Childhood Hydrocephalus in Sokoto: Experience with 401 Series.

BACKGROUND: Hydrocephalus is a complex and multifactorial neurological disorders. Childhood hydrocephalus like other chronic childhood illness is a major contributor to poor quality of life and huge financial burden to the affected family and nation. Epidemiological factors tend to vary with geographical location. Unlike in developed countries, most data from developing countries showed infection as the most common etiology. This study was conducted to analyze our epidemiological features of childhood hydrocephalus in Sokoto with a review of the literature. AIMS: The aims of this study were to determine the frequency of causes of hydrocephalus in Sokoto and to determine the short-term outcomes of treatment and compare results with the literatures.
MATERIALS AND METHODS: This was a retrospective study with patients' data from the theatre records, patients' case notes, and radiological records. Outcomes were based on complications and changes in the occipitofrontal circumferences. Criteria for statistical significant was P < 0.05.
RESULTS: One hundred and thirty-eight patients satisfied inclusion criteria. No sex preponderance was found with a mean age of 16.41 months. Maternal illiteracy rate was 60% with 49.3% of the parents at lower socioeconomic class. Infection was the most frequent etiology (45.7%). Myelomeningocele associated hydrocephalus was also common (16.7%). However, post-hemorrhagic hydrocephalus was rare (2.9%). Mean preoperative and postoperative occipitofrontal circumferences were 54.22 cm and 47.92 cm, respectively, with P = 0.001.
CONCLUSION: Poverty and illiteracy were strongly associated with childhood hydrocephalus in our patients. Infection was predominantly associated with morbidity with large number of patients being lost to follow-up. Copyright:

INTRODUCTION

Hydrocephalus is a complex and multifactorial neurological disorders.[1] The most common etiological factors are myelomeningocele and post-hemorrhagic hydrocephalus of prematurity.[2] However, a well-documented prospective series in East Africa showed infection to be the most common etiological factor accounting for 57% of all cases studied, this is followed by myelomeningocele associated hydrocephalus which accounted for 13% of the patients in this study.[13] Incidence and prevalence of post-infective hydrocephalus are likely higher in Sokoto because of high prevalence of untreated and/or poorly treated neonatal meningitis and nutritional deficiencies among children living in the rural communities in Sokoto State where majority of the patients studied resides. There is therefore the need to review our patient records for hydrocephalus treated at the Regional Centre for Neurosurgery, Sokoto with the hope that our finding will play a useful role in patients counseling and management approaches.

Aims

The aims of this study were to determine the frequency of causes of hydrocephalus in Sokoto and to determine the short-term outcomes of treatment and compare results with the literatures.

MATERIALS AND METHODS

This was a retrospective study of all cases of childhood hydrocephalus seen and managed at the Regional Centre for Neurosurgery, Sokoto between 2008 and 2012 with data collected from the operation records, patients’ case files, and radiological reports. Outcomes were measured based on complications and observed changes in the occipitofrontal circumferences. Patients who defaulted from treatment and/or follow-up after treatment; and patients who died before the end of 1-year follow-up were all excluded from the study. Only patients who attended follow-up clinic up to 1 year or more after surgery were included in this study. A value of P < 0.05 was considered statistically significant. Data were analyzed using Statistical Package for the Social Sciences (SPSS) software program (Version 21.0, IBM Corp., Armonk, NY).

RESULTS

A total of 401 patients were seen in during the study period. Fifty-six (13.97%) of the patients defaulted from care before surgery before surgery, whereas 61 (15.21%) died before intending surgery or during postoperative admission, however, there was no intraoperative mortality. Two hundred and eighty-four (70.82%) patients where discharged home successfully from the hospital after surgery of which 146 (36.41%) defaulted from follow-up before 1-year postoperative day, whereas the remaining 138 patients (34.42%) who were followed up to 1-year postoperative day or more satisfied the inclusion criteria for the study with equal number of male and female patients [Tables 1 and 2]. One hundred and seven (77.5%) patients were neonates and infants, whereas 17.4% were toddlers and preschool-age children with a mean age of 16.41 months at diagnoses [Table 3].

Table 1

Distribution of patients

Total number of patients	Preoperative death	Defaulted from care	Number of surgeries	Lost to follow-up	Study group
401	61	56	284	146	138

Table 2

Sex distribution

Total number of patients	Males	Females
138	69	69

Table 3

Age distribution

Age grade	Frequency	Percentage
Infants and neonates (0–12 months)	107	77.5
Toddlers and preschool ages (13–60 months)	24	17.4
School age, middle childhood, and teenagers (61–180 months)	7	5.1
Total	138	100

Eighty-three (60.1%) of patients’ mothers had no formal education, whereas 53 (38.4%) had either primary or secondary level of education. Only two (1.4%) of the patients’ mothers had tertiary level of education [Figure 1]. Fifty percent of patients’ fathers were in the lower socioeconomic class, 29% were in the middle socioeconomic class, whereas the remaining 21% were in the upper socioeconomic class (based on Ogunlesi et al.[4] classifications) [Figure 2]. Even though 60 (43.5%) of the patients’ mothers had antenatal care during pregnancy only 51 (37%) had Obstetric Ultrasonic Examination with no single case of pre-natal ultrasonic diagnosis of congenital hydrocephalus [Figure 3].

Figure 1

Patients’ mothers level of education

Figure 2

Patients’ fathers socioeconomic class

Figure 3

History of obstetric ultrasound in pregnancy

The neuroimaging mostly done was trans fontanelle ultrasound which showed 73.2% cases of non-obstructive hydrocephalus and 26.8% cases of obstructive hydrocephalus [Figure 4]. The most frequent etiology seen was infection (45.7%) followed by neural tube defect mostly myelomeningocele (16.7%) [Figure 5]. Complications of treatment were seen in 24(18%) cases with postoperative infection as the most frequent cause of complications (54.2%). Peri-catheter cerebrospinal fluid leak (CSF leaks around the shunt hardware connectors) accounted for 25% of the complications seen, whereas ventriculoperitoneal shunt blockages and shunt migrations accounted for the rest of complications (20. 8%) [Table 4 and Figure 6]. Reoperation was done in 11 (8%) of patients [Figure 7]. There was a significant reduction in the occipitofrontal circumferences following treatment with P = 0.001 [Table 5].

Figure 4

Ultrasonic diagnoses

Figure 5

Etiology

Table 4

Complications

Complication	Frequency	Percentage
Shunt infection	13	10.1
Shunt blockages	4	2.9
Shunt migration	1	0.7
Pericatheter CSF leaks	6	4.3
No complication	114	82
Total	138	100

Figure 6

Percentage distribution of complications

Figure 7

Revision surgery

Table 5

Occipitofrontal circumference changes before and after surgery

Paired samples correlations
	N	Correlation	Sig.
Pair 1	OFC1 and OFC2	123	.793	.001

DISCUSSION

Childhood hydrocephalus like other chronic childhood illness is a major contributor to poor quality of life and huge financial burden to the affected family and nation.[56] There has been an overall decline in the incidence of childhood hydrocephalus in developed countries as a result of increased awareness and use of peri-conception folic acid by women of childbearing ages to prevent neural tube defects which hitherto accounted for the majority of the childhood hydrocephalus in these parts of the world.[7] However, the incidence remains high in the developing countries where there is a lack of public health campaign and awareness on the prevention of neural tube defects by peri-conception use of folic acid.[7] The burden of hydrocephalus in Africa is even made worse by high prevalence of infectious diseases. In Uganda, a study on three hundred consecutive cases of childhood hydrocephalus found that 60% of the cases were caused by cerebrospinal fluid infection.[78] This is similar to our finding in this study with infectious etiology as the most common cause of hydrocephalus in Sokoto (45.7%). Infectious etiologies were made through cerebrospinal fluid examination obtained preoperatively via lumbar puncture for communicating hydrocephalus and ventricular taps preoperatively or intraoperatively during ventriculoperitoneal shunt surgeries.

A study conducted on Health Facility Delivery in Sub-Sahara Africa showed that birth among women in the richest quantile were 68% more likely to occur in health facilities compared to women in the lowest wealth quantile; and women with at least primary level of education were twice more likely to give birth in health facilities compared to women with no formal education.[9] This was largely supported by our finding with majority (56.5%) of the patients’ mothers not undergoing antenatal care and maternal illiteracy rate as high as 60%. Because illiteracy frequently has a causal associated with poverty, high maternal illiteracy (60%) seen was not surprisingly associated with finding of large number of paternal low-income status (78%). These two socioeconomic factors were most likely responsible for the low antenatal care attendance rate and inability to provide fund for brain computed tomography scan or magnetic resonance imaging by majority of the patients.

Post-hemorrhagic hydrocephalus of prematurity is one of the most frequent causes of hydrocephalus in developed countries with an incidence between 25% and 50%.[10] Advancement in neonatal care services in developed countries leading to majority of the preterm neonates surviving into the childhood is responsible for the relatively high incidence of post-hemorrhagic hydrocephalus of prematurity.[1112] However, only 2.9% of our patients had post-hemorrhagic hydrocephalus of prematurity. This relative rarity can be ascribed to the underdevelopment of neonatal care services in our centre and/or its unavailability to the poor patients who mostly reside in the rural environment.

Complications are common with ventriculoperitoneal shunt insertion. Erikci et al.[13] found complications range of 5%–47% from his review of literatures. Ali in Egypt had complications in 14.6% of his patients.[14] These were congruous with our complication rate of 16%. These high complications seen by most surgons in published works have direct causal relationship with a high rate of ventriculoperitoneal shunt revision surgery. Alexander et al.[14] and Pradyumna[15] had ventrculoperitoneal shunt revision rates of 22% and 27%, respectively, in their studies. However, only 8% of our patients had ventriculoperitoneal shunt revision. Our low revision surgery rate is grossly at variance with findings from most studies in the literature and also averse to the report that two-thirds of the patients with ventriculoperitoneal shunt insertions will require at least one revision.[16] However, the short duration of follow-up of our patients might have affected our result. Obstructions and disconnections were the most frequent complications seen by Lumenta and Skotarczak[17] In Pradyumna[15] study, shunt obstruction was the most common complication for accounted for 45.9% of all complications he had. But Ali in Egypt found shunt exposure as the most frequent complication which is responsible for 23.3% of all his complications, whereas shunt obstruction was the second most common complication in his study accounting for 13.3%.[1819] However, we found shunt-related infection as the most frequent complication accounting for 43% of all our complications with peri-catheter cerebrospinal fluid leaks (as the second most common complication (25%). Shunt obstruction was responsible for 16.6% of our complications. We found ventriculoperitoneal shunting insertion to be associated with a statistically significant reduction in occipitofrontal circumferences postoperatively with P < 0.001. The high mortality rate in our study (15.21%) mostly occurred during preoperative resuscitation and operative planning majorly due to delivery at patients’ homes and traditional birth attendance centre under septic condition with late presentation to the neurosurgical centre.

CONCLUSION

Poverty and illiteracy are significantly associated with hydrocephalus in our environment. Infection is a major cause of morbidity in hydrocephalus in our practice. A significant reduction of occipitofrontal circumference occurred with a P < 0.001 following surgery. This study was limited by a large number of patients who defaulted before and after surgery thereby leading to large exclusions from the study.

Interventions to increase health facility delivery should focus on addressing inequalities associated with maternal educations, women empowerment, increased access to health facilities as well as narrowing the gap between the rural and the urban areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.