Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda

Abhaya V. Kulkarni, Steven J. Schiff, Edith Mbabazi-Kabachelor, John Mugamba, Peter Ssenyonga, Ruth Donnelly, Jody Levenbach, Vishal Monga, Mallory Peterson, Michael MacDonald, Venkateswararao Cherukuri, Benjamin C. Warf

Research output: Contribution to journalArticle

25 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)2456-2464
Number of pages9
JournalNew England Journal of Medicine
Volume377
Issue number25
DOIs
StatePublished - Dec 21 2017

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Ventriculostomy
Cautery
Choroid Plexus
Uganda
Hydrocephalus
Confidence Intervals
Treatment Failure
Brain
Language
Therapeutics
Ventriculoperitoneal Shunt
Africa South of the Sahara
Child Development
Reoperation
Tomography
Health
Growth

All Science Journal Classification (ASJC) codes

  • Medicine(all)

Cite this

Kulkarni, A. V., Schiff, S. J., Mbabazi-Kabachelor, E., Mugamba, J., Ssenyonga, P., Donnelly, R., ... Warf, B. C. (2017). Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda. New England Journal of Medicine, 377(25), 2456-2464. https://doi.org/10.1056/NEJMoa1707568
Kulkarni, Abhaya V. ; Schiff, Steven J. ; Mbabazi-Kabachelor, Edith ; Mugamba, John ; Ssenyonga, Peter ; Donnelly, Ruth ; Levenbach, Jody ; Monga, Vishal ; Peterson, Mallory ; MacDonald, Michael ; Cherukuri, Venkateswararao ; Warf, Benjamin C. / Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda. In: New England Journal of Medicine. 2017 ; Vol. 377, No. 25. pp. 2456-2464.
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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.",
author = "Kulkarni, {Abhaya V.} and Schiff, {Steven J.} and Edith Mbabazi-Kabachelor and John Mugamba and Peter Ssenyonga and Ruth Donnelly and Jody Levenbach and Vishal Monga and Mallory Peterson and Michael MacDonald and Venkateswararao Cherukuri and Warf, {Benjamin C.}",
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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 2017, 'Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda', New England Journal of Medicine, vol. 377, no. 25, pp. 2456-2464. https://doi.org/10.1056/NEJMoa1707568

Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda. / Kulkarni, Abhaya V.; Schiff, Steven J.; Mbabazi-Kabachelor, Edith; Mugamba, John; Ssenyonga, Peter; Donnelly, Ruth; Levenbach, Jody; Monga, Vishal; Peterson, Mallory; MacDonald, Michael; Cherukuri, Venkateswararao; Warf, Benjamin C.

In: New England Journal of Medicine, Vol. 377, No. 25, 21.12.2017, p. 2456-2464.

Research output: Contribution to journalArticle

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T1 - Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda

AU - Kulkarni, Abhaya V.

AU - Schiff, Steven J.

AU - Mbabazi-Kabachelor, Edith

AU - Mugamba, John

AU - Ssenyonga, Peter

AU - Donnelly, Ruth

AU - Levenbach, Jody

AU - Monga, Vishal

AU - Peterson, Mallory

AU - MacDonald, Michael

AU - Cherukuri, Venkateswararao

AU - Warf, Benjamin C.

PY - 2017/12/21

Y1 - 2017/12/21

N2 - 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.

AB - 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.

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Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R et al. Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda. New England Journal of Medicine. 2017 Dec 21;377(25):2456-2464. https://doi.org/10.1056/NEJMoa1707568