Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda

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 .).

Figure 1

Enrollment, Randomization, Treatment, and Follow-up.

Figure 2. Kaplan–Meier Survival Curves for Time to First Treatment Failure in the Intention-to-Treat Population

ETV–CPC denotes endoscopic third ventriculostomy with choroid plexus cauterization.

Figure 3. Brain Volume

Panels A and B show brain-volume trajectories for female and male patients, determined by examination of preoperative, 6-month postoperative, and 12-month postoperative scans. Curve fits (Weibull distribution) to normative data are indicated with black lines representing the age-adjusted mean and 1 and 2 SD above and below the mean. The scans represented by the circled data points in Panel A are shown in Panels C and D (for a patient in each treatment group who had catch-up growth to the normal range), and the scans represented by circled data points in Panel B are shown in Panels E and F (for a patient in each treatment group who had growth failure). In Panels C through F, the preoperative (baseline) scan is shown on the left, and the corresponding 12-month postoperative scan is shown on the right.