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Shahbandi A, Jahangiri P, Meybodi KT, Nejat F, Habibi Z. Implementation of an adapted perioperative ventriculoperitoneal shunting protocol in a tertiary center located in a low-to-middle-income country. Childs Nerv Syst 2024; 40:1839-1847. [PMID: 38557895 DOI: 10.1007/s00381-024-06374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Preventative protocols have efficaciously reduced shunt infection in developed countries. However, the generalizability of these protocols in low-to-middle-income countries (LMICs) remains unclear. Previously, shunt insertion in the authors' center was routinely performed under institutional preventative precautions, which was updated via merging with the Hydrocephalus Clinical Research Network (HCRN) protocol. This study aimed to investigate the ventriculoperitoneal shunt (VPS) infection rates in pediatric patients following the implementation of the adapted protocol. METHODS The adapted protocol was implemented in all first-time VPS implantations between 2011 and 2021. The primary outcome was a 6-month shunt infection. The Pearson chi-square test was used for categorical variables and the Mann-Whitney U-test for numeric variables to evaluate the correlation with shunt infection. RESULTS A total of 352 first-time VPS procedures were performed adhering to the adapted protocol. The median age was 5 months, and 189 (53.7%) were male. Overall, 37 patients (10.5%) experienced shunt infection, with 30 (8.5%) occurring within the first 6 months, which was lower than 13.3% infection rate of the previous series of the same center. The infection rate was slightly higher than the 5.7% and 6.0% rates reported by HCRN studies. Patients with shunt infection were significantly younger (7.5 versus 17.5 months, P < 0.001). CONCLUSIONS This study validates the efficacy of an adapted perioperative protocol in mitigating shunt infection in a high-volume center in a LMIC. Adhering to a step-by-step protocol, modified to suit the healthcare resources and financial constraints of LMICs, could maintain low shunt infection rates that are roughly comparable to those of centers in high-income countries.
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Affiliation(s)
- Ataollah Shahbandi
- Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Pedram Jahangiri
- Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Keyvan Tayebi Meybodi
- Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farideh Nejat
- Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Habibi
- Department of Pediatric Neurosurgery, Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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2
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Kovács J, Máté V, Obeidat M, Nagy R, Agócs G, Kiss-Dala S, Hegyi P, Kiss-Miki R, Párniczky A, Müller KE, Garami M. Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis. Neurosurgery 2024:00006123-990000000-01179. [PMID: 38808998 DOI: 10.1227/neu.0000000000003009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/29/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Antibiotic-impregnated shunts seem to be beneficial in preventing bacterial infections and decreasing mortality by effectively inhibiting microbial growth in the shunt system and reducing the risk of shunt-associated infections. This study aimed to evaluate the efficacy of antibiotic-impregnated shunt catheters (AISC) in reducing the incidence of bacterial shunt infection in patients with hydrocephalus. METHODS The protocol was registered on PROSPERO. A meta-analysis was conducted by searching 3 databases (PubMed, Scopus, CENTRAL) for relevant randomized controlled trials and observational studies. We included all studies published until November 2022 in any language. The primary outcome was the rate of bacterial infections, whereas the rate of shunt failure was our secondary endpoint. Odds ratios (OR) with 95% CI were calculated using a random-effects model. RESULTS A total of 27 articles with 27 266 shunt operations were included in this study. The results indicated that using AISC is significantly associated with reduction in infections (OR = 0.42; 95% CI: 0.33-0.54). Regarding shunt failure, there was a tendency in favor of AISC use (OR = 0.73; 95% CI: 0.51-1.06). CONCLUSION Our study provided evidence that AISC is significantly associated with the reduction in the rate of bacterial ventriculoperitoneal-shunt infection. In addition, there was a tendency toward AISC to decrease shunt failure compared with the standard shunt.
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Affiliation(s)
- Janka Kovács
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Vanda Máté
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Mahmoud Obeidat
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Rita Nagy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gergely Agócs
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Szilvia Kiss-Dala
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Renáta Kiss-Miki
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Andrea Párniczky
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Katalin E Müller
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Department of Family Care Methodology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
| | - Miklós Garami
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
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Aetiology and diagnostics of paediatric hydrocephalus across Africa: a systematic review and meta-analysis. Lancet Glob Health 2022; 10:e1793-e1806. [PMID: 36400085 DOI: 10.1016/s2214-109x(22)00430-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/01/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND We aimed to identify the aetiological distribution and the diagnostic methods for paediatric hydrocephalus across Africa, for which there is currently scarce evidence. METHODS In this systematic review and meta-analysis, we searched MEDLINE (Ovid), the Cochrane Database of Systematic Reviews (Wiley), Embase (Ovid), Global Health (Ovid), Maternity & Infant Care (Ovid), Scopus, African Index Medicus (Global Index Medicus, WHO) and Africa-Wide Information (EBSCO) from inception to Nov 29, 2021. We included studies from any African country reporting on the distribution of hydrocephalus aetiology in children aged 18 years and younger, with no language restrictions. Hydrocephalus was defined as radiological evidence of ventriculomegaly or associated clinical symptoms and signs of the disorder, or surgical treatment for hydrocephalus. Exclusion criteria were studies only reporting on one specific subgroup or one specific cause of hydrocephalus. We also excluded conference and meetings abstracts, grey literature, editorials, commentaries, historical reviews, systematic reviews, case reports and clinical guidelines, as well as studies on non-humans, fetuses, or post-mortem reports. The proportions of postinfectious hydrocephalus, non-postinfectious hydrocephalus, and hydrocephalus related to spinal dysraphism were calculated using a random-effects model. Additionally, we included a category for unclear cases. Diagnostic methods were described qualitatively. To assess methodological study quality, we applied critical appraisal checklists provided by the Joanna Briggs Institute. The study was registered in Prospero (CRD42020219038). FINDINGS Our search yielded 3783 results, of which 1880 (49·7%) were duplicates and were removed. The remaining 1903 abstracts were screened and 122 (6·4%) full articles were sought for retrieval; of these, we included 38 studies from 18 African countries that studied a total of 6565 children. The pooled proportion of postinfectious hydrocephalus was 28% (95% CI 22-36), non-postinfectious hydrocephalus was 21% (95% CI 13-30), and of spinal dysraphism was 16% (95% CI 12-20), with substantial heterogeneity. The pooled proportion of hydrocephalus of unclear aetiology was 20% (95% CI 13-28). INTERPRETATION Our findings suggest that postinfectious hydrocephalus is the single most common cause of paediatric hydrocephalus in Africa. For targeted investments to be optimal, there is a need for consensus regarding the aetiological classification of hydrocephalus and improved access to diagnostic services. FUNDING Rikshospitalet, Oslo University Hospital, Oslo, Norway.
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Mulugeta B, Seyoum G, Mekonnen A, Ketema E. Assessment of the prevalence and associated risk factors of pediatric hydrocephalus in diagnostic centers in Addis Ababa, Ethiopia. BMC Pediatr 2022; 22:145. [PMID: 35303805 PMCID: PMC8932009 DOI: 10.1186/s12887-022-03212-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 03/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background Hydrocephalus (HCP) is a common disorder of cerebral spinal fluid (CSF) physiology resulting in abnormal expansion of the cerebral ventricles. Infants commonly present with progressive macrocephaly whereas children older than 2 years generally present with signs and symptoms of intracranial hypertension. Neither qualitatively nor quantitatively are there adequate data to determine the prevalence and incidence of HCP in the developing world. HCP is a treatable condition that when left untreated, has fatal consequences. Objective The objective of this study was to assess the prevalence of pediatric HCP and associated risk factors in diagnostic centers in Addis Ababa, Ethiopia. Methods This study was conducted using a cross-sectional facility-based study design over a two-time period, i.e. a 2-year retrospective data collection from January 2018 to January 2020 included 1101 patients and a prospective data collection from May 2019 to February 2020 included 99 patients. Children aged 5 years and below who came to the selected diagnostic centers for MRI/CT examination were studied. The collected data were analyzed using binary logistic regression. Result The retrospective study included 639(58%) males and 462 (42%) females. The mean age calculated was 22.3 months. Infants aged younger than 24 months 753 (68.4%) were significantly associated with HCP development (P < 0.05). In the retrospective study, HCP etiologies; Aqueductal stenosis (17.9%), Neural Tube defects (NTDs) (35.7%), post-infectious (10.1%) were identified. In the prospective study, the gender and age distribution was 57(57.6%) males, 42 (42.4%) females, 60.6% infants aged younger than 24 months with a mean age of 24.9 months. Inadequate consumption of folic acid and development of HCP was found to be statistically significant (P < 0.05). In the prospective study, HCP etiologies; Aqueductal stenosis (26.1%), Neural Tube defects (26.08%), and post-infectious (8.69%) were identified. The 3 years prevalence of HCP calculated in both studies was 22% (223 per 1000 live births). Conclusion The results of this study suggest that the high prevalence of HCP was due to the high prevalence of aqueductal stenosis and neural tube defects; with a small contribution of post-infectious causes. The majority of infants who present with HCP were aged younger than 24 months.
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Affiliation(s)
- Blein Mulugeta
- Department of Medical Radiologic Technology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girma Seyoum
- Department of Anatomy, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Abebe Mekonnen
- Department of Radiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Elbet Ketema
- Departmetn of Pediatrics, Addis Ababa University, Addis Ababa, Ethiopia
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Enslin JMN, Thango NS, Figaji A, Fieggen GA. Hydrocephalus in Low and Middle-Income Countries - Progress and Challenges. Neurol India 2021; 69:S292-S297. [PMID: 35102979 DOI: 10.4103/0028-3886.332285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Johannes M N Enslin
- Department of Surgery, Division of Neurosurgery, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Nqobile S Thango
- Department of Surgery, Division of Neurosurgery, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Anthony Figaji
- Department of Surgery, Division of Neurosurgery, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Graham A Fieggen
- Department of Surgery, Division of Neurosurgery, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Schiff SJ, Kulkarni AV, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, Levenbach J, Monga V, Peterson M, Cherukuri V, Warf BC. Brain growth after surgical treatment for infant postinfectious hydrocephalus in Sub-Saharan Africa: 2-year results of a randomized trial. J Neurosurg Pediatr 2021; 28:326-334. [PMID: 34243157 PMCID: PMC8742836 DOI: 10.3171/2021.2.peds20949] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/17/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Hydrocephalus in infants, particularly that with a postinfectious etiology, is a major public health burden in Sub-Saharan Africa. The authors of this study aimed to determine whether surgical treatment of infant postinfectious hydrocephalus in Uganda results in sustained, long-term brain growth and improved cognitive outcome. METHODS The authors performed a trial at a single center in Mbale, Uganda, involving infants (age < 180 days old) with postinfectious hydrocephalus randomized to endoscopic third ventriculostomy plus choroid plexus cauterization (ETV+CPC; n = 51) or ventriculoperitoneal shunt (VPS; n = 49). After 2 years, they assessed developmental outcome with the Bayley Scales of Infant Development, Third Edition (BSID-III), and brain volume (raw and normalized for age and sex) with CT scans. RESULTS Eighty-nine infants were assessed for 2-year outcome. There were no significant differences between the two surgical treatment arms in terms of BSID-III cognitive score (p = 0.17) or brain volume (p = 0.36), so they were analyzed together. Raw brain volumes increased between baseline and 2 years (p < 0.001), but this increase occurred almost exclusively in the 1st year (p < 0.001). The fraction of patients with a normal brain volume increased from 15.2% at baseline to 50.0% at 1 year but then declined to 17.8% at 2 years. Substantial normalized brain volume loss was seen in 21.3% patients between baseline and year 2 and in 76.7% between years 1 and 2. The extent of brain growth in the 1st year was not associated with the extent of brain volume changes in the 2nd year. There were significant positive correlations between 2-year brain volume and all BSID-III scores and BSID-III changes from baseline. CONCLUSIONS In Sub-Saharan Africa, even after successful surgical treatment of infant postinfectious hydrocephalus, early posttreatment brain growth stagnates in the 2nd year. While the reasons for this finding are unclear, it further emphasizes the importance of primary infection prevention and mitigation strategies along with optimizing the child's environment to maximize brain growth potential.
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Affiliation(s)
- Steven J. Schiff
- Center for Neural Engineering; The Pennsylvania State University, State College, Pennsylvania
- Department of Neurosurgery, The Pennsylvania State University, State College, Pennsylvania
- Department of Engineering Science and Mechanics, The Pennsylvania State University, State College, Pennsylvania
- Department of Physics, The Pennsylvania State University, State College, Pennsylvania
| | - Abhaya V. Kulkarni
- Department of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - John Mugamba
- CURE Children’s Hospital of Uganda, Mbale, Uganda
| | | | - Ruth Donnelly
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jody Levenbach
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vishal Monga
- Center for Neural Engineering; The Pennsylvania State University, State College, Pennsylvania
| | - Mallory Peterson
- Center for Neural Engineering; The Pennsylvania State University, State College, Pennsylvania
| | | | - Benjamin C. Warf
- Department of Neurosurgery, Boston Children’s Hospital, Boston, Massachusetts
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7
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Zhou WX, Hou WB, Zhou C, Yin YX, Lu ST, Liu G, Fang Y, Li JW, Wang Y, Liu AH, Zhang HJ. Systematic Review and Meta-Analysis of Antibiotic-Impregnated Shunt Catheters on Anti-Infective Effect of Hydrocephalus Shunt. J Korean Neurosurg Soc 2021; 64:297-308. [PMID: 33626856 PMCID: PMC7969052 DOI: 10.3340/jkns.2019.0219] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/04/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Shunt infection is a common complication while treating hydrocephalus. The antibiotic-impregnated shunt catheter (AISC) was designed to reduce shunt infection rate. A meta-analysis was conducted to study the effectiveness of AISCs in reduction of shunt infection in terms of age, follow-up time and high-risk patient population. METHODS This study reviewed literature from three databases including PubMed, EMBASE, and Cochrane Library (from 2000 to March 2019). Clinical studies from controlled trials for shunt operation were included in this analysis. A subgroup analysis was performed based on the patient's age, follow-up time and high-risk population. The fixed effect in RevMan 5.3 software (Cochrane Collaboration) was used for this meta-analysis. RESULTS This study included 19 controlled clinical trials including 10105 operations. The analysis demonstrated that AISC could reduce the infection rate in shunt surgery compared to standard shunt catheter (non-AISC) from 8.13% to 4.09% (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.40-0.58; p=0.01; I2=46%). Subgroup analysis of different age groups showed that AISC had significant antimicrobial effects in all three groups (adult, infant, and adolescent). Follow-up time analysis showed that AISC was effective in preventing early shunt infections (within 6 months after implant). AISC is more effective in high-risk population (OR, 0.24; 95% CI, 0.14-0.40; p=0.60; I2=0%) than in general patient population. CONCLUSION The results of meta-analysis indicated that AISC is an effective method for reducing shunt infection. We recommend that AISC should be considered for use in infants and high-risk groups. For adult patients, the choice for AISC could be determined based on the treatment cost.
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Affiliation(s)
- Wen-Xiu Zhou
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Wen-Bo Hou
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Chao Zhou
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Yu-Xia Yin
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Shou-Tao Lu
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Guang Liu
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Yi Fang
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Jian-Wen Li
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Yan Wang
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Ai-Hua Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hai-Jun Zhang
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China.,Department of Vascular & Intervention, Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Alborg, Denmark
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Harper JR, Zárate C, Krauch F, Muhumuza I, Molina J, Obungoloch J, Schiff SJ. An Unmatched Radio Frequency Chain for Low-Field Magnetic Resonance Imaging. FRONTIERS IN PHYSICS 2021; 9:727536. [PMID: 36213526 PMCID: PMC9536774 DOI: 10.3389/fphy.2021.727536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Magnetic Resonance Imaging (MRI) is a safe and versatile diagnostic tool for intracranial imaging, however it is also one of the most expensive and specialized making it scarce in low- to middle-income countries (LMIC). The affordability and portability of low-field MRI offers the potential for increased access to brain imaging for diseases like Hydrocephalus in LMIC. In this tutorial style work, we show the design of a low powered and low cost radio frequency chain of electronics to be paired with a previously reported prepolarized low-field MRI for childhood hydrocephalus imaging in sub-Saharan Africa where the incidence of this condition is high. Since the Larmor frequency for this system is as low as 180 kHz, we are able to minimize the impedance of the transmit coil to 5 ohms rather than match to 50 ohms as is traditionally the case. This reduces transmit power consumption by a factor of 10. We also show the use of inexpensive and commonly available animal enclosure fencing ("chicken wire") as a shield material at this frequency and compare to more traditional shield designs. These preliminary results show that highly portable and affordable low-field MRI systems could provide image resolution and signal-to-noise sufficient for planning hydrocephalus treatment in areas of the world with substantial resource limitations. Employment of these technologies in sub-Saharan Africa offers a cost-effective, sustainable approach to neurological diagnosis and treatment planning in this disease burdened region.
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Affiliation(s)
- Joshua R. Harper
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, United States
| | - Cristhian Zárate
- Laboratory of Mechanics and Energy, Department of Engineering, National University of Asunción, Asunción, Paraguay
| | - Federico Krauch
- Laboratory of Mechanics and Energy, Department of Engineering, National University of Asunción, Asunción, Paraguay
| | - Ivan Muhumuza
- Low Field MRI Lab, Department of Biomedical Engineering, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jorge Molina
- Laboratory of Mechanics and Energy, Department of Engineering, National University of Asunción, Asunción, Paraguay
| | - Johnes Obungoloch
- Low Field MRI Lab, Department of Biomedical Engineering, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Steven J. Schiff
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, United States
- Department of Neurosurgery, The Pennsylvania State University, University Park, PA, United States
- Department of Physics, The Pennsylvania State University, University Park, PA, United States
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Bauer DF, Baird LC, Klimo P, Mazzola CA, Nikas DC, Tamber MS, Flannery AM. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Treatment of Pediatric Hydrocephalus: Update of the 2014 Guidelines. Neurosurgery 2020; 87:1071-1075. [DOI: 10.1093/neuros/nyaa434] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
BACKGROUND
The Congress of Neurological Surgeons reviews its guidelines according to the Institute of Medicine's recommended best practice of reviewing guidelines every 5 yrs. The authors performed a planned 5-yr review of the medical literature used to develop the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines” and determined the need for an update to the original guideline based on new available evidence.
OBJECTIVE
To perform an update to include the current medical literature for the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines”, originally published in 2014.
METHODS
The Guidelines Task Force used the search terms and strategies consistent with the original guidelines to search PubMed and Cochrane Central for relevant literature published between March 2012 and November 2019. The same inclusion/exclusion criteria were also used to screen abstracts and to perform the full-text review. Full text articles were then reviewed and when appropriate, included as evidence and recommendations were added or changed accordingly.
RESULTS
A total of 41 studies yielded by the updated search met inclusion criteria and were included in this update.
CONCLUSION
New literature resulting from the update yielded a new recommendation in Part 2, which states that neuro-endoscopic lavage is a feasible and safe option for the removal of intraventricular clots and may lower the rate of shunt placement (Level III). Additionally a recommendation in part 7 of the guideline now states that antibiotic-impregnated shunt tubing reduces the risk of shunt infection compared with conventional silicone hardware and should be used for children who require placement of a shunt (Level I). <https://www.cns.org/guidelines/browse-guidelines-detail/pediatric-hydrocephalus-guideline>
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Affiliation(s)
- David F Bauer
- Department of Neurosurgery, Texas Children's Hospital, Pediatric Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Lissa C Baird
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul Klimo
- Semmes Murphey Department of Neurosurgery, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Catherine A Mazzola
- Goryeb Children’s Hospital, Morristown, New Jersey, Rutgers Department of Neurological Surgery, Newark, New Jersey
| | - Dimitrios C Nikas
- Division of Pediatric Neurosurgery, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Mandeep S Tamber
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ann Marie Flannery
- Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana
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10
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Reynolds RA, Bhebhe A, Garcia RM, Zhao S, Lam S, Sichizya K, Shannon CN. Pediatric hydrocephalus outcomes in Lusaka, Zambia. J Neurosurg Pediatr 2020; 26:624-635. [PMID: 32916646 PMCID: PMC7947024 DOI: 10.3171/2020.5.peds20193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/21/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Rebecca A. Reynolds
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee
| | - Arnold Bhebhe
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Roxanna M. Garcia
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Shilin Zhao
- Vanderbilt Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandi Lam
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Kachinga Sichizya
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Chevis N. Shannon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee
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11
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Lepard JR, Dewan MC, Chen SH, Bankole OB, Mugamba J, Ssenyonga P, Kulkarni AV, Warf BC. The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings. BMJ Glob Health 2020; 5:e002100. [PMID: 32133193 PMCID: PMC7042585 DOI: 10.1136/bmjgh-2019-002100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/07/2019] [Accepted: 12/23/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction Managing paediatric hydrocephalus with shunt placement is especially risky in resource-limited settings due to risks of infection and delayed life-threatening shunt obstruction. This study evaluated a new evidence-based treatment algorithm to reduce shunt-dependence in this context. Methods A prospective cohort design was used. The CURE Protocol employs preoperative and intraoperative data to choose between endoscopic treatment and shunt placement. Data were prospectively collected for 730 children in Uganda (managed by local neurosurgeons highly experienced in the protocol) and, for external validation, 96 children in Nigeria (managed by a local neurosurgeon trained in the protocol). Results The age distribution was similar between Uganda and Nigeria, but there were more cases of postinfectious hydrocephalus in Uganda (64.2% vs 26.0%, p<0.001). Initial treatment of hydrocephalus was similar at both centres and included either a shunt at first operation or endoscopic management without a shunt. The Nigerian cohort had a higher failure rate for endoscopic cases (adjusted HR 2.5 (95% CI 1.6 to 4.0), p<0.001), but not for shunt cases (adjusted HR 1.3 (0.5 to 3.0), p=0.6). Despite the difference in endoscopic failure rates, a similar proportion of the entire cohort was successfully treated without need for shunt at 6 months (55.2% in Nigeria vs 53.4% in Uganda, p=0.74). Conclusion Use of the CURE Protocol in two centres with different populations and surgeon experience yielded similar 6-month results, with over half of all children remaining shunt-free. Where feasible, this could represent a better public health strategy in low-resource settings than primary shunt placement.
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Affiliation(s)
- Jacob R Lepard
- Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Michael C Dewan
- Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephanie H Chen
- Neurological Surgery, University of Miami Health System, Miami, Florida, USA
| | | | - John Mugamba
- Neurosurgery, CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Peter Ssenyonga
- Neurosurgery, CURE Children's Hospital of Uganda, Mbale, Uganda
| | | | - Benjamin C Warf
- Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
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12
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Benachinmardi KK, Ravikumar R, Indiradevi B. Role of Biofilm in Cerebrospinal Fluid Shunt Infections: A Study at Tertiary Neurocare Center from South India. J Neurosci Rural Pract 2019; 8:335-341. [PMID: 28694609 PMCID: PMC5488550 DOI: 10.4103/jnrp.jnrp_22_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Biofilms are the source of persistent infections of many pathogenic microbes. They are responsible for nosocomial infection and also associated with many surgical conditions including indwelling medical devices such as ventriculoperitoneal shunt. A significant problem encountered in shunt procedures is obstruction followed by infection, with infection rate ranging from 2% to 27%, often with poor outcome. MATERIALS AND METHODS This study was conducted in the Department of Neuromicrobiology at a tertiary neuroinstitute for 6 months from July 1 to December 31, 2014. The samples comprised cerebrospinal fluid (CSF) from suspected cases of shunt infections. Laboratory diagnosis of causative agent was established by adopting standard procedures. Then, isolates were evaluated for production of biofilm by tissue culture plate (TCP) method and tube method. RESULTS Of the 1642 shunt CSF samples obtained from neurosurgery, 14.79% were culture positive which yielded 254 isolates. About 51.97% were Gram-negative bacilli (GNB), 46.46% were Gram-positive cocci (GPC), and 1.57% were Candida albicans. Among GNB, nonfermenters were the most common (51.52%) followed by Pseudomonas aeruginosa (15.9%). Among GPC, coagulase-negative Staphylococci were 88.13%, out of which 43.26% were methicillin-resistant. Other GPC were Enterococcus spp. (4.24%), Staphylococcus aureus (5.08%), and Streptococcus spp. (2.54%). Among all isolates, 120 were tested for biofilm production, out of which 57.5% were biofilm producers and 42.5% were nonproducers. CONCLUSIONS TCP was the better method to detect biofilm. Most of the biofilm producers were resistant pathogens.
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Affiliation(s)
- Kirtilaxmi K Benachinmardi
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - R Ravikumar
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - B Indiradevi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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13
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Mbabazi-Kabachelor E, Shah M, Vaughan KA, Mugamba J, Ssenyonga P, Onen J, Nalule E, Kapur K, Warf BC. Infection risk for Bactiseal Universal Shunts versus Chhabra shunts in Ugandan infants: a randomized controlled trial. J Neurosurg Pediatr 2019; 23:397-406. [PMID: 30611153 DOI: 10.3171/2018.10.peds18354] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/04/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical and economic repercussions of ventricular shunt infections are magnified in low-resource countries. The efficacy of antibiotic-impregnated shunts in this setting is unclear. A previous retrospective cohort study comparing the Bactiseal Universal Shunt (BUS) and the Chhabra shunt provided clinical equipoise; thus, the authors conducted this larger randomized controlled trial in Ugandan children requiring shunt placement for hydrocephalus to determine whether there was, in fact, any advantage of one shunt over the other. METHODS Between April 2013 and September 2016, the authors randomly assigned children younger than 16 years of age without evidence of ventriculitis to either BUS or Chhabra shunt implantation in this single-blind randomized controlled trial. The primary outcome was shunt infection, and secondary outcomes included reoperation and death. The minimum follow-up was 6 months. Time to outcome was assessed using the Kaplan-Meier method. The significance of differences was tested using Wilcoxon rank-sum, chi-square, Fisher’s exact, and t-tests. RESULTS Of the 248 patients randomized, the BUS was implanted in 124 and the Chhabra shunt in 124. There were no differences between the groups in terms of age, sex, or hydrocephalus etiology. Within 6 months of follow-up, there were 14 infections (5.6%): 6 BUS (4.8%) and 8 Chhabra (6.5%; p = 0.58). There were 14 deaths (5.6%; 5 BUS [4.0%] vs 9 Chhabra [7.3%], p = 0.27) and 30 reoperations (12.1%; 15 BUS vs 15 Chhabra, p = 1.00). There were no significant differences in the time to primary or secondary outcomes at 6 months’ follow-up (p = 0.29 and 0.17, respectively, Wilcoxon rank-sum test). CONCLUSIONS Among Ugandan infants, BUS implantation did not result in a lower incidence of shunt infection or other complications. Any recommendation for a more costly standard of care in low-resource countries must have contextually relevant, evidence-based support. Clinical trial registration no.: PACTR201804003240177 (http://www.pactr.org/)
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Affiliation(s)
| | - Meghal Shah
- 2Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,4Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kerry A Vaughan
- 2Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,3Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Kush Kapur
- 6Department of Neurology, Harvard Medical School, Harvard University; and.,7Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Benjamin C Warf
- 1CURE Children's Hospital, Mbale, Uganda.,2Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.,5Department of Neurosurgery, Boston Children's Hospital
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14
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Treating Pediatric Hydrocephalus at the Neurosurgery Education and Development Institute: The Reality in the Zanzibar Archipelago, Tanzania. World Neurosurg 2018; 117:e450-e456. [DOI: 10.1016/j.wneu.2018.06.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 11/21/2022]
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15
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Mangat HS, Schöller K, Budohoski KP, Ngerageza JG, Qureshi M, Santos MM, Shabani HK, Zubkov MR, Härtl R, Stieg PE. Neurosurgery in East Africa: Foundations. World Neurosurg 2018; 113:411-424. [PMID: 29702965 DOI: 10.1016/j.wneu.2018.01.086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This article is the first in a series of 3 articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). We review the history and evolution of neurosurgery as a clinical specialty in East Africa. We also review Kenya, Uganda, and Tanzania in some detail and highlight contributions of individuals and local and regional organizations that helped to develop and shape neurosurgical care in East Africa. Neurosurgery has developed steadily as advanced techniques have been adopted by local surgeons who trained abroad, and foreign surgeons who have dedicated part of their careers in local hospitals. New medical schools and surgical training programs have been established through regional and international partnerships, and the era of regional specialty surgical training has just begun. As more surgical specialists complete training, a comprehensive estimation of disease burden facing the neurosurgical field is important. We present an overview with specific reference to neurotrauma and neural tube defects, both of which are of epidemiologic importance as they gain not only greater recognition, but increased diagnoses and demands for treatment. Neurosurgery in East Africa is poised to blossom as it seeks to address the growing needs of a growing subspecialty.
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Affiliation(s)
- Halinder S Mangat
- Department of Neurology, Division of Stroke and Critical Care, Weill Cornell Medicine, New York, New York, USA.
| | - Karsten Schöller
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Karol P Budohoski
- Department of Neurosurgery, Addenbrookes Hospital, University of Cambridge, United Kingdom
| | - Japhet G Ngerageza
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Mahmood Qureshi
- Department of Neurosurgery, Aga Khan University Hospital, Nairobi, Kenya
| | - Maria M Santos
- The Center for Global Health, Weill Cornell Medicine, New York, New York, USA; Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Micaella R Zubkov
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Roger Härtl
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Philip E Stieg
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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16
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Yuen J, Selbi W, Muquit S, Berei T. Complication rates of external ventricular drain insertion by surgeons of different experience. Ann R Coll Surg Engl 2018; 100:221-225. [PMID: 29364007 PMCID: PMC5930101 DOI: 10.1308/rcsann.2017.0221] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Insertion of external ventricular drain (EVD) is a widely accepted, routinely performed procedure for treatment of hydrocephalus and raised intracranial pressure. The purpose of this study was to investigate whether a surgeon's experience affects the associated complication rate. Methods This retrospective study included all adult patients undergoing EVD insertion at a single centre between July 2013 and June 2015. Medical records were retrieved to obtain details on patient demographics, surgical indication, risk factors for infection and use of anticoagulants or antiplatelets. Surgeon experience, operative time, intraoperative antibiotic prophylaxis, need for revision surgery and EVD associated infection were examined. Information on catheter tip position and radiological evidence of intracranial haemorrhage was obtained from postoperative imaging. Results A total of 89 patients were included in the study. The overall infection, haemorrhage and revision rates were 4.8%, 7.8% and 13.0% respectively, with no significant difference among surgeons of different experience. The mean operating time for patients who developed an infection was 22 minutes while for those without an infection, it was 33 minutes (p=0.474). Anticoagulation/antiplatelet use did not appear to increase the rate of haemorrhage. The infection rate did not correlate with known risk factors (eg diabetes and steroids), operation start time (daytime vs out of hours) or duration of surgery although intraoperative (single dose) antibiotic prophylaxis seemed to reduce the infection rate. There was also a correlation between longer duration of catheterisation and increased risk of infection. Conclusions This is the first study demonstrating there is no significant difference in complication rates between surgeons of different experience. EVD insertion is a core neurosurgical skill and junior trainees should be trained to perform it.
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Affiliation(s)
- J Yuen
- Plymouth Hospitals NHS Trust, UK
| | - W Selbi
- Plymouth Hospitals NHS Trust, UK
| | - S Muquit
- Plymouth Hospitals NHS Trust, UK
| | - T Berei
- Plymouth Hospitals NHS Trust, UK
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17
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Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, Levenbach J, Monga V, Peterson M, MacDonald M, Cherukuri V, Warf BC. Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda. N Engl J Med 2017; 377:2456-2464. [PMID: 29262276 PMCID: PMC5784827 DOI: 10.1056/nejmoa1707568] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Postinfectious hydrocephalus in infants is a major health problem in sub-Saharan Africa. The conventional treatment is ventriculoperitoneal shunting, but surgeons are usually not immediately available to revise shunts when they fail. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV-CPC) is an alternative treatment that is less subject to late failure but is also less likely than shunting to result in a reduction in ventricular size that might facilitate better brain growth and cognitive outcomes. METHODS We conducted a randomized trial to evaluate cognitive outcomes after ETV-CPC versus ventriculoperitoneal shunting in Ugandan infants with postinfectious hydrocephalus. The primary outcome was the Bayley Scales of Infant Development, Third Edition (BSID-3), cognitive scaled score 12 months after surgery (scores range from 1 to 19, with higher scores indicating better performance). The secondary outcomes were BSID-3 motor and language scores, treatment failure (defined as treatment-related death or the need for repeat surgery), and brain volume measured on computed tomography. RESULTS A total of 100 infants were enrolled; 51 were randomly assigned to undergo ETV-CPC, and 49 were assigned to undergo ventriculoperitoneal shunting. The median BSID-3 cognitive scores at 12 months did not differ significantly between the treatment groups (a score of 4 for ETV-CPC and 2 for ventriculoperitoneal shunting; Hodges-Lehmann estimated difference, 0; 95% confidence interval [CI], -2 to 0; P=0.35). There was no significant difference between the ETV-CPC group and the ventriculoperitoneal-shunt group in BSID-3 motor or language scores, rates of treatment failure (35% and 24%, respectively; hazard ratio, 0.7; 95% CI, 0.3 to 1.5; P=0.24), or brain volume (z score, -2.4 and -2.1, respectively; estimated difference, 0.3; 95% CI, -0.3 to 1.0; P=0.12). CONCLUSIONS This single-center study involving Ugandan infants with postinfectious hydrocephalus showed no significant difference between endoscopic ETV-CPC and ventriculoperitoneal shunting with regard to cognitive outcomes at 12 months. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01936272 .).
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Affiliation(s)
- Abhaya V Kulkarni
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Steven J Schiff
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Edith Mbabazi-Kabachelor
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - John Mugamba
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Peter Ssenyonga
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Ruth Donnelly
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Jody Levenbach
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Vishal Monga
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Mallory Peterson
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Michael MacDonald
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Venkateswararao Cherukuri
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
| | - Benjamin C Warf
- From the University of Toronto (A.V.K.) and the Hospital for Sick Children (A.V.K., R.D., J.L.), Toronto; Pennsylvania State University, University Park (S.J.S., V.M., M.P., M.M., V.C.); CURE Children's Hospital of Uganda, Mbale (E.M.-K., J.M., P.S., B.C.W.); and Harvard Medical School and Boston Children's Hospital, Boston (B.C.W.)
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Santos MM, Rubagumya DK, Dominic I, Brighton A, Colombe S, O'Donnell P, Zubkov MR, Härtl R. Infant hydrocephalus in sub-Saharan Africa: the reality on the Tanzanian side of the lake. J Neurosurg Pediatr 2017; 20:423-431. [PMID: 28885096 DOI: 10.3171/2017.5.peds1755] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Infant hydrocephalus is estimated to affect more than 100,000 new infants each year in sub-Saharan Africa (SSA). Bugando Medical Centre (BMC), a government-funded and patient cost-shared referral center, serves over 13 million people in the Lake and Western regions of Tanzania. The goals of this study were to characterize the infant population affected by hydrocephalus who presented to BMC and were treated with a ventriculoperitoneal shunt (VPS) to determine the rate of early complications associated with this surgical procedure and to assess its potential risk factors. METHODS Data were prospectively collected from all patients less than 1 year of age who, over a period of 7 months, were diagnosed with hydrocephalus and admitted to BMC for insertion of a primary VPS. Demographic data, maternal history, preoperative studies, surgical procedure, and surgical complications developing by the time of the first follow-up visit were analyzed. Risk factors associated with the surgical complications were determined. RESULTS During the 7-month study period, 125 infants eligible for the study were included in the analysis. Overall, 75% were younger than 6 months of age, and 56% were males. Only 7% of mothers had a gestational ultrasound, 98% did not receive preconception folic acid, and 25% delivered their child at home. In most patients with hydrocephalus the etiology was uncertain (56%), and other patients had postinfectious (22.4%) or myelomeningocele-associated (16%) hydrocephalus. Patients' mean head circumference on admission was 51.4 ± 6.3 cm. Their median age at shunt surgery was 137 days, and 22.4% of the patients were operated on without having undergone radiological assessment. The majority of shunts were placed in a right parietooccipital location. Thirteen patients had undergone a previous intraventricular endoscopic procedure. Overall, at least one surgical complication was found in 33.6% of patients up to the first follow-up assessment (median follow-up time of 70 days); shunt infection was the most common complication. The postoperative mortality rate was 9%. The risk factors associated with early surgical complications were tumor-related etiology, larger head circumference, and postoperative hospital stays of greater duration. CONCLUSIONS In a region of the continent where most infant hydrocephalus cases had an uncertain etiology, most patients presented to the hospital in a late stage, with no prenatal diagnosis and with large head circumferences. Standard preoperative investigations were not uniformly performed, and the surgical complications, led by VPS infection, were disturbingly high. Younger patient age, previous endoscopic procedure, surgeon involved, and cranial location of the VPS had no statistical relation to the surgical complications. This study shows that the positive results previously reported by SSA mission hospitals, subspecialized in pediatric neurosurgery, are still not generalizable to every hospital in East Africa. To improve maternal and neonatal care in the Lake region of Tanzania, the development of a fluxogram to determine hydrocephalus etiology, a strict perioperative protocol for VPS insertion, and an increase in the number of endoscopic procedures are recommended to BMC.
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Affiliation(s)
- Maria M Santos
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, and
| | - Derick K Rubagumya
- Catholic University for Health and Allied Sciences, Bugando Medical Centre, Mwanza, Tanzania
| | - Imani Dominic
- Catholic University for Health and Allied Sciences, Bugando Medical Centre, Mwanza, Tanzania
| | - Amos Brighton
- Catholic University for Health and Allied Sciences, Bugando Medical Centre, Mwanza, Tanzania
| | | | - Philip O'Donnell
- Weill Cornell Medical College, NewYork-Presbyterian, New York, New York; and
| | - Micaella R Zubkov
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, and
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, and
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Warf BC. Growing Brains: How Adapting to Africa Advanced the Treatment of Infant Hydrocephalus. Neurosurgery 2017; 64:37-39. [DOI: 10.1093/neuros/nyx246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/15/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Benjamin C. Warf
- Department Neurosurgery, Harvard Med-ical School, Boston Children's Hospital, Boston, Massachusetts
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20
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Management of Hydrocephalus with Ventriculoperitoneal Shunts: Review of 109 Cases of Children. World Neurosurg 2016; 96:129-135. [DOI: 10.1016/j.wneu.2016.06.111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/25/2016] [Accepted: 06/27/2016] [Indexed: 02/07/2023]
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Muir RT, Wang S, Warf BC. Global surgery for pediatric hydrocephalus in the developing world: a review of the history, challenges, and future directions. Neurosurg Focus 2016; 41:E11. [DOI: 10.3171/2016.7.focus16273] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Pediatric hydrocephalus is one of the most common neurosurgical conditions and is a major contributor to the global burden of surgically treatable diseases. Significant health disparities exist for the treatment of hydrocephalus in developing nations due to a combination of medical, environmental, and socioeconomic factors. This review aims to provide the international neurosurgery community with an overview of the current challenges and future directions of neurosurgical care for children with hydrocephalus in low-income countries.
METHODS
The authors conducted a literature review around the topic of pediatric hydrocephalus in the context of global surgery, the unique challenges to creating access to care in low-income countries, and current international efforts to address the problem.
RESULTS
Developing countries face the greatest burden of pediatric hydrocephalus due to high birth rates and greater risk of neonatal infections. This burden is related to more general global health challenges, including malnutrition, infectious diseases, maternal and perinatal risk factors, and education gaps. Unique challenges pertaining to the treatment of hydrocephalus in the developing world include a preponderance of postinfectious hydrocephalus, limited resources, and restricted access to neurosurgical care. In the 21st century, several organizations have established programs that provide hydrocephalus treatment and neurosurgical training in Africa, Central and South America, Haiti, and Southeast Asia. These international efforts have employed various models to achieve the goals of providing safe, sustainable, and cost-effective treatment.
CONCLUSIONS
Broader commitment from the pediatric neurosurgery community, increased funding, public education, surgeon training, and ongoing surgical innovation will be needed to meaningfully address the global burden of untreated hydrocephalus.
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Affiliation(s)
| | - Shelly Wang
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
- 3Department of Biostatistics and Epidemiology, Harvard T.H. Chan School of Public Health
| | - Benjamin C. Warf
- 4Department of Neurosurgery, Boston Children's Hospital, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; and
- 5CURE Children's Hospital of Uganda, Mbale, Uganda
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22
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Yang B, Song Y, Gao P, Bao N. Prevention of infection by antibiotic-impregnated shunts after pediatric hydrocephalus treatment: A single center, retrospective study in China. Clin Neurol Neurosurg 2016; 151:92-95. [PMID: 27816893 DOI: 10.1016/j.clineuro.2016.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/09/2016] [Accepted: 10/12/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate infection prevention by antibiotic-impregnated shunts (AIS) relative to conventional ones after pediatric hydrocephalus treatment. METHODS This single center, retrospective analysis comprised 807 consecutive pediatric cases of hydrocephalus shunting performed by the same neurosurgeon between January 2001 and February 2013. Conventional and AIS catheters were used in 303 and 504 cases, respectively. Study outcomes were infection rates at 6 months (primary), and at 1 month and between 1 and 6 months (secondary). An infant (<1year) subgroup was also analyzed. RESULTS The AIS relative to the conventional catheter group had significantly lower infection rates at 6 months (1.98% [10/504] vs. 5.95% [18/303], two-tailed p=0.0046; central nervous system: 60% and 55.56%; abdominal: 20% and 27.77%; wound: 20% and 16.67%, respectively) and 1 month (0.19% [1/504] vs. 2.65% [8/303], p=0.0023, respectively), but statistically similar rates between 1 and 6 months (1.79% [9/504] vs. 3.30% [10/303], p=0.2296, respectively). In the infant subgroup, AIS application was also associated with reduction in shunt infection (1.49% [7/470] vs. 3.76% [10/266], p=0.0489, respectively). CONCLUSION AIS as compared to conventional catheter use appears to lower infection risk at 6 months, mainly during the first month, after hydrocephalus therapy in children.
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Affiliation(s)
- Bo Yang
- Department of Neurosurgery, Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Pudong, Shanghai 200127, PR China
| | - Yunhai Song
- Department of Neurosurgery, Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Pudong, Shanghai 200127, PR China
| | - Pingping Gao
- Department of Neurosurgery, Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Pudong, Shanghai 200127, PR China
| | - Nan Bao
- Department of Neurosurgery, Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Pudong, Shanghai 200127, PR China.
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Abstract
Hydrocephalus is a common disorder of cerebral spinal fluid (CSF) physiology resulting in abnormal expansion of the cerebral ventricles. Infants commonly present with progressive macrocephaly whereas children older than 2 years generally present with signs and symptoms of intracranial hypertension. The classic understanding of hydrocephalus as the result of obstruction to bulk flow of CSF is evolving to models that incorporate dysfunctional cerebral pulsations, brain compliance, and newly characterised water-transport mechanisms. Hydrocephalus has many causes. Congenital hydrocephalus, most commonly involving aqueduct stenosis, has been linked to genes that regulate brain growth and development. Hydrocephalus can also be acquired, mostly from pathological processes that affect ventricular outflow, subarachnoid space function, or cerebral venous compliance. Treatment options include shunt and endoscopic approaches, which should be individualised to the child. The long-term outcome for children that have received treatment for hydrocephalus varies. Advances in brain imaging, technology, and understanding of the pathophysiology should ultimately lead to improved treatment of the disorder.
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Affiliation(s)
- Kristopher T Kahle
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - David D Limbrick
- Division of Neurosurgery, St Louis Children's Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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The Need for Cost-Effective Neurosurgical Innovation—A Global Surgery Initiative. World Neurosurg 2015; 84:1458-61. [DOI: 10.1016/j.wneu.2015.06.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/18/2015] [Accepted: 06/20/2015] [Indexed: 11/20/2022]
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Konstantelias AA, Vardakas KZ, Polyzos KA, Tansarli GS, Falagas ME. Antimicrobial-impregnated and -coated shunt catheters for prevention of infections in patients with hydrocephalus: a systematic review and meta-analysis. J Neurosurg 2015; 122:1096-112. [PMID: 25768831 DOI: 10.3171/2014.12.jns14908] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to evaluate the effectiveness of antimicrobial-impregnated and -coated shunt catheters (antimicrobial catheters) in reducing the risk of infection in patients undergoing CSF shunting or ventricular drainage. METHODS The PubMed and Scopus databases were searched. Catheter implantation was classified as either shunting (mainly ventriculoperitoneal shunting) or ventricular drainage (mainly external [EVD]). Studies evaluating antibioticimpregnated catheters (AICs), silver-coated catheters (SCCs), and hydrogel-coated catheters (HCCs) were included. A random effects model meta-analysis was performed. RESULTS Thirty-six studies (7 randomized and 29 nonrandomized, 16,796 procedures) were included. The majority of data derive from studies on the effectiveness of AICs, followed by studies on the effectiveness of SCCs. Statistical heterogeneity was observed in several analyses. Antimicrobial shunt catheters (AICs, SCCs) were associated with lower risk for CSF catheter-associated infections than conventional catheters (CCs) (RR 0.44, 95% CI 0.35-0.56). Fewer infections developed in the patients treated with antimicrobial catheters regardless of randomization, number of participating centers, funding, shunting or ventricular drainage, definition of infections, de novo implantation, and rate of infections in the study. There was no difference regarding gram-positive bacteria, all staphylococci, coagulase-negative streptococci, and Staphylococcus aureus, when analyzed separately. On the contrary, the risk for methicillin-resistant S. aureus (MRSA, RR 2.64, 95% CI 1.26-5.51), nonstaphylococcal (RR 1.75, 95% CI 1.22-2.52), and gram-negative bacterial (RR 2.13, 95% CI 1.33-3.43) infections increased with antimicrobial shunt catheters. CONCLUSIONS Based on data mainly from nonrandomized studies, AICs and SCCs reduce the risk for infection in patients undergoing CSF shunting. Future studies should evaluate the higher risk for MRSA and gram-negative infections. Additional trials are needed to investigate the comparative effectiveness of the different types of antimicrobial catheters.
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