Neurocognitive outcome and ventricular volume in children with myelomeningocele treated for hydrocephalus in Uganda

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Despite lower failure and infection rates compared with shunt placement, it has not been known whether endoscopic third ventriculostomy/choroid plexus cauterization (ETV/CPC) might be inferior in regard to neurocognitive development. This study is the first to describe neurocognitive outcome and ventricle volume in infants with hydrocephalus due to myelomeningocele that was treated primarily by ETV/CPC.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The modified Bayley Scales of Infant Development (BSID-III) test was administered to 93 children with spina bifida who were 5–52 months of age. Fifty-five of these children had been treated by ETV/CPC, 19 received ventriculoperitoneal (VP) shunts, and 19 had required no treatment for hydrocephalus. Raw scores were converted to scaled scores for comparison with age-corrected norms. Ventricular volume was assessed by frontal/occipital horn ratio (FOR) calculated from late postoperative CT scans. The mean values between and among groups of patients were compared using independent samples t-test and ANOVA. The comparison of mean values to population normal means was performed using the single-sample t-test. Linear regression analyses were performed using BSID scores as the dependent variables, with treatment group and ventricular size (FOR) as the independent variables. Probability values &lt; 0.05 were considered significant.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>. There was no significant difference in mean age at assessment among groups (p = 0.8). The mean scale scores for untreated patients were no different from normal (all p &gt; 0.27) in all portions of the BSID (excluding gross motor), and were generally significantly better than those for both VP shunt–treated and ETV/CPC groups. The ETV/ CPC-treated patients had nonsignificantly better mean scores than patients treated with VP shunts in all portions of the BSID (all p &gt; 0.06), except receptive communication, which was significantly better for the ETV/CPC group (p = 0.02). The mean FOR was similar among groups, with no significant difference between the untreated group and either the VP shunt or ETV/CPC groups. The FOR did not correlate with performance.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The ETV/CPC and VP shunt groups had similar neurocognitive outcomes. Neurocognitive outcomes for infants not requiring treatment for hydrocephalus were normal and significantly better than in those requiring treatment. The mean ventricular volume was similar among all 3 groups, and significantly larger than normal. There was no association between FOR and performance. Stable mild-to-moderate ventriculomegaly alone should not trigger intervention in asymptomatic infants with spina bifida.</jats:p></jats:sec>

Volumetric brain analysis in neurosurgery: Part 2. Brain and CSF volumes discriminate neurocognitive outcomes in hydrocephalus

“…2D). Because Warf et al did not find a correlation between treatment type and cognitive outcome, 18 all treatment types are analyzed together here, although they are distinguished by symbols in the figures for clarity.…”

“…Therefore the sum of the three cognitive scores has a maximum of 60 and a mean of 30. After adding these three scores together, the cognitive data were grouped by low (< 15), medium (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30), and high (> 30) cognitive outcomes. The Wilks test statistic, W, was used to test for the significance of the classification.…”

“…18 Institutional review board oversight for data analysis was provided by CURE, Harvard University, and Penn State University (the last of which provided an exemption determination for de-identified images). Hydrocephalus was treated either by ventriculoperitoneal (VP) shunt placement or by endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC).…”

“…The CT scans and BSID-III tests were administered postoperatively, with a mean age of the patients at the time of assessment of 15.6 months, with no significant difference in mean age among the groups (16.8 months for the untreated, 14.5 for the VP shunt, and 15.6 for the ETV/CPC group; p = 0.8). 18 The BSID-III included measurements of fine motor skill, gross motor skill, expressive communication, receptive communication, cognitive ability, and social-emotional scores. In this present study, we analyze brain parenchymal volumes (including cerebral hemispheres, cerebellum, and brainstem) and intra-brain fluid volumes (including ventricular fluid and fluid contained within the boundary of the brain parenchyma) for 33 of these patients (ages 2 weeks to 72 months): 9 were treated for hydrocephalus with a VP shunt, 17 were treated with ETV/CPC, and 7 did not require treatment for hydrocephalus.…”

“…8 We argue that in cases of pediatric hydrocephalus, brain volume is more important in determining neurocognitive performance than fluid volume alone. In this second of 3 companion papers, we build on previous work 18 by exploring the relationship of brain and CSF volumes with neurocognitive outcome in Ugandan children with myelomeningocele treated for hydrocephalus.…”