dec;69(Supplement):S413-S419. doi: 10.4103/0028-3886.332277. Mallucci CL, Jenkinson MD, Conroy EJ, Hartley JC, Brown M, Dalton J, Kearns T, Moitt T, Griffiths MJ, Culeddu G, Solomon T, Hughes D, Gamble C BASICS Study collaborators. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6332443","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":443768933,"identity":"99bf1cac-363c-46ec-965e-8163c95c29cb","order_by":0,"name":"Wei Wang","email":"","orcid":"","institution":"Nursing Department, The Second Affiliated Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Wang","suffix":""},{"id":443768934,"identity":"0630454e-ce32-4df8-a6bf-21fb6bb874c0","order_by":1,"name":"Jun Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIie3RMWsCMRTA8RcCuSX21jj0OxwcSEHQr5JwoIt0dnB4INwkuJ7fQuji+MKBU0pXt25de9K11EYnpxi3QvPfHrwfPHgAqdQfLM+WRMfv0ygH0H7mt0l/tTd2g7zqYywpDrOy7SFnW7rMEQRIF3azE7x8ow8F86HB7JWCgiFpOjr5MCCaKHBTg/JZBwn3xjZC8YHFiWJ1a1DJIkiEN60UBXtZgic/EUQKDm2v1mwrzgQjiJICbOOoUg6qJ72flrWchcn4/fOr6+Y0ytfOHLrF8HGduTC5vlFfnili930Z3bGcSqVS/6lfJC5Khkta7EsAAAAASUVORK5CYII=","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Jun","middleName":"","lastName":"Lin","suffix":""},{"id":443768935,"identity":"56858bce-10ec-4103-b8da-5aed78d87a1c","order_by":2,"name":"Xiaoming Guo","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Xiaoming","middleName":"","lastName":"Guo","suffix":""},{"id":443768936,"identity":"62b16fe9-808b-453c-bf92-4ae36344824c","order_by":3,"name":"Shiqi Gao","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Shiqi","middleName":"","lastName":"Gao","suffix":""},{"id":443768937,"identity":"2435bfad-6588-4c5a-b367-472660bbf3f4","order_by":4,"name":"Junming Zhu","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Junming","middleName":"","lastName":"Zhu","suffix":""},{"id":443768939,"identity":"942f0018-154f-47d8-acb7-daa38b06f020","order_by":5,"name":"Yuan Hong","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Hong","suffix":""}],"badges":[],"createdAt":"2025-03-29 07:08:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6332443/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6332443/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-08799-1","type":"published","date":"2025-07-15T16:05:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82055690,"identity":"a8ee9285-e005-4f26-9443-8a6eef877af5","added_by":"auto","created_at":"2025-05-06 10:25:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":120248,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6332443/v1/d24b9894a3ced99a4680511e.jpg"},{"id":87220905,"identity":"b18ab88b-fcff-400d-871a-9691f1d2a61b","added_by":"auto","created_at":"2025-07-21 16:13:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":788880,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6332443/v1/927f757a-6840-4ff8-b55b-29bebf92a3c0.pdf"},{"id":82057284,"identity":"03558eaa-e3b7-4f76-9be0-736e4d9d44dd","added_by":"auto","created_at":"2025-05-06 10:41:31","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":100352,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklistcasecontrol.doc","url":"https://assets-eu.researchsquare.com/files/rs-6332443/v1/3b973e4f70475c373eeafc6e.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk factor and Operation Influence of intracranial hemorrhage following ventriculoperitoneal shunt","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVP shunt surgery is a well-established neurosurgical procedure primarily used to treat hydrocephalus by diverting cerebrospinal fluid (CSF) from the brain ventricles into the peritoneal cavity[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite its efficacy, it can lead to various complications, including infections, shunt malfunction, and rarely, intracranial hemorrhage[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although uncommon, intracranial hemorrhage following VP shunt surgery may result in severe neurological deterioration, seizures, or mortality[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Identifying the predisposing factors for intracranial hemorrhage is essential for optimizing surgical techniques and postoperative management.\u003c/p\u003e \u003cp\u003ePrevious studies have suggested that mechanical factors (e.g., catheter misplacement) and perioperative anticoagulation may contribute to intracranial hemorrhage[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], but comprehensive evidence remains limited. This study aimed to systematically evaluate the risk factors of intracranial hemorrhage following VP shunt surgery.\u003c/p\u003e \u003cp\u003eThis study aimed to investigate the risk factors that may contribute to cerebral hemorrhage following VP shunt surgery. By identifying these factors, we aimed to provide a comprehensive guide for clinicians to reduce the incidence of this complication and enhance the overall safety of VP shunt surgeries.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study included 838 patients who underwent VP shunt surgery at the Second Affiliated Hospital of the Zhejiang University School of Medicine between January 2021 and July 2023. The inclusion criteria were first-time VP shunt placement and postoperative CT imaging within 24 hours. The patients were divided into two groups: no prior neurosurgery and prior neurosurgery (e.g., craniotomy or decompressive craniectomy).\u003c/p\u003e \u003cp\u003eAs Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows, we divided all patients into two groups according to whether they had a history of other neurosurgical procedures before undergoing VP shunt: no prior surgery and prior surgery. Neurosurgical history was defined as any intracranial procedure before VP shunt placement, including craniotomy, burr hole drainage, decompressive craniectomy, or skull reconstruction. Patients with endovascular interventions (e.g., coiling or embolization) were excluded. No cerebrovascular interventional surgery was performed. This information can be distinguished by medical history or imaging findings prior to surgery. Following surgery, the patients were further divided into two groups based on whether they experienced cerebral hemorrhage, as confirmed by CT imaging: a hemorrhage group and a non-hemorrhage group.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAnticoagulant/antiplatelet agents were discontinued 7 days preoperatively. For patients at high thrombotic risk (e.g., mechanical heart valves), bridging therapy with low molecular weight heparin was administered until 24 hours before surgery. The Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine approved the study protocol, and all patients provided informed consent. All data were collected in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVariables and Definitions\u003c/h3\u003e\n\u003cp\u003eSeveral clinical and demographic variables were recorded for each patient, including age, sex, and length of hospital stay. Medical history factors, such as hypertension, diabetes, smoking, alcohol consumption, history of craniotomy, and use of antiplatelet or anticoagulant medications, were also collected.\u003c/p\u003e \u003cp\u003ePreoperative intracranial pressure was assessed using lumbar puncture. Other preoperative data, including preoperative GCS score, were also recorded. Postoperative data included the extent of pericatheter edema, seizures, fever, and intracranial infection.\u003c/p\u003e \u003cp\u003eMeanwhile, we collected and measured operation-related data based on postoperative CT images, as follows:\u003c/p\u003e \u003cp\u003e \u003cb\u003ePuncture laterality\u003c/b\u003e (left/right): The puncture point of the VP shunt was located on the left or right side.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCatheter depth\u003c/strong\u003e \u003cp\u003eDepth of the catheter through the brain parenchyma, excluding the part that passes through the skull and into the ventricle.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDistance from the puncture point to the coronal suture\u003c/strong\u003e \u003cp\u003eThe projected distance between the puncture point and coronal suture in the horizontal plane. Positive if the puncture point was in front of the coronal suture and negative behind the coronal suture.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePericatheter edema\u003c/strong\u003e \u003cp\u003eDetermine the presence of edema around the catheter according to the CT images.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAll statistical analyses were performed using SPSS version 22.0 (IBM Corp.). Continuous variables were compared using Student\u0026rsquo;s t-test or the Mann-Whitney U test, depending on the data distribution. Categorical variables were analyzed using the chi-squared test or Fisher\u0026rsquo;s exact test. Univariate analysis was conducted, and variables with a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 were included in a binary logistic regression to identify independent risk factors associated with cerebral hemorrhage. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePatient and Treatment Demographics\u003c/h2\u003e \u003cp\u003eA total of 838 patients participated in this study from January 2021 to July 2023. The age of the patients was 63\u0026thinsp;\u0026plusmn;\u0026thinsp;17 years (median\u0026thinsp;\u0026plusmn;\u0026thinsp;IQR), with a range of 18 to 87 years. The median length of hospital stay was 12\u0026thinsp;\u0026plusmn;\u0026thinsp;8 days (range: 3\u0026ndash;409 days). Of the 838 samples, 789 patients did not develop cerebral hemorrhage after VP shunt placement and 49 patients developed cerebral or ventricular hemorrhage after surgery. The proportion of patients with postoperative cerebral hemorrhage was 5.85%.\u003c/p\u003e \u003cp\u003eAmong those who experienced hemorrhage, 21 had no history of surgery. 17 had a history of craniotomy, eight underwent decompressive craniectomy, and three underwent cranioplasty. All patients with a history of surgery were included in the group. In terms of craniotomy history, the rate of cerebral hemorrhage varied: 6.65% in patients with no craniotomy history, 6.94% in those with craniotomy, 5.75% in patients with an open skull, and 3.37% in patients with cranioplasty.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eUnivariate and Logistic Regression Analysis\u003c/h3\u003e\n\u003cp\u003eAs Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows, in all samples, factors such as preoperative (P\u0026thinsp;=\u0026thinsp;0.037) and postoperative(P\u0026thinsp;=\u0026thinsp;0.001) use of anticoagulants or antiplatelets, catheter placement location(P\u0026thinsp;=\u0026thinsp;0.026), and the distance between the puncture site and the coronal suture(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly associated with cerebral hemorrhage. After excluding patients with a history of neurosurgery, we further analyzed the remaining patients. Pre-(P\u0026thinsp;=\u0026thinsp;0.042) and postoperative(P\u0026thinsp;=\u0026thinsp;0.030) GCS scores, depth of catheter passage through the brain parenchyma(P\u0026thinsp;=\u0026thinsp;0.012), location of the puncture point(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), distance between the puncture point and coronary suture(P\u0026thinsp;=\u0026thinsp;0.039), pericardial edema(P\u0026thinsp;=\u0026thinsp;0.009), and postoperative seizure(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were correlated with cerebral hemorrhage after VP shunting.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate analysis of variables associated withVP-shunt and ICH\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eIncluded patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eNo prior surgery group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003ePrior surgery group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-hemorrhage (n\u0026thinsp;=\u0026thinsp;789 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHemorrhage (n\u0026thinsp;=\u0026thinsp;49 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNon-hemorrhage (n\u0026thinsp;=\u0026thinsp;316 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHemorrhage (n\u0026thinsp;=\u0026thinsp;21 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNon-hemorrhage (n\u0026thinsp;=\u0026thinsp;473 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHemorrhage (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDemographics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e465/324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28/21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.805\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e175/141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e290/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e183/13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.415\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (Median\u0026thinsp;\u0026plusmn;\u0026thinsp;IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.00\u0026thinsp;\u0026plusmn;\u0026thinsp;16.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.00\u0026thinsp;\u0026plusmn;\u0026thinsp;17.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.00\u0026thinsp;\u0026plusmn;\u0026thinsp;16.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e66.00\u0026thinsp;\u0026plusmn;\u0026thinsp;26.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e60.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e55.00\u0026thinsp;\u0026plusmn;\u0026thinsp;9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePast history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.899\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.369\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrinking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.694\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative antiplatelet or anticoagulant use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative GCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.042\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.457\u0026thinsp;\u0026plusmn;\u0026thinsp;4.164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10.107\u0026thinsp;\u0026plusmn;\u0026thinsp;3.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImage characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture laterality(Left/Right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e207/582\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20/29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22/294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7/14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e185/288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.442\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe distance from the puncture point to the coronal suture (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.306\u0026thinsp;\u0026plusmn;\u0026thinsp;6.266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.036\u0026thinsp;\u0026plusmn;\u0026thinsp;5.927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.15\u0026thinsp;\u0026plusmn;\u0026thinsp;7.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.078\u0026thinsp;\u0026plusmn;\u0026thinsp;6.361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12.445\u0026thinsp;\u0026plusmn;\u0026thinsp;6.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePericatheter edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e293\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatheter depth(mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.32\u0026thinsp;\u0026plusmn;\u0026thinsp;8.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.00\u0026thinsp;\u0026plusmn;\u0026thinsp;11.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.81\u0026thinsp;\u0026plusmn;\u0026thinsp;7.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.57\u0026thinsp;\u0026plusmn;\u0026thinsp;11.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32.001\u0026thinsp;\u0026plusmn;\u0026thinsp;7.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e31.449\u0026thinsp;\u0026plusmn;\u0026thinsp;9.396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostop. clinical characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative GCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.490\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.011\u0026thinsp;\u0026plusmn;\u0026thinsp;4.205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9.893\u0026thinsp;\u0026plusmn;\u0026thinsp;3.804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.885\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative anticoagulant use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.734\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.458\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.570\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLogistic regression(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) identified preoperative anticoagulant or antiplatelet use, pericatheter edema, and postoperative seizures as independent predictors of cerebral hemorrhage in the group with no history of surgery. Notably, left-sided placement of the shunt (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, OR\u0026thinsp;=\u0026thinsp;0.150) and the short length of the catheter passing through the brain parenchyma(P\u0026thinsp;=\u0026thinsp;0.022, OR\u0026thinsp;=\u0026thinsp;0.925) increased the risk of hemorrhage.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis identifying independent predictive factors of VP shunt and ICH\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eNo prior surgery group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture site(Left/Right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.052\u0026ndash;0.4432\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatheter depth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.925\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.865\u0026ndash;0.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eVP shunt surgery is an essential treatment for hydrocephalus, but it carries the risk of various complications[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Infections, shunt obstructions, and subdural hematomas are more commonly reported complications, but cerebral hemorrhage, while rare, poses a serious risk[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The incidence of cerebral hemorrhage in our study (5.85%) is consistent with previous findings, but slightly higher than earlier reports, such as the 4% rate of delayed hemorrhage reported by Savitz and Bobroff[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The differences in incidence rates may be due to differences in surgical techniques, patient selection, or postoperative monitoring protocols.\u003c/p\u003e \u003cp\u003eThe mechanism of cerebral hemorrhage after VP shunting has not yet been fully elucidated. Khandelwal et al. suggested that diffuse endovascular coagulation may be the cause of cerebral hemorrhage after VP shunt[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Okazaki et al. suggested that congenital CNS abnormalities and respiratory problems cause cerebral hemorrhage after a VP shunt[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, our findings revealed that the choice of puncture site significantly affected postoperative cerebral hemorrhage. First, we confirmed that performing VP shunting (VPS) on the left side was a risk factor for delayed postoperative hemorrhage. This may be because performing VPS on the patient\u0026rsquo;s dominant hemisphere increases the risk of cerebral hemorrhage[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Second, the distance between the puncture site and coronal suture is also an important factor influencing the risk of postoperative cerebral hemorrhage. Specifically, in reference to the coronal suture, the probability of hemorrhage was lower for puncture sites located farther from the suture, suggesting that we need to improve the accuracy of catheter puncture to avoid regions with a high density of blood vessels. Selecting a more anterior puncture site may increase the distance to the ventricle, which could explain why the risk of hemorrhage is lower in patients without surgical history when the puncture path through the brain parenchyma is longer.\u003c/p\u003e \u003cp\u003eOur findings corroborate previous reports indicating that left-sided shunt placement significantly increases the risk of hemorrhage. Cui Y et al. consider that there is a correlation between lateralization of cerebral basal ganglia hemorrhage and handedness. This means that right-handers are more likely to have a hemorrhage on the left side of the brain and vice versa[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. They also found that the mean blood flow velocity in the right middle cerebral arteries of most left-handed individuals was relatively higher, and the mean blood flow velocity in the left middle cerebral arteries of most right-handed individuals was relatively higher. This is consistent with our findings. We believe that the difference in the bilateral bleeding risk during VP shunt surgery is due to the same reason. Left-sided catheter trajectories may traverse regions with higher vascular density (e.g., perisylvian arteries) in the dominant hemisphere, thereby increasing the risk of inadvertent vessel injury. In conventional surgery, the right side is always selected as the surgical approach for VP shunting. However, in some cases, a left VP shunt is chosen because it has left non-communicating hydrocephalus or lesions on the right side that are deemed unsuitable for surgery. Surgeons must carefully weigh the risk of bleeding.\u003c/p\u003e \u003cp\u003eAdditionally, the proximity of the puncture site to the coronal suture also appears to influence the hemorrhage risk, with more anterior placements associated with higher rates of ICH. Yamada et al. recommended using the right parieto-occipital approach for VP shunt placement to reduce the risk of hemorrhage[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although we did not find enough literature to support the advantages of selecting the later location of the puncture site, we suspect that the parieto-occipital approach may also reduce the risk of hemorrhage after the VP shunt because it will reduce head rotation. Therefore, we suggest that, when selecting the puncture point during surgery, the catheter should not be too close to the frontal lobe. Coronal suture is an important sign of the skull, but it cannot be located by the naked eye before surgery because of scalp obstruction. Therefore, it is recommended that the surgeon first locate the location using imaging, such as CT, before the operation.\u003c/p\u003e \u003cp\u003ePericatheter edema, another independent risk factor, may be related to increased intracranial venous pressure or direct damage to the small vessels during catheter placement. Edema around the catheter may exacerbate the risk of ICH, particularly in patients with fragile vascular structures. Chen JC et al. have proposed that catheter insertion may lead to a disturbance in venous return or hemostasis of a cortical vein and then contribute to subcortical hemorrhage[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Brain edema around the catheter is regarded as a radiographic sign of vascular erosion and can be used to predict ICH. Our results are consistent with those of previous studies. We also considered that as the water around the catheter recedes, bleeding occurs in some of the damaged vessels that were originally compressed.\u003c/p\u003e \u003cp\u003eHowever, studies have shown that postoperative intracranial hemorrhage correlates with the distance of the catheter through the brain parenchyma. Catheters in the ICH group had a shorter distance through the brain parenchyma than those without ICH. We consider this to be due to different degrees of hydrocephalus pressing on the brain parenchyma. As with ICH due to pericatheter edema, highly compressed brain parenchyma is released after surgery due to pressure, increasing the risk of bleeding. The greater the degree of compression of the brain parenchyma, the shorter the distance of the catheter through the brain parenchyma. Surgeons need to carefully assess the degree of compression of the brain parenchyma before surgery to avoid ICH.\u003c/p\u003e \u003cp\u003eOne of the most significant findings of our study was the strong association between perioperative anticoagulant or antiplatelet use and postoperative hemorrhage. While anticoagulant therapy is necessary for patients with comorbid conditions, such as atrial fibrillation or a history of thromboembolism, our results suggest that the use of these medications increases the likelihood of hemorrhage. Kandula V et al. study found no significant association between low molecular weight heparin use and deep vein thrombosis in patients after surgery[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, our study found an association between anticoagulant use after surgery and ICH after VP shunt placement. Therefore, more attention should be paid to the risk of bleeding caused by anticoagulants after surgery. Careful perioperative management, including timely discontinuation of anticoagulants and close monitoring of coagulation status, is essential to mitigate this risk.\u003c/p\u003e \u003cp\u003ePostoperative seizures were also strongly correlated with hemorrhage, suggesting that seizures may be both a consequence and a cause of hemorrhage. Seizures can lead to sudden increases in intracranial pressure, causing vascular rupture and hemorrhage, particularly in patients with preexisting vascular fragility.\u003c/p\u003e \u003cp\u003eThe results of this study provide valuable insights into the management of patients who undergo VP shunt surgery. Surgeons should carefully evaluate the risk of hemorrhage, particularly in patients with a history of anticoagulant or antiplatelet use. In addition, selecting the puncture site based on anatomical considerations, such as avoiding the dominant hemisphere and minimizing the distance from the coronal suture, may reduce the risk of postoperative hemorrhage. Postoperative monitoring should be particularly vigilant in patients who experience seizures or present with pericatheter edema.\u003c/p\u003e \u003cp\u003eThe present study has several limitations. First, this was a retrospective study that used multivariate analysis to minimize patient selection bias. Second, the inclusion criteria of the samples in this study were relatively lenient, and patients with different surgical histories were not analyzed in more detail. Third, the prognosis and long-term follow-up of patients should be studied.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIntracranial hemorrhage following VP shunt surgery is multifactorial, with key modifiable risks, including anticoagulant use and catheter placement strategies. Future studies should focus on vascular mapping to optimize the surgical trajectories.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosure of Conflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors has any conflicts of interest to disclose.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eW.W. contributed to the study design and data collection. J.L. contributed to the study design, data collection and analysis, and manuscript drafting. X.G. and S.G. collected data. Y.H. and J.Z. designed the study and revised the manuscript critically. All authors have contributed to the manuscript and approved the submitted version.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe raw data supporting the conclusions of this article will be made available by the authors without undue reservation. One can contact J.L. to request the data from this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTsakanikas D, Relkin N. Normal pressure hydrocephalus. Semin Neurol. 2007 Feb;27(1):58-65. doi: 10.1055/s-2006-956756.\u003c/li\u003e\n\u003cli\u003eKatiyar V, Sharma R, Tandon V, Garg K, Narwal P, Chandra PS, Suri A, Kale SS. Comparison of Programmable and Non-Programmable Shunts for Normal Pressure Hydrocephalus: A Meta-Analysis and Trial Sequential Analysis. Neurol India. 2021 Nov-Dec;69(Supplement):S413-S419. doi: 10.4103/0028-3886.332277.\u003c/li\u003e\n\u003cli\u003eMallucci CL, Jenkinson MD, Conroy EJ, Hartley JC, Brown M, Dalton J, Kearns T, Moitt T, Griffiths MJ, Culeddu G, Solomon T, Hughes D, Gamble C BASICS Study collaborators. Antibiotic or silver vs standard ventriculoperitoneal shunts (BASICS): a multicentre, single-blinded, randomised trial and economic evaluation. 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J Neurosurg Pediatr. 2015;16:42\u0026ndash;45. doi: 10.3171/2014.11.\u003c/li\u003e\n\u003cli\u003eGong W, et al. Characteristics of delayed intracerebral hemorrhage after ventriculoperitoneal shunt insertion. Oncotarget. 2017;8:42693\u0026ndash;42699. doi: 10.18632/oncotarget.17444. \u003c/li\u003e\n\u003cli\u003eGuo L, Chen X, Yu B, Shen L, Zhang X. Delayed intracerebral hemorrhage secondary to ventriculoperitoneal shunt: A retrospective study. World Neurosurg. 2017;107:160\u0026ndash;167. doi: 10.1016/j.wneu.2017.07.133. \u003c/li\u003e\n\u003cli\u003eQian Z, Gao L, Wang K, Pandey S. Delayed catheter-related intracranial hemorrhage after a ventriculoperitoneal or ventriculoatrial shunt in hydrocephalus. World Neurosurg. 2017;107:846\u0026ndash;851. doi: 10.1016/j.wneu.2017.08.098. \u003c/li\u003e\n\u003cli\u003eJang SY, Kim CH, Cheong JH, Kim JM. Risk factors of delayed intracranial hemorrhage following ventriculoperitoneal shunt. Korean J. Neurotrauma. 2018;14:112\u0026ndash;117. doi: 10.13004/kjnt.2018.14.2.112.\u003c/li\u003e\n\u003cli\u003eFowler JB, De Jesus O, Mesfin FB. Ventriculoperitoneal Shunt. 2023 Aug 23. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan\u0026ndash;. PMID: 29083724.\u003c/li\u003e\n\u003cli\u003eBlount JP, Campbell JA, Haines SJ. Complications in ventricular cerebrospinal fluid shunting. Neurosurg Clin N Am. 1993;4:633\u0026ndash;656. \u003c/li\u003e\n\u003cli\u003eSayers MP. Shunt complications. Clin Neurosurg. 1976;23:393\u0026ndash;400. doi: 10.1093/neurosurgery/23.cn_suppl_1.393.\u003c/li\u003e\n\u003cli\u003eSavitz MH, Bobroff LM. Low incidence of delayed intracerebral hemorrhage secondary to ventriculoperitoneal shunt insertion. J Neurosurg. 1999 Jul;91(1):32-4. doi: 10.3171/jns.1999.91.1.0032. \u003c/li\u003e\n\u003cli\u003eKhandelwal A, Singh PK, Basheer N, Mahapatra AK. Delayed bilateral thalamic bleeding post-ventriculoperitoneal shunt. Childs Nerv Syst. 2011 Jun;27(6):1025-7. doi: 10.1007/s00381-011-1429-6. \u003c/li\u003e\n\u003cli\u003eOkazaki M, Fukuhara T, Namba Y. Delayed germinal matrix hemorrhage induced by ventriculoperitoneal shunt insertion for congenital hydrocephalus. J Neurosurg Pediatr. 2013 Jul;12(1):67-70. doi: 10.3171/2013.4.PEDS1259.\u003c/li\u003e\n\u003cli\u003eCui Y, Zhang Z, Huo X, Dai J, Zheng G, Feng X, Wang C. The correlation between lateralization of intracerebral hemorrhage in basal ganglia and handedness. Acta Cir Bras. 2013 Mar;28(3):228-32. doi: 10.1590/s0102-86502013000300012. \u003c/li\u003e\n\u003cli\u003eYamada S. [New Preoperative Simulations for the Future of Hydrocephalus Surgery]. No Shinkei Geka. 2024 Mar;52(2):289-298. Japanese. doi: 10.11477/mf.1436204913 \u003c/li\u003e\n\u003cli\u003eChen JC, Duan SX, Xue ZB, Yang SY, Li Y, Lai RL, Tan DH. Risk factors for delayed intracranial hemorrhage secondary to ventriculoperitoneal shunt: A retrospective study. World J Clin Cases. 2022 Jul 26;10(21):7302-7313. doi: 10.12998/wjcc.v10.i21.7302. \u003c/li\u003e\n\u003cli\u003eKandula V, Shah PV, Thirunavu VM, Yerneni K, Karras C, Abecassis ZA, Hopkins B, Bloch O, Potts MB, Jahromi BS, Tate MC. Low-molecular-weight Heparin (enoxaparin) versus unfractionated heparin for venous thromboembolism prophylaxis in patients undergoing craniotomy. Clin Neurol Neurosurg. 2022 Dec;223:107482. doi: 10.1016/j.clineuro.2022.107482.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intracranial hemorrhage, ventriculoperitoneal shunt, complication, hydrocephalus","lastPublishedDoi":"10.21203/rs.3.rs-6332443/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6332443/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eIntracranial hemorrhage is a rare but significant complication of ventriculoperitoneal (VP) shunt surgery. This study aimed to identify and assess the risk factors associated with intracranial hemorrhage in patients undergoing VP shunt surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study included patients who underwent a VP shunt surgery between January 2021 and July 2023. The patients were stratified into two groups based on whether they had a history of prior neurosurgical procedures. Demographic and clinical variables were analyzed for their correlation with postoperative hemorrhage risk. Postoperative CT confirmed hemorrhage. Univariate and logistic regression analyses were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the 838 patients, 49 (5.85%) developed intracranial hemorrhage. In the overall cohort, preoperative (P\u0026thinsp;=\u0026thinsp;0.037) and postoperative anticoagulant or antiplatelet use (P\u0026thinsp;=\u0026thinsp;0.001), left-sided catheter placement (P\u0026thinsp;=\u0026thinsp;0.026), and pericardial edema (P\u0026thinsp;=\u0026thinsp;0.052) were associated with hemorrhage. In patients without prior neurosurgery, independent predictors included pericatheter edema (P\u0026thinsp;=\u0026thinsp;0.009), postoperative seizures (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), shorter catheter depth (P\u0026thinsp;=\u0026thinsp;0.022), and left-sided placement (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Postoperative anticoagulant use was significant in patients with prior neurosurgery (P\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePerioperative anticoagulant and antiplatelet use, left-sided catheter placement, and pericatheter edema are critical risk factors for intracranial hemorrhage after VP shunt surgery. Surgical planning should prioritize the vascular anatomy and minimize anticoagulant exposure.\u003c/p\u003e","manuscriptTitle":"Risk factor and Operation Influence of intracranial hemorrhage following ventriculoperitoneal shunt","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 10:25:26","doi":"10.21203/rs.3.rs-6332443/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-16T10:19:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-12T17:47:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9797078259575034587971317736372667738","date":"2025-04-10T10:14:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-05T18:28:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4539355487550493750969504390618936421","date":"2025-04-03T07:31:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-03T02:33:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-03T02:32:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-02T05:59:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-31T11:39:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-03-29T06:52:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9b6567b2-b029-42b1-a6a0-48e426a1fb69","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":47247109,"name":"Biological sciences/Neuroscience/Diseases of the nervous system"},{"id":47247110,"name":"Health sciences/Medical research"},{"id":47247111,"name":"Health sciences/Neurology"},{"id":47247112,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-07-21T16:12:32+00:00","versionOfRecord":{"articleIdentity":"rs-6332443","link":"https://doi.org/10.1038/s41598-025-08799-1","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-07-15 16:05:33","publishedOnDateReadable":"July 15th, 2025"},"versionCreatedAt":"2025-05-06 10:25:26","video":"","vorDoi":"10.1038/s41598-025-08799-1","vorDoiUrl":"https://doi.org/10.1038/s41598-025-08799-1","workflowStages":[]},"version":"v1","identity":"rs-6332443","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6332443","identity":"rs-6332443","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}