Complications and 3-month outcomes of children with hydrocephalus treated with ventriculoperitoneal shunts in Malawi

Restricted access


Hydrocephalus is the most common pediatric neurosurgical condition, with a high prevalence in low- and middle-income countries. Untreated, hydrocephalus leads to neurological disability or death. The epidemiology and outcomes of hydrocephalus treated by ventriculoperitoneal (VP) shunts in Sub-Saharan Africa are not well defined and vary by region. The aim of the present study was to examine the mortality and morbidity rates and predictors of mortality in children treated by VP shunt placement for hydrocephalus at Kamuzu Central Hospital in Lilongwe, Malawi.


This is a prospective study of 100 consecutive children presenting with hydrocephalus who were treated with VP shunt placement from January 2015 to August 2017. Demographics, nutritional status, maternal characteristics, developmental delay, shunt complications, readmissions, and in-hospital and 3-month mortality data were collected. Multivariate logistic regression was used to identify predictors of death within 3 months of surgery.


Overall, 46% of participants were female, with an average age of 5.4 ± 3.7 months at the time of surgery. The majority of patients were term deliveries (87.8%) and were not malnourished (72.9%). Only 10.8% of children were diagnosed with meningitis before admission. In-hospital and 3-month mortality rates were 5.5% and 32.1%, respectively. The only significant association with mortality was maternal age, with older maternal age demonstrating decreased odds of 3-month mortality (OR 0.9, 95% CI 0.8–1.0, p = 0.045).


Surgical management of hydrocephalus with VP shunts portends a high mortality rate in Malawi. The association of younger maternal age with mortality is likely a proxy for social determinants, which appear to contribute as much to mortality as patient factors. VP shunting is inadequate as a sole surgical management of hydrocephalus in resource-limited settings.

ABBREVIATIONS CPC = choroid plexus cauterization; ETV = endoscopic third ventriculostomy; HIC = high-income country; KCH = Kamuzu Central Hospital; LMICs = low- and middle-income countries; ROC = receiver operating characteristic; VP = ventriculoperitoneal.

Article Information

Correspondence Trista Reid: UNC School of Medicine, University of North Carolina, Chapel Hill, NC.

INCLUDE WHEN CITING Published online May 10, 2019; DOI: 10.3171/2019.2.PEDS18325.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Patient follow-up over 6 months. aPatients were lost to follow-up despite attempts to reach them by cell phone, home visit, and asking the village elder. Figure is available in color online only.

  • View in gallery

    ROC curve for all-cause mortality by 3 months after surgery.


  • 1

    Biluts HAdmasu AK: Outcomes of endoscopic third ventriculostomy in pediatric patients at Zewditu Memorial Hospital, Ethiopia. World Neurosurg 92:3603652016

  • 2

    Boivin MJKakooza AMWarf BCDavidson LLGrigorenko EL: Reducing neurodevelopmental disorders and disability through research and interventions. Nature 527:S155S1602015

  • 3

    Centers for Disease Control and Prevention: CDC’s Developmental Milestones. CDC, U.S. Department of Health & Human Services ( [Accessed March 18 2019]

  • 4

    Dakurah TKAdams FIddrissu MWepeba GKAkoto HBankah P: Management of hydrocephalus with ventriculoperitoneal shunts: review of 109 cases of children. World Neurosurg 96:1291352016

  • 5

    Dewan MCRattani AMekary RGlancz LJYunusa IBaticulon RE: Global hydrocephalus epidemiology and incidence: systematic review and meta-analysis. J Neurosurg 130:106510792019

  • 6

    Drake JMKestle JRMilner RCinalli GBoop FPiatt J Jr: Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 43:2943051998

  • 7

    Ellegala DBSimpson LMayegga ENuwas ESamo HNaman N: Neurosurgical capacity building in the developing world through focused training. J Neurosurg 121:152615322014

  • 8

    Emejulu JKUgwu JO: Combating complications following ventriculoperitoneal shunting in a new centre. Pediatr Neurosurg 45:4464502009

  • 9

    Flannery AMMitchell L: Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 1: Introduction and methodology. J Neurosurg Pediatr 14 (Suppl 1):372014

  • 10

    Gathura EPoenaru DBransford RAlbright AL: Outcomes of ventriculoperitoneal shunt insertion in Sub-Saharan Africa. J Neurosurg Pediatr 6:3293352010

  • 11

    Kulkarni AVDrake JMKestle JRMallucci CLSgouros SConstantini S: Endoscopic third ventriculostomy vs cerebrospinal fluid shunt in the treatment of hydrocephalus in children: a propensity score-adjusted analysis. Neurosurgery 67:5885932010

  • 12

    Kulkarni AVSchiff SJMbabazi-Kabachelor EMugamba JSsenyonga PDonnelly R: Endoscopic treatment versus shunting for infant hydrocephalus in Uganda. N Engl J Med 377:245624642017

  • 13

    Laurence KMCoates S: The natural history of hydrocephalus. Detailed analysis of 182 unoperated cases. Arch Dis Child 37:3453621962

  • 14

    Mugamba JStagno V: Indication for endoscopic third ventriculostomy. World Neurosurg 79 (2 Suppl):20.e1920.e232013

  • 15

    Muir RTWang SWarf BC: Global surgery for pediatric hydrocephalus in the developing world: a review of the history, challenges, and future directions. Neurosurg Focus 41(5):E112016

  • 16

    Mwachaka PMObonyo NGMutiso BKRanketi SMwang’ombe N: Ventriculoperitoneal shunt complications: a three-year retrospective study in a Kenyan national teaching and referral hospital. Pediatr Neurosurg 46:152010

  • 17

    Mwang’ombe NJOmulo T: Ventriculoperitoneal shunt surgery and shunt infections in children with non-tumour hydrocephalus at the Kenyatta National Hospital, Nairobi. East Afr Med J 77:3863902000

  • 18

    Paulsen AHLundar TLindegaard KF: Pediatric hydrocephalus: 40-year outcomes in 128 hydrocephalic patients treated with shunts during childhood. Assessment of surgical outcome, work participation, and health-related quality of life. J Neurosurg Pediatr 16:6336412015

  • 19

    Salvador SFHenriques JCMunguambe MVaz RMBarros HP: Hydrocephalus in children less than 1 year of age in northern Mozambique. Surg Neurol Int 5:1752014

  • 20

    Simon TDHall MRiva-Cambrin JAlbert JEJeffries HELafleur B: Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 4:1561652009

  • 21

    Sims-Williams HJSims-Williams HPKabachelor EMFotheringham JWarf BC: Ten-year survival of Ugandan infants after myelomeningocele closure. J Neurosurg Pediatr 19:70762017

  • 22

    Townsend CMBeauchamp RDEvers BMMattox KL (eds): Sabiston Textbook of Surgery ed 20. Philadelphia: Elsevier Saunders2017

  • 23

    Tunkel ARHasbun RBhimraj AByers KKaplan SLMichael Scheld W: 2017 Infectious Diseases Society of America’s clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis 64:e34e652017

  • 24

    Warf BC: Congenital idiopathic hydrocephalus of infancy: the results of treatment by endoscopic third ventriculostomy with or without choroid plexus cauterization and suggestions for how it works. Childs Nerv Syst 29:9359402013

  • 25

    Warf BC: Hydrocephalus in Uganda: the predominance of infectious origin and primary management with endoscopic third ventriculostomy. J Neurosurg 102 (1 Suppl):1152005

  • 26

    Warf BCMugamba JKulkarni AV: Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus in Uganda: report of a scoring system that predicts success. J Neurosurg Pediatr 5:1431482010

  • 27

    Warf BCTracy SMugamba J: Long-term outcome for endoscopic third ventriculostomy alone or in combination with choroid plexus cauterization for congenital aqueductal stenosis in African infants. J Neurosurg Pediatr 10:1081112012

  • 28

    The World Bank: Mortality rate, under-5 (per 1,000 live births). The World Bank. The World Bank Group ( [Accessed March 18 2019]




All Time Past Year Past 30 Days
Abstract Views 151 151 151
Full Text Views 24 24 24
PDF Downloads 12 12 12
EPUB Downloads 0 0 0


Google Scholar