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

Abstract

IntroductionManaging paediatric hydrocephalus with shunt placement is especially risky in resource-limited settings due to risks of infection and delayed life-threatening shunt obstruction. This study evaluated a new evidence-based treatment algorithm to reduce shunt-dependence in this context.MethodsA prospective cohort design was used. The CURE Protocol employs preoperative and intraoperative data to choose between endoscopic treatment and shunt placement. Data were prospectively collected for 730 children in Uganda (managed by local neurosurgeons highly experienced in the protocol) and, for external validation, 96 children in Nigeria (managed by a local neurosurgeon trained in the protocol).ResultsThe age distribution was similar between Uganda and Nigeria, but there were more cases of postinfectious hydrocephalus in Uganda (64.2% vs 26.0%, p<0.001). Initial treatment of hydrocephalus was similar at both centres and included either a shunt at first operation or endoscopic management without a shunt. The Nigerian cohort had a higher failure rate for endoscopic cases (adjusted HR 2.5 (95% CI 1.6 to 4.0), p<0.001), but not for shunt cases (adjusted HR 1.3 (0.5 to 3.0), p=0.6). Despite the difference in endoscopic failure rates, a similar proportion of the entire cohort was successfully treated without need for shunt at 6 months (55.2% in Nigeria vs 53.4% in Uganda, p=0.74).ConclusionUse of the CURE Protocol in two centres with different populations and surgeon experience yielded similar 6-month results, with over half of all children remaining shunt-free. Where feasible, this could represent a better public health strategy in low-resource settings than primary shunt placement.

Endoscopic Third Ventriculostomy with Choroid Plexus Cauterization in Infantile Hydrocephalus: An Experience from Mali

“…Systematic coagulation of the choroid plexus was performed to increase the success of ETV as reported in the literature [5]. Our success rate of 47% was adversely affected by the predominance of the youngest age group (1st group, less than 3 months) and by our not shunting those found to have significant cisternal scarring at the time of the ETV, as in the prospective studies from Nigeria and Uganda reported by Lepard et al [4]. Nonetheless, similar to their results, we were able to successfully avoid shunt dependence in nearly half of all infants presenting with hydrocephalus at less than 1 year of age by employing ETV/CPC as the preferred treatment, including all etiologies, those with a cisternal scar, and those under the age of 3 months.…”

“…A retrospective study analyzed the outcome of hydrocephalus children aged under 12 months old who underwent ETV/CPC between July 2013 and January 2015 in Bamako, Mali, according to the CURE protocol as recently published by Lepard and coauthors (Table 1) [4]. One important difference from their protocol was that a shunt was not automatically placed when a scarred prepontine cistern was encountered at the time of the ETV, but rather, the procedure was given a chance to work.…”

Global neurosurgery over a 60-year period: Conceptual foundations, time reference, emerging Co-ordinates and prospects for collaborative interventions in low and middle income countries

“…Egypt, Brazil and Morocco and Uganda are salient examples- Fig. 3 ( Lepard et al., 2020 ). The transition of these nations from recipients to facilitators represents a salient success story for global neurosurgery and an encouragement for more global collaborations between HNRC and LNRC.…”

“…Following the success of the Cure International Hydrocephalus Program in Uganda, It has become a reference center for post residency fellowship in pediatric neurosurgery specifically for competency training in Endoscopic Third Ventriculostomy and Choroid Plexus Cauterization around the world. ( Lepard et al., 2020 , Warf, 2005 , Warf and Campbell, 2008 ) In this instance the role of a facilitator represents an upward migration of resource and activity profile. Observation in our model represents a search or readiness to collaborate across profiles of resource strength.…”

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

“…1 A dominant contributor appears to be post-infectious hydrocephalus following neonatal sepsis. 2,3 Surgical treatment of hydrocephalus in this setting has proven to be safe 4 and with a favorable benefit-cost ratio. 5 A recent US National Institutes of Health-funded randomized trial in Uganda has shown that the two available treatment options – ventriculoperitoneal shunt (VPS) 6,7 and the newer endoscopic third ventriculostomy combined with choroid plexus cauterization (ETV/CPC) 8–13 – are both able to relieve symptoms and allow the brain to grow at 1 year after treatment, often regaining normal size.…”