Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda

The Landscape of Pediatric Hydrocephalus in the Province of KwaZulu-Natal: A Comparative Analysis of the Referral Pattern, Etiology, and Management Outcomes in 4 Distinct 5-Year Periods

BACKGROUND

Pediatric hydrocephalus is a significant health burden globally, particularly in low- and middle-income countries. Data from specific regions such as KwaZulu-Natal, South Africa, are lacking. This study aimed to investigate pediatric hydrocephalus by comparing 4 distinct 5-year periods.

METHODS

Data were collected retrospectively (2003-2007, 2008-2012, and 2013-2017) and prospectively (2018-2022). Children (≤18 years old) treated for hydrocephalus were included. Data on demographics, referral patterns, etiology, treatment modalities, and outcomes were collected and analyzed.

RESULTS

A total of 3325 children were treated. The peak period was 2008-2012 (35.3%). Most children (51.4%) were from rural areas (P = 0.013), and 47.9% were referred from regional hospitals (P < 0.001). Boys (56.4%) and infants (60.2%) were predominant groups (P < 0.001). Postinfectious etiology (32.7%) was predominant (P < 0.001), particularly tuberculous meningitis (54.1%). Ventriculoperitoneal shunts were the mainstay treatment (84.2%), with notable complication rates (20.4%), including infections (9.6%). Human immunodeficiency virus co-infection was diagnosed in 2.5% of cases. Weekend procedures were associated with ventriculoperitoneal shunt complications (hazard ratio [HR] = 1.3, 95% confidence [CI]1.03-1.66, P = 0.03). Mortality rate was 7.9%, and age ≥1 year (HR = 2.43, 95% CI 1.87-3.17, P < 0.001), tertiary hospital referral (HR = 1.48, 95% CI 1.06-2.04, P = 0.019), ventriculoperitoneal shunt infection (HR = 3.63, 95% CI 2.66-4.95, P < 0.001), acute abdomen (HR = 2.17, 95% CI 1.11-4.25, P = 0.024), and pneumonia (HR = 7.32, odds ratio = 4.84-11.06, P < 0.001) were associated with mortality.

CONCLUSIONS

This study provides comprehensive insights into pediatric hydrocephalus in KwaZulu-Natal. Monitoring temporal trends and predictors of outcomes will guide future interventions to mitigate the burden of pediatric hydrocephalus in the region.

Paediatric hydrocephalus

Hydrocephalus is classically considered as a failure of cerebrospinal fluid (CSF) homeostasis that results in the active expansion of the cerebral ventricles. Infants with hydrocephalus can present with progressive increases in head circumference whereas older children often present with signs and symptoms of elevated intracranial pressure. Congenital hydrocephalus is present at or near birth and some cases have been linked to gene mutations that disrupt brain morphogenesis and alter the biomechanics of the CSF-brain interface. Acquired hydrocephalus can develop at any time after birth, is often caused by central nervous system infection or haemorrhage and has been associated with blockage of CSF pathways and inflammation-dependent dysregulation of CSF secretion and clearance. Treatments for hydrocephalus mainly include surgical CSF shunting or endoscopic third ventriculostomy with or without choroid plexus cauterization. In utero treatment of fetal hydrocephalus is possible via surgical closure of associated neural tube defects. Long-term outcomes for children with hydrocephalus vary widely and depend on intrinsic (genetic) and extrinsic factors. Advances in genomics, brain imaging and other technologies are beginning to refine the definition of hydrocephalus, increase precision of prognostication and identify nonsurgical treatment strategies.

Low surgical weight associated with ETV failure in pediatric hydrocephalus patients

The use of endoscopic third ventriculostomy (ETV) for treatment of pediatric hydrocephalus has higher failure rates in younger patients. Here we investigate the impact of select perioperative variables, specifically gestational age, chronological age, birth weight, and surgical weight, on ETV failure rates. A retrospective review was performed on patients treated with ETV - with or without choroid plexus cauterization (CPC) - from 2010 to 2021 at a large academic center. Analyses included Cox regression for independent predictors and Kaplan-Meier survival curves for time to-event outcomes. In total, 47 patients were treated with ETV; of these, 31 received adjunctive CPC. Overall, 66% of the cohort experienced ETV failure with a median failure of 36 days postoperatively. Patients aged < 6 months at time of surgery experienced 80% failure rate, and those > 6 months at time of surgery experienced a 41% failure rate. Univariate Cox regression analysis showed weight at the time of ETV surgery was significantly inversely associated with ETV failure with a hazard ratio of 0.92 (95% CI 0.82, 0.99). Multivariate analysis redemonstrated the inverse association of weight at time of surgery with ETV failure with hazard ratio of 0.76 (95% CI 0.60, 0.92), and sensitivity analysis showed < 4.9 kg as the optimal cutoff predicting ETV/CPC failure. Neither chronologic age nor gestational age were found to be significantly associated with ETV failure.In this study, younger patients experienced higher ETV failure rates, but multivariate regression found that weight was a more robust predictor of ETV failure than chronologic age or gestational age, with an optimal cutoff of 4.9 kg in our small cohort. Given the limited sample size, further study is needed to elucidate the independent role of weight as a peri-operative variable in determining ETV candidacy in young infants. Previous presentations: Poster Presentation, Congress of Neurological Surgeons.

Outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of paediatric hydrocephalus: Systematic review and meta-analysis

PURPOSE

To evaluate the outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of paediatric hydrocephalus.

METHODS

We searched PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials databases for articles published from 2000 to May 2023 (last search date May 6, 2023). Keywords searched included "endoscopic third ventriculostomy", "ventriculoperitoneal shunting", "paediatric population", and "outcomes". Using random-effects models, we compared success rates and complications of ETV and VPS. The primary outcome was ETV vs.VPS success rates, and the secondary outcome was post-treatment complications. Included studies reported on treatment success and complication rates.

RESULTS

Out of 126 articles, 8 RCTs and 1 prospective study were included. Six studies reported primary outcome data (806 patients identified: 464 in ETV group, 342 in VPS group). Combined success rates were 81.8% (n = 283/346) for ETV and 86.7% (n = 182/210) for VPS (median follow-up 41 months). There was no difference in success rates between ETV and VPS groups (risk ratio 0.84, 95% confidence interval 0.80-0.90, I2 = 0%, p = 0.93). Combined complication rates were 4.6% (n = 16/346) in the ETV group and 27.1% (n = 57/210) in the VPS group. ETV had a lower rate of postoperative complications (risk ratio 0.76, 95% confidence interval 0.42-1.38, I2 = 53%, p = 0.04).

CONCLUSIONS

Both ETV and VPS are viable surgical options for the management of paediatric hydrocephalus with similar success rates when used as first-line treatment. However, our study concluded that VPS results in a higher complication rate.

REGISTRATION

This systematic review and meta-analysis was formally registered in the PROSPERO International database under the registration number CRD42023452907 on the 29th of August 2023.

The genetic basis of hydrocephalus: genes, pathways, mechanisms, and global impact

Hydrocephalus (HC) is a heterogenous disease characterized by alterations in cerebrospinal fluid (CSF) dynamics that may cause increased intracranial pressure. HC is a component of a wide array of genetic syndromes as well as a secondary consequence of brain injury (intraventricular hemorrhage (IVH), infection, etc.) that can present across the age spectrum, highlighting the phenotypic heterogeneity of the disease. Surgical treatments include ventricular shunting and endoscopic third ventriculostomy with or without choroid plexus cauterization, both of which are prone to failure, and no effective pharmacologic treatments for HC have been developed. Thus, there is an urgent need to understand the genetic architecture and molecular pathogenesis of HC. Without this knowledge, the development of preventive, diagnostic, and therapeutic measures is impeded. However, the genetics of HC is extraordinarily complex, based on studies of varying size, scope, and rigor. This review serves to provide a comprehensive overview of genes, pathways, mechanisms, and global impact of genetics contributing to all etiologies of HC in humans.

Long Noncoding RNA GAS5-Involved Progression of Neonatal Hydrocephalus and Inflammatory Responses

Intraventricular hemorrhage results in posthemorrhagic hydrocephalus (PHH). Neonatal hydrocephalus remains a challenging disease due to the high failure rate of all management strategies. We evaluated long noncoding RNA growth arrest-specific 5 (GAS5)-mediated network in neonatal hydrocephalus, providing a new direction for the treatment of hydrocephalus. The PHH model was constructed in neonatal rats after intracerebroventricular injection with GAS5, miR-325-3p, and chaperonin containing T-complex protein 1, subunit 8 (CCT8) plasmids, or oligonucleotides. Next, behavioral tests, measurement of serum inflammation, observation of brain tissue pathology, and calculation of hemoglobin and brain water contents were implemented. GAS5, miR-325-3p, and CCT8 expression, in combination with their interactions, was checked. As the results reported, collagenase infusion induced hydrocephalus, impairing neurological function, enhancing inflammation and neuronal apoptosis, and increasing hemoglobin and brain water contents. GAS5 and CCT8 were up-regulated, while miR-325-3p was down-regulated in hydrocephalic rats. Downregulating GAS5/CCT8 or upregulating miR-325-3p could inhibit inflammatory response and improve neurological function in young hydrocephalic rats. GAS5 promotes CCT8 expression through sponge adsorption of miR-325-3p. GAS5 silencing-mediated protections against hydrocephalus were counteracted by CCT8 overexpression. In summary, GAS5 aggravates neonatal hydrocephalus and inflammatory responses in a way of leasing miR-325-3p-involved regulation of CCT8.

Comparing motor development in children with hydrocephalus after treatment with ventriculoperitoneal shunt and endoscopic third ventriculostomy: a cross-sectional study

Introduction

Ventriculoperitoneal shunt insertion (VPSI) and endoscopic third ventriculostomy (ETV) are the major procedures for treating pediatric hydrocephalus. However, studies comparing motor development following the two treatments are limited.

Objective

We aimed to determine motor development outcomes in children with hydrocephalus up to 2 years of age after undergoing VPSI or ETV, to identify which surgical approach yields better motor outcomes and may be more effective for Malawian children.

Methods

This was a cross-sectional study where we recruited two groups of participants: one group consisted of children with hydrocephalus treated with VP shunt whilst the other group were treated with ETV, at least 6 months prior to this study. Participants were identified from the hospital records and were called to come for neurodevelopmental assessment using the Malawi Development Assessment Tool (MDAT).

Results

A total 152 children treated for hydrocephalus within an 18-month period met the inclusion criteria. Upon follow up and tracing, we recruited 25 children who had been treated: 12 had VPSI and 13 had ETV. MDAT revealed delays in both assessed motor domains: 19 out of the 25 children had delayed gross motor whilst 16 of 25 had delayed fine motor development. There was no significant difference between the shunted and the ETV groups.

Conclusion

Children with hydrocephalus demonstrate delays in motor development six to 18 months after treatment with either VPSI or ETV. This may necessitate early and prolonged intensive rehabilitation to restore motor function after surgery. Long-term follow-up studies with bigger sample sizes are required to detect the effect of the two treatment approaches.

Brain imaging with portable low-field MRI

The advent of portable, low-field MRI (LF-MRI) heralds new opportunities in neuroimaging. Low power requirements and transportability have enabled scanning outside the controlled environment of a conventional MRI suite, enhancing access to neuroimaging for indications that are not well suited to existing technologies. Maximizing the information extracted from the reduced signal-to-noise ratio of LF-MRI is crucial to developing clinically useful diagnostic images. Progress in electromagnetic noise cancellation and machine learning reconstruction algorithms from sparse k-space data as well as new approaches to image enhancement have now enabled these advancements. Coupling technological innovation with bedside imaging creates new prospects in visualizing the healthy brain and detecting acute and chronic pathological changes. Ongoing development of hardware, improvements in pulse sequences and image reconstruction, and validation of clinical utility will continue to accelerate this field. As further innovation occurs, portable LF-MRI will facilitate the democratization of MRI and create new applications not previously feasible with conventional systems.

Morbidity and etiology-based success rate of combined endoscopic ventriculostomy and choroid plexus cauterization: a systematic review and meta-analysis of 1918 infants

Approaches to the treatment of infant hydrocephalus vary among centers. Standard shunting carries a significant infection rate, an unpredictable time-to-failure, and the life-long risk of recurrent failures. Combined choroid plexus cauterization (CPC) and endoscopic third ventriculostomy (ETV) have been increasingly employed over the past decade as an alternative approach in an attempt to avoid shunt dependency. We performed a systematic review and meta-analysis to explore the reported morbidity associated with ETV/CPC and its rate of success reported for specific etiologies of infant hydrocephalus. The protocol of this study was registered with the International prospective register of Systematic Reviews (PROSPERO) with the following registration number: CRD 42022343898. The study utilized four databases of medical literature to perform a systematic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Several parameters were extracted from the included studies including authors, publication year, region, study design, sample size, mean age, success rate, complication rate, reported complications, hydrocephalus etiology, median time-to-failure, secondary management after failure, and mean follow-up time. The outcomes of interest, success, and complication rates were pooled using 95% confidence intervals (CI) and a random effects model. Heterogeneity was assessed using the I2 test. Twenty-eight studies met the inclusion criteria from an initial search result of 472 studies. The study included 1938 infants (1918 of which were included in the meta-analysis). The overall success rate of combined ETV/CPC is 0.59 (95% CI (0.53, 0.64), I2 = 82%). Etiology-based success rate is 0.71, 0.70, 0.64, and 0.52 for aqueductal stenosis, myelomeningocele, postinfectious hydrocephalus, and posthemorrhagic hydrocephalus, respectively. The overall complication rate is 0.04 (95% CI (0.02, 0.05), I2 = 14%). Our study presents a comprehensive analysis of the current evidence on the use of ETV/CPC for treating hydrocephalus in infants. The findings demonstrate the potential efficacy of this procedure; however, it is crucial to acknowledge the limitations inherent in the included studies, such as selection bias and limited follow-up, which could have impacted the reported outcomes.

What has changed in pediatric neurosurgical care in spina bifida? A 30-year UAB/Children's of Alabama observational overview

Spina bifida (SB) remains the most serious and most common congenital anomaly of the human nervous system that is compatible with life. The open myelomeningocele on the back is perhaps the most obvious initial problem, but the collective impact of dysraphism upon the entirety of the nervous system and innervated organs is an equal or greater longitudinal threat. As such, patients with myelomeningocele (MMC) are best managed in a multi-disciplinary clinic that brings together experienced medical, nursing, and therapy teams that provide high standards of care while studying outcomes and sharing insights and experiences. Since its inception 30 years ago, the spina bifida program at UAB/Children's of Alabama has remained dedicated to providing exemplary multi-disciplinary care for affected children and their families. During this time, there has been great change in the care landscape, but many of the neurosurgical principles and primary issues have remained the same. In utero myelomeningocele closure (IUMC) has revolutionized initial care and has favorable impact on several important co-morbidities of SB including hydrocephalus, the Chiari II malformation, and the functional level of the neurologic deficit. Hydrocephalus however is not solved by IUMC, and hydrocephalus management remains at the center of neurosurgical care in SB. Ventricular shunts were long the cornerstone of treatment for hydrocephalus, but we came to assess and incorporate endoscopic third ventriculostomy with choroid plexus coagulation (ETV-CPC). Educated and nurtured by an experienced senior mentor, we dedicated ourselves to fundamental concepts but persistently evaluated our care outcomes and evolved our protocols and paradigms for improvement. Active conversations amidst networks of treasured colleagues were central to this development and growth. While hydrocephalus support and treatment of tethered spinal cord remained our principal neurosurgical charges, we evolved to embrace a holistic perspective and approach that is reflected and captured in the Lifetime Care Plan. Our team engaged actively in important workshops and guideline initiatives and was central to the development and support of the National Spina Bifida Patient Registry. We started and developed an adult SB clinic to support our patients who aged out of pediatric care. Lessons there taught us the importance of a model of transition that emphasized personal responsibility and awareness of health and the crucial role of dedicated support over time. Support for sleep, bowel health, and personal intimate cares are important contributors to overall health and care. This paper details our growth, learning, and evolution of care provision over the past 30 years.

The burden, prevention and care of infants and children with congenital anomalies in sub-Saharan Africa: A scoping review

The aim of this scoping review was to determine the scope, objectives and methodology of contemporary published research on congenital anomalies (CAs) in sub-Saharan Africa (SSA), to inform activities of the newly established sub-Saharan African Congenital Anomaly Network (sSCAN). MEDLINE was searched for CA-related articles published between January 2016 and June 2021. Articles were classified into four main areas (public health burden, surveillance, prevention, care) and their objectives and methodologies summarized. Of the 532 articles identified, 255 were included. The articles originated from 22 of the 49 SSA countries, with four countries contributing 60% of the articles: Nigeria (22.0%), Ethiopia (14.1%), Uganda (11.7%) and South Africa (11.7%). Only 5.5% of studies involved multiple countries within the region. Most articles included CA as their primary focus (85%), investigated a single CA (88%), focused on CA burden (56.9%) and care (54.1%), with less coverage of surveillance (3.5%) and prevention (13.3%). The most common study designs were case studies/case series (26.6%), followed by cross-sectional surveys (17.6%), retrospective record reviews (17.3%), and cohort studies (17.2%). Studies were mainly derived from single hospitals (60.4%), with only 9% being population-based studies. Most data were obtained from retrospective review of clinical records (56.1%) or via caregiver interviews (34.9%). Few papers included stillbirths (7.5%), prenatally diagnosed CAs (3.5%) or terminations of pregnancy for CA (2.4%).This first-of-a-kind-scoping review on CA in SSA demonstrated an increasing level of awareness and recognition among researchers in SSA of the contribution of CAs to under-5 mortality and morbidity in the region. The review also highlighted the need to address diagnosis, prevention, surveillance and care to meet Sustainable Development Goals 3.2 and 3.8. The SSA sub-region faces unique challenges, including fragmentation of efforts that we hope to surmount through sSCAN via a multidisciplinary and multi-stakeholder approach.

Outcomes and prognostic factors of infantile acquired hydrocephalus: a single-center experience

AIM

To assess the etiologies and adverse outcomes of infantile acquired hydrocephalus and predict prognosis.

METHODS

A total of 129 infants diagnosed with acquired hydrocephalus were recruited from 2008 to 2021. Adverse outcomes included death and significant neurodevelopmental impairment which was defined as Bayley Scales of Infant and Toddler Development III score < 70, cerebral palsy, visual or hearing impairment, and epilepsy. Chi-squared was used to evaluate the prognostic factors of adverse outcomes. A receiver operating characteristic curve was calculated to determine the cutoff value.

RESULTS

Of 113 patients with outcome data, 55 patients (48.7%) had adverse outcomes. Late surgical intervention time (13 days) and severe ventricular dilation were associated with adverse outcomes. The combination of surgical intervention time and cranial ultrasonography (cUS) indices was a better predictive marker compared with any of them (surgical intervention time, P = 0.05; cUS indices, P = 0.002). Post-hemorrhage (54/113, 48%), post-meningitis (28/113, 25%), and hydrocephalus arising from both hemorrhage and meningitis (17/113, 15%) accounted for a large proportion of the etiologies in our study. Hydrocephalus occurs secondary to post-hemorrhage and had a favorable outcome compared with other etiologies in both preterm and term groups. A significant difference in adverse outcomes between the inherited error of metabolism as a cause and other etiologies (P = 0.02).

CONCLUSION

Late surgical treatment times and severe ventricular dilation can predict adverse outcomes in infants with acquired hydrocephalus. It is crucial to identify the causes of acquired hydrocephalus to predict the adverse outcomes. Research into measures of improving adverse outcomes following infantile acquired hydrocephalus is urgently necessary.

Choroid plexus-targeted NKCC1 overexpression to treat post-hemorrhagic hydrocephalus

Post-hemorrhagic hydrocephalus (PHH) refers to a life-threatening accumulation of cerebrospinal fluid (CSF) that occurs following intraventricular hemorrhage (IVH). An incomplete understanding of this variably progressive condition has hampered the development of new therapies beyond serial neurosurgical interventions. Here, we show a key role for the bidirectional Na-K-Cl cotransporter, NKCC1, in the choroid plexus (ChP) to mitigate PHH. Mimicking IVH with intraventricular blood led to increased CSF [K+] and triggered cytosolic calcium activity in ChP epithelial cells, which was followed by NKCC1 activation. ChP-targeted adeno-associated viral (AAV)-NKCC1 prevented blood-induced ventriculomegaly and led to persistently increased CSF clearance capacity. These data demonstrate that intraventricular blood triggered a trans-choroidal, NKCC1-dependent CSF clearance mechanism. Inactive, phosphodeficient AAV-NKCC1-NT51 failed to mitigate ventriculomegaly. Excessive CSF [K+] fluctuations correlated with permanent shunting outcome in humans following hemorrhagic stroke, suggesting targeted gene therapy as a potential treatment to mitigate intracranial fluid accumulation following hemorrhage.

Proportion of Infant Neurodevelopment Trials Reporting a Null Finding: A Systematic Review

CONTEXT

Discovering new interventions to improve neurodevelopmental outcomes is a priority; however, clinical trials are challenging and methodological issues may impact the interpretation of intervention efficacy.

OBJECTIVES

Characterize the proportion of infant neurodevelopment trials reporting a null finding and identify features that may contribute to a null result.

DATA SOURCES

The Cochrane library, Medline, Embase, and CINAHL databases.

STUDY SELECTION

Randomized controlled trials recruiting infants aged <6 months comparing any "infant-directed" intervention against standard care, placebo, or another intervention. Neurodevelopment assessed as the primary outcome between 12 months and 10 years of age using a defined list of tools.

DATA EXTRACTION

Two reviewers independently extracted data and assessed quality of included studies.

RESULTS

Of n = 1283 records screened, 21 studies (from 20 reports) were included. Of 18 superiority studies, >70% reported a null finding. Features were identified that may have contributed to the high proportion of null findings, including selection and timing of the primary outcome measure, anticipated effect size, sample size and power, and statistical analysis methodology and rigor.

LIMITATIONS

Publication bias against null studies means the proportion of null findings is likely underestimated. Studies assessing neurodevelopment as a secondary or within a composite outcome were excluded.

CONCLUSIONS

This review identified a high proportion of infant neurodevelopmental trials that produced a null finding and detected several methodological and design considerations which may have contributed. We make several recommendations for future trials, including more sophisticated approaches to trial design, outcome assessment, and analysis.

Outcomes of the 2019 hydrocephalus association workshop, "Driving common pathways: extending insights from posthemorrhagic hydrocephalus"

The Hydrocephalus Association (HA) workshop, Driving Common Pathways: Extending Insights from Posthemorrhagic Hydrocephalus, was held on November 4 and 5, 2019 at Washington University in St. Louis. The workshop brought together a diverse group of basic, translational, and clinical scientists conducting research on multiple hydrocephalus etiologies with select outside researchers. The main goals of the workshop were to explore areas of potential overlap between hydrocephalus etiologies and identify drug targets that could positively impact various forms of hydrocephalus. This report details the major themes of the workshop and the research presented on three cell types that are targets for new hydrocephalus interventions: choroid plexus epithelial cells, ventricular ependymal cells, and immune cells (macrophages and microglia).

Mortality and complications 1 year after treatment of hydrocephalus with endoscopic third ventriculostomy and ventriculoperitoneal shunt in children at Queen Elizabeth Central Hospital, Malawi

BACKGROUND

Over the past two decades, the management of hydrocephalus has witnessed the addition of endoscopic third ventriculostomy with or without choroid plexus cauterization (ETV ± CPC) to the traditional methods including ventriculoperitoneal shunt insertion (VPSI). We conducted this study to assess mortality and complications with surgical implications associated with the two procedures in children with hydrocephalus.

METHODS

We reviewed our operating theater registry to identify children below 17 years old who underwent hydrocephalus surgery for the first time in 2016. The patients were followed for up to 1 year from the date of the initial operation. Their vital status was confirmed by follow-up visits by a community nurse. Descriptive analyses were used to describe the characteristics of the patients and evaluate the study outcomes (i.e., mortality and complications).

RESULTS

One hundred fifty-three patients were eligible for the study; 56% were males and 73.2% had primary ETV ± CPC. Complete 1-year follow-up data was available for 79 patients, and 73.4% of these had ETV ± CPC. One-year success (event-free) rates for ETV and VPSI were similar at 67.4% and 66.7%, respectively. ETVs in infants under 6 months performed poorly; failing in half the infants, who were subsequently converted to VPS. Shunt sepsis was very high, 21.4% (95% CI 10.3-36.8). The majority of surgical complications (81.8%) occurred within 3 months of surgery.

CONCLUSION

ETV ± CPC and VPSI carry a similar frequency of mortality and complications in our setting, and therefore, both should be considered as a treatment option for patients with hydrocephalus. As VP shunt is still used for managing most of the patients, there is still a need to prioritize measures to reduce shunt infections.

Type IV Pili Are a Critical Virulence Factor in Clinical Isolates of Paenibacillus thiaminolyticus

Hydrocephalus, the leading indication for childhood neurosurgery worldwide, is particularly prevalent in low- and middle-income countries. Hydrocephalus preceded by an infection, or postinfectious hydrocephalus, accounts for up to 60% of hydrocephalus in these areas. Since many children with hydrocephalus suffer poor long-term outcomes despite surgical intervention, prevention of hydrocephalus remains paramount. Our previous studies implicated a novel bacterial pathogen, Paenibacillus thiaminolyticus, as a causal agent of neonatal sepsis and postinfectious hydrocephalus in Uganda. Here, we report the isolation of three P. thiaminolyticus strains, Mbale, Mbale2, and Mbale3, from patients with postinfectious hydrocephalus. We constructed complete genome assemblies of the clinical isolates as well as the nonpathogenic P. thiaminolyticus reference strain and performed comparative genomic and proteomic analyses to identify potential virulence factors. All three isolates carry a unique beta-lactamase gene, and two of the three isolates exhibit resistance in culture to the beta-lactam antibiotics penicillin and ampicillin. In addition, a cluster of genes carried on a mobile genetic element that encodes a putative type IV pilus operon is present in all three clinical isolates but absent in the reference strain. CRISPR-mediated deletion of the gene cluster substantially reduced the virulence of the Mbale strain in mice. Comparative proteogenomic analysis identified various additional potential virulence factors likely acquired on mobile genetic elements in the virulent strains. These results provide insight into the emergence of virulence in P. thiaminolyticus and suggest avenues for the diagnosis and treatment of this novel bacterial pathogen. IMPORTANCE Postinfectious hydrocephalus, a devastating sequela of neonatal infection, is associated with increased childhood mortality and morbidity. A novel bacterial pathogen, Paenibacillus thiaminolyticus, is highly associated with postinfectious hydrocephalus in an African cohort. Whole-genome sequencing, RNA sequencing, and proteomics of clinical isolates and a reference strain in combination with CRISPR editing identified type IV pili as a critical virulence factor for P. thiaminolyticus infection. Acquisition of a type IV pilus-encoding mobile genetic element critically contributed to converting a nonpathogenic strain of P. thiaminolyticus into a pathogen capable of causing devastating diseases. Given the widespread presence of type IV pilus in pathogens, the presence of the type IV pilus operon could serve as a diagnostic and therapeutic target in P. thiaminolyticus and related bacteria.

Costs of pediatric hydrocephalus treatment for the Brazilian public health system in the Northeast of Brazil

PURPOSE

To estimate the costs of the surgical treatment of pediatric hydrocephalus, specifically ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV), for the Brazilian public health system (SUS).

METHODS

Retrospective cohort study of health records of patients < 14 years of age with a diagnosis of hydrocephalus who underwent VPS or ETV between September 2009 and June 2016, regularly followed up for 24 months.

RESULTS

Seventy-six medical records were included. The groups of children who underwent VPS and ETV consisted of 60 and 16 patients, respectively. Complications during 2 years of follow-up were identified in 56% of the children undergoing VPS and in 18% of those undergoing ETV (p = 0.0103). The initial cost of VPS was lower than that of ETV up to approximately 1 year of post-surgical follow-up. After that, VPS generated higher expenses for the SUS due to higher rates of late post-surgical complications and repeated readmissions.

CONCLUSION

Higher public expenditures were observed in the group of children undergoing VPS due to higher rates of infectious and mechanical complications requiring repeated hospitalizations and prosthesis replacements. Public policies must be tailored to offer the best treatment to children with hydrocephalus and to make judicious use of public resources without compromising the quality of treatment.

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt insertion for the management of pediatric hydrocephalus in African centers – A systematic review and meta-analysis

Background:

Ventriculoperitoneal shunt (VPS) insertion and endoscopic third ventriculostomy (ETV) are common surgical procedures used to treat pediatric hydrocephalus. There have been numerous studies comparing ETV and VPS, but none from an African perspective. In this study, we sought to compare outcomes from African neurosurgical centers and review the associated complications.

Methods:

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in conducting this study. PubMed, Google Scholar, and African Journal Online were searched. Data on treatment successes and failures for ETV and VPS were pooled together and analyzed with a binary meta-analysis. A clinically successful outcome was defined as no significant event or complication occurring after surgery and during follow-up (e.g., infection, failure, CSF leak, malfunction, and mortality). Seven studies fully satisfied the eligibility criteria and were used in this review.

Results:

There was no statistically significant difference between the outcomes of ETV and VPS (OR- 0.27; 95% CI −0.39–0.94, P = 0.42). After reviewing the rates of complications of ETV and VPS from the identified studies, four were recurrent. The infection rates of ETV versus VPS were 0.02% versus 0.1%. The mortality rates were 0.01% versus 0.05%. The reoperation rates were 0.05% versus 0.3%, while the rates of ETV failure and shunt malfunction were 0.2% versus 0.2%.

Conclusion:

This study concludes that there is no significant difference between the outcomes of ETV and VPS insertion.

Pathogenesis of posthemorrhagic hydrocephalus of prematurity: New horizons

Posthemorrhagic hydrocephalus of prematurity (PHHP) remains a vexing problem for patients, their families, and the healthcare system. The complexity of the pathogenesis of PHHP also presents a unique challenge within the fields of neonatology, neurology and neurosurgery. Here we focus on pathogenesis of PHHP and its impact on the development of CSF dynamics including choroid plexus, ependymal motile cilia and glymphatic system. PHHP is contrasted with infantile hydrocephalus from other etiologies, and with other types of posthemorrhagic hydrocephalus that occur later in life. The important concept that distinguishing ventricular volume from brain health and function is highlighted. The influence of the pathogenesis of PHHP on current interventions is reviewed, with particular emphasis on how the unique pathogenesis of PHHP contributes to the high rate of failure of current existing interventions. Finally, we discuss emerging interventions. A thorough understanding of the pathogenesis of PHHP is essential to developing effective non-surgical therapeutics to prevent the transformation from severe IVH to PHHP.

Metformin Alleviates Delayed Hydrocephalus after Intraventricular Hemorrhage by Inhibiting Inflammation and Fibrosis

Intraventricular hemorrhage (IVH) is a subtype of intracerebral hemorrhage (ICH) with high morbidity and mortality. Posthemorrhagic hydrocephalus (PHH) is a common and major complication that affects prognosis, but the mechanism is still unclear. Inflammation and fibrosis have been well established as the major causes of PHH after IVH. In this study, we aimed to investigate the effects of metformin on IVH in adult male mice and further explored the underlying molecular mechanisms of these effects. In the acute phase, metformin treatment exerted dose-dependent neuroprotective effects by reducing periependymal apoptosis and neuronal degeneration and decreasing brain edema. Moreover, high-dose metformin reduced inflammatory cell infiltration and the release of proinflammatory factors, thus protecting ependymal structure integrity and subependymal neurons. In the chronic phase, metformin administration improved neurocognitive function and reduced delayed hydrocephalus. Additionally, metformin significantly inhibited basal subarachnoid fibrosis and ependymal glial scarring. The ependymal structures partially restored. Mechanically, IVH reduced phospho-AMPK (p-AMPK) and SIRT1 expression and activated the phospho-NF-κB (p-NF-κB) inflammatory signaling pathway. However, metformin treatment increased AMPK/SIRT1 expression and lowered the protein expression of p-NF-κB and its downstream inflammation. Compound C and EX527 administration reversed the anti-inflammatory effect of metformin. In conclusion, metformin attenuated neuroinflammation and subsequent fibrosis after IVH by regulating AMPK /SIRT1/ NF-κB pathways, thereby reducing delayed hydrocephalus. Metformin may be a promising therapeutic agent to prevent delayed hydrocephalus following IVH.

Repeat endoscopic third ventriculostomy combined with choroid plexus cauterization as salvage surgery for failed endoscopic third ventriculostomy

PURPOSE

Although the endoscopic third ventriculostomy (ETV) is an effective treatment for hydrocephalus, failures do on occasion occur. In such cases, a repeat ETV or shunt insertion is usually performed. However, there is, as of yet, no clear consensus on the best measure to take in the event of a failed ETV. We herein examined the outcomes of a repeat ETV combined with choroid plexus cauterization for ETV failure.

METHODS

All patients who underwent an ETV at the Department of Neurosurgery at Tokyo Metropolitan Children's Medical Center between April 2013 and March 2019 were retrospectively analyzed.

RESULTS

In total, 36 patients received an ETV. Six patients experienced ETV failure; three of these underwent a repeat ETV combined with choroid plexus cauterization. Three of the six patients who experienced early ETV failure received a ventriculoperitoneal shunt. During the median follow-up period of 42 months (range: 32-73 months), all repeat ETVs were successful.

CONCLUSION

A repeat ETV combined with choroid plexus cauterization can be an effective salvage therapy in the event of ETV failure.

Clinical outcomes in pediatric hydrocephalus patients treated with endoscopic third ventriculostomy and choroid plexus cauterization: a systematic review and meta-analysis

OBJECTIVE

Endoscopic third ventriculostomy and choroid plexus cauterization (ETV+CPC) is a novel procedure for infant hydrocephalus that was developed in sub-Saharan Africa to mitigate the risks associated with permanent implanted shunt hardware. This study summarizes the hydrocephalus literature surrounding the ETV+CPC intraoperative abandonment rate, perioperative mortality rate, cerebrospinal fluid infection rate, and failure rate.

METHODS

This systematic review and meta-analysis followed a prespecified protocol and abides by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy using MEDLINE, EMBASE, PsychInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Web of Science was conducted from database inception to October 2019. Studies included controlled trials, cohort studies, and case-control studies of patients with hydrocephalus younger than 18 years of age treated with ETV+CPC. Pooled estimates were calculated using DerSimonian and Laird random-effects modeling, and the significance of subgroup analyses was tested using meta-regression. The quality of the pooled outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

After screening and reviewing 12,321 citations, the authors found 16 articles that met the inclusion criteria. The pooled estimate for the ETV+CPC failure rate was 0.44 (95% CI 0.37-0.51). Subgroup analysis by geographic income level showed statistical significance (p < 0.01), with lower-middle-income countries having a lower failure rate (0.32, 95% CI 0.28-0.36) than high-income countries (0.53, 95% CI 0.47-0.60). No difference in failure rate was found between hydrocephalus etiology (p = 0.09) or definition of failure (p = 0.24). The pooled estimate for perioperative mortality rate (n = 7 studies) was 0.001 (95% CI 0.00-0.004), the intraoperative abandonment rate (n = 5 studies) was 0.04 (95% CI 0.01-0.08), and the postoperative CSF infection rate (n = 5 studies) was 0.0004 (95% CI 0.00-0.003). All pooled outcomes were found to be low-quality evidence.

CONCLUSIONS

This systematic review and meta-analysis provides the most comprehensive pooled estimate for the ETV+CPC failure rate to date and demonstrates, for the first time, a statistically significant difference in failure rate by geographic income level. It also provides the first reported pooled estimates for the risk of ETV+CPC perioperative mortality, intraoperative abandonment, and CSF infection. The low quality of this evidence highlights the need for further research to improve the understanding of these critical clinical outcomes and their relevant explanatory variables and thus to appreciate which patients may benefit most from an ETV+CPC. Systematic review registration no.: CRD42020160149 (https://www.crd.york.ac.uk/prospero/).

Pragmatism in Pediatric Neurosurgery: More Than a Pipe Dream? A Systematic Literature Review and Analysis

BACKGROUND

Classic randomized controlled trials (RCTs) form the cornerstone for medical guidelines and protocols. However, in neurosurgery, RCTs are not always applicable to everyday clinical practice. Pragmatic controlled trials aim to incorporate real-life data with the preservation of the methodologic quality. This study is a systematic literature review of all pediatric neurosurgical RCTs published between 2000 and 2020 and an analysis of their pragmatism.

METHODS

An electronic database search was performed in PubMed, EMBASE, and the Cochrane Library to identify all relevant trials. Pragmatism was evaluated retrospectively on 9 domains: eligibility, recruitment, setting, organization, flexibility (delivery and adherence), follow-up, primary outcome, and primary analysis.

RESULTS

Of the 1862 studies included, 15 met the inclusion criteria. On average, studies scored between equally pragmatic/explanatory and rather pragmatic (M = 3.59, standard deviation [SD] = 0.56). Lowest ratings were seen for setting (M = 2.80, SD = 1.66) and eligibility (M = 3.20, SD = 1.66). Highest scores of pragmatism were given to analysis (M = 4.67, SD = 0.82) and intervention organization (M = 4.60, SD = 1.06). There was no significant difference between studies based on number of patients included, main subject, or publication year.

CONCLUSIONS

Pediatric neurosurgical RCTs scored reasonably well on overall pragmatism. In the future, there will be a greater need for pragmatic controlled trials in pediatric neurosurgery to bridge the divide between real-life data and reliable methodological quality. There is an opportunity to develop further applications of pragmatism tailored to surgical interventions.

Improving Infant Hydrocephalus Outcomes in Uganda: A Longitudinal Prospective Study Protocol for Predicting Developmental Outcomes and Identifying Patients at Risk for Early Treatment Failure after ETV/CPC

Infant hydrocephalus poses a severe global health burden; 80% of cases occur in the developing world where patients have limited access to neurosurgical care. Surgical treatment combining endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC), first practiced at CURE Children's Hospital of Uganda (CCHU), is as effective as standard ventriculoperitoneal shunt (VPS) placement while requiring fewer resources and less post-operative care. Although treatment focuses on controlling ventricle size, this has little association with treatment failure or long-term outcome. This study aims to monitor the progression of hydrocephalus and treatment response, and investigate the association between cerebral physiology, brain growth, and neurodevelopmental outcomes following surgery. We will enroll 300 infants admitted to CCHU for treatment. All patients will receive pre/post-operative measurements of cerebral tissue oxygenation (SO2), cerebral blood flow (CBF), and cerebral metabolic rate of oxygen consumption (CMRO2) using frequency-domain near-infrared combined with diffuse correlation spectroscopies (FDNIRS-DCS). Infants will also receive brain imaging, to monitor tissue/ventricle volume, and neurodevelopmental assessments until two years of age. This study will provide a foundation for implementing cerebral physiological monitoring to establish evidence-based guidelines for hydrocephalus treatment. This paper outlines the protocol, clinical workflow, data management, and analysis plan of this international, multi-center trial.

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

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.

Chinese Color Nest Project : An accelerated longitudinal brain-mind cohort

The ongoing Chinese Color Nest Project (CCNP) was established to create normative charts for brain structure and function across the human lifespan, and link age-related changes in brain imaging measures to psychological assessments of behavior, cognition, and emotion using an accelerated longitudinal design. In the initial stage, CCNP aims to recruit 1520 healthy individuals (6-90 years), which comprises three phases: developing (devCCNP: 6-18 years, N = 480), maturing (matCCNP: 20-60 years, N = 560) and aging (ageCCNP: 60-84 years, N = 480). In this paper, we present an overview of the devCCNP, including study design, participants, data collection and preliminary findings. The devCCNP has acquired data with three repeated measurements from 2013 to 2017 in Southwest University, Chongqing, China (CCNP-SWU, N = 201). It has been accumulating baseline data since July 2018 and the second wave data since September 2020 in Chinese Academy of Sciences, Beijing, China (CCNP-CAS, N = 168). Each participant in devCCNP was followed up for 2.5 years at 1.25-year intervals. The devCCNP obtained longitudinal neuroimaging, biophysical, social, behavioral and cognitive data via MRI, parent- and self-reported questionnaires, behavioral assessments, and computer tasks. Additionally, data were collected on children's learning, daily life and emotional states during the COVID-19 pandemic in 2020. We address data harmonization across the two sites and demonstrated its promise of characterizing the growth curves for the overall brain morphometry using multi-center longitudinal data. CCNP data will be shared via the National Science Data Bank and requests for further information on collaboration and data sharing are encouraged.

Assessing the utility of low resolution brain imaging: treatment of infant hydrocephalus

As low-field MRI technology is being disseminated into clinical settings around the world, it is important to assess the image quality required to properly diagnose and treat a given disease and evaluate the role of machine learning algorithms, such as deep learning, in the enhancement of lower quality images. In this post hoc analysis of an ongoing randomized clinical trial, we assessed the diagnostic utility of reduced-quality and deep learning enhanced images for hydrocephalus treatment planning. CT images of post-infectious infant hydrocephalus were degraded in terms of spatial resolution, noise, and contrast between brain and CSF and enhanced using deep learning algorithms. Both degraded and enhanced images were presented to three experienced pediatric neurosurgeons accustomed to working in low- to middle-income countries (LMIC) for assessment of clinical utility in treatment planning for hydrocephalus. In addition, enhanced images were presented alongside their ground-truth CT counterparts in order to assess whether reconstruction errors caused by the deep learning enhancement routine were acceptable to the evaluators. Results indicate that image resolution and contrast-to-noise ratio between brain and CSF predict the likelihood of an image being characterized as useful for hydrocephalus treatment planning. Deep learning enhancement substantially increases contrast-to-noise ratio improving the apparent likelihood of the image being useful; however, deep learning enhancement introduces structural errors which create a substantial risk of misleading clinical interpretation. We find that images with lower quality than is customarily acceptable can be useful for hydrocephalus treatment planning. Moreover, low quality images may be preferable to images enhanced with deep learning, since they do not introduce the risk of misleading information which could misguide treatment decisions. These findings advocate for new standards in assessing acceptable image quality for clinical use.

Programmable Shunt Valves for Pediatric Hydrocephalus: 22-Year Experience from a Singapore Children's Hospital

(1) Background: pediatric hydrocephalus is a challenging condition. Programmable shunt valves (PSV) have been increasingly used. This study is undertaken to firstly, to objectively evaluate the efficacy of PSV as a treatment modality for pediatric hydrocephalus; and next, review its associated patient outcomes at our institution. Secondary objectives include the assessment of our indications for PSV, and corroboration of our results with published literature. (2) Methods: this is an ethics-approved, retrospective study. Variables of interest include age, gender, hydrocephalus etiology, shunt failure rates and incidence of adjustments made per PSV. Data including shunt failure, implant survival, and utility comparisons between PSV types are subjected to statistical analyses. (3) Results: in this case, 51 patients with PSV are identified for this study, with 32 index and 19 revision shunts. There are 3 cases of shunt failure (6%). The mean number of adjustments per PSV is 1.82 times and the mean number of adjustments made per PSV is significantly lower for MEDTRONIC™ Strata PSVs compared with others (p = 0.031). Next, PSV patients that are adjusted more frequently include cases of shunt revisions, PSVs inserted due to CSF over-drainage and tumor-related hydrocephalus. (4) Conclusion: we describe our institutional experience of PSV use in pediatric hydrocephalus and its advantages in a subset of patients whose opening pressures are uncertain and evolving.

Impact of ventricle size on neuropsychological outcomes in treated pediatric hydrocephalus: an HCRN prospective cohort study

OBJECTIVE

In pediatric hydrocephalus, shunts tend to result in smaller postoperative ventricles compared with those following an endoscopic third ventriculostomy (ETV). The impact of the final treated ventricle size on neuropsychological and quality-of-life outcomes is currently undetermined. Therefore, the authors sought to ascertain whether treated ventricle size is associated with neurocognitive and academic outcomes postoperatively.

METHODS

This prospective cohort study included children aged 5 years and older at the first diagnosis of hydrocephalus at 8 Hydrocephalus Clinical Research Network sites from 2011 to 2015. The treated ventricle size, as measured by the frontal and occipital horn ratio (FOR), was compared with 25 neuropsychological tests 6 months postoperatively after adjusting for age, hydrocephalus etiology, and treatment type (ETV vs shunt). Pre- and posttreatment grade point average (GPA), quality-of-life measures (Hydrocephalus Outcome Questionnaire [HOQ]), and a truncated preoperative neuropsychological battery were also compared with the FOR.

RESULTS

Overall, 60 children were included with a mean age of 10.8 years; 17% had ≥ 1 comorbidity. Etiologies for hydrocephalus were midbrain lesions (37%), aqueductal stenosis (22%), posterior fossa tumors (13%), and supratentorial tumors (12%). ETV (78%) was more commonly used than shunting (22%). Of the 25 neuropsychological tests, including full-scale IQ (q = 0.77), 23 tests showed no univariable association with postoperative ventricle size. Verbal learning delayed recall (p = 0.006, q = 0.118) and visual spatial judgment (p = 0.006, q = 0.118) were negatively associated with larger ventricles and remained significant after multivariate adjustment for age, etiology, and procedure type. However, neither delayed verbal learning (p = 0.40) nor visual spatial judgment (p = 0.22) was associated with ventricle size change with surgery. No associations were found between postoperative ventricle size and either GPA or the HOQ.

CONCLUSIONS

Minimal associations were found between the treated ventricle size and neuropsychological, academic, or quality-of-life outcomes for pediatric patients in this comprehensive, multicenter study that encompassed heterogeneous hydrocephalus etiologies.

Inflammatory hydrocephalus

Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells, and physical irritants. However, inappropriately triggered or sustained inflammation can respectively initiate, propagate, or prolong disease. Post-hemorrhagic (PHH) and post-infectious hydrocephalus (PIH) are the most common forms of hydrocephalus worldwide. They are treated using neurosurgical cerebrospinal fluid (CSF) diversion techniques with high complication and failure rates. Despite their distinct etiologies, clinical studies in human patients have shown PHH and PIH share similar CSF cytokine and immune cell profiles. Here, in light of recent work in model systems, we discuss the concept of "inflammatory hydrocephalus" to emphasize potential shared mechanisms and potential therapeutic vulnerabilities of these disorders. We propose that this change of emphasis could shift our thinking of PHH and PIH from a framework of life-long neurosurgical disorders to that of preventable conditions amenable to immunomodulation.

Hydrocephalus in Low and Middle-Income Countries - Progress and Challenges

Hydrocephalus remains one of the most commonly treated neurosurgical conditions worldwide. Caring for patients with hydrocephalus requires infrastructure and political support and initiative; these are often difficult to obtain in low- and middle-income countries (LMICs). Some innovations that have arisen in LMICs have traveled up the financial gradient to high-income countries, such as the combination of endoscopic third ventriculostomy with choroid plexus coagulation to manage hydrocephalus. The development of neuro-endoscopy has played a major role in managing hydrocephalus worldwide; however, LMICs still face specific challenges, such as limited access to shunt hardware, a disproportionately high incidence of post-infectious hydrocephalus, unique microbiological spectra, and often poor access to follow-up care and neuroimaging. This has received increased attention since the Lancet Commission on Global Surgery. The goal of improving access to quality neurosurgical care through various initiatives in LMICs will be discussed in this manuscript. The need for neurosurgeons continues to grow in LMICs, where better access to neurosurgical care, adequate neurosurgical training and political support, and patient education are needed to improve the quality of life for patients with common neurosurgical conditions. Despite these challenges, treating hydrocephalus remains a worthwhile endeavor for many patients.

Endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) for hydrocephalus of infancy: a technical review

In the twenty-first century, choroid plexus cauterization (CPC) in combination with endoscopic third ventriculostomy (ETV) has emerged as an effective treatment for some infants with hydrocephalus, leading to the favourable condition of 'shunt independence'. Herein we provide a narrative technical review considering the indications, procedural aspects, morbidity and its avoidance, postoperative care and follow-up. The CP has been the target of hydrocephalus treatment for more than a century. Early eminent neurosurgeons including Dandy, Putnam and Scarff performed CPC achieving generally poor results, and so the procedure fell out of favour. In recent years, the addition of CPC to ETV was one of the reasons greater ETV success rates were observed in Africa, compared to developed nations, and its popularity worldwide has since increased. Initial results indicate that when ETV/CPC is performed successfully, shunt independence is more likely than when ETV is undertaken alone. CPC is commonly performed using a flexible endoscope via septostomy and aims to maximally cauterize the CP. Success is more likely in infants aged >1 month, those with hydrocephalus secondary to myelomeningocele and aqueductal obstruction and those with >90% cauterized CP. Failure is more likely in those with post-haemorrhagic hydrocephalus of prematurity (PHHP), particularly those <1 month of corrected age and those with prepontine scarring. High-quality evidence comparing the efficacy of ETV/CPC with shunting is emerging, with data from ongoing and future trials offering additional promise to enhance our understanding of the true utility of ETV/CPC.

Risk factors for unchanged ventricles during pediatric shunt malfunction

OBJECTIVE

Children whose ventricles do not change during shunt malfunction present a diagnostic dilemma. This study was performed to identify risk factors for unchanged ventricular size at shunt malfunction.

METHODS

This retrospective 1:1 age-matched case-control study identified children with shunted hydrocephalus who underwent shunt revision with intraoperative evidence of malfunction at one of the three participating institutions from 1997 to 2019. Cases were defined as patients with a change of < 0.05 in the frontal-occipital horn ratio (FOR) between malfunction and baseline, and controls included patients with FOR changes ≥ 0.05. The presence of infection, abdominal pseudocyst, pseudomeningocele, or wound drainage and lack of baseline cranial imaging at the time of malfunction warranted exclusion.

RESULTS

Of 450 included patients, 60% were male, 73% were Caucasian, and 67% had an occipital shunt. The median age was 4.3 (IQR 0.97-9.21) years at malfunction. On univariable analysis, unchanged ventricles at malfunction were associated with a frontal shunt (41% vs 28%, p < 0.001), programmable valve (17% vs 9%, p = 0.011), nonsiphoning shunt (85% vs 66%, p < 0.001), larger baseline FOR (0.44 ± 0.12 vs 0.38 ± 0.11, p < 0.001), no prior shunt infection (87% vs 76%, p = 0.003), and no prior shunt revisions (68% vs 52%, p < 0.001). On multivariable analysis with collinear variables removed, patients with a frontal shunt (OR 1.67, 95% CI 1.08-2.70, p = 0.037), programmable valve (OR 2.63, 95% CI 1.32-5.26, p = 0.007), nonsiphoning shunt at malfunction (OR 2.76, 95% CI 1.63-4.67, p < 0.001), larger baseline FOR (OR 3.13, 95% CI 2.21-4.43, p < 0.001), and no prior shunt infection (OR 2.34, 95% CI 1.27-4.30, p = 0.007) were more likely to have unchanged ventricles at malfunction.

CONCLUSIONS

In a multicenter cohort of children with shunt malfunction, those with a frontal shunt, programmable valve, nonsiphoning shunt, baseline large ventricles, and no prior shunt infection were more likely than others to have unchanged ventricles at shunt failure.

Endoscopic third ventriculostomy in the treatment of hydrocephalus: A 20-year retrospective analysis of 209 consecutive cases

Background

Endoscopic third ventriculostomy (ETV) has been shown to be a sufficient alternative to shunts in surgical treatment of obstructive hydrocephalus. Long-term failure, age limitations, and outcome by cause are some of the issues debated in literature. The objective of this article is to analyze the clinical success and failure of ETV and its main complications.

Methods

A total of 209 patients with hydrocephalus were submitted to ETV, including a mixed population of children and adults (from 0 to 59 years). Patients were divided into five groups: A - tumors, B - aqueductal stenosis, C - myelomeningocele, D - infection and hemorrhage, and E - arachnoid cyst. Variables were analyzed: age, ETV success rate, cerebrospinal fluid (CSF) fistula, mortality, and complications.

Results

The two main causes of hydrocephalus were tumors (44.9%) and aqueductal stenosis (25.3%). The overall success rate was of 82.8%, and patients in Group E had the highest rate 90.9%. Group A had a success rate of 89.3%, and Group B had a rate of 88.6%. The ETV success rate was significantly higher in patients older than 1 year (P < 0.001); the former also had a lower risk of CSF fistula (P < 0.0001). The overall mortality rate was 2.8%.

Conclusion

Better results were observed in the groups of patients with tumors, aqueductal stenosis, and arachnoid cysts, while those whose primary causes of hydrocephalus were myelomeningocele, infections, or bleeding had higher rates of failure after the procedure. This study demonstrated that age under 1 year and hydrocephalus caused by myelomeningocele, bleeding, and infection were considered independent risk factors of poor prognosis in ETV.

Endoscopic third ventriculostomy and cerebrospinal fluid shunting for pure communicating hydrocephalus in children

PURPOSE

Recent reports regarding endoscopic third ventriculostomy (ETV) for pediatric hydrocephalus revealed that ETV could avoid cerebrospinal fluid (CSF) shunting in certain types of hydrocephalus. However, the effectiveness of ETV for "pure" communicating hydrocephalus that has no obstruction through CSF pathway is still unknown. In this study, we report clinical outcome of ETV and CSF shunting for communicating hydrocephalus and discuss the efficacy of ETV for pure communicating hydrocephalus.

METHODS

Children less than 15 years old who underwent ETV or CSF shunting for communicating hydrocephalus were retrospectively reviewed. The absence of obstruction through CSF circulation was confirmed by CT cisternography or cine-contrast image in MRI.

RESULTS

Sixty-three patients (45 CSF shunting and 18 ETV) were included. The mean follow-up period was 6.1 years. The success rate was 60% in CSF shunting and 67% in ETV at the last visit (p = 0.867). Normal development was observed in 24 patients (53%) in CSF shunting and 12 patients (67%) in ETV (p = 0.334). There was a significant difference in the mean time to failure (CSF shunting: 51.1 months, ETV 3.6 months, p = 0.004). The factor that affected success rate in ETV was the age at surgery (success 21.6 months, failure 4.4 months, p = 0.024) and ETV success score (success 66.7, failure 50.0, p = 0.047).

CONCLUSION

Clinical outcomes of ETV were not inferior to those of CSF shunting in patients with communicating hydrocephalus. Further studies is required to elucidate to establish the consensus of ETV as a treatment option for communicating hydrocephalus.

Palliative endoscopic third ventriculostomy for pediatric primary brain tumors: a single-institution case series

OBJECTIVE

Children with nonoperative brain tumors, such as diffuse intrinsic pontine gliomas (DIPGs), often have life-threatening hydrocephalus. Palliative shunting is common in such cases but can be complicated by hardware infection and mechanical failure. Endoscopic third ventriculostomy (ETV) is a minimally invasive alternative to treat hydrocephalus without implanted hardware. Herein, the authors report their institutional experience with palliative ETV for primary pediatric brain tumors.

METHODS

The authors conducted a retrospective review of consecutive patients who had undergone palliative ETV for hydrocephalus secondary to nonresectable primary brain tumors over a 10-year period at Rady Children's Hospital. Collected variables included age, sex, tumor type, tumor location, presence of leptomeningeal spread, use of a robot for ETV, complications, ETV Success Score (ETVSS), functional status, length of survival, and follow-up time. A successful outcome was defined as an ETV performed without clinically significant perioperative complications or secondary requirement for a new shunt.

RESULTS

Fifteen patients met the study inclusion criteria (11 males, 4 females; average age 7.9 years, range 0.8-21 years). Thirteen patients underwent manual ETV, and 2 patients underwent robotic ETV. Preoperative symptoms included gaze palsy, nausea/vomiting, headache, lethargy, hemiparesis, and seizures. Tumor types included DIPG (3), intraventricular/thalamic glioblastoma (2), and leptomeningeal spread of medulloblastoma (2), anaplastic oligo-/astrocytoma (2), rhabdoid tumor (2), primitive neuroectodermal tumor (1), ganglioglioma (1), pineoblastoma (1), and embryonal carcinoma (1). The mean preoperative ETVSS was 79 ± 8.8. There was 1 perioperative complication, a wound breakdown consistent with refractory hydrocephalus. The mean follow-up was 4.9 ± 5.5 months overall, and mean survival for the patients who died was 3.2 ± 3.6 months. Two patients remained alive at a mean follow-up of 15.7 months. Palliative ETV was successful in 7 patients (47%) and unsuccessful in 8 (53%). While patients with successful ETV were significantly older (11.9 ± 5.6 vs 4.4 ± 4.1 years, p = 0.010), there were no significant differences in preoperative ETVSS (p = 0.796) or postoperative survival (p = 0.476) between the successful and unsuccessful groups. Overall, functional outcomes were similar between the two groups; there was no significant difference in posttreatment Karnofsky Performance Status scores (68.6 ± 19.5 vs 61.3 ± 16.3, p = 0.454), suggesting that including ETV in the treatment algorithm did not worsen outcomes.

CONCLUSIONS

Palliative ETV is a safe and potentially efficacious treatment option in selected pediatric patients with hydrocephalus from nonoperative brain tumors. Close follow-up, especially in younger children, is required to ensure that patients with refractory symptoms receive appropriate secondary CSF diversion.

Implementation Science to Improve Quality of Neurological Care

Neurological disorders are the leading cause of disability and the second leading cause of death globally. To challenge this enormous disease burden, scientists are pursuing innovative solutions to maintain and improve the quality of neurological care. Despite the availability of many effective evidence-based practices, many patients with neurological disorders cannot access these (or receive them inefficiently after a long delay) and may be exposed to unnecessary, expensive, and potentially harmful treatments. To promote the systematic uptake of evidence-based practices into the real world, a new scientific study of methods has been developed: implementation science. In implementation science research, transdisciplinary research teams systematically (using theory, model, and framework) assess local barriers to facilitate the adoption of evidence-based practices and examine potential solutions using implementation strategies (interventions that help adoption of intended practices) targeting multiple levels in the health care system, including patient, provider, clinic, facility, organization, or broader community and policy environment. The success of these strategies (implementation outcomes) is measured by the extent and quality of the implementation. Implementation studies can be either observational or interventional but are distinct from traditional efficacy or effectiveness studies. Traditional neuroscience research and clinical trials, conducted in controlled settings, focus on discovering new insights with little consideration of translating those insights into the everyday practice of a resource-constrained and dynamic health care system. Thus, neurologists should become familiar with implementation science to reduce the knowledge-practice gap, maximize health care value, and improve management of brain disorders affecting public health.

Rigid versus flexible neuroendoscopy: a systematic review and meta-analysis of endoscopic third ventriculostomy for the management of pediatric hydrocephalus

OBJECTIVE

Endoscopic third ventriculostomy (ETV), with or without choroid plexus cauterization (±CPC), is a technique used for the treatment of pediatric hydrocephalus. Rigid or flexible neuroendoscopy can be used, but few studies directly compare the two techniques. Here, the authors sought to compare these methods in treating pediatric hydrocephalus.

METHODS

A systematic MEDLINE search was conducted using combinations of keywords: "flexible," "rigid," "endoscope/endoscopic," "ETV," and "hydrocephalus." Inclusion criteria were as follows: English-language studies with patients 2 years of age and younger who had undergone ETV±CPC using rigid or flexible endoscopy for hydrocephalus. The primary outcome was ETV success (i.e., without the need for further CSF diversion procedures). Secondary outcomes included ETV-related and other complications. Statistical significance was determined via independent t-tests and Mood's median tests.

RESULTS

Forty-eight articles met the study inclusion criteria: 37 involving rigid endoscopy, 10 involving flexible endoscopy, and 1 propensity scored-matched comparison. A cumulative 560 patients had undergone 578 rigid ETV±CPC, and 661 patients had undergone 672 flexible ETV±CPC. The flexible endoscopy cohort had a significantly lower average age at the time of the procedure (0.33 vs 0.53 years, p = 0.001) and a lower preoperatively predicted ETV success score (median 40, IQR 32.5-57.5 vs 62.5, IQR 50-70; p = 0.033). Average ETV success rates in the rigid versus flexible groups were 54.98% and 59.65% (p = 0.63), respectively. ETV-related complication rates did not differ significantly at 0.63% for flexible endoscopy and 3.46% for rigid endoscopy (p = 0.30). There was no significant difference in ETV success or complication rate in comparing ETV, ETV+CPC, and ETV with other concurrent procedures.

CONCLUSIONS

Despite the lower expected ETV success scores for patients treated with flexible endoscopy, the authors found similar ETV success and complication rates for ETV±CPC with flexible versus rigid endoscopy, as reported in the literature. Further direct comparison between the techniques is necessary.

Paenibacillus infection with frequent viral coinfection contributes to postinfectious hydrocephalus in Ugandan infants

Postinfectious hydrocephalus (PIH), which often follows neonatal sepsis, is the most common cause of pediatric hydrocephalus worldwide, yet the microbial pathogens underlying this disease remain to be elucidated. Characterization of the microbial agents causing PIH would enable a shift from surgical palliation of cerebrospinal fluid (CSF) accumulation to prevention of the disease. Here, we examined blood and CSF samples collected from 100 consecutive infant cases of PIH and control cases comprising infants with non-postinfectious hydrocephalus in Uganda. Genomic sequencing of samples was undertaken to test for bacterial, fungal, and parasitic DNA; DNA and RNA sequencing was used to identify viruses; and bacterial culture recovery was used to identify potential causative organisms. We found that infection with the bacterium Paenibacillus, together with frequent cytomegalovirus (CMV) coinfection, was associated with PIH in our infant cohort. Assembly of the genome of a facultative anaerobic bacterial isolate recovered from cultures of CSF samples from PIH cases identified a strain of Paenibacillus thiaminolyticus This strain, designated Mbale, was lethal when injected into mice in contrast to the benign reference Paenibacillus strain. These findings show that an unbiased pan-microbial approach enabled characterization of Paenibacillus in CSF samples from PIH cases, and point toward a pathway of more optimal treatment and prevention for PIH and other proximate neonatal infections.

Multi-omic analysis elucidates the genetic basis of hydrocephalus

We conducted PrediXcan analysis of hydrocephalus risk in ten neurological tissues and whole blood. Decreased expression of MAEL in the brain was significantly associated (Bonferroni-adjusted p < 0.05) with hydrocephalus. PrediXcan analysis of brain imaging and genomics data in the independent UK Biobank (N = 8,428) revealed that MAEL expression in the frontal cortex is associated with white matter and total brain volumes. Among the top differentially expressed genes in brain, we observed a significant enrichment for gene-level associations with these structural phenotypes, suggesting an effect on disease risk through regulation of brain structure and integrity. We found additional support for these genes through analysis of the choroid plexus transcriptome of a murine model of hydrocephalus. Finally, differential protein expression analysis in patient cerebrospinal fluid recapitulated disease-associated expression changes in neurological tissues, but not in whole blood. Our findings provide convergent evidence highlighting the importance of tissue-specific pathways and mechanisms in the pathophysiology of hydrocephalus.

Immune activation during Paenibacillus brain infection in African infants with frequent cytomegalovirus co-infection

Inflammation during neonatal brain infections leads to significant secondary sequelae such as hydrocephalus, which often follows neonatal sepsis in the developing world. In 100 African hydrocephalic infants we identified the biological pathways that account for this response. The dominant bacterial pathogen was a Paenibacillus species, with frequent cytomegalovirus co-infection. A proteogenomic strategy was employed to confirm host immune response to Paenibacillus and to define the interplay within the host immune response network. Immune activation emphasized neuroinflammation, oxidative stress reaction, and extracellular matrix organization. The innate immune system response included neutrophil activity, signaling via IL-4, IL-12, IL-13, interferon, and Jak/STAT pathways. Platelet-activating factors and factors involved with microbe recognition such as Class I MHC antigen-presenting complex were also increased. Evidence suggests that dysregulated neuroinflammation propagates inflammatory hydrocephalus, and these pathways are potential targets for adjunctive treatments to reduce the hazards of neuroinflammation and risk of hydrocephalus following neonatal sepsis.

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There is a characteristic immune response to Paenibacillus brain infection

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There is a characteristic immune response to CMV brain infection

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The matching immune response validates pathogen genomic presence

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The combined results support molecular infection causality

Pediatric hydrocephalus outcomes in Lusaka, Zambia

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.