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Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda
Abhaya V Kulkarni1, Steven J Schiff1, Edith Mbabazi-Kabachelor1
1From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.).
Insights
Endoscopic third ventriculostomy with choroid plexus cauterization (ETV-CPC) and ventriculoperitoneal shunting showed similar infant cognitive outcomes for postinfectious hydrocephalus. This study evaluated ETV-CPC versus shunting in Ugandan infants, finding no significant differences in cognitive, motor, or language scores.
Area of Science:
- Pediatric Neurosurgery
- Global Health
- Infant Neurological Disorders
Background:
- Postinfectious hydrocephalus poses a significant health challenge for infants in sub-Saharan Africa.
- Conventional treatment, ventriculoperitoneal shunting, faces challenges due to limited surgical availability for revisions.
- Endoscopic third ventriculostomy with choroid plexus cauterization (ETV-CPC) offers an alternative with lower late failure rates but potentially different impacts on brain development.
Purpose of the Study:
- To compare cognitive outcomes in Ugandan infants with postinfectious hydrocephalus treated with ETV-CPC versus ventriculoperitoneal shunting.
- To evaluate secondary outcomes including motor and language development, treatment failure rates, and brain volume.
- To provide evidence for optimal treatment strategies in resource-limited settings.
Main Methods:
- A randomized trial involving 100 Ugandan infants with postinfectious hydrocephalus.
- Infants were assigned to either ETV-CPC or ventriculoperitoneal shunting.
- Cognitive, motor, and language outcomes were assessed using the Bayley Scales of Infant Development, Third Edition (BSID-3) at 12 months post-surgery.
Main Results:
- No significant difference in median BSID-3 cognitive scores at 12 months between ETV-CPC (4) and ventriculoperitoneal shunting (2) groups (P=0.35).
- Secondary outcomes including motor scores, language scores, treatment failure rates (35% vs. 24%), and brain volume showed no significant differences between the groups.
- The Hodges-Lehmann estimated difference for cognitive scores was 0, with a 95% confidence interval of -2 to 0.
Conclusions:
- In Ugandan infants with postinfectious hydrocephalus, endoscopic ETV-CPC demonstrated comparable 12-month cognitive outcomes to ventriculoperitoneal shunting.
- The study found no significant differences in motor, language, treatment failure, or brain volume between the two surgical interventions.
- Findings suggest ETV-CPC is a viable alternative to shunting in this population, particularly where surgical resources are limited.
Background:
Postinfectious hydrocephalus in infants is a major health problem in sub-Saharan Africa. The conventional treatment is ventriculoperitoneal shunting, but surgeons are usually not immediately available to revise shunts when they fail. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV-CPC) is an alternative treatment that is less subject to late failure but is also less likely than shunting to result in a reduction in ventricular size that might facilitate better brain growth and cognitive outcomes.
Methods:
We conducted a randomized trial to evaluate cognitive outcomes after ETV-CPC versus ventriculoperitoneal shunting in Ugandan infants with postinfectious hydrocephalus. The primary outcome was the Bayley Scales of Infant Development, Third Edition (BSID-3), cognitive scaled score 12 months after surgery (scores range from 1 to 19, with higher scores indicating better performance). The secondary outcomes were BSID-3 motor and language scores, treatment failure (defined as treatment-related death or the need for repeat surgery), and brain volume measured on computed tomography.
Results:
A total of 100 infants were enrolled; 51 were randomly assigned to undergo ETV-CPC, and 49 were assigned to undergo ventriculoperitoneal shunting. The median BSID-3 cognitive scores at 12 months did not differ significantly between the treatment groups (a score of 4 for ETV-CPC and 2 for ventriculoperitoneal shunting; Hodges-Lehmann estimated difference, 0; 95% confidence interval [CI], -2 to 0; P=0.35). There was no significant difference between the ETV-CPC group and the ventriculoperitoneal-shunt group in BSID-3 motor or language scores, rates of treatment failure (35% and 24%, respectively; hazard ratio, 0.7; 95% CI, 0.3 to 1.5; P=0.24), or brain volume (z score, -2.4 and -2.1, respectively; estimated difference, 0.3; 95% CI, -0.3 to 1.0; P=0.12).
Conclusions:
This single-center study involving Ugandan infants with postinfectious hydrocephalus showed no significant difference between endoscopic ETV-CPC and ventriculoperitoneal shunting with regard to cognitive outcomes at 12 months. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01936272 .).