Brain growth and neurodevelopment after surgical treatment of infant post-infectious hydrocephalus in sub-Saharan Africa

Abstract

ImportancePost-infectious hydrocephalus in infants is a major public health burden in sub-Saharan Africa.ObjectiveTo determine long-term brain growth and cognitive outcome after surgical treatment of infant post-infectious hydrocephalus in Uganda.DesignProspective follow-up of a previously randomized cohort.SettingSingle center in Mbale, Uganda.ParticipantsInfants (<180 days old) with post-infectious hydrocephalus.InterventionsEndoscopic or shunt surgery.Main outcomesBayley Scales of Infant Development (BSID-3) and brain volume on computed tomography (raw and normalized for age and sex) at 2 years after treatment.ResultsEighty-nine infants were assessed for 2-year outcome. There were no significant differences between the two surgical treatment arms, so they were analyzed together. Raw brain volumes increased between baseline and 24 months (median change=361 cc, IQR=293 to 443, p<0.001), but almost all of this increase was seen in the first year (median change=381 cc, IQR=310 to 442, p<0.001), with very little change between 12 and 24 months (median change=-5 cc, IQR=-52 to 42, p=0.66). The fraction of those with a normal brain volume increased from 15% at baseline to 50% at 1 year, but then declined to 18% at 2 years. Substantial normalized brain volume loss was seen in 21% between baseline and year 2 and in 77% between years 1 and 2. The extent of brain growth in the first year was not associated with extent of brain volume changes in the second year. There were significant positive correlations between 2-year brain volume and all BSID-3 scores and BSID-3 changes from baseline.Conclusions and RelevanceIn sub-Saharan Africa, even after successful surgical treatment of infant post-infectious hydrocephalus, post-treatment brain growth stagnates in the second year. While the reasons for this are unclear, this emphasizes the importance of primary infection prevention strategies along with optimizing the child’s environment to maximize brain growth potential.Trial RegistrationClinicalTrials.gov number, NCT01936272KEY POINTSQuestionWhat is the brain growth and cognitive trajectory of infants treated for post-infectious hydrocephalus in Uganda?FindingsIn this prospective follow-up of a cohort of 89 infants, early normalization of brain volume after treatment was followed by brain growth stagnation in the second year, with many falling back into the sub-normal range. Poor brain growth was associated with poor cognitive outcome.MeaningSuccessful surgical treatment of hydrocephalus is not sufficient to allow for adequate brain growth and cognitive development. Interventions aimed at primary infection prevention and reducing comorbidities are needed to improve brain growth potential.

Assessing the Utility of Low Resolution Brain Imaging: Treatment of Infant Hydrocephalus

“…We focus on the most common form of infant hydrocephalus in sub-Saharan Africa -postinfectious [33]. This form of hydrocephalus is uncommon outside of LMIC [1], and the only abundant high-resolution comparative images are from CT. We developed an image utility assessment which was completed by three senior neurosurgeons with extensive experience in the treatment and management of hydrocephalus in low-resource settings [33][34][35]. Qualitative and quantitative measures of image utility are used to classify images revealing the quality threshold for treatment planning of hydrocephalus in terms of resolution, noise, and contrast between brain and CSF.…”