Endoscopic Treatment versus Shunting for Infant Hydrocephalus in Uganda

Abstract

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. 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. 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). 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.)