The Incidence of Postoperative Seizures Following Treatment of Postinfectious Hydrocephalus in Ugandan Infants: A Post Hoc Comparison of Endoscopic Treatment vs Shunt Placement in a Randomized Controlled Trial

Abstract

BACKGROUND There are currently no published data directly comparing postoperative seizure incidence following endoscopic third ventriculostomy (ETV), with/without choroid plexus cauterization (CPC), to that for ventriculoperitoneal shunt (VPS) placement. OBJECTIVE To compare postoperative epilepsy incidence for ETV/CPC and VPS in Ugandan infants treated for postinfectious hydrocephalus (PIH). METHODS We performed an exploratory post hoc analysis of a randomized trial comparing VPS and ETV/CPC in 100 infants (<6 mo old) presenting with PIH. Minimum follow-up was 2 yr. Variables associated with and the incidence of postoperative epilepsy were compared (intention-to-treat) using a bivariate analysis. Time to first seizure was compared using the Kaplan–Meier method, and the relative risk for the 2 treatments was determined using Mantel-Haenszel hazard ratios. RESULTS Seizure incidence was not related to age (P = .075), weight (P = .768), sex (P = .151), head circumference (P = .281), time from illness to hydrocephalus onset (P = .973), or hydrocephalus onset to treatment (P = .074). Irritability (P = .027) and vision deficit (P = .04) were preoperative symptoms associated with postoperative seizures. Ten (10%) patients died, and 20 (20%) developed seizures over the follow-up period. Overall seizure incidence was 9.4 per 100 person-years (9.4 and 9.5 for ETV/CPC and VPS, respectively; P = .483), with no significant difference in seizure risk between groups (hazard ratio, 1.02; 95% CI: 0.42, 2.45; P = .966). Mean time to seizure onset was 8.5 mo for ETV/CPC and 11.2 mo for VPS (P = .464). As-treated, per-protocol, and attributable-intervention analyses yielded similar results. CONCLUSION Postoperative seizure incidence following treatment of PIH was 20% within 2 yr, regardless of treatment modality.

Outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of paediatric hydrocephalus: Systematic review and meta-analysis

“…There was a limited number of RCTs with heterogenous methodological limitations in study protocols as aforementioned, potentially introducing reporting bias which may have affected the degree of our research robustness in our findings. Four studies reported incomplete reporting of outcomes, hence introducing “some concerns” and “high risk of bias” limitation of the overall quality and reliability of the evidence synthesised in this review and meta-analysis [ 1 , 6 , 9 , 11 ]. Further, four studies were found to have “some concerns” in terms of the randomisation process which again may introduce reduced generalisability of our findings [ 1 , 9 , 12 , 13 ].…”

“…The choice between ETV and VPS is influenced by several factors, including the aetiology of hydrocephalus, patient age, anatomical considerations, and surgeon expertise [ 6 ]. Both procedures have shown promising results in individual studies, yet considerable debate persists regarding their comparative effectiveness and safety in paediatric patients [ 7 ].…”

The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings

“…A recent randomised trial has confirmed that treatment outcomes with respect to neurocognitive developmental, brain growth and most complications (aside from a higher infection rate for shunts) are similar for ETV/CPC and VPS in patients aged <6 months with postinfectious hydrocephalus 2. A post hoc analysis also demonstrated no difference in seizure incidence between the treatment groups 7…”

“…Unlike shunts, which can, and typically do, fail and require emergency revision over the course of the patient’s life, the majority of endoscopic treatment failures occur within 6 months of surgery, in a manner that is obvious to the family, and usually sub-acutely or chronically, allowing time for the family to return for evaluation. Our previous research, including a recent randomised trial,2 has shown either superior or similar outcomes between endoscopic treatment and VPS with respect to infection, seizure incidence, morbidity, and mortality as well as no difference in early developmental outcome and brain growth 3–8. We have also demonstrated equivalence of the initial cost between the two treatments, with significantly increased cost of treatment by VPS with each required revision 9…”