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Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus
Published on: October 14, 2022
Pediatric hydrocephalus outcomes in Lusaka, Zambia
Rebecca A Reynolds1,2,3, Arnold Bhebhe2, Roxanna M Garcia4
11Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
Insights
Pediatric hydrocephalus in Zambia is predominantly postinfectious, with many children presenting late. Postoperative complications, especially infections and CSF leaks, significantly increase mortality risk in these patients.
Area of Science:
- Global Health
- Pediatric Neurosurgery
- Epidemiology
Background:
- Hydrocephalus is a significant global health issue, particularly affecting low- and middle-income countries.
- Sub-Saharan Africa has limited data on pediatric hydrocephalus epidemiology and outcomes.
- This study addresses this gap by focusing on Lusaka, Zambia.
Purpose of the Study:
- To describe the epidemiology of pediatric hydrocephalus in Lusaka, Zambia.
- To analyze the outcomes, including mortality and complications, of surgical hydrocephalus treatment in Zambian children.
- To identify risk factors for complications and mortality in this population.
Main Methods:
- A retrospective cohort study of pediatric patients (<18 years) undergoing hydrocephalus surgery in Lusaka, Zambia (August 2017 - May 2019).
- Surgical procedures included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC).
- Descriptive and multivariable analyses were performed on demographics, clinical presentation, etiologies, complications, and mortality.
Main Results:
- 378 pediatric patients were included; the median age at first surgery was 5.5 months.
- Postinfectious hydrocephalus was the predominant etiology (65%), with 42% presenting with severe disease.
- The overall complication rate was 20%, with infection being most common. Mortality was 7%, and postoperative complications were significant predictors of mortality (OR 42.9). Shunt revisions had higher complication rates than ETV/CPC or primary shunt insertions.
Conclusions:
- Postinfectious hydrocephalus is the leading cause in Lusaka, similar to other sub-Saharan African regions.
- Children often present with neglected hydrocephalus, indicating late diagnosis.
- Shunt revisions are associated with higher complication rates, and postoperative complications are critical determinants of mortality.
Objective:
Hydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia.
Methods:
This retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications.
Results:
A total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26-4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3-149.1], p < 0.001).
Conclusions:
Pediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.
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