Hydrocephalus in children born in 1999-2002: epidemiology, outcome and ophthalmological findings

Temporal trends in paediatric hydrocephalus - Rising prematurity and persistent ophthalmological challenges

AIM

To study changes in aetiology, prematurity, comorbidity and ophthalmological outcomes in children with surgically treated hydrocephalus to provide information needed to maintain the best possible healthcare for a fragile and changing population.

METHODS

Two population-based cohorts, born two decades apart in Region Västra Götaland Sweden, surgically treated for hydrocephalus at Sahlgrenska University Hospital in Gothenburg were recruited at approximately 10 years of age. The participants were examined according to an ophthalmological protocol, including history taking regarding perceptual visual dysfunction (PVD). Gestational age, aetiology and comorbidities were registered.

RESULTS

The 1989-1993 group, comprised 52 children (48% girls; mean age 10, range 7.7-12.8 years), was compared with 24 children, born in 2007-2012 (29% girls; mean age 10, range 7.0-13.8 years). Extreme prematurity (gestational age ≤ 28 weeks) increased over time (p = 0.001). The vast majority of the children showed ophthalmological abnormalities, although motility defects and nystagmus decreased in the latter population. Subnormal visual acuity was associated with extreme prematurity (RR = 4.69; p = 0.030), and PVD with learning disability (RR = 2.44; p = 0.032).

CONCLUSION

Paediatric hydrocephalus populations may change with improved healthcare. Since a high percentage shows ophthalmological abnormalities and more children are born extremely preterm, the entirety needs consideration both neurologically and ophthalmologically.

Early postnatal microglial ablation in the Ccdc39 mouse model reveals adverse effects on brain development and in neonatal hydrocephalus

BACKGROUND

Neonatal hydrocephalus is a congenital abnormality resulting in an inflammatory response and microglial cell activation both clinically and in animal models. Previously, we reported a mutation in a motile cilia gene, Ccdc39 that develops neonatal progressive hydrocephalus (prh) with inflammatory microglia. We discovered significantly increased amoeboid-shaped activated microglia in periventricular white matter edema, reduced mature homeostatic microglia in grey matter, and reduced myelination in the prh model. Recently, the role of microglia in animal models of adult brain disorders was examined using cell type-specific ablation by colony-stimulating factor-1 receptor (CSF1R) inhibitor, however, little information exists regarding the role of microglia in neonatal brain disorders such as hydrocephalus. Therefore, we aim to see if ablating pro-inflammatory microglia, and thus suppressing the inflammatory response, in a neonatal hydrocephalic mouse line could have beneficial effects.

METHODS

In this study, Plexxikon 5622 (PLX5622), a CSF1R inhibitor, was subcutaneously administered to wild-type (WT) and prh mutant mice daily from postnatal day (P) 3 to P7. MRI-estimated brain volume was compared with untreated WT and prh mutants P7-9 and immunohistochemistry of the brain sections was performed at P8 and P18-21.

RESULTS

PLX5622 injections successfully ablated IBA1-positive microglia in both the WT and prh mutants at P8. Of the microglia that are resistant to PLX5622 treatment, there was a higher percentage of amoeboid-shaped microglia, identified by morphology with retracted processes. In PLX-treated prh mutants, there was increased ventriculomegaly and no change in the total brain volume was observed. Also, the PLX5622 treatment significantly reduced myelination in WT mice at P8, although this was recovered after full microglia repopulation by P20. Microglia repopulation in the mutants worsened hypomyelination at P20.

CONCLUSIONS

Microglia ablation in the neonatal hydrocephalic brain does not improve white matter edema, and actually worsens ventricular enlargement and hypomyelination, suggesting critical functions of homeostatic ramified microglia to better improve brain development with neonatal hydrocephalus. Future studies with detailed examination of microglial development and status may provide a clarification of the need for microglia in neonatal brain development.

Diagnosis and Surgical Management of Neonatal Hydrocephalus

Neonatal hydrocephalus represents an important pathological condition with significant impact on medical care and neurocognitive development. This condition requires early recognition, appropriate medical and surgical management, and long-term surveillance by clinicians and pediatric neurosurgeons. Common etiologies of neonatal and infant hydrocephalus include intraventricular hemorrhage related to prematurity with subsequent post-hemorrhagic hydrocephalus, myelomeningocele, and obstructive hydrocephalus due to aqueductal stenosis. Clinical markers of elevated intracranial pressure include rapid increases in head circumference across percentiles, elevation and firmness of the anterior fontanelle, splitting or splaying of cranial sutures, upgaze palsy, lethargy, frequent emesis, or episodic bradycardia (unrelated to other comorbidities). Complementing these clinical markers, imaging modalities used for the diagnosis of neonatal hydrocephalus include head ultrasonography, brain magnetic resonance imaging, and head computed tomography in urgent or emergent situations. Following diagnosis, temporizing measures may be employed prior to definitive treatment and include ventricular access device or ventriculo-subgaleal shunt insertion. Definitive surgical management involves permanent cerebrospinal fluid (CSF) diversion via CSF shunt insertion, or endoscopic third ventriculostomy with or without choroid plexus cauterization. Surgical decision-making and approaches vary based on patient age, hydrocephalus etiology, neuroanatomy, imaging findings, and medical comorbidities. Indications, surgical techniques, and clinical outcomes of these procedures continue to evolve and elicit significant attention in the research environment. In this review we describe the epidemiology, pathophysiology, clinical markers, imaging findings, early management, definitive surgical management, and clinical outcomes of pediatric patients with neonatal hydrocephalus.

An audit of endoscopic third ventriculostomy (ETV) in a regional paediatric neurosurgical centre assessing the accuracy and feasibility of the ETV success score

BACKGROUND

Endoscopic third ventriculostomy success score (ETVss) is widely utilised to predict outcomes for ETV. Accurate prediction of success for a procedure is of vital importance both for selecting the optimal management plan and for obtaining informed consent. Existing literature demonstrates a variety of opinions on the accuracy of the currently utilised ETVss and recommends a range of techniques to reduce the number of subsequent ventriculo-peritoneal (VP)-shunt insertions, prompting the present study.

METHODS

We retrospectively analysed data for ETV cases since 2007 to review success rate in our regional paediatric neurosurgical centre and if the currently utilised ETVss successfully predicted outcomes. Failed ETV cases were defined as any patient who received a VP-shunt at any time following ETV. Data was analysed with MS Excel^R and RStudio^R.

RESULTS

44 ETVs were performed over 13 years with approximately equal distribution between male and female patients; median age 7 years (IQR 4-13 years). Overall, mean ETVss for these 44 procedures was 78%; actual success rate was 70% with no statistically significant difference between them (p = 0.286; Welch two sample t-test). Accuracy of ETVss varied with pathology: tectal gliomas (mean ETVss 75% and actual success 78%); cerebellar tumours (mean ETVss 85% and actual success 81%); other tumours (mean ETVss 75% and actual success 81%); aqueduct stenosis (mean ETVss 71% and actual success 69%); and other pathologies (mean ETVss 70% and actual success 60%). < 1 month and 1-6 months and 1-10 years and > 10 years contributed equally to the accuracy of ETVss.

CONCLUSION

Non-telencephalon tumours and obstruction at the level of the mid-brain are most strongly associated with successful ETV outcome. These findings can be used to modify the currently utilised ETVss to further improve accuracy of outcome prediction. We recommend a modified-ETVss (m-ETVss) and a future larger adequately powered prospective study to validate this.

Thinner peripapillary retinal nerve fibre layer and macular retinal thickness in adolescents with surgically treated hydrocephalus in infancy

PURPOSE

To map the morphology of the retina and optic disc in adolescents with surgically treated hydrocephalus (HC) in infancy and to compare the results with healthy controls.

METHODS

The study comprised 26 adolescents (16 male, mean age 15 years) with HC and 31 sex- and aged-matched controls. The following optical coherence tomography (OCT) parameters were obtained: macular retinal thickness (MRT) and volume (MRV), thickness of the macular and peripapillary retinal nerve fibre layer (ppRNFL), and area of the optic disc, cup and rim.

RESULTS

The MRT was thinner amongst those with HC compared with controls (right eye (RE) 262.2 ± 15.3 and 275.8 ± 15.1 μm; p = 0.0051), and the MRV was smaller (RE 7.37 ± 0.36 and 7.83 ± 0.35 mm³ ; p = 0.0002). The HC group showed a thinner ppRNFL (RE 88.3 ± 14.9 and 103.5 ± 8.1 μm; p = 0.0002) but a thicker central macular RNFL (RE 11.6 ± 10.4 and 2.07 ± 3.00 μm; p = <0.0001) and foveal minimum (RE 211.1 ± 32.0 and 186.3 ± 15.9 μm; p = 0.0013). Optic disc variables showed no difference between groups. Correlations were found in the HC group between best corrected visual acuity (expressed in logMAR) and ppRNFL (RE r = -0.56, p = 0.018), and disc area (RE r = -0.52, p = 0.033).

CONCLUSION

Thinner ppRNFL and MRT and smaller MRV were found in adolescents with surgically treated HC in infancy compared with controls. In contrast, the central macular RNFL and foveal minimum were thicker. Further studies are required to evaluate the diagnostic value of OCT to indicate increased intracranial pressure timely and follow-up in individuals with surgically treated HC.

Neuroophthalmological manifestations of congenital aqueductal stenosis

OBJECTIVE

Congenital aqueductal stenosis (CAS) is a common etiology of hydrocephalus that occurs in a subset of infants and may be linked to an increased incidence of ophthalmological abnormalities and delayed developmental milestones. Although hydrocephalus is common and widely studied, sparse literature exists on patients with isolated (no identifiable genetic link) CAS along with analysis of ophthalmological manifestations. In this study, the authors sought to describe the ophthalmological abnormalities and delayed developmental milestones of patients with isolated CAS.

METHODS

Data of patients with CAS were prospectively entered and monitored in a surgical database maintained by the Department of Neurological Surgery at Children's Hospital of Pittsburgh from January 2005 to October 2016. Patients with a family history of congenital hydrocephalus, positive testing for genetic forms of aqueductal stenosis, other congenital abnormalities suggesting an underlying genetic syndrome, and stenosis/obstruction due to secondary causes were excluded from this study. Prenatal and perinatal history, CSF diversion history, and a variety of outcomes, including ophthalmological deficits and developmental milestones, were collected and analyzed.

RESULTS

A total of 41 patients with isolated CAS were identified, with a mean follow-up duration of 6 years. Among that cohort, 26 patients (63.4%) developed neuroophthalmological complications, which were further stratified. Fourteen patients (34.1%) developed strabismus and 11 (26.8%) developed astigmatism, and 1 patient (2.4%) with papilledema was recorded. Among patients with ophthalmological abnormalities, 76.9% had delayed developmental milestones (p = 0.045).

CONCLUSIONS

Patients with CAS were found to have increased risk of ophthalmological abnormalities requiring correction, along with an increased risk of delayed developmental milestones. Importantly, there was a significant correlation between the development of ophthalmological abnormalities and delayed developmental milestones that was independent of CSF diversion history. Larger patient cohort studies are required to explore whether earlier development of hydrocephalus, as is the case in CAS, causes elevated rates of neurological and ophthalmological complications, and if earlier CSF diversion correlates with improved outcomes.

Study of Neurodevelopmental Outcome in Patients with Non-tumoral Hydrocephalus with Shunt Surgery Done in Infancy

Background:

Hydrocephalus (HC) is a common neurological disorder presenting in infancy, with a myriad of etiologies requiring early neurosurgical intervention.

Objective:

To study neurodevelopmental outcome in patients with HC with shunt surgery done in infancy.

Materials and Methods:

This was an observational retrospective cohort study of 50 pediatric patients (2 years to 16 years of age). These patients were diagnosed with HC and were operated on with ventriculo-peritoneal shunt (VP shunt) insertion in infancy (did not include patients with brain tumors) and then later following in the neurology outpatient department (OPD). Clinical records and neurodevelopmental assessment (intelligence quotient [IQ]/development quotient [DQ] and vision and hearing assessment) were reviewed.

Results:

Only 50% of the patients with congenital HC were diagnosed at birth, which included patients who had been diagnosed antenatally and they had lesser complications and better intellectual outcome (P = 0.12), compared with those who presented later with HC. Patient-related factors such as etiology of HC, antenatal diagnosis, and requirement of shunt revisions had poor correlation with neurodevelopmental outcome. Patients with late postoperative complications had significantly poor neurodevelopmental outcome (P ≤ 0.001). Patients with post-meningitis HC required a significantly higher number of shunt revisions than patients with other causes (P = 0.04).

Conclusion:

Better neurodevelopmental outcome depends on early diagnosis and early referral for the management than the cause of HC. Regular head circumference monitoring is the most feasible and sensitive screening tool for early pickup. Larger studies are needed for accurate prognostication.

TrkA mediates effect of novel KIDINS220 mutation in human brain ventriculomegaly

Congenital hydrocephalus is a potentially devastating, highly heterogeneous condition whose genetic subset remains incompletely known. We here report a consanguineous family where three fetuses presented with brain ventriculomegaly and limb contractures and shared a very rare homozygous variant of KIDINS220, consisting of an in-frame deletion of three amino acids adjacent to the fourth transmembrane domain. Fetal brain imaging and autopsy showed major ventriculomegaly, reduced brain mass, and with no histomorphologic abnormalities. We demonstrate that the binding of KIDINS220 to TrkA is diminished by the deletion mutation. This family is the second that associates a KIDINS220 genetic variant with human ventriculomegaly and limb contractures, validating causality of the gene and indicating TrkA as a likely mediator of the phenotype.

Comparison of endoscopic third ventriculostomy with or without choroid plexus cauterization in pediatric hydrocephalus: a systematic review and meta-analysis

OBJECTIVE

Pediatric hydrocephalus is a significant contributor to infant morbidity and mortality, particularly in developing countries. The mainstay of treatment has long been shunt placement for CSF diversion, but recent years have seen the rise of alternative procedures such as endoscopic third ventriculostomy (ETV), which provides similar efficacy in selected patients. The addition of choroid plexus cauterization (CPC) to ETV has been proposed to increase efficacy, but the evidence of its utility is limited. This systematic review and meta-analysis aimed to determine the efficacy and safety of ETV+CPC in comparison to ETV alone for the treatment of pediatric all-cause hydrocephalus.

METHODS

MEDLINE, Embase, Cochrane CENTRAL, ClinicalTrials.gov, and ICRCTN databases were searched from conception through to October 2018 for comparative studies including both ETV+CPC and ETV in a pediatric population. The primary outcome was success rate, defined as no secondary procedure required for CSF diversion; secondary outcomes included time to failure, mortality, and complications. Data were pooled using random-effects models of meta-analysis, and relative risk (RR) was calculated.

RESULTS

Five studies were included for final qualitative and quantitative analysis, including 2 prospective and 3 retrospective studies representing a total of 963 patients. Overall, there was no significant difference in success rates between ETV and ETV+CPC (RR 1.24, 95% CI 0.88-1.75, p = 0.21). However, a subgroup analysis including the 4 studies focusing on African cohorts demonstrated a significant benefit of ETV+CPC (RR 1.38, 95% CI 1.08-1.78, p = 0.01). There were no notable differences in complication rates among studies.

CONCLUSIONS

This systematic review and meta-analysis failed to find an overall benefit to the addition of CPC to ETV; however, a subgroup analysis showed efficacy in sub-Saharan African populations. This points to the need for future randomized clinical trials investigating the efficacy of ETV+CPC versus ETV in varied patient populations and geographic locales.

The quality of YouTube videos on endoscopic third ventriculostomy and endoscopic third ventriculostomy with choroid plexus cauterization procedures available to families of patients with pediatric hydrocephalus

OBJECTIVE

YouTube has become an important information source for pediatric neurosurgical patients and their families. The goal of this study was to determine whether the informative quality of videos of endoscopic third ventriculostomy (ETV) and endoscopic third ventriculostomy with choroid plexus cauterization (ETV + CPC) is associated with metrics of popularity.

METHODS

This cross-sectional study used comprehensive search terms to identify videos pertaining to ETV and ETV + CPC presented on the first 3 pages of search results on YouTube. Two pediatric neurosurgeons, 1 neurosurgery resident, and 2 patient families independently reviewed the selected videos. Videos were assessed for overall informational quality by using a validated 5-point Global Quality Score (GQS) and compared to online metrics of popularity and engagement such as views, likes, likes/views ratio, comments/views ratio, and likes/dislikes ratio. Weighted kappa scores were used to measure agreement between video reviewers.

RESULTS

A total of 58 videos (47 on ETV, 7 on ETV + CPC, 4 on both) of 120 videos assessed met the inclusion criteria. Video styles included "technical" (62%), "lecture" (24%), "patient testimonial" (4%), and "other" (10%). In terms of GQS, substantial agreement was seen between surgeons (kappa 0.67 [95% CI 0.55, 0.80]) and excellent agreement was found between each surgeon and the neurosurgical resident (0.77 [95% CI 0.66, 0.88] and 0.89 [95% CI 0.82, 0.97]). Only fair to moderate agreement was seen between professionals and patient families, with weighted kappa scores ranging from 0.07 to 0.56. Academic lectures were more likely to be rated good or excellent (64% vs 0%, p < 0.001) versus surgical procedure and testimonial video types. There were significant associations between a better GQS and more likes (p = 0.01), views (p = 0.02), and the likes/dislikes ratio (p = 0.016). The likes/views ratio (p = 0.31) and comments/views ratio (p = 0.35) were not associated with GQS. The number of likes (p = 0.02), views (p = 0.03), and the likes/dislikes ratio (p = 0.015) were significantly associated with video style (highest for lecture-style videos).

CONCLUSIONS

Medical professionals tended to agree when assessing the overall quality of YouTube videos, but this agreement was not as strongly seen when compared to parental ratings. The online metrics of likes, views, and likes/dislikes ratio appear to predict quality. Neurosurgeons seeking to increase their online footprint via YouTube would be well advised to focus more on the academic lecture style because these were universally better rated.

Surgical intervention for hydrocephalus in infancy; etiology, age and treatment data in a Dutch cohort

PURPOSE

To gain insight into the patient characteristics of surgically treated hydrocephalus in the Netherlands, we report the first data from the Dutch Quality Registry NeuroSurgery (QNRS) database for infants with hydrocephalus requiring surgical intervention.

METHODS

We used the prospectively gathered database concerning infants ≤ 2 years of age surgically treated for hydrocephalus. We report data from start of registry, concerning etiology, age, and treatment of patients registered. We compared data with the Hydrocephalus Clinical Research Network (HCRN), a multicenter network of pediatric neurosurgical institutions in North America.

RESULTS

A total of 359 operated infants was registered in the period from 2010 to 2017. A drop in patients registered was seen in 2015, possibly due to revisions of the database. Most infants were operated on between 1 and 6 months of age. Cause of hydrocephalus was predominantly intracranial hemorrhage, followed by congenital causes. The proportion of infants with aqueduct stenosis and myelomeningocele as cause of hydrocephalus stayed relatively stable during this period of registration. Initial shunting was performed in 40% and reservoir/ETV as initial treatment was done in 60%. In both groups, 50% needed revision surgery.

CONCLUSIONS

The first data concerning surgically treated pediatric hydrocephalus from a prospectively collected Dutch register are presented, showing similar results when comparing to the HCRN database.

Age-specific global epidemiology of hydrocephalus: Systematic review, metanalysis and global birth surveillance

Background

Hydrocephalus is a debilitating disorder, affecting all age groups. Evaluation of its global epidemiology is required for healthcare planning and resource allocation.

Objectives

To define age-specific global prevalence and incidence of hydrocephalus.

Methods

Population-based studies reporting prevalence of hydrocephalus were identified (MEDLINE, EMBASE, Cochrane, and Google Scholar (1985–2017)). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Two authors reviewed abstracts, full text articles and abstracted data. Metanalysis and meta-regressions were used to assess associations between key variables. Heterogeneity and publication bias were assessed. Main outcome of interest was hydrocephalus prevalence among pediatric (≤ 18 years), adults (19–64 years), and elderly (≥ 65) patients. Annual hydrocephalus incidence stratified by country income level and folate fortification requirements were obtained (2003–2014) from the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR).

Results

Of 2,460 abstracts, 52 met review eligibility criteria (aggregate population 171,558,651). Mean hydrocephalus prevalence was 85/100,000 [95% CI 62, 116]. The prevalence was 88/100,000 [95% CI 72, 107] in pediatrics; 11/100,000 [95% CI 5, 25] in adults; and 175/100,000 [95% CI 67, 458] in the elderly. The ICBDSR-based incidence of hydrocephalus diagnosed at birth remained stable over 11 years: 81/100,000 [95% CI 69, 96]. A significantly lower incidence was identified in high-income countries.

Conclusion

This systematic review established age-specific global hydrocephalus prevalence. While high-income countries had a lower hydrocephalus incidence according to the ICBDSR registry, folate fortification status was not associated with incidence. Our findings may inform future healthcare resource allocation and study.

Hydrocephalus after Intrathecal Administration of Dextran to Rhesus Macaques (Macaca mulatta)

Dextrans have been used extensively as medical therapies and labeling agents in biomedical research to investigate the blood-brain barrier and CSF flow and absorption. Adverse effects from dextrans include anaphylactic reaction and dilation of the cerebral ventricles due to administration into the subarachnoid space. This retrospective study describes 51 rhesus macaques (Macaca mulatta) that received dextran intrathecally. The purpose of intrathecal administration was to enable detection of long-lived, dextran-labeled macrophages and to study monocyte-macrophage turnover in the CNS of SIV- or SHIV- infected and uninfected animals by using immunofluorescence. Of the 51 dextran-treated macaques, 8 that received dextran diluted in saline developed hydrocephalus; 6 of these 8 animals exhibited neurologic signs. In contrast, none of the macaques that received intrathecal dextran diluted in PBS developed hydrocephalus. These data suggest the use of saline diluent and the duration of dextran exposure as potential factors contributing to hydrocephalus after intrathecal dextran in rhesus macaques.

Global hydrocephalus epidemiology and incidence: systematic review and meta-analysis

OBJECTIVEHydrocephalus is one of the most common brain disorders, yet a reliable assessment of the global burden of disease is lacking. The authors sought a reliable estimate of the prevalence and annual incidence of hydrocephalus worldwide.METHODSThe authors performed a systematic literature review and meta-analysis to estimate the incidence of congenital hydrocephalus by WHO region and World Bank income level using the MEDLINE/PubMed and Cochrane Database of Systematic Reviews databases. A global estimate of pediatric hydrocephalus was obtained by adding acquired forms of childhood hydrocephalus to the baseline congenital figures using neural tube defect (NTD) registry data and known proportions of posthemorrhagic and postinfectious cases. Adult forms of hydrocephalus were also examined qualitatively.RESULTSSeventy-eight articles were included from the systematic review, representative of all WHO regions and each income level. The pooled incidence of congenital hydrocephalus was highest in Africa and Latin America (145 and 316 per 100,000 births, respectively) and lowest in the United States/Canada (68 per 100,000 births) (p for interaction < 0.1). The incidence was higher in low- and middle-income countries (123 per 100,000 births; 95% CI 98-152 births) than in high-income countries (79 per 100,000 births; 95% CI 68-90 births) (p for interaction < 0.01). While likely representing an underestimate, this model predicts that each year, nearly 400,000 new cases of pediatric hydrocephalus will develop worldwide. The greatest burden of disease falls on the African, Latin American, and Southeast Asian regions, accounting for three-quarters of the total volume of new cases. The high crude birth rate, greater proportion of patients with postinfectious etiology, and higher incidence of NTDs all contribute to a case volume in low- and middle-income countries that outweighs that in high-income countries by more than 20-fold. Global estimates of adult and other forms of acquired hydrocephalus are lacking.CONCLUSIONSFor the first time in a global model, the annual incidence of pediatric hydrocephalus is estimated. Low- and middle-income countries incur the greatest burden of disease, particularly those within the African and Latin American regions. Reliable incidence and burden figures for adult forms of hydrocephalus are absent in the literature and warrant specific investigation. A global effort to address hydrocephalus in regions with the greatest demand is imperative to reduce disease incidence, morbidity, mortality, and disparities of access to treatment.

Trends in the prevalence of congenital hydrocephalus in 14 cities in Liaoning province, China from 2006 to 2015 in a population-based birth defect registry from the Liaoning Women and Children's Health Hospital

The aim of this study was to assess the prevalence and trends of congenital hydrocephalus (CH) using a large population-based sample with cases retrieved from the Liaoning Birth Defects Registry, which included 14 cities, over a 10-year period. CH prevalence, percent change, average change, and contribution rates of each city were calculated. Statistical analysis was performed using a Poisson regression model. There was a total of 3008 CH cases among 3,248,954 live births during the observational period (9.26 cases/10,000 live births). On average, the prevalence of CH had significantly decreased by 11.84% each year (P < 0.01). The three leading cities with the highest prevalence of CH were Chaoyang (13.73/10,000), Huludao (13.18/10,000), and Fuxin (12.71/10,000), while Yingkou (6.06/10,000), Dalian (6.27/10,000), and Anshan (6.56/10,000) had the lowest prevalence. Notably, significantly decreasing trends were observed in 10 (71.4%) of these 14 cities. In addition, the cities of Fushun, Shenyang, and Dalian had contributed to more than one-third of the decreasing trend in Liaoning province. In conclusion, this study provides evidence of the decreasing prevalence of CH over a 10-year period (2006–2015) in Liaoning province. Preventative efforts should be strengthened to further reduce the risk of CH in these high prevalence areas.

Controlled Trial to Compare Therapeutic Efficacy of Endoscopic Third Ventriculostomy Plus Choroid Plexus Cauterization with Ventriculoperitoneal Shunt in Infants with Obstructive Hydrocephalus

Context:

Ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV) are the established surgical treatments for obstructive hydrocephalus (HCP). Powerful evidence regarding the best therapeutic approach for infants with obstructive HCP is lacked.

Aims:

Comparison of the therapeutic efficacy of VP shunt and ETV/choroid plexus cauterization (CPC) in infants with obstructive HCP.

Settings and Design:

This was a randomized, active control, unblind, single-center, clinical trial.

Methods:

Infants with obstructive HCP were randomly allocated to each intervention group (ETV/CPC or VP shunt). They were monitored for at least 6 months for any sign of raised intracranial pressure (rICP). The recurrence of rICP signs requiring surgical intervention was considered as intervention failure.

Statistical Analysis:

The association between intervention group and outcome was tested with Chi-square test, and P = 0.05 or less was considered statistically significant.

Results:

Of the total fifty patients entering the study, 49 were included in the final analysis, 27 of them were in VP shunt and 22 in ETV/CPC group. Seventeen patients (34%) were female and 33 (66%) were male with mean age of 3.74 ± 3.1 months (range = 10 days – 11 months). Thirty-nine (79.6%) were under 6 months of age and the remaining were 6 months or older. The overall success rate in 36-month follow-up was 88.5% and 68.2% for VP shunt and ETV/CPC, respectively, with the difference being not statistically significant.

Conclusion:

The current study determined no inferiority of ETV/CPC compared to VP shunt, and therefore, it may become an efficient treatment for obstructive HCP in infants.

Changes in prevalence and perinatal outcomes of congenital hydrocephalus among Chinese newborns: a retrospective analysis based on the hospital-based birth defects surveillance system

Background

Little is known about the epidemiology of congenital hydrocephalus (CH) in China. This study aimed to depict recent changes in CH prevalence and perinatal outcomes of the affected newborns.

Methods

Data were obtained from the Chinese Birth Defects Monitoring Network (CBDMN), which collects demographic information on all newborns above 28 weeks of gestation, and clinical information on neonates with congenital anomalies. CH cases delivered during 2005–2012 were analyzed. Poisson regression was used to calculate prevalence ratios (PR) and 95% confidence intervals, and linear chi-square test was used to examine time trend of CH prevalence.

Results

Five thousand two hundred forty-five isolated and 1245 associated CH cases were identified among 10,574,061 newborns, yielding the prevalence of 4.96, 1.18 and 6.14 per 10,000 births for the isolated, associated and overall hydrocephalus, respectively. The annual prevalence of CH presented a decreasing trend (from 7.52 to 5.98 per 10,000 births, P < 0.001). Higher prevalence was found in both younger (<20 years, PR: 1.81, 95% CI: 1.56–2.10) and older (≥35 years, PR: 1.48, 95% CI: 1.36–1.61) maternal-age groups in comparison with the maternal-age group of 20 to 24 years. Higher prevalence was also found in infants born to mothers resided in rural areas, male infants, and multiple births. Of non-aborted infants with congenital hydrocephalus, 38.11% were born with low birth weight, 37.53% were preterm birth, and 20.69% died within 7 days after birth.

Conclusions

Our findings present a relatively high prevalence and poor perinatal outcomes of CH in China, which can serve as a baseline for future study.

Epidemiology of adult-onset hydrocephalus: institutional experience with 2001 patients

OBJECTIVE Adult-onset hydrocephalus is not commonly discussed in the literature, especially regarding its demographic distribution. In contrast to pediatric hydrocephalus, which is related to a primary CSF pathway defect, its development in adults is often secondary to other pathologies. In this study, the authors investigated the epidemiology of adult-onset hydrocephalus as it pertains to different etiologies and in reference to age, sex, and race distributions. METHODS The authors retrospectively reviewed the clinical notes of 2001 patients with adult-onset hydrocephalus who presented to Louisiana State University Health Sciences Center within a 25-year span. Significant differences between the groups were analyzed by a chi-square test; p < 0.05 was considered significant. RESULTS The overall mean (± SEM) incidence of adult hydrocephalus in this population was 77 ± 30 per year, with a significant increase in incidence in the past decade (55 ± 3 [1990-2003] vs 102 ± 6 [2004-2015]; p < 0.0001). Hydrocephalus in a majority of the patients had a vascular etiology (45.5%) or was a result of a tumor (30.2%). The incidence of hydrocephalus in different age groups varied according to various pathologies. The incidence was significantly higher in males with normal-pressure hydrocephalus (p = 0.03) or head injury (p = 0.01) and higher in females with pseudotumor cerebri (p < 0.0001). In addition, the overall incidence of hydrocephalus was significantly higher in Caucasian patients (p = 0.0002) than in those of any other race. CONCLUSIONS Knowledge of the demographic variations in adult-onset hydrocephalus is helpful in achieving better risk stratification and better managing the disease in patients. For general applicability, these results should be validated in a large-scale meta-analysis based on a national population database.

Long-term mortality rates in pediatric hydrocephalus-a retrospective single-center study

PURPOSE

Very long-term follow-up and outcome are rare for pediatric patients with hydrocephalus and shunt operations. The aim of this study was to determine the long-term mortality rates in these patients.

METHODS

Pediatric patients with first shunt operation between 1982 and 1992 were included. For each patient, time and cause of death were determined. Further, patients with first operation from 1982 to 1987 were compared to those first operated from 1988 to 1992.

RESULTS

One-hundred thirty-seven patients were included. Etiologies of hydrocephalus were intraventricular hemorrhage (31.4 %), meningomyelocele (25.5 %), postinfectious (11.7 %), congenital (10.2 %), posterior fossa cyst (8.8 %), aqueductal stenosis (8 %), and others (4.4 %). Overall, 53 patients (38.7 %) died. The percentage of patients surviving 1, 2, 10, and 20 years after first operation were 82.6, 73.6, 69.4, and 65.3 %, respectively. In 23 patients, the cause of death was related to shunt treatment: shunt infection was diagnosed in 18 and acute shunt dysfunction in 5 patients. Mortality was considerably higher for patients with their first operation in time period 1982-1987 compared to time period 1988-1992 (51 versus 25 %). The reduction of mortality was mainly due to an increased survival after shunt infection. Eighty-seven patients survived more than 20 years after initial shunt operation. Of those long-term survivors, three (3.4 %) patients died 22-24 years after first operation.

CONCLUSION

Mortality in hydrocephalic pediatric patients is high especially in the first postoperative years but is even significant in adult patients with pediatric hydrocephalus. As deaths occur even after 20 years, routine follow-up of long-term survivors remains necessary.

Periventricular hyperintensity in children with hydrocephalus

BACKGROUND

Magnetic resonance images of children with hydrocephalus often include a rim of hyperintensity in the periventricular white matter (halo).

OBJECTIVE

The purpose of this study was to decide between the hypothesis that the halo is caused by cerebrospinal fluid (CSF) flow during the cardiac cycle, and the alternate hypothesis that the halo is caused by anatomical changes (stretching and compression of white matter).

MATERIALS AND METHODS

Participants were selected from a multicenter imaging study of pediatric hydrocephalus. We compared 19 children with hydrocephalus to a group of 52 controls. We quantified ventricle enlargement using the frontal-occipital horn ratio. We conducted qualitative and quantitative analysis of diffusion tensor imaging in the corpus callosum and posterior limb of the internal capsule. Parameters included the fractional anisotropy (FA), mean diffusivity, axial diffusivity and radial diffusivity.

RESULTS

The halo was seen in 16 of the 19 children with hydrocephalus but not in the controls. The corpus callosum of the hydrocephalus group demonstrated FA values that were significantly decreased from those in the control group (P = 4 · 10(-6)), and highly significant increases were seen in the mean diffusivity and radial diffusivity in the hydrocephalus group. In the posterior limb of the internal capsule the FA values of the hydrocephalus group were higher than those for the control group (P = 0.002), and higher values in the hydrocephalus group were also noted in the axial diffusivity. We noted correlations between the diffusion parameters and the frontal-occipital horn ratio.

CONCLUSION

Our results strongly support the hypothesis that the halo finding in hydrocephalus is caused by structural changes rather than pulsatile CSF flow.

Abnormal structural connectivity in the brain networks of children with hydrocephalus

Increased intracranial pressure and ventriculomegaly in children with hydrocephalus are known to have adverse effects on white matter structure. This study seeks to investigate the impact of hydrocephalus on topological features of brain networks in children. The goal was to investigate structural network connectivity, at both global and regional levels, in the brains in children with hydrocephalus using graph theory analysis and diffusion tensor tractography. Three groups of children were included in the study (29 normally developing controls, 9 preoperative hydrocephalus patients, and 17 postoperative hydrocephalus patients). Graph theory analysis was applied to calculate the global network measures including small-worldness, normalized clustering coefficients, normalized characteristic path length, global efficiency, and modularity. Abnormalities in regional network parameters, including nodal degree, local efficiency, clustering coefficient, and betweenness centrality, were also compared between the two patients groups (separately) and the controls using two tailed t-test at significance level of p < 0.05 (corrected for multiple comparison). Children with hydrocephalus in both the preoperative and postoperative groups were found to have significantly lower small-worldness and lower normalized clustering coefficient than controls. Children with hydrocephalus in the postoperative group were also found to have significantly lower normalized characteristic path length and lower modularity. At regional level, significant group differences (or differences at trend level) in regional network measures were found between hydrocephalus patients and the controls in a series of brain regions including the medial occipital gyrus, medial frontal gyrus, thalamus, cingulate gyrus, lingual gyrus, rectal gyrus, caudate, cuneus, and insular. Our data showed that structural connectivity analysis using graph theory and diffusion tensor tractography is sensitive to detect abnormalities of brain network connectivity associated with hydrocephalus at both global and regional levels, thus providing a new avenue for potential diagnosis and prognosis tool for children with hydrocephalus.

Pediatric endoscopic third ventriculostomy: a population-based study

OBJECT

Endoscopic third ventriculostomy (ETV) is an alternative to ventriculoperitoneal shunting for hydrocephalus treatment. Choice of treatment options raises questions about which patients are likely to benefit from ETV. The authors performed a population-based analysis using an administrative claims database, examining current practice and outcomes for pediatric patients in the US.

METHODS

The authors queried the MarketScan (Truven Health Analytics) database for Current Procedural Terminology codes corresponding to ETV and ventriculoperitoneal shunting from 2003 to 2011; they included patients 19 years or younger and extracted data from initial and subsequent hospitalizations. Hydrocephalus etiology was classified with ICD-9-CM coding. ETV failure was defined as any subsequent ETV or shunt procedure.

RESULTS

Five hundred one patients underwent ETV. Of these, 46% were female. The mean age was 8.7 ± 6.4 years (± SD). The mean follow-up was 1.9 ± 1.8 years. Etiology of hydrocephalus was primarily tumor (41.7%) and congenital/aqueductal stenosis (24.4%). ETV was successful in 354 patients (71%). The mean time to failure was 109.9 ± 233 days. Of the 147 patients with ETV failure, 35 (24%) underwent repeat ETV and 112 (76%) had shunt placement. Patients in age groups 0 to < 6 months and 6 months to < 1 year had a significantly higher rate of ETV failure than those 10-19 years (HR 2.9, p = 0.05; and HR 2.3, p = 0.001, respectively). History of prior shunt was associated with higher risk of failure (HR 2.5, p < 0.001). There were no significant associations between hydrocephalus etiology and risk of failure. A second wave of failures occurred at 2.5-3.5 years postoperative in tumor and congenital/aqueductal stenosis patients; this was not observed in other etiology groups.

CONCLUSIONS

This study represents a cross-section of nationwide ETV practice over 9 years. ETV success was more likely among children 1 year and older and those with no history of prior shunt.

Factors affecting quality of life in early childhood in patients with congenital hydrocephalus

BACKGROUND

Predicting the outcome of congenital hydrocephalus in early infancy and childhood is difficult. Various consequences of hydrocephalus like ophthalmic, audiometric, musculoskeletal, and the developmental abnormalities play a complex role. We analyzed the quality of life of these patients in early life.

METHODS

A prospective multispecialty assessment of the patients with congenital hydrocephalus, who had undergone ventriculoperitoneal shunt in the Pediatric Surgery unit of a tertiary care hospital, was carried out and analyzed.

RESULTS

There were 24 boys and 6 girls. Eighty-three percent were operated before the age of 3 months. Mean age at follow up was 6 years (3-9 years). Shunt complications were seen in 53% (16) of the patients, out of which 68.75% had shunt blocks. In 70% (21) of the patients, the ventricle to hemisphere ratio (VHR) was between 51 and 70%, 20% (6) had a VHR of more than 70% and only 3 patients had a VHR between 40-50%. Audiological and ophthalmic problems were seen in 20 and 66% of the children, respectively. Musculoskeletal abnormalities were present in 36% of the patients. Developmental profile showed 44% being normal, 30% retarded, and 26% were borderline cases. The schooling had started in 56.6%, out of which only one child went to a special school.

CONCLUSIONS

A multitude of problems associated with congenital hydrocephalus should be diligently diagnosed, aggressively followed and intervened with in the early years of life. Preschool management well before the peer interaction should optimize the social integration and improve the quality of life in these patients.

Study of the association between the incidences of congenital anomalies and hydrocephalus in Sudanese fetuses

This study was designed with an aim to detect the congenital anomalies appear to be linked to and in conjunction with hydrocephalus fetuses in Sudan, when ultrasound is used to exam fetuses in the second and third trimesters of pregnancy. This prospective cohort study was performed from December 2011 to December 2013, in a group consists of 5000 single gestation pregnant Sudanese women. In all cases, maternal ages were 35 years up to 48 years; mean age of 42.5 years. Pelvic; obstetric ultrasound scanning protocol used should meet the standards established by the American Institute of Ultrasound in Medicine (AIUM) for scanning in the second and third trimesters of pregnancy. Statistical Package for the Social Sciences (SPSS) was used to analyze the results. Diagnosed hydrocephalus cases (0.4%) were found to be associated with other fetal anomalies as aqueduct stenosis (45%), spina bifida (30%), Arnold-Chiari malformation (20%) and Dandy-Walker malformation (5%). The incidence of congenital anomalies and hydrocephalus in Sudanese fetuses showed considerable variation among different regions of Sudan. Hydrocephalus is associated with certain congenital anomalies. In agreement with previous studies, hydrocephalus is predominantly in male rather than female fetuses. The prevalence of fetal anomalies and hydrocephalus are within previously reported ranges.

Endoscopic third ventriculostomy with/without choroid plexus cauterization for hydrocephalus due to hemorrhage, infection, Dandy-Walker malformation, and neural tube defect: a meta-analysis

OBJECT

Endoscopic third ventriculostomy (ETV) is a viable alternative to CSF shunting in hydrocephalic patients and is used with varying degrees of success dependent on age and etiology. The purpose of this meta-analysis is to analyze data on ETV and ETV/CPC (choroid plexus cauterization) outcomes in hopes of providing a clear understanding of their limitations in patients with hydrocephalus due to hemorrhage, infection, Dandy-Walker malformation, or neural tube disorders.

METHODS

An extensive PubMed search dating back 11 years was performed on primary ETV or ETV/CPC procedures for hydrocephalus due to infection, hemorrhage, neural tube defects, and Dandy-Walker malformation. ETV success was defined as no intraoperative or post-operative complications and no need for revision surgery at follow-up.

RESULTS

Ten studies were identified for analysis. The data represent 534 patients undergoing primary ETV and 167 patients undergoing primary ETV/CPC. The ETV group reached a 55 % success rate, while the ETV/CPC group reached a 67 % success rate. Success rates of ETV alone for hydrocephalus due to infection, neural tube defects, and intraventricular hemorrhage reached 54, 55, and 57 %, respectively. 84 % success was found in patients older than 2 years of age and 52 % success in patients less than 2 years of age.

CONCLUSIONS

ETV is a valid treatment for hydrocephalus of any etiology. There exists a small difference in success rates between infection, hemorrhage, and neural tube disorders, though not enough to discount ETV for these etiologies. Initial data utilizing ETV/CPC are promising, and additional studies will need to be done to verify such results.

Visual function in preterm infants: visualizing the brain to improve prognosis

Considerable development of the visual system occurs in the third trimester of life, a time when very preterm-born infants are in a neonatal intensive care unit (NICU). Their very early birth during a period of rapid and marked neurodevelopment and their clinical course makes them a very high-risk population. A range of different events impacts brain development and the visual system, leading to significant long-term visual dysfunction. Improved neuroimaging techniques provide an important window on the early brain and visual system development of these vulnerable infants. Greater understanding of the etiology of visual impairment subsequent to preterm birth and the timing of critical processes will allow early recognition and the earlier implementations of interventions. In the longer term, this will help clinicians optimize NICU practice to reduce the incidence of visual dysfunction in these children.

Pediatric hydrocephalus outcomes: a review

The outcome of pediatric hydrocephalus, including surgical complications, neurological sequelae and academic achievement, has been the matter of many studies. However, much uncertainty remains, regarding the very long-term and social outcome, and the determinants of complications and clinical outcome. In this paper, we review the different facets of outcome, including surgical outcome (shunt failure, infection and independence, and complications of endoscopy), clinical outcome (neurological, sensory, cognitive sequels, epilepsy), schooling and social integration. We then provide a brief review of the English-language literature and highlighting selected studies that provide information on the outcome and sequelae of pediatric hydrocephalus, and the impact of predictive variables on outcome. Mortality caused by hydrocephalus and its treatments is between 0 and 3%, depending on the duration of follow-up. Shunt event-free survival (EFS) is about 70% at one year and 40% at ten years. The EFS after endoscopic third ventriculostomy (ETV) appears better but likely benefits from selection bias and long-term figures are not available. Shunt infection affects between 5 and 8% of surgeries, and 15 to 30% of patients according to the duration of follow-up. Shunt independence can be achieved in 3 to 9% of patients, but the definition of this varies. Broad variations in the prevalence of cognitive sequelae, affecting 12 to 50% of children, and difficulties at school, affecting between 20 and 60%, attest of disparities among studies in their clinical evaluation. Epilepsy, affecting 6 to 30% of patients, has a serious impact on outcome. In adulthood, social integration is poor in a substantial number of patients but data are sparse. Few controlled prospective studies exist regarding hydrocephalus outcomes; in their absence, largely retrospective studies must be used to evaluate the long-term consequences of hydrocephalus and its treatments. This review aims to help to establish the current state of knowledge and to identify conflicting data and unanswered questions, in order to direct future studies.

Lysophosphatidic acid signaling may initiate fetal hydrocephalus

Fetal hydrocephalus (FH), characterized by the accumulation of cerebrospinal fluid, an enlarged head, and neurological dysfunction, is one of the most common neurological disorders of newborns. Although the etiology of FH remains unclear, it is associated with intracranial hemorrhage. Here, we report that lysophosphatidic acid (LPA), a blood-borne lipid that activates signaling through heterotrimeric guanosine 5'-triphosphate-binding protein (G protein)-coupled receptors, provides a molecular explanation for FH associated with hemorrhage. A mouse model of intracranial hemorrhage in which the brains of mouse embryos were exposed to blood or LPA resulted in development of FH. FH development was dependent on the expression of the LPA(1) receptor by neural progenitor cells. Administration of an LPA(1) receptor antagonist blocked development of FH. These findings implicate the LPA signaling pathway in the etiology of FH and suggest new potential targets for developing new treatments for FH.

Time trends and age-related etiologies of pediatric hydrocephalus: results of a groupwise analysis in a clinical cohort

OBJECTIVE

The current study aimed at evaluating experience with pediatric hydrocephalus and reviewing time trends and age-related differences in etiology, management, and outcomes of pediatric hydrocephalus at a tertiary care center in a south Asian country.

METHODS

We conducted a retrospective cohort study based on case note review of pediatric patients (age, 1 month to 15 years) with hydrocephalus managed at Aga Khan University Hospital Karachi, over an 18-year period (1988-2005). For analysis, the study period was divided into two epochs (period A, 1988-1996; period B, 1997-2005) and study population was divided into two age groups (0-12 months and 1-15 years).

RESULTS

A total of 338 cases of pediatric hydrocephalus were identified. Most common etiology of pediatric hydrocephalus was meningitis (38.1%), followed by congenital hydrocephalus (20.4%) and brain tumors (8.3%). Shunt infection and blockage were seen in 38 (11.2%) and 54 (16.0%) children, respectively; 67 (19.8%) required shunt revision. Highest rates of shunt failure were seen in bacterial meningitis (35.3%) and aqueductal stenosis (29.2%). Neurological and/or cognitive deficits were observed more frequently in children under 1 year of age (P = 0.029). Duration of hospital stay in period A was significantly higher than in period B (P < 0.001). Mortality occurred in 38 (11.2%); it did not differ between two epochs and age groups (P = 0.059 and P = 0.865, respectively). Highest mortality was associated with intraventricular hemorrhage (23.1%) and brain tumors (21.4%).

CONCLUSION

Despite recent advancements, hydrocephalus is still associated with high rate of shunt failure and mortality. Factors associated with poor outcome include younger age group and etiology of hydrocephalus.

Adult outcome of pediatric hydrocephalus

INTRODUCTION

The outlook of pediatric hydrocephalus has spectacularly improved over the past decades; however, the adult outcome is still poorly documented. Determining the healthcare profile of these patients is important in order to organize the management of this growing population. We decided to review our pediatric hydrocephalus database for pediatric patients treated for hydrocephalus and followed up into adulthood.

METHODS

Our institution has a virtual monopoly for pediatric hydrocephalus, serving a four-million-plus population; the transition to adult care is also managed in the same institution. We retrospectively reviewed patients younger than 18 treated for hydrocephalus since 1980 and followed up beyond the age of 20.

RESULTS

We reviewed 456 patients, with a mean initial age of 55.6 months, and followed up for a mean of 24.2 years. In 81 patients (17.8%), the last shunt operation occurred after 20 years; 22 of these (4.9% of the total) having never been revised earlier. Sixteen patients (3.5%) could be weaned of their shunt. Thirteen patients died in adult age, 5 of these dying of shunt-related causes. The most prominent sequels were motor (46.5%) and cognitive (47.6%); only 82 patients (18.0%) had no sequel at all. Intelligence quotient values were ≥80 in 54.5% of tested patients; however, schooling was normal in only 41.4%, and only 33.7% was employed in the competitive labor market.

CONCLUSION

Adults treated for hydrocephalus in childhood require a life-long follow-up. Late mortality is low but not null, morbidity is high, and many patients require shunt surgery during adulthood. The transition from child to adult neurosurgery needs to be organized for these vulnerable patients.

Low-pressure valves in hydrocephalic children: a retrospective analysis

PURPOSE

A series of 100 children under 2 years of age treated for hydrocephalus is described. All patients received a standard differential low-pressure (SD low) valve as the first cerebrospinal fluid (CSF) shunt treatment. The performance of this group during follow-up is analysed.

METHODS

A retrospective cohort study was performed using the intern electronic health record from our hospital. Children younger than 2 years who underwent initial CSF shunt treatment with a SD low valve between 1998 and 2008 were eligible.

RESULTS

Mean follow-up was 7 years. The majority of 81% (81 of 100) of the children did not receive an upgrade of pressure profile throughout follow-up. The first revision was done after a mean of 456 days (median, 64 days; min, 3; and max, 4,183). The 1-year survival rate of the CSF shunt in this cohort was 42%. In the relatively large group of myelomeningocele patients (37 of 100), only one patient developed symptomatic overdrainage. A total of 9% (9 of 100) of the children presented with symptoms of overdrainage. In 3% (3 out of 100) of these children, symptoms of overdrainage persisted, in spite of multiple valve mutations. During the total follow-up, 26% (26 of 100) of the patients had never received shunt revision surgery. Fifteen percent (15 of 100) of the children developed a shunt infection within the first year.

CONCLUSIONS

The use of SD low valves in the youngest age group is effective in the majority of children. The aetiology of myelomeningocele appears to protect the patient from symptomatic overdrainage.

Descriptive epidemiology of selected heritable birth defects in Texas

BACKGROUND

Few population-based studies exist on descriptive epidemiologic characteristics of rare heritable birth defects. The number of birth defect cases in the Texas Birth Defects Registry (one of the largest active birth defects surveillance systems in the world) enabled us to examine six different heritable disorders (aqueductal stenosis, infantile polycystic kidney disease, achondroplasia, thanatophoric dwarfism, chondrodysplasia/dwarfism not otherwise specified (NOS), and osteogenesis imperfecta) for a variety of descriptive demographic variables.

METHODS

The Texas Birth Defects Registry was used to identify infants or fetuses with heritable birth defects. Crude prevalence rates were calculated and Poisson regression was used to test the association of each demographic variable (e.g., maternal age) with each of the selected genetic birth defects.

RESULTS

White non-Hispanics exhibited higher rates of achondroplasia and osteogenesis imperfecta than other race/ethnic groups. Lower maternal education level and to a lesser extent, paternal education level, was associated with higher rates of several disorders. The birth prevalence rate for achondroplasia decreased from 1999 through 2006.

CONCLUSION

The use of a large birth defects registry provides a sufficient count of cases to perform some basic epidemiologic analysis on selected rare heritable birth defects.

Very long-term follow-up of adults treated in infancy for hydrocephalus

PURPOSE

The purpose of this study is to perform a population-based, very long-term follow-up of adults who had been shunt treated for hydrocephalus in infancy.

METHODS

The 72 children with hydrocephalus born in 1967-1978 in western Sweden, who had participated in a follow-up at school age, were re-examined at 30-43 years of age. The 29 with mental retardation were described in terms of developmental level and survival, whereas the remaining 43 were invited to take part in a follow-up and 28 accepted. The assessments included a semi-structured interview pertaining to medical issues, academic achievements and social function.

RESULTS

Six children had died, i.e. a mortality rate of 8%. Mental retardation was present in 29 (40%), severe (IQ <50) in 13 and mild (IQ 50-70) in 16. Four of the 28 (14%) had cerebral palsy and 8 (28%) had other motor problems. Five (18%) had epilepsy and nine (32%) had visual impairments. A total of 20 (71%) reported some kind of health problem. Repeated revisions of the shunt had been performed in 23 (82%). Many worried about their shunt and requested a systematic medical follow-up. Nineteen subjects (68%) lived with a partner and 16 (57%) were parents. The majority had completed secondary school and 9 (32%) had completed university studies, while 18 (64%) worked full time, equal to the general population.

CONCLUSION

In general, the group of normally gifted individuals with hydrocephalus, who had been shunt treated during infancy, was functioning well as adults and participated in society to the same extent as other people.

Expression of aquaporin 1 and 4 in a congenital hydrocephalus rat model

BACKGROUND

Hydrocephalus occurs because of an imbalance of bulk fluid flow in the brain, and aquaporins (AQPs) play pivotal roles in cerebral water movement as essential mediators during edema and fluid accumulation. AQP1 is a water channel found in the choroid plexus (CP), and AQP4 is expressed at the brain-CSF interfaces and astrocytic end feet; excessive fluid accumulation may involve expression of changes in these AQPs during various stages of hydrocephalus.

OBJECTIVE

To determine the alterations of CP AQP1 expression in congenital hydrocephalus; detect hydrocephalus-induced AQP1 expression in the cortical parenchyma, ependyma, and pia mater of hydrocephalic animals; and evaluate AQP4 expression in congenital hydrocephalus through progressive stages of the condition.

METHODS

We evaluated differential expression of AQPs 1 and 4 in the congenital hydrocephalus Texas rat at postnatal days 5, 10, and 26 in isolated CP and cortex by enzyme-linked immunosorbent assay, Western blot, quantitative reverse transcriptase polymerase chain reaction, and immunohistochemistry.

RESULTS

The CP exhibited a 34% decrease in AQP1 expression in young hydrocephalic pups (postnatal days 5 and 10), which became normal (postnatal day 26) just before death. With advancing hydrocephalus, expression of AQPs 1 and 4 increased at the brain-CSF interfaces; AQP1 was localized to the endothelium of cortical capillaries with increased AQP4 expression in surrounding astrocytes end feet. AQP1 expression level was increased in the pia mater, with prominent AQP4 expression in the subpial layers. Subependymal capillaries expressed AQP1 in the endothelium, with increasing AQP4 expression in surrounding astrocytes. Hydrocephalic animals (postnatal day 26) had significant nonendothelial (CD34) AQP1 expression in the septal nucleus of the basal forebrain, an area affected by increased intracranial pressure.

CONCLUSION

Biphasic AQP1 expression in the CP with increased AQPs 1 and 4 at the brain-fluid interfaces may indicate compensatory mechanisms to regulate choroidal cerebrospinal fluid secretion and increase parenchymal fluid absorption in the high-pressure hydrocephalic condition.

Prevalence of congenital hydrocephalus in California, 1991-2000

In a population-based retrospective cohort of 5,353,022 California births from 1991 to 2000, 3,152 newborns were diagnosed with congenital hydrocephalus during the birth hospitalization. We compared demographic and clinical characteristics of infants with and without congenital hydrocephalus, and examined in-hospital fatality rates. The prevalence of congenital hydrocephalus was 5.9 per 10,000. During the study period, there was a decline in congenital hydrocephalus due to spina bifida (1.4 to 0.9 per 10,000), and an increase in congenital hydrocephalus due to obstructive hydrocephalus (0.5 to 1.0 per 10,000). Independent risk factors for congenital hydrocephalus were birth weight <1,500 g (odds ratio [OR] 51.6, 95% confidence interval [CI] 47.7-55.8) and birth weight 1,500-2,000 g (OR 14.1, 95% CI 12.4-16) compared to birth weight greater than 2,000 g, low socioeconomic status (OR 1.5, 95% CI 1.4-1.6), and male sex (OR 1.2, 95% CI 1.1-1.3). Asians had a decreased risk for congenital hydrocephalus (OR 0.7, 95% CI 0.6-0.8) when compared to whites. Thirteen percent of affected neonates died before hospital discharge.

Development and in-vitro characterization of an implantable flow sensing transducer for hydrocephalus

An implantable transducer for monitoring the flow of Cerebrospinal fluid (CSF) for the treatment of hydrocephalus has been developed which is based on measuring the heat dissipation of a local thermal source. The transducer uses passive telemetry at 13.56 MHz for power supply and read out of the measured flow rate. The in vitro performance of the transducer has been characterized using artificial Cerebrospinal Fluid (CSF) with increased protein concentration and artificial CSF with 10% fresh blood. After fresh blood was added to the artificial CSF a reduction of flow rate has been observed in case that the sensitive surface of the flow sensor is close to the sedimented erythrocytes. An increase of flow rate has been observed in case that the sensitive surface is in contact with the remaining plasma/artificial CSF mix above the sediment which can be explained by an asymmetric flow profile caused by the sedimentation of erythrocytes having increased viscosity compared to artificial CSF. After removal of blood from artificial CSF, no drift could be observed in the transducer measurement which could be associated to a deposition of proteins at the sensitive surface walls of the packaged flow transducer. The flow sensor specification requirement of +-10% for a flow range between 2 ml/h and 40 ml/h. could be confirmed at test conditions of 37 degrees C.

Neuropathology and structural changes in hydrocephalus

In the context of spina bifida, hydrocephalus is usually caused by crowding of the posterior fossa with obstruction to cerebrospinal fluid flow from the forth ventricle, and less often by malformation of the cerebral aqueduct. Enlargement of the cerebral ventricles causes gradual destruction of periventricular white matter axons. Motor, sensory, visual, and memory systems may be disturbed through involvement of the long projection axons, periventricular structures including the corpus callosum, and the fimbria-fornix pathway. Secondary changes occur in neuronal cell bodies and synapses, but there is minimal death of neurons. The clinical syndrome of hydrocephalic brain dysfunction is thus due to subcortical disconnection. Some of the brain dysfunction is reversible by shunting, probably through restoration of cerebral blood flow and normalization of the extracellular environment. However, destroyed axons cannot be restored.

A modifier locus on chromosome 5 contributes to L1 cell adhesion molecule X-linked hydrocephalus in mice

Humans with L1 cell adhesion molecule (L1CAM) mutations exhibit X-linked hydrocephalus, as well as other severe neurological disorders. L1-6D mutant mice, which are homozygous for a deletion that removes the sixth immunoglobulin-like domain of L1cam, seldom display hydrocephalus on the 129/Sv background. However, the same L1-6D mutation produces severe hydrocephalus on the C57BL/6J background. To begin to understand how L1cam deficiencies result in hydrocephalus and to identify modifier loci that contribute to X-linked hydrocephalus by genetically interacting with L1cam, we conducted a genome-wide scan on F2 L1-6D mice, bred from L1-6D 129S2/SvPasCrlf and C57BL/6J mice. Linkage studies, utilizing chi-square tests and quantitative trait loci mapping techniques, were performed. Candidate modifier loci were further investigated in an extension study. Linkage was confirmed for a locus on chromosome 5, which we named L1cam hydrocephalus modifier 1 (L1hydro1), p = 4.04 X 10(-11).

Third ventriculostomy in a single pediatric surgical unit

PURPOSE

Endoscopic third ventriculostomy (ETV) is a successful method of treatment for obstructive hydrocephalus that has become popular over the last 20 years. The purpose of this paper is to study the outcome of infants with obstructive hydrocephalus treated by ETV by a single surgeon and to evaluate the safety, reliability, and efficacy of this treatment.

METHODS

All data were collected retrospectively. Between July 1999 and June 2005, 14 children underwent an ETV. In one child, a second ETV was performed. The age of the eight female and six male patients at the time of ETV ranged from less than 1 month up to 13 years and 11 months. The indication for an ETV was an obstructive hydrocephalus. Median follow-up period was 5 years and 9 months. The need of a further operation after ETV was defined as a failure of ETV.

RESULTS

In six patients, the first ETV was successful. In the remaining eight patients, there was a need for further treatment (ventriculoperitoneal shunt). Although the follow-up shunt failed in one patient, he was successfully treated by a second ETV.

CONCLUSION

Our study suggests that ETV can be successfully done in a small pediatric unit, but with a lower success rate because of small caseload, and therefore, lower experience and routine of the surgeon. Therefore, we propose a centralization of patients to obtain a higher number of cases. We confirm that ETV is a safe, reliable, and efficient method with a better outcome in children than infants.

Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus

OBJECTIVE

To develop a model to predict the probability of endoscopic third ventriculostomy (ETV) success in the treatment for hydrocephalus on the basis of a child's individual characteristics.

STUDY DESIGN

We analyzed 618 ETVs performed consecutively on children at 12 international institutions to identify predictors of ETV success at 6 months. A multivariable logistic regression model was developed on 70% of the dataset (training set) and validated on 30% of the dataset (validation set).

RESULTS

In the training set, 305/455 ETVs (67.0%) were successful. The regression model (containing patient age, cause of hydrocephalus, and previous cerebrospinal fluid shunt) demonstrated good fit (Hosmer-Lemeshow, P = .78) and discrimination (C statistic = 0.70). In the validation set, 105/163 ETVs (64.4%) were successful and the model maintained good fit (Hosmer-Lemeshow, P = .45), discrimination (C statistic = 0.68), and calibration (calibration slope = 0.88). A simplified ETV Success Score was devised that closely approximates the predicted probability of ETV success.

CONCLUSIONS

Children most likely to succeed with ETV can now be accurately identified and spared the long-term complications of CSF shunting.

On the changing epidemiology of hydrocephalus

PURPOSE

The purpose of this study is to evaluate the changing epidemiology of paediatric hydrocephalus over the past three decades in a single institution.

METHODS

All children treated for newly diagnosed hydrocephalus during the 1985-1990 (group A) and the 2000-2005 periods (group B) were enrolled and classified according to the associated cause of hydrocephalus.

RESULTS

A significant 8.8% decrease of the incidence of hydrocephalus was noticed between the two time periods, resulting from the reduction of hydrocephalus associated to myelomeningocele, aqueduct stenosis (p = 0.04), CNS infection (p = 0.03), cranio-cerebral malformation and head injuries; post-haemorrhagic hydrocephalus remained stable, while the tumour-associated one increased (p < 0.0001). No consistent differences in terms of rate of adjunctive surgery (30.3% versus 23.9%) and number revision procedures (200 versus 104) were recorded.

CONCLUSIONS

The present study confirmed data from the literature about the declined incidence of paediatric hydrocephalus, which mainly results from the decrease of congenital malformations. In spite of the recent advances in neuroendoscopy and in the shunting valve design, the impact of hydrocephalus in the paediatric neurosurgical practice remains high.