The landscape of paediatric hydrocephalus in the Province of KwaZulu-Natal. A comparative analysis of the referral pattern, aetiology and management outcomes over four distinct five-year periods.

BACKGROUND: Paediatric hydrocephalus causes significant health burden globally, particularly in low and middle-income countries. There's a dearth of data from specific regions such as KwaZulu-Natal, South Africa. This study aimed to investigate the landscape of paediatric hydrocephalus, comparing four distinct five-year periods. METHODS: Data were collected retrospectively (2003 to 2007, 2008 to 2012, and 2013 to 2017) and prospectively (2018 to 2022). Children (≤18 years) treated for hydrocephalus were included. Data on demographics, referral patterns, aetiology, treatment modalities, and outcomes were collected and analyzed. RESULTS: A total of 3325 children were treated. The peak period was 2008 to 2012 (35.3%). Majority (51.4%) were from rural areas (p=0.013) and 47.9% were referred from regional hospitals, p=<0.001. Males (56.4%) and infants (60.2%) were predominant groups (p<0.001). Post-infectious aetiology (32.7%) was predominant (p<0.001), particularly tuberculous meningitis (54.1%). Ventriculoperitoneal shunts (VPSs) were the mainstay treatment (84.2%), with notable complication rates (20.4%), including infections (9.6%). HIV co-infection was diagnosed in 2.5% of cases. Weekend procedures were associated with VPS complications (HR1.3, CI:1.03-1.66, p=0.03). The mortality rate was 7.9%, and age ≥1 year (HR, 2.43 CI: 1.87-3.17, p<0.001), tertiary hospital referral (HR 1.48, CI: 1.06-2.04, p=0.019), VPS infection (HR, 3.63 CI: 2.66-4.95, p<0.001), acute abdomen (HR 2.17, CI: 1.11-4.25, p=0.024) and pneumonia (HR 7.32, OR 4.84 -11.06, p<0.001) were associated with mortality. CONCLUSION: This study provides comprehensive insights into pediatric hydrocephalus in KZN. Monitoring temporal trends and predictors of outcomes will aid guide future interventions aimed at mitigating the burden of pediatric hydrocephalus in the region.

A comparison of the surgical outcomes of ventriculoperitoneal versus lumbar peritoneal shunts in the management of intracranial hypertension secondary to cryptococcal meningitis in HIV infected adult patients.

OBJECTIVE: Cryptococcal meningitis (CM), an AIDS-defining illness, significantly impacts morbidity and mortality. This study aims to compare complications arising from ventriculoperitoneal shunt (VPS) and lumbar peritoneal shunt (LPS) procedures used to manage refractory intracranial hypertension (IH) secondary to CM in HIV-infected patients. METHODS: Retrospective data were collected from January 2003 to January 2015 for HIV-infected adults diagnosed with refractory IH secondary to CM and subsequently shunted. Demographics, clinical characteristics, antiretroviral therapy, laboratory findings (including CD4 count and CSF results), CT brain scan results, shunt-related complications, and mortality were compared between VPS and LPS groups. RESULTS: This study included 83 patients, with 60 (72%) undergoing VPS and 23 (28%) receiving LPS. Mean ages were comparable between VPS (32.5) and LPS (32.2) groups (p = 0.89). Median CD4+ counts were 76 cells/µl (IQR= 30-129) in VPS versus 54 cells/µl (IQR= 31-83) in LPS (p=0.45). VPS group showed a higher mean haemoglobin of 11.5 g/dl compared to 9.9 g/dl in the LPS group (p=0.001). CT brain scans showed hydrocephalus in 55 VPS and 13 LPS patients respectively. Shunt complications were observed in 17 (28%) VPS patients versus 10 (43.5%) LPS patients (p=0.5). Patients developing shunt sepsis in the VPS group exhibited a median CD4+ count of 117 cells/µl (IQR= 76-129) versus 48 cells/µl (IQR= 31- 66) in the LPS group (p=0.03). Early shunt malfunction occurred more frequently in the LPS group compared to VPS group (p=0.044). The mean hospital stay was 6.2 days for VPS versus 5.4 days for LPS patients (p=0.9). In-hospital mortality was 6%, occurring in three VPS and two LPS patients respectively. CONCLUSION: Shunting procedures remain important surgical interventions for refractory IH secondary to HIV-related CM. However, cautious consideration is warranted for patients with CD4 counts below 200 cells/µL due to increased shunt complications. This study suggests a trend toward higher complication rates in patients undergoing LPS insertion.

Factors associated with in-hospital mortality in HIV-infected children treated for tuberculous meningitis hydrocephalus.

PURPOSE: The study aimed to investigate factors associated with in-hospital mortality in children diagnosed with tuberculous meningitis (TBM) hydrocephalus and HIV co-infection undergoing cerebrospinal fluid diversion procedures and their complications. METHODS: Data were collected retrospectively and prospectively between 2007 and 2022. Data collected included demographics, clinical characteristics, antiretroviral therapy (ART) status, biochemistry results, CD4 count, radiology findings, CSF diversion procedures (and complications), length of hospital stay (LOHS), and in-hospital mortality. RESULTS: Thirty-one children were included, with a mean age of 6.7 ± 5.3 years and 67.7% males. Median admission Glasgow Coma Scale (GCS) was 11 (IQR 9-15). Hypertonia (64.5%) and seizures (51.6%) were frequently observed clinical characteristics. Sixty-one percent of children were on ART. Cerebral infarcts and extra-meningeal TB were diagnosed in 64.5% and 19.3% of cases, respectively. The median CD4 count was 151 (IQR 70-732) cells/µL. Surgical procedures included ventriculoperitoneal shunt (VPS) in 26 cases and endoscopic third ventriculostomy (ETV) in five children. VPS complication rate was 27%. No complications were reported for ETV. Median LOHS was 7 days (IQR 4-21). Eleven children (35.5%) died during admission. Factors associated with mortality included GCS (p = 0.032), infarcts (p = 0.004), extra-meningeal TB (p = 0.003), VPS infection (p = 0.018), low CD4 count (p = 0.009), and hyponatremia (p = 0.002). No statistically significant factors were associated with VPS complications. CONCLUSION: TBM hydrocephalus in HIV-infected children carries a high mortality. Clinicians in high-prevalence settings should have a high suspicion index and institute early treatment.

Cerebrospinal Fluid Shunting in Children with Hydrocephalus and Increased Intracranial Pressure Secondary to Human Immunodeficiency Virus-Related Cryptococcal Meningitis.

BACKGROUND: Hydrocephalus and increased intracranial pressure secondary to human immunodeficiency virus-related cryptococcal meningitis are rare in children. The role and outcomes of cerebrospinal fluid (CSF) shunting in children are not well reported. We report our experience with CSF shunting in the management of this condition in children over a 14-year period. METHODS: This was a retrospective review of data collected from a single neurosurgery unit. Data collected included demographics, clinical characteristics, Glasgow Coma Scale score, lumbar puncture opening pressure, antiretroviral therapy, laboratory results, neuroimaging findings, shunting procedures, complications, and mortality. RESULTS: Seventeen children underwent CSF shunting. Median age was 10 years (range, 6-13), most being male (76%). All children were on antiretroviral therapy. Median Glasgow Coma Scale score was 15 (interquartile range [IQR], 14-15). Clinical characteristics included headaches (100%), visual impairment (82%), and seizures (47%). Lumbar puncture opening pressure was >30 cm H2O in 88% of children. Median CD4 count was 45 cells/µL (IQR, 17-56). Computed tomography brain scans showed hydrocephalus in 14 children (82%). Surgical procedures included ventriculoperitoneal shunts (82%) and lumboperitoneal shunts (18%). Shunt complications included infection (18%) and obstruction (18%). Staphylococcus aureus was cultured in all infections. Median follow-up was 45 months (IQR, 7.5-74). Three children (18%) died during the admission period. Ten children (59%) were alive at 1 year follow-up. CONCLUSIONS: This study is the largest series reporting on CSF shunting of hydrocephalus and increased intracranial pressure in children with human immunodeficiency virus-related cryptococcal meningitis. Treatment with ventriculoperitoneal shunt and lumboperitoneal shunt regardless of the CD4 count is an important option in suitable children to reduce mortality.

Compound elevated skull fractures: a retrospective descriptive study.

BACKGROUND: Traumatic skull fractures have been traditionally classified into those that involve the base or vault with distinct entities linear or depressed. Compound elevated skull fracture is a newer entity with scanty reports in the literature. OBJECTIVE: To describe the clinical presentation, neuro-radiology findings by development of a classification system, medical and surgical management, and complications of patients with compound elevated skull fractures at a tertiary referral neurosurgical department. METHODS: Medical records of consecutive patients admitted from January 2005 to December 2018 with compound elevated skull fractures at the single neurosurgical referral hospital were retrospectively evaluated. Data was analyzed for demographics, clinical presentation, mechanisms of injury, neuro-radiology findings, management and outcomes. RESULTS: Eighteen patients were included in this series with a median age of 28 years, median admission Glasgow Coma Scale was 12. Ten patients presented with focal neurological deficits which included hemiparesis [n = 8, 44%] and unilateral afferent pupil deficit [n = 2, 11%]. Intra-cerebral haematoma was the most common associated neuro-radiological finding [n = 10, 55%] followed by acute extradural haematoma [n = 4, 22%]. Three distinct neuro-radiological subtypes were identified: Type 1 - fractured segment with minimal loss of contact with rest of cranial vault, Type 2 - fractured segment with partial loss of contact with rest of cranial vault, Type 3 - fractured segment with complete loss of contact with rest of cranial vault. All patients underwent surgical debridement and of which 11 [61%] required duroplasty and 10[55%] re-placement of elevated bone flap. Septic complications included meningitis [n = 5, 27%], brain abscess [2, 11%] and surgical site infection [n = 1, 5%]. Seventeen patients had favourable outcomes at discharge (Glasgow Outcome Scale 4 or 5). CONCLUSION: Compound elevated skull fracture is an additional subtype of skull vault fracture. Prompt neurosurgical management with appropriate operative management of dura and elevated bone fragment reduces morbidity from septic complications.

MRI characteristics of intracranial masses in the paediatric population of KwaZulu-Natal: A neuroimaging-based study.

BACKGROUND: MRI is the imaging modality of choice for the assessment of intracranial masses in children. Imaging is vital in planning further management. OBJECTIVES: The purpose of this study was to describe the common intracranial masses and their imaging characteristics in the paediatric population referred to Inkosi Albert Luthuli Central Hospital for MRI of the brain. METHOD: We retrospectively reviewed the medical records of paediatric patients (aged from birth to 18 years) who underwent MRI investigations for intracranial masses between January 2010 and December 2016. RESULTS: A total of 931 MRI brain scans were performed. One hundred and seven scans met the inclusion criteria, of which 92 were primary brain tumours and 15 were inflammatory masses. The majority were females (56%). The mean age was 12 ± 4.52 (range of 3-18 years). The most common presenting symptom was seizures (70/107, 65.4%). We categorised the masses according to supra- and infratentorial compartments. The most common site for masses was the supratentorial compartment (n = 56, 52%). The most common masses in the supratentorial compartment were craniopharyngiomas (14/45, 31.1%), whilst in the infratentorial compartment, the most common masses were medulloblastomas (24/47, 51.1%). CONCLUSION: In our series, the supratentorial compartment was the commonest site for intracranial masses. The most common tumour in the infratentorial compartment was medulloblastoma. This information is vital in formulating differential diagnoses of intracranial masses.

HIV, Tuberculosis, and Otogenic Intracranial Sepsis: A Devastating Disease With a Subtle Presentation.

OBJECTIVES: To undertake a large-scale review of otogenic intracranial sepsis in an area of highly prevalent HIV and tuberculosis (TB) to re-examine and inform early diagnosis and treatment efforts. METHODS: Seventy-seven consecutive cases of otogenic intracranial sepsis in KwaZulu-Natal, South Africa were reviewed for demographics, presentation, imaging, HIV status, culture results, and outcomes. RESULTS: The most common intracranial complications were intracranial abscess (46.8%), hydrocephalus (31.2%), subdural empyema (28.6%), and epidural empyema (26.0%). Ear discharge (87.0%), postauricular abscess (29.9%), and hearing loss (29.9%) were notable presenting symptoms. Overall mortality was 15.6%. Of the 45.5% of patients with HIV testing, 54.2% were HIV+, Mortality among HIV+ patients was 15.8% but only 6.3% in HIV- patients (p = 0.61, OR = 2.8). Eight patients (10.4%) had culture or histological evidence of TB infection. CONCLUSIONS: Otogenic intracranial complications continue to present late and are associated with significant mortality and morbidity, despite advances in diagnostic and treatment modalities. This study represents one of the largest case-series in the literature, and the first to specifically evaluate the effects of HIV and TB infection.Patient presentation and severity of illness varied; however, a majority of patients presented with ear discharge and no focal neurological signs. An effect size for higher mortality among HIV+ patients compared with HIV- patients was noted but was not significant. Tuberculosis infection was prevalent compared with previous studies.This study reinforces the need for enhanced screening and early treatment of ear disease to minimize associated mortality and morbidity, particularly in immunocompromised patients.

Retained garden fork following cranial stab injury.

Retained garden fork is a rare complication of penetrating cranial trauma. Retained knife blade is the most commonly reported presentation. We report an unusual case of a 30-year-old male patient treated at our institution, who presented with a retained garden fork following a stab to the head, with no associated neurological deficits. Computerized tomographic scan of the brain was performed preoperatively to assess the trajectory of the weapon and parenchymal injury. A craniectomy was performed to facilitate removal of the weapon in the operating theatre under general anaesthesia. Intravenous prophylactic antibiotics were administered pre- and postoperatively to prevent septic complications. The patient recovered well and was discharged home.

Spinal stab injury with retained knife blades: 51 Consecutive patients managed at a regional referral unit.

BACKGROUND: Spinal stab wounds presenting with retained knife blades (RKB) are uncommon, often resulting in spinal cord injury (SCI) with catastrophic neurological consequences. The purpose of this study is to report a single unit's experience in management of this pattern of injury at this regional referral centre. METHODS: Retrospective review of medical records identified 51 consecutive patients with spinal stabs presenting with a RKB at the Neurosurgery Department at Inkosi Albert Luthuli Central Hospital between January 2003 and February 2015. The data was analyzed for patient characteristics, level of the RKB, neurological status using the ASIA impairment scale, associated injuries, radiological investigations, management, hospital length of stay, complications and mortality. RESULTS: The mean age was 28±10.9 years (range 14-69), with 45 (88%) males (M: F=7.5:1). The median Injury Severity Score was 16 (range 4-26). RKB were located in the cervical [9,18%], thoracic [38,74%], lumbar [2,4%] and sacral [2,4%] spine. Twelve patients (24%) sustained complete SCI (ASIA A), while 21 (41%) had incomplete (ASIA B, C, D), of which 17 had features of Brown-Sequard syndrome. Eighteen (35%) patients were neurologically intact (ASIA E). There were 8 (16%) associated pneumothoraces and one vertebral artery injury. Length of hospital stay was 10±7.1 days (range 1-27). One patient (2%) died during this period. CONCLUSIONS: Stab injuries to the spine presenting with RKB are still prevalent in South Africa. Resources should be allocated to prevention strategies that decrease the incidence of inter-personal violence. All RKBs should be removed in the operating theatre by experienced surgeons to minimise complications.

Cranial injuries secondary to assault with a machete.

BACKGROUND: Assaults with a machete cause compound skull fractures which present as a neurosurgical emergency. We aimed to profile cranial injuries caused by a machete over a 10 year period in a single neurosurgical unit. MATERIALS AND METHODS: Retrospective data analysis of cranial injuries following assault with a machete, admitted to the neurosurgery ward, from January 2003 to December 2012 was performed. Medical records were analyzed for demographics, clinical presentation, CT scan findings, surgical treatment and Glasgow Outcome Scale (GOS) at discharge. Management involved wound debridement with antibiotic cover. RESULTS: Of 185 patients treated 172 (93%) were male. Mean age was 31±11.4 years. Mean GCS on admission was 13±2. Presenting features were focal neurological deficit (48%), brain matter oozing from wounds (20%), and post traumatic seizures (12%). Depressed skull fractures were found in 162 (88%) patients. Findings on CT brain scan were intra-cranial haematoma (88%), pneumocephalus (39%) and features of raised intra-cranial pressure (37%). Thirty-one patients (17%) presented with septic head wounds. One hundred and fifty seven patients (85%) were treated surgically. The median hospital stay was 8 days (range 1-145). The median GOS at discharge was 5 (range 1-5). Twelve patients died within the same admission (6.5%). CONCLUSION: Machetes cause complex cranial injuries with associated neurological deficit and should be treated as neurosurgical emergency. Timeous intervention and good surgical principles are advocated to prevent secondary infection and further neurological deterioration.