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.

Parent perception of telemetric intracranial pressure monitoring in children - A qualitative case study.

Introduction: Telemetric monitoring of intracranial pressure (ICP) in children with a complex cerebrospinal disorder might help parents distinguish acute and potential life-threatening symptoms of hydrocephalus from other illnesses. Research question: What is patient and parent perceptions of system utility of telemetric ICP monitoring, and how does a long-term telemetric implant influence daily life of both patients and their families? Material and methods: A qualitative case study design with a focus group interview including parents of children with a complex cerebrospinal fluid disorder and an implanted telemetric ICP sensor. Results: Three parents participated. Based on thematic analysis, three themes were created: 'Daily living with telemetric ICP monitoring', 'Parenting a child with a CSF disorder', and 'The healthy sibling'. The ICP sensor provided the parents with security and made them trust their intuition, while the possibility of home monitoring ensured stability for the entire family and had a calming effect on healthy siblings. Home monitoring was seen as the system's greatest advantages, whereas size, weight, and functionality of the external monitoring equipment were highlighted as disadvantages. Discussion and conclusion: All parents supported the telemetric ICP sensor as a valued tool in treatment guidance of their child and stated that advantages exceeded disadvantages. It was stated that the possibility of conducting ICP measurements at home reduced the need for acute hospital admissions, which consequently led to a more stable daily life for the entire family. Suggestions regarding technical improvements with focus on more compatible external monitoring equipment were raised by all parents included.

Spontaneous regression of migrated ventriculoperitoneal shunt catheter from scrotum to peritoneum: a case-based review.

OBJECTIVE: The incidence of scrotal migration of a ventriculoperitoneal shunt (VPS) catheter is rare and may lead to life-threatening visceral complications. Management requires prompt removal of the migrated portion of the shunt and closure of the scrotal sac. We report an interesting case of a young child who presented with asymptomatic unilateral swelling of his scrotum secondary to a migrated VPS catheter. A repeat X-ray prior to his surgery to remove the migrated catheter showed that the entire length of the distal VPS catheter was back in the peritoneal cavity. In view of this unusual phenomenon, the case is discussed in corroboration with published literature. METHODS AND RESULTS: A systematic search of publications in the English language is performed in PubMed and Google Scholar. Our findings show that there are 49 reported cases (including our patient) of scrotal migration of shunt catheters in patients less than 18 years old. There is only 1 other case of spontaneous resolution of shunt catheter from the scrotum. Favoured management of choice is repositioning the distal shunt catheter back into the peritoneal cavity and herniotomy in the same setting, if possible. Overall, the literature suggests this is a shunt-related complication that has a good prognosis if intervention is timely. CONCLUSION: Scrotal migration of a VPS catheter is a rare but potentially life-threatening complication in children. Our case report highlights the role of updated preoperative imaging and the need for consistent long-term shunt surveillance in children.

Automatic volumetry of cerebrospinal fluid and brain volume in severe paediatric hydrocephalus, implementation and clinical course after intervention.

BACKGROUND: In childhood hydrocephalus, both the amount of cerebrospinal fluid and the brain volume are relevant for the prognosis of the development and for therapy monitoring. Since classical planar measurements of ventricular size are subject to strong limitations, imprecise and neglect brain volume, 3D volumetry is most desirable. We used and evaluated the robust segmentation algorithms of the freely available FSL-toolbox in paediatric hydrocephalus patients before and after specific therapy. METHODS: Retrospectively 76 pre- and postoperative high-resolution T2-weighted MRI sequences (true FISP, 1 mm isovoxel) were analyzed in 38 patients with paediatric hydrocephalus (mean 4.4 ± 5.1 years) who underwent surgical treatment (ventriculo-peritoneal (VP) shunt n = 22, endoscopic third ventriculostomy (ETV) n = 16). After preprocessing, the 3D-datasets were skull stripped to estimate the inner skull surface. Following, a 2 class segmentation into different tissue types (brain matter and CSF) was performed. The volumes of CSF and brain were calculated. RESULTS: The method could be implemented in an automated fashion in all 76 MRIs. In the VP shunt cohort, the amount of CSF (p < 0.001) decreased. Consecutively brain volume increased significantly (p < 0.001). Following ETV, CSF volume (p = 0.019) decreased significantly (p = 0.012) although the reduction was less pronounced than after shunt implantation. Brain volume expanded (p = 0.02). CONCLUSION: A reliable automated segmentation of CSF and brain could be performed with the implemented algorithm. The method was able to track changes after therapy and detected significant differences in CSF and brain volumes after shunting and after ETV.

Paediatric External Ventricular Drains: Experience from a tertiary care hospital of a Developing Country.

The aim of the study was to describe indications and complications of external ventricular drain (EVD) placement in children aged between 1 month and 16 years. This retrospective chart review was conducted at the Aga Khan University Hospital, Karachi, and comprised all children who underwent EVD placement from January 2007 to December 2014. Of the 177 patients identified, 117(66%) were males 60(34%) were girls. The overall mean age was 5.4±5.2 years. The median Glasgow Coma Scale score on presentation and discharge was 13 (interquartile range [IQR]: 7) and 15 (IQR: 4), respectively. Major diagnosis included intracranial tumour 60(34%), bacterial meningitis 34(19%), tuberculous meningitis 33(18.6%), and haemorrhage 23(13%). Clinical indications for EVD insertion were acute hydrocephalus secondary to infection 64(36.2%), tumour 54(30.5%), and haemorrhage 23(13%) ventriculoperitoneal shunt malfunction or infection 25(14.1%) and traumatic brain injury 11(6.2%). Complications were observed in 47(26%) patients including infections 25(14.1%), malfunction 11(6.2%), haemorrhage 6(3.4%), misplacement 3(1.7%) and obstruction 2(1.1%). Staphylococcus was the main organism isolated. Moreover, 25(14%) patients expired. Acute hydrocephalus was the major indication and EVD infection was the major complication.

Benign external hydrocephalus in infants. A single centre experience and literature review.

External hydrocephalus (EH) is a benign clinical entity in which macrocephaly is associated with an increase in volume of the subarachnoid space, especially overlying both frontal lobes, and a normal or only slight increase in volume of the lateral ventricles. Several pathogenic hypotheses have been proposed but the most accredited theory seems to be delayed maturation of the arachnoid villi. There is a consensus that this is a benign entity, correlated to a familial predisposition and, in some cases, inheritance. CT and MRI are very important to make a diagnosis but also to establish the prognosis in patients who encounter the rare complications such as subdural haematomas. In conclusion, CT and MRI can provide a highly accurate diagnosis in these patients, allowing a preliminary assessment of the prognosis, particularly regarding the enlarged subarachnoid space limits and the "cortical vein" sign which can predict a further complication. These results are obtained with the same examination performed in a standard CT or MRI study of the brain and no injection of contrast medium is needed.