Neurosurgery Education and Development program to treat hydrocephalus and to develop neurosurgery in Africa using mobile neuroendoscopic training

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OBJECT

A shortage of neurosurgeons and a lack of knowledge of neuroendoscopic management of hydrocephalus limits modern care in sub-Saharan Africa. Hence, a mobile teaching project for endoscopic third ventriculostomy (ETV) procedures and a subsequent program to develop neurosurgery as a permanent specialty in Kenya and Zanzibar were created and sponsored by the Neurosurgery Education and Development (NED) Foundation and the Foundation for International Education in Neurological Surgery. The objective of this work was to evaluate the results of surgical training and medical care in both projects from 2006 to 2013.

METHODS

Two portable neuroendoscopy systems were purchased and a total of 38 ETV workshops were organized in 21 hospitals in 7 different countries. Additionally, 49 medical expeditions were dispatched to the Coast General Hospital in Mombasa, Kenya, and to the Mnazi Moja Hospital in Zanzibar.

RESULTS

From the first project, a total of 376 infants with hydrocephalus received surgery. Six-month follow-up was achieved in 22%. In those who received follow-up, ETV efficacy was 51%. The best success rates were achieved with patients 1 year of age or older with aqueductal stenosis (73%). The main causes of hydrocephalus were infection (56%) and spina bifida (23%). The mobile education program interacted with 72 local surgeons and 122 nurses who were trained in ETV procedures. The second project involved 49 volunteer neurosurgeons who performed a total of 360 nonhydrocephalus neurosurgical operations since 2009. Furthermore, an agreement with the local government was signed to create the Mnazi Mmoja NED Institute in Zanzibar.

CONCLUSIONS

Mobile endoscopic treatment of hydrocephalus in East Africa results in reasonable success rates and has also led to major developments in medicine, particularly in the development of neurosurgery specialty care sites.

ABBREVIATIONSETV = endoscopic third ventriculostomy; FIENS = Foundation for International Education in Neurological Surgery; NED = Neurosurgery Education and Development.

Abstract

OBJECT

A shortage of neurosurgeons and a lack of knowledge of neuroendoscopic management of hydrocephalus limits modern care in sub-Saharan Africa. Hence, a mobile teaching project for endoscopic third ventriculostomy (ETV) procedures and a subsequent program to develop neurosurgery as a permanent specialty in Kenya and Zanzibar were created and sponsored by the Neurosurgery Education and Development (NED) Foundation and the Foundation for International Education in Neurological Surgery. The objective of this work was to evaluate the results of surgical training and medical care in both projects from 2006 to 2013.

METHODS

Two portable neuroendoscopy systems were purchased and a total of 38 ETV workshops were organized in 21 hospitals in 7 different countries. Additionally, 49 medical expeditions were dispatched to the Coast General Hospital in Mombasa, Kenya, and to the Mnazi Moja Hospital in Zanzibar.

RESULTS

From the first project, a total of 376 infants with hydrocephalus received surgery. Six-month follow-up was achieved in 22%. In those who received follow-up, ETV efficacy was 51%. The best success rates were achieved with patients 1 year of age or older with aqueductal stenosis (73%). The main causes of hydrocephalus were infection (56%) and spina bifida (23%). The mobile education program interacted with 72 local surgeons and 122 nurses who were trained in ETV procedures. The second project involved 49 volunteer neurosurgeons who performed a total of 360 nonhydrocephalus neurosurgical operations since 2009. Furthermore, an agreement with the local government was signed to create the Mnazi Mmoja NED Institute in Zanzibar.

CONCLUSIONS

Mobile endoscopic treatment of hydrocephalus in East Africa results in reasonable success rates and has also led to major developments in medicine, particularly in the development of neurosurgery specialty care sites.

Hydrocephalus in sub-Saharan Africa occurs mainly in infants and is vastly undertreated. Hydrocephalus is frequently associated with infection, and estimates suggest that 100,000 newborns26 will develop the illness during their first year.17–19 The result is a regional health crisis with a devastating rate of death and permanent disability. The management of hydrocephalus in developing countries is challenging due to lack of resources and trained staff. Europe has roughly 1 neurosurgeon per 100,000 inhabitants, while in this region of Africa 1 specialist cares for more than 7 million people on average. Estimates indicate that less than 5% of children with hydrocephalus in Africa receive standard shunt surgery each year; however, due to multiple factors, including infection of permanent implants, the failure rate of shunt surgery performed on the children who actually receive it ranges from 25% to 50%.14,18,19

Placement of a ventriculoperitoneal shunt creates lifetime dependency. In addition to the need for periodic monitoring, this surgery presents numerous complications such as infections or mechanical malfunctions, and local doctors are often not qualified to find a solution.1,13,20 More importantly, widespread shunt surgery is presently impractical in Africa due to financial, social, and sanitary conditions, adding to the economic burden for families, and follow-up and re-evaluation of patients is often impossible if problems arise.

An alternative, and minimally invasive, treatment is endoscopic third ventriculostomy (ETV).5,8,11 In ETV, the floor of the third ventricle is perforated, creating a natural bypass through which CSF drains toward the subarachnoid spaces. In selected patients, ETV is the safer option in a limited context such as sub-Saharan Africa.17–19,25 Innovative studies by Warf and others have shown that ETV can improve hydrocephalus in more than 70% of cases,28 with a low rate of complications (approximately 5%) and a normalizing of CSF dynamics.2

A mobile neuroendoscopy training program was developed in 2006 by the Neurosurgery Education and Development (NED) Foundation and the Foundation for International Education in Neurological Surgery (FIENS). The NED Foundation is dedicated to providing neurosurgical education in East Africa, and FIENS to the development of neurosurgical training and service in developing countries.6 This program was aimed at training local neurosurgeons and nurses in different hospitals and countries in sub-Saharan Africa to perform ETV with the aid of a mobile system. This system partly compensates for the shortage of qualified personnel as it can be used by a single local surgeon who can cover a large region including several hospitals, and also reach provincial hospitals in distant rural areas.

The objective of this report is to describe the results of this program between 2006 and 2013, together with the unexpected outcome of multinational contact between neurosurgeons, and the launch of a subsequent project to develop specialized neurosurgery centers in this region of Africa.

Methods

Between 2006 and 2013, a medical team composed of 3 neurosurgeons (M.M.Q., P.H.Y., and J.P.) developed an educational and health care project aimed at establishing neuroendoscopy as an initial treatment for infant hydrocephalus in various sub-Saharan countries. This project involved the acquisition of portable neuroendoscopic equipment and the implementation of an educational program to train local staff. By teaching in 21 hospitals and in 7 countries, this team hoped to rapidly achieve familiarity with this methodology, and also establish the regional contacts needed for ongoing educational programs.

The neuroendoscopic device consists of a display unit with a camera and a light source manufactured to be conveniently transported in a single suitcase (Telepack, Karl Storz). It includes a rigid-rod neuroendoscope that is equally versatile and easy to use, the Oi Handy-Pro, with a 0° autoclavable Hopkins II telescope.16 The system can be used with 1 hand, thus allowing the surgeon to safely perform the endoscopic fenestration without assistance (Fig. 1).

FIG. 1.
FIG. 1.

A mobile compact neuroendoscopy system. The equipment incorporates a processing unit combined with a camera and light source. The Oi Handy-Pro, Hopkins II endoscope enables neuroendoscopy to be performed by a single neurosurgeon. Figure is available in color online only.

Educational Resources

Since August 2006, 87 NED medical missions have been organized. These missions included 38 ETV training experiences in the form of conferences, seminars, handson courses, and supervised surgeries in hospitals from East, Central, and South Africa.

Hydrocephalus Patient Characteristics

Patients treated with this mobile equipment were under the age of 18, with clinical symptoms of hypertensive hydrocephalus confirmed through ultrasonography, and CT when available. ETV was performed through a bur hole or frontal fontanel. Fenestration of the floor of the third ventricle was achieved using a conventional technique and without choroid plexus cauterization, because a suitable bipolar or monopolar coagulator is not available in most hospitals. Patient follow-up was very complex due to the peculiarities of this interhospital international project within the context of extreme poverty. The intervention was considered effective when no subsequent hydrocephalus procedure was necessary within 6 months after ETV.

Results

Surgical Outcomes

Over a period of 7 years, 38 ETV mobile endoscopic workshops were held in 21 different hospitals, during which 376 children with hydrocephalus received surgery using only 2 mobile devices. Most of the interventions were performed in regional hospitals in rural areas with poor health infrastructures and lack of neurosurgical care services (Table 1). Six-month follow-up was completed in only 84 cases (22%) due to both the mobile nature of the training and the difficulty of travel for patients and families. Patients with complete follow-up were classified according to age and status of the aqueduct of Sylvius (Table 2). Most of these cases presented with a history of infection (56%), followed by hydrocephalus related to spina bifida (23%). Approximately one-fifth of the patients (21%) had noninfectious hydrocephalus of other origin.

TABLE 1

Endoscopic third ventriculostomy workshops held in East Africa by NED Foundation teams from 2006 to 2013

HospitalYearCityCountryNo. of ETVs Performed
Kenyatta Hospital2006NairobiKenya8
Nyeri Provincial Hospital2006NyeriKenya1
Aga Khan Hospital2007KisumuKenya2
Aga Khan Hospital2007MombasaKenya4
Aga Khan University Hospital2007NairobiKenya6
Coast Provincial General Hospital2007MombasaKenya6
Kenyatta Hospital2007NairobiKenya16
Kijabe Mission Hospital2007Rift ValleyKenya6
Muhimbili Orthopaedic Institute2007Dar es SalaamTanzania6
Bethel Teaching General Hospital2008Addis AbabaEthiopia3
Black Lion Hospital2008Addis AbabaEthiopia3
Kenyatta Hospital2008NairobiKenya24
Kigali National Hospital2008KigaliRwanda2
Mnazi Mmoja Hospital2008ZanzibarTanzania4
Moi Teaching and Referral Hospital2008EldoretKenya5
Muhimbili Orthopaedic Institute2008Dar es SalaamTanzania30
Mulago Hospital Complex2008KampalaUganda5
Myunsung Christian Mission2008Addis AbabaEthiopia4
Kenyatta Hospital2009NairobiKenya36
Kigali National Hospital2009KigaliRwanda8
Mnazi Mmoja Hospital2009ZanzibarTanzania6
Gertrude's Garden Children's Hospital2010NairobiKenya6
Kenyatta Hospital2010NairobiKenya14
Mewa Hospital2010MombasaKenya5
Mnazi Mmoja Hospital2010ZanzibarTanzania24
Neurospine Center2010JartumSudan5
Police Hospital2010MandaniSudan4
Coast Provincial General Hospital2011MombasaKenya16
Kenyatta Hospital2011NairobiKenya1
Mnazi Mmoja Hospital2011ZanzibarTanzania13
Muhimbili Orthopaedic Institute2011Dar es SalaamTanzania2
Bugando Teaching Hospital2012MwanzaTanzania6
Coast Provincial General Hospital2012MombasaKenya14
Mnazi Mmoja Hospital2012ZanzibarTanzania26
Bugando Teaching Hospital2013MwanzaTanzania7
Harare Central Hospital2013HarareZimbabwe11
Mnazi Mmoja Hospital2013ZanzibarTanzania33
Nyeri Provincial Hospital2013NyeriKenya4
Total376
TABLE 2

Patient classification according to age and state of the aqueduct of Sylvius for those who completed the 6-month follow-up evaluation

TypeAge (yrs)Aqueduct of SylviusNo. of Cases
A<1Open39
B≥1Open9
C<1Closed21
D≥1Closed15

The efficacy of ETV in patients with complete followup was 51%, which correlated with age, status of the fourth ventricle, and clinical history (Table 3). The group with the best results was patients with hydrocephalus of at least 1-year progression with or without a history of infection.

TABLE 3

Endoscopic third ventriculostomy outcomes according to patient group and cause of hydrocephalus

CauseNo. of Patients (%)Type of Patient:* ETV Success (%)
Hydrocephalus secondary to infection47 (56)A: 9/22 (41)
B: 4/7 (57)
C: 6/10 (60)
D: 5/8 (62)
Hydrocephalus not associated w/ infection (& other than spina bifida)18 (21)A: 2/6 (33)
B: 1/2 (50)
C: 1/3 (33)
D: 6/7 (86)
Hydrocephalus related to myelomeningocele19 (23)A: 5/11 (45)
C: 4/8 (50)

According to the classification in Table 2.

Neuroendoscopy Training Program

The program gave local staff of both neurosurgeons and nurses specialized training in sterilization, neuroendoscopic procedures, and equipment maintenance. Overall, 72 local surgeons (38 neurosurgeons and 34 resident clinicians) and 122 ward nurses were trained with the same 2 portable endoscopic systems. Currently, 5 more neuroendoscopes have been donated to hospitals located in Kenya, Rwanda, Uganda, Tanzania, and Sudan, and 20 surgeons continue to use the technique. Thus, by the time the mobile unit left, there were 7 neurosurgeons in Kenya, 3 in Uganda, 3 in Tanzania, 3 in Zimbabwe, 2 in Rwanda, 1 in Ethiopia, and 1 in Sudan with the ability to independently perform ETV.

This project stimulated the interest of local clinicians to train as neurosurgeons and adapt these techniques to their own medical practice. This lasting contribution of the program—which is the most promising interaction between NED, FIENS, and local clinicians—drew the attention of the Kenyan and Zanzibar health ministries, creating new projects for the development of neurosurgery in these countries.

Project for the Comprehensive Development of Neurosurgery

In this context, two parallel programs to develop neurosurgery at the Coast General Hospital in Mombasa, Kenya, and at the Mnazi Moja Hospital in Zanzibar have been established since 2009. These programs are being organized by 49 volunteer neurosurgeons, mainly from Spain but also from other European, American, and African hospitals during monthly expeditions (Table 4). Between 2009 and 2013, thousands of patients have been examined in the framework of these programs, and a total of 360 neurosurgical interventions, apart from hydrocephalus, have been performed to treat other pathologies (Table 5). In addition, 87 volunteers from 8 other medical specialties are presently involved in the development of nursing, intensive care, anesthesiology, radiology, traumatology internal medicine, pediatrics, otolaryngology, plastic surgery, and obstetrics/gynecology (Table 6).

TABLE 4

Neurosurgery Education and Development volunteer neurosurgeons by hospital and city

Work CenterCity, Province, or StateCountryNo. of Neurosurgeons
Hospital Univ. de Álava (Sede Santiago Apóstol)ÁlavaSpain1
Hospital Univ. Central de AsturiasAsturiasSpain3
Hospital Santa Creu I Santa PauBarcelonaSpain3
Hospital del MarBarcelonaSpain3
Hospital Dr. Josep TruetaGeronaSpain1
Hospital Univ. Virgen de las NievesGranadaSpain1
Complejo Hospitalario Universitario de la CoruñaLa CoruñaSpain2
Hospital Universitario Dr. NegrinLas Palmas De Gran CanariaSpain1
Complejo Hospitalario de LeónLeónSpain1
Hospital Clínico San CarlosMadridSpain1
Hospital 12 de OctubreMadridSpain1
Hospital General Universitario Gregorio MarañonMadridSpain1
Hospital Univeristario la PazMadridSpain1
Hospital Univ. Virgen de ArrixacaMurciaSpain1
Hospital Univ. Virgen del RocíoSevilleSpain1
Hospital Ntra. Sra. de la CandelariaSta. Cruz De TenerifeSpain5
Hospital Universitario la FeValenciaSpain2
Hospital Universitario de la RiberaValenciaSpain4
Hospital Univ. Miguel ServetZaragozaSpain3
Nemocnice eske Bud jovice, A.S.Bud joviceCzech Republic1
Masaryk HospitalJilemniceCzech Republic1
Hospital de Egas MonizLisbonPortugal3
St. Louis UniversityMissouriUS1
University of Wisconsin Hospital & ClinicsWisconsinUS1
Aga Khan University HospitalNairobiKenya1
Kenyatta General HospitalMombasaKenya2
Coast General Provincial HospitalMombasaKenya1
Mnazi Mmoja HospitalZanzibarTanzania2
Total49
TABLE 5

Interventions, other than ETV procedures, performed at the Coast General Hospital in Mombasa, Kenya, and at the Mnazi Moja Hospital in Zanzibar (2009–2013)

Type20092010201120122013Total
Spinal microsurgery231153135114
Brain tumor524242626105
Spinal trauma21026727
Spina bifida2476423
Brain trauma091514846
Other3812418
Infections00301013
Skull111508
Spinal tumor006006
Total360
TABLE 6

Neurosurgery Education and Development volunteers by medical specialty

SpecialtyTotal
Neurosurgery49
Pediatrics/gynecology12
Intensive care/anesthesia12
Traumatology6
General & plastic surgery5
Internal medicine3
Otolaryngology2
Radiology2
Nursing45
Total136

During one of the teams' expeditions to Zanzibar in August 2009, the first brain tumor operation in the history of the island was performed on an 18-month-old child with giant brain neoplasia, who was comatose. The intervention was successful and the patient was discharged from the hospital after 1 week (Fig. 2). This event received a great deal of media attention throughout the region, and even the President of the Republic showed an interest in the case. As a result, the Zanzibar Ministry of Health signed an agreement to create a Neurosurgery and Neurocritical Care Institute at the Mnazi Mmoja Hospital. The contract to build the Mnazi Mmoja NED Institute was signed in June 2013. The third phase of construction, financed by the NED Foundation, was started in December 2013 (Fig. 3). The role of this international institute, which will include 2 operating rooms, 1 intensive care unit, 3 wards, and 2 examination rooms, is to improve neurosurgical care in Zanzibar and train African neurosurgeons in this specialized field. When we started our project, there were 21 neurosurgeons in East Africa, a region of some 300 million people. The total number of neurosurgeons in the whole region has increased from 21 to 40 in the 7 years since the project was begun.

FIG. 2.
FIG. 2.

Preoperative (left) and postoperative (right) axial CT scans from the first brain tumor operation in the history of Zanzibar.

FIG. 3.
FIG. 3.

The completed Mnazi Mmoja NED Institute in January 2015. The role of this international institute, which will include 2 operating rooms, 1 intensive care unit, 3 wards, and 2 examination rooms, is to improve neurosurgical care in Zanzibar and train African neurosurgeons in this specialized field. Figure is available in color online only.

Discussion

Ventriculostomy of the third ventricle was described by Jarvis in 1949 as one of the most attractive options to treat hydrocephalus in developing countries.9 Due to the great number of unforeseen difficulties, both infectious and mechanical, and the absence of neurosurgical care services, this procedure is a safe alternative to high-risk shunt surgery in the context of poverty18,19 and infection, as well as preventing life-long dependence on a shunt.

It should be emphasized that the initial success of ETV suggests the likelihood of long-term positive results. According to Warf,25 initial success of ETV within 6 months is associated with a 95% success rate after 3 years. Therefore, this indicates that caregivers, policy makers, and families must be made aware of the need to clinically monitor patients, at least during the first year following surgery. This can only be completed by the repeated presence and the development of a health infrastructure beyond an isolated procedure.

Patient follow-up during this project was complicated, in spite of our efforts to raise awareness; for many, travel is difficult, and many families cannot afford to travel long distances and pay for extended stays away from their homes. Because of these difficulties, more than 77% of the initial sample was lost to follow-up within 6 months of the postoperative period. Despite obvious limitations, our success rate is particularly significant because inclusion and exclusion criteria for patients were not taken into consideration, and we expected a higher rate of problems with the children who continued to be cared for at the hospitals.5,8,15 It is possible in this setting that successful cases would be less likely to return to the hospital for follow-up evaluation.

The clinical presentation of hydrocephalus in Africa significantly differs from that in the Western world. Infection is rife, and the patients are often only brought for care at an advanced stage of ventriculomegaly.4,17–19,21,22,24,25,29 In the current setting, the effectiveness of ETV was 51%, which is only slightly lower than that reported in other patient series in a similar geographic context.22,24,25,29 A possible reason for this is that we were unable to perform choroid plexus coagulation, as suggested by Warf et al.22–24,27 In addition, we realize that children healthy after ETV may not return for follow-up due to travel and cost limitations. To improve follow-up, contacts are currently being made with mobile cell phone companies and other corporate donors to obtain cell phones with airtime for every child who has undergone an ETV procedure. The parent/ mother is taught how to check head circumference and asked to send monthly reports with a picture and milestone to our database. This program has begun in Sudan, but no reports are yet available.

As shown in Table 3, favorable results are associated with age (> 1 year), stenosis of the aqueduct of Sylvius, and absence of infection. There is some evidence to suggest that age in infants could correlate negatively with failure of ETV procedures. A number of studies of ETV in young infants (< 1 year of age) have been published since 1990.3,7,10,12,22 In patients less than 1 year of age, Javadpour et al.10 observed a success rate of 48%, with the best outcomes in patients with congenital aqueduct stenosis (71%). Koch and Wagner12 reported a 31% success rate of ETV, whereas Warf,22 whose surgeries included choroid plexus cauterization, reported a 47% success rate. In our series, the success rate was 45% for patients under 1 year of age, with a better prognosis for patients with a closed aqueduct of Sylvius (52%), independent of the cause of hydrocephalus. In patients over 1 year of age the success rate was 67%, with best results in children with a closed aqueduct of Sylvius (73%), irrespective of whether the hydrocephalus had an infectious origin.

Success rates were slightly lower in patients with infection (51%) than in those without (56%). Nevertheless, even in the case of infectious hydrocephalus, good results were obtained in 60% of children over the age of 1 year, or in those under 1 year with a closed aqueduct of Sylvius, and in 41% of children under 1 year with an open aqueduct of Sylvius. This is possibly the most useful finding of the clinical part of our study, that ETV can be effective in hydrocephalus with a history of infection. This conclusion is consistent with results from previous studies.24,25

Because neuroimaging studies were lacking in most cases, preoperative evaluation of the brain was practically impossible and was performed in situ. Thus, anatomical abnormalities forced the interruption of the procedure in several cases. In this regard, guidelines are being drawn up in collaboration with the African Federation of Neurosurgical Societies to classify the endoscopic and anatomical findings from ETV. This will allow clinicians to adjust the diagnostic sensitivity of neuroendoscopy and direct future treatment.

Conclusions

Our NED project in Africa started in the summer of 2006 with the organization of the first workshop on endoscopic treatment of hydrocephalus. From there, the first group of local neurosurgeons learned the technique and extended its use to the entire region. One of the trainees, Dr. Mubashir Mahmood Qureshi, became a key trainer. Seventy-two surgeons have been trained and 20 local neurosurgeons are now able to perform ETV to treat hydrocephalus, with success rates similar to those already published, considering that no choroid plexus cauterization was performed. The data confirm that infectious hydrocephalus can also be successfully treated in Africa.

One crucial contribution to the success of this training program has been the repeated trips made by Dr. José Piquer to the site, as a result of which he saw a possibility of developing an even greater presence with two permanent training sites. This new Integral Development of Neurosurgery Project is under development thanks to the good will of Spanish neurosurgeons making monthly expeditions. Specifically, 87 expeditions have been organized so far, in which 136 voluntary professionals from 9 different specialties have made 312 trips to the region, performing approximately 100 operations annually, offering their time, effort, and knowledge, and even contributing toward the financial cost of the project. The outstanding outcome of this collaboration between NED, FIENS, and local government is the planned construction of the new Neurosurgery and Neurocritical Care Institute at the Mnazi Mmoja Hospital in collaboration with the Ministry of Health of Zanzibar.

The project has poured 2 million euros of health care and educational resources into one of the most impoverished regions of the planet, and has achieved international recognition as an innovative model of humanitarian help and a framework for health development achieved through multinational cooperation and involvement of local doctors and government.

Acknowledgments

We would like to thank all the volunteers who have participated in this project. Without their generosity, help, and work none of this would have been possible. The NED Foundation is registered in the Register of Foundations under no. 487; it meets good practice requirements for nongovernmental organizations and is audited by an external firm. The NED Foundation encourages and welcomes voluntary cooperation. More information can be gathered through the webpage at www.nedfundacion.org.

Author Contributions

Conception and design: Piquer. Acquisition of data: Piquer, Qureshi. Analysis and interpretation of data: Piquer. Drafting the article: all authors. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Piquer.

References

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    Aschoff AKremer PHashemi BKunze S: The scientific history of hydrocephalus and its treatment. Neurosurg Rev 22:67951999

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    Boulton MFlessner MArmstrong DHay JJohnston M: Determination of volumetric cerebrospinal fluid absorption into extracranial lymphatics in sheep. Am J Physiol 274:R88R961998

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    Buxton NMacarthur DMallucci CPunt JVloeberghs M: Neuroendoscopic third ventriculostomy in patients less than 1 year old. Pediatr Neurosurg 29:73761998

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    Cinalli GEndoscopic third ventriculostomy. Cinalli GMaixner WJSainte-Rose C: Pediatric Hydrocephalus MilanSpringer2004. 361388

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    Dempsey RJNakaji P: Foundation for International Education in Neurological Surgery (FIENS) global health and neurosurgical volunteerism. Neurosurgery 73:107010712013

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    Fritsch MJMehdorn M: Endoscopic intraventricular surgery for treatment of hydrocephalus and loculated CSF space in children less than one year of age. Pediatr Neurosurg 36:1831882002

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    Kamalo P: Exit ventriculoperitoneal shunt; enter endoscopic third ventriculostomy (ETV): contemporary views on hydrocephalus and their implications on management. Malawi Med J 25:78822013

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    Noorani SK: Complications of Ventriculoperitoneal Shunting Seen at the Kenyatta National Hospital: a Prospective Study September 2001–February 2002 [dissertation] Nairobi, KenyaUniversity of Nairobi2003

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    Oi SClassification and definition of hydrocephalus: origin, controversy and assignment of the terminology. Cinalli GSainte-Rose CMaixner WJ: Pediatric Hydrocephalus 2005. 95111

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    Oi SSamii ASamii M: Frameless free-hand maneuvering of a small-diameter rigid-rod neuroendoscope with a working channel used during high-resolution imaging. Technical note. J Neurosurg 102:1 Suppl1131182005

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    Piquer JQureshi MMYoung PH: Impact of mobile endoscopy on neurosurgical development in East Africa. World Neurosurg 73:2802842010

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    Qureshi MMPiquer Belloch J: Impact of a portable neuroendoscopic equipment system to provide an outreach service in Sub-Saharan Africa. J Hydrocephalus 1:11142009

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    Qureshi MMPiquer JYoung PH: Mobile endoscopy: a treatment and training model for childhood hydrocephalus. World Neurosurg 79:2 SupplS24.e1S24.e42013

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    Sarguna PLakshmi V: Ventriculoperitoneal shunt infections. Indian J Med Microbiol 24:52542006

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    Schiff SJRanjeva SLSauer TDWarf BC: Rainfall drives hydrocephalus in East Africa. J Neurosurg Pediatr 10:1611672012

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    Warf BC: Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children. J Neurosurg 103:6 Suppl4754812005

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    Warf BC: Endoscopic third ventriculostomy and choroid plexus cauterization for pediatric hydrocephalus. Clin Neurosurg 54:78822007

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    Warf BC: Hydrocephalus in Uganda: the predominance of infectious origin and primary management with endoscopic third ventriculostomy. J Neurosurg 102:1 Suppl1152005

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Article Information

Correspondence José Piquer, Neurosurgical Unit, Hospital Universitario de la Ribera, Carretera Corbera, km 1, Alzira 46600 (Valencia), Spain. email: jpiquer@hospital-ribera.com.

INCLUDE WHEN CITING Published online March 6, 2015; DOI: 10.3171/2014.10.PEDS14318.

DISCLOSURE Dr. Piquer belongs to the governing board of the NED Foundation.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A mobile compact neuroendoscopy system. The equipment incorporates a processing unit combined with a camera and light source. The Oi Handy-Pro, Hopkins II endoscope enables neuroendoscopy to be performed by a single neurosurgeon. Figure is available in color online only.

  • View in gallery

    Preoperative (left) and postoperative (right) axial CT scans from the first brain tumor operation in the history of Zanzibar.

  • View in gallery

    The completed Mnazi Mmoja NED Institute in January 2015. The role of this international institute, which will include 2 operating rooms, 1 intensive care unit, 3 wards, and 2 examination rooms, is to improve neurosurgical care in Zanzibar and train African neurosurgeons in this specialized field. Figure is available in color online only.

References

1

Aschoff AKremer PHashemi BKunze S: The scientific history of hydrocephalus and its treatment. Neurosurg Rev 22:67951999

2

Boulton MFlessner MArmstrong DHay JJohnston M: Determination of volumetric cerebrospinal fluid absorption into extracranial lymphatics in sheep. Am J Physiol 274:R88R961998

3

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