Five-year survival and outcome of treatment for postinfectious hydrocephalus in Ugandan infants

Clinical article

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Object

Neonatal infection is the most common cause of infant hydrocephalus in Uganda. Postinfectious hydrocephalus (PIH) is often accompanied by primary brain injury from the original infection. Since 2001, ETV (with or without choroid plexus cauterization) has been our primary treatment for PIH. The long-term outcome in these children is unknown.

Methods

We studied the 5-year outcome in a cohort of 149 infants treated for PIH from 2001 to 2005 and who lived in 4 districts close to the hospital. Survival analysis was performed using the Kaplan-Meier method. Statistical significance was determined using the Fisher, Breslow, and log-rank tests.

Results

The patients' mean age at presentation was 9.5 months (median 3.0 months). Eighty-four patients (56.4%) were successfully treated without a shunt. Operative mortality was 1.2% for ETV and 4.4% for shunt placement (p = 0.3). Five-year survival was 72.8% in the non–shunt-treated group and 67.6% in the shunt-treated group, with no difference in survival (log rank p = 0.43, Breslow p = 0.46). Of 43 survivors assessed at 5–11 years, those with shunts had significantly worse functional outcomes (p = 0.003–0.035), probably reflecting treatment selection bias since those with the worst sequelae of ventriculitis were more likely to be treated with shunt placement.

Conclusions

Nearly one-third of treated infants died within 5 years, and at least one-third of the survivors were severely disabled. There was no survival advantage for non–shunt-treated patients at 5 years. A randomized trial of endoscopic third ventriculostomy versus shunt placement for treating PIH may be indicated. Public health measures that prevent these infections are urgently needed.

Abbreviations used in this paper: CCHU = CURE Children's Hospital of Uganda; CPC = choroid plexus cauterization; ETV = endoscopic third ventriculostomy; PIH = postinfectious hydrocephalus; VP = ventriculoperitoneal.

Article Information

Address correspondence to: Benjamin C. Warf, M.D., Department of Neurosurgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, Massachusetts 02115. email: benjamin.warf@childrens.harvard.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Endoscopic view of the cerebral aqueduct in a child with PIH. The posterior commissure is seen in the upper third of the image. Note diffuse punctate inflammatory deposits and obstructing membrane over the aqueduct with only a pinhole-sized opening.

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    Flowchart demonstrating the treatment path for 149 patients in the study cohort.

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    Kaplan-Meier survival curves. Left: Graph showing survival curves for ETV with or without CPC and shunt treatment. The time points at which patients were lost to follow-up (without known subsequent death) are shown as censored (short vertical marks). For those patients known to have died but for whom the date of death was not known, the time of last encounter was considered the length of survival. Patients who reached 60 months' survival and who might have subsequently died were also censored for statistical calculations (but not marked). Note that there is a trend toward early and late shunt failures, but global statistical comparisons of the curves show that there is no overall statistical difference between the survival groups (p > 0.4 for both log-rank and Breslow generalized Wilcoxon tests). Right: Graph showing 95% CIs (broken lines, blue for ETV and green for shunt treatment) for the cumulative survival functions using Greenwood's formula (Mathworks implementation), demonstrating that the survival curves at all survival times remain within each others' CIs with the solitary exception of the shunt curve at 12 months.

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    Noncontrast axial CT scan of the brain obtained in a 5-month-old girl with a history of fever and seizures at 1 month of age and rapid development of macrocephaly. Note the severe, diffuse parenchymal destruction. A tapping reservoir was placed to externally drain CSF for 2 weeks until it was sufficiently clear. Ventriculoscopy revealed severe, diffuse ependymal scar, yellow intraventricular inflammatory deposits, and an occluded aqueduct. Endoscopic third ventriculostomy revealed arachnoid scarring within the prepontine cistern. Treatment with ETV/CPC failed and a VP shunt was placed 1 month later.

References

1

Li LPadhi ARanjeva SLDonaldson SCWarf BCMugamba J: Association of bacteria with hydrocephalus in Ugandan infants. Clinical article. J Neurosurg Pediatr 7:73872011

2

Warf BC: Comparison of 1-year outcomes for the Chaabra and Codman-Hakim Micro Precision shunt systems in Uganda: a prospective study in 195 children. J Neurosurg 102:4 Suppl3583622005

3

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

4

Warf BC: Hydrocephalus associated with neural tube defects: characteristics, management, and outcome in sub-Saharan Africa. Childs Nerv Syst (in press)

5

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

6

Warf BCAlkire BCBhai SHughes CSchiff SVincent JR: Costs and benefits of neurosurgical intervention for infant hydrocephalus in sub-Saharan Africa. Clinical article. J Neurosurg Pediatr 8:5095212011

7

Warf BCCampbell JW: Combined endoscopic third ventriculostomy and choroid plexus cauterization as primary treatment of hydrocephalus for infants with myelomeningocele: long-term results of a prospective intent-to-treat study in 115 East African infants. Clinical article. J Neurosurg Pediatr 2:3103162008

8

Warf BCCampbell JWRiddle E: Initial experience with combined endoscopic third ventriculostomy and choroid plexus cauterization for post-hemorrhagic hydrocephalus of prematurity: the importance of prepontine cistern status and the predictive value of FIESTA MRI imaging. Childs Nerv Syst 27:106310712011

9

Warf BCDewan MMugamba J: Management of Dandy-Walker complex–associated infant hydrocephalus by combined endoscopic third ventriculostomy and choroid plexus cauterization. Clinical article. J Neurosurg Pediatr 8:3773832011

10

Warf BCKulkarni AV: Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on success of endoscopic third ventriculostomy in 403 African children. Clinical article. J Neurosurg Pediatr 5:2042092010

11

Warf BCOndoma SKulkarni ADonnelly RAmpeire MAkona J: Neurocognitive outcome and ventricular volume in children with myelomeningocele treated for hydrocephalus in Uganda. Clinical article. J Neurosurg Pediatrics 4:5645702009

12

Warf BCStagno VMugamba J: Encephalocele in Uganda: ethnic distinctions in lesion location, endoscopic management of hydrocephalus, and survival in 110 consecutive children. Clinical article. J Neurosurg Pediatr 7:88932011

13

Warf BCWright EJKulkarni AV: Factors affecting survival of infants with myelomeningocele in southeastern Uganda. Clinical article. J Neurosurg Pediatr 7:1271332011

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