Preoperative risk and postoperative outcome from subdural fluid collections in African infants with postinfectious hydrocephalus

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  • 1 Department of Neurosurgery, Penn State College of Medicine, Hershey;
  • | 2 Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park;
  • | 3 Department of Public Health Sciences, Penn State College of Medicine, Hershey;
  • | 4 School of Electrical Engineering and Computer Science, The Pennsylvania State University, University Park;
  • | 5 Department of Physics, The Pennsylvania State University, University Park, Pennsylvania;
  • | 6 CURE Children’s Hospital of Uganda, Mbale;
  • | 7 Mulago National Referral Hospital, Kampala, Uganda;
  • | 8 Division of Neurosurgery, University of Toronto, Hospital for Sick Children, Toronto;
  • | 9 Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; and
  • | 10 Department of Neurosurgery, Boston Children’s Hospital and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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OBJECTIVE

This study investigated the incidence of postoperative subdural collections in a cohort of African infants with postinfectious hydrocephalus. The authors sought to identify preoperative factors associated with increased risk of development of subdural collections and to characterize associations between subdural collections and postoperative outcomes.

METHODS

The study was a post hoc analysis of a randomized controlled trial at a single center in Mbale, Uganda, involving infants (age < 180 days) with postinfectious hydrocephalus randomized to receive either an endoscopic third ventriculostomy plus choroid plexus cauterization or a ventriculoperitoneal shunt. Patients underwent assessment with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III; sometimes referred to as BSID-III) and CT scans preoperatively and then at 6, 12, and 24 months postoperatively. Volumes of brain, CSF, and subdural fluid were calculated, and z-scores from the median were determined from normative curves for CSF accumulation and brain growth. Linear and logistic regression models were used to characterize the association between preoperative CSF volume and the postoperative presence and size of subdural collection 6 and 12 months after surgery. Linear regression and smoothing spline ANOVA were used to describe the relationship between subdural fluid volume and cognitive scores. Causal mediation analysis distinguished between the direct and indirect effects of the presence of a subdural collection on cognitive scores.

RESULTS

Subdural collections were more common in shunt-treated patients and those with larger preoperative CSF volumes. Subdural fluid volumes were linearly related to preoperative CSF volumes. In terms of outcomes, the Bayley-III cognitive score was linearly related to subdural fluid volume. The distribution of cognitive scores was significantly different for patients with and those without subdural collections from 11 to 24 months of age. The presence of a subdural collection was associated with lower cognitive scores and smaller brain volume 12 months after surgery. Causal mediation analysis demonstrated evidence supporting both a direct (76%) and indirect (24%) effect (through brain volume) of subdural collections on cognitive scores.

CONCLUSIONS

Larger preoperative CSF volume and shunt surgery were found to be risk factors for postoperative subdural collection. The size and presence of a subdural collection were negatively associated with cognitive outcomes and brain volume 12 months after surgery. These results have suggested that preoperative CSF volumes could be used for risk stratification for treatment decision-making and that future clinical trials of alternative shunt technologies to reduce overdrainage should be considered.

ABBREVIATIONS

Bayley-III = Bayley Scales of Infant and Toddler Development, Third Edition; ETV/CPC = endoscopic third ventriculostomy plus choroid plexus cauterization; ITT = intention to treat; PIH = postinfectious hydrocephalus; TR = treatment received; VPS = ventriculoperitoneal shunt.

Supplementary Materials

    • Supplementary Figs. 1 and 2 (PDF 689 KB)

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