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Essossinam Kpélao, Kodjo M. Hobli Ahanogbé, Komi Egu, Agbéko K Doléagbénou, Abd El Kader Moumouni, Senamé Sossoukpe, Kossi K. Ségbédji, H. EssoSolim Bakondé, Dzidoula Lawson, Bawoubadi Abaltou, Hima-Maïga Abdoulaye, Katanga A. Békéti
  1. Neurosurgery Unit, Essossinam KPELAO, CHU SO, Lomé, Togo.

Correspondence Address:
Essossinam Kpélao, Neurosurgery Unit, CHU SO, Lomé, Togo.

DOI:10.25259/SNI_927_2022

Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Essossinam Kpélao, Kodjo M. Hobli Ahanogbé, Komi Egu, Agbéko K Doléagbénou, Abd El Kader Moumouni, Senamé Sossoukpe, Kossi K. Ségbédji, H. EssoSolim Bakondé, Dzidoula Lawson, Bawoubadi Abaltou, Hima-Maïga Abdoulaye, Katanga A. Békéti. Children hydrocephalus in Togo: etiologies, treatment, and outcomes. 02-Dec-2022;13:560

How to cite this URL: Essossinam Kpélao, Kodjo M. Hobli Ahanogbé, Komi Egu, Agbéko K Doléagbénou, Abd El Kader Moumouni, Senamé Sossoukpe, Kossi K. Ségbédji, H. EssoSolim Bakondé, Dzidoula Lawson, Bawoubadi Abaltou, Hima-Maïga Abdoulaye, Katanga A. Békéti. Children hydrocephalus in Togo: etiologies, treatment, and outcomes. 02-Dec-2022;13:560. Available from: https://surgicalneurologyint.com/surgicalint-articles/12040/

Date of Submission
08-Oct-2022

Date of Acceptance
16-Nov-2022

Date of Web Publication
02-Dec-2022

Abstract

Background: Hydrocephalus is frequent in sub-Saharan African countries. The postinfectious hydrocephalus tends to decrease. The objective of this study was to identify the etiologies and outcomes of hydrocephalus.

Methods: This was a retrospective study of hydrocephalus cases (0–15 years old) treated in the neurosurgery unit of the Sylvanus Olympio Hospital in Lomé over 10 years (2012–2021). At 1 year, the evolution distinguished in two categories: (1) Good psychomotor development: no delay in the acquisition of walking, language, and school. (2) Psychomotor delay: delay in the acquisition of walking, language, and school.

Results: We reported 305 children treated for hydrocephalus representing 1.8% of all neurosurgery unit patients and 34.2% of pediatric pathologies. There was a male predominance (60.6%). We noted second degree consanguinity in 8.5%. The positive maternal serologies were HIV (12.4%), syphilis (8.2%), and toxoplasmosis (2.6%). A malaria episode had been treated during the first trimester in 36.7% of the mothers. The main clinical sign of hydrocephalus was 91.5% of Macrocephalus. Congenital Malformafions were the most common etiologies of hydrocephalus (68.5%). Ventriculoperitoneal shunt was the main surgical method used and 16 deaths were recorded. The medium-term evolution (1 year) was evaluated in 36.1% and noted 61.8% of psychomotor retardation.

Conclusion: This study confirms the trend of the predominance of congenital causes of hydrocephalus in Africa, even if maternal infections can be involved in the development of some of them. The morbimortality of this pathology remains important, especially concerning neurocognitive outcomes.

Keywords: Etiologies, Hydrocephalus in children, Togo

INTRODUCTION

Hydrocephalus is active dilation of ventricles.[ 9 ] It is an important health problem in most subSaharan African countries.[ 1 , 3 , 4 , 8 , 16 , 24 ] If in developed countries, the malformative causes are leading, postinfectious hydrocephalus was predominant in underdeveloped countries. This predominance nevertheless tends to decrease in our current practice due to a large campaign of vaccination making most vaccines accessible to populations. In Togo, management was for a long time exclusively shunt but with acquiring of endoscope, we have an additional method. The objective of this study was to identify the etiologies of hydrocephalus in our country for possible preventive action and also to report the results of their management.

MATERIALS AND METHODS

This was a retrospective study of hydrocephalus cases (0–15 years old) treated in the neurosurgery unit of the Sylvanus Olympio Hospital in Lomé over 10 years (2012–2021). The results were assessed at discharge and 1 year later. The postoperative parameters evaluated were complicated, the neurological disabilities and the psychomotor development were distinguished in two categories: (1) Good psychomotor development: no delay in the acquisition of walking, language, and school. (2) Psychomotor delay: delay in the acquisition of walking, language, and school.

RESULTS

A total of 305 children were treated for hydrocephalus representing 1.8% of all neurosurgery unit patients and 34.2% of pediatric pathologies. Infants were the most age range represented (88.2%). Antenatal diagnosis was made in 11 cases (3.6%). There was a male predominance of 60.6%.

The parents of children affected were mainly poor (87.2%) according to the UN definition. The average age of the mothers was 23.7 years. Their main antecedents were occasional alcoholism (52.4%), high blood tension (3.9%), diabetes (2%), and 29.2% were in single mothers. We noted second degree consanguinity in 8.5%. Pregnancy was well monitored with malaria and anemic prophylaxis in 90.8%. The positive maternal serologies were HIV (12.4%), syphilis (8.2%), and toxoplasmosis (2.6%). A malaria episode had been treated during the 1st trimester in 36.7% of the mothers. The antenatal diagnosis of hydrocephalus was made during the 3rd trimester ultrasound in 33 cases (10.8%) and 4.9% were premature.

The main clinical sign of hydrocephalus was macrocephalus (91.5%). The macrocephalus was present in 34.4% at birth (head circumference >35 cm). The average of head circumference was 56.9 cm. The average consultation time after birth was 4.7 months, with psychomotor retardation in 23.6% [ Table 1 ]. Cerebral CT was honored in 96.1% with a predominance of tetra ventricular hydrocephalus (63.3%). There were 2.6% in hydranencephaly. Spina bifida (myelomeningocele) was associated to hydrocephalus in 17.4%. Malformative etiologies of hydrocephalus predominant are shown in [ Table 2 ]. Ventriculoperitoneal shunt was the main surgical method used [ Table 3 ]. The average age at the intervention was 5.2 months.


Table 1:

Clinical signs of children at admission.

 

Table 2:

Etiologies of hydrocephalus. Number (n) Percentage (%) Malformativea

 

Table 3:

Therapeutic modalities. Number (n)

 

The immediate postoperative outcomes were simple in 75.4%. The main complications recorded were hyperthermia (4.3%), pressure sores (2.3%), and over drainage (3.3%). We recorded 16 deaths (staphylococcal meningitis, ventriculitis, and sepsis). During the period of study, we had 11 valve malfunctions with shunt revision (5.6% of 267 shunts)

The medium-term evolution (1 year) was evaluated in 36.1%. The results at this term are summarized in Table 4 .


Table 4:

Outcomes at 1 year concerning 110 patients (36.1%).

 

The retardation, especially walking, affected mostly congenital hydrocephalus (malformative). Among eight hydranencephaly, only two were shown up at control. The normal neurocognition evolution concerned secondary hydrocephalus and three malformative hydrocephalus. Cranium sizes according age were normal in 21 after 1 year.

DISCUSSION

Hydrocephalus is the main pathology in pediatric neurosurgery. Our frequency does not reflect the reality because it is not all patients who are consulting. Indeed because of farness and poverty, a lot of rural population do not have access to medical facilities as reported also in another countries.[ 16 , 24 ] Furthermore, we noted a diagnosis delay illustrated, for example, by prenatal diagnosis which is relatively low regarding the number of obstetrical ultrasounds performed during pregnancies. Some authors even reported no antenatal diagnosis.[ 15 ] According to the etiologies, it is classic to distinguish two types of hydrocephalus: congenital and secondary even there is a pathway between them. Hydrocephalus without an obvious extrinsic cause is usually referred to as congenital hydrocephalus, since it is often present at birth. When hydrocephalus occurs as a complication of another condition such as hemorrhage, infection, or neoplasm, it is usually called acquired or secondary hydrocephalus. However, forces such as hemorrhage and infection can act prenatally and also cause “congenital” hydrocephalus.[ 21 ]

In fact, maternal factors have a major role in development of hydrocephalus, such as stress, diabetes, alcohol, first-trimester infection, drug, and malnutrition.[ 20 ] We suspected without formal proof of malaria, diabetes, syphilis, and toxoplasmosis as being potentially responsible of some congenital hydrocephalus without neglecting genetic factors through as inbreeding we found in our series.[ 17 , 18 , 22 ] We clinically evoked a Bicker-Adam syndrome in two cases without confirmation. The most syndrome frequently seen in practice is Dandy Walker, which is common cause of congenital hydrocephalus.[ 12 , 19 ] Previously, in Africa, the postinfectious etiology was predominant.[ 14 , 25 ] However, this predominance tends to decrease, as like in developed countries.[ 1 , 15 , 26 ] This trend is confirmed in our study with only 16.4% of postinfectious etiology against 68.5% for congenital causes.

Then, the prevention of hydrocephalus for modifiable causes involves early treatment of infections in pregnant women, perinatal supplementation with folic acid, and the fight against poverty.

Although postoperative mortality is low (5.2%), the main problem is morbidity especially the cognitive deficiency. Neurocognitive deficits are well reported in children with hydrocephalous. Numerous factors such as etiology, age at onset, raised intracranial pressure, the rate of ventricular enlargement, ventricular size, the duration of hydrocephalus, coexisting pathological changes, and shunt complications have been shown to influence cognitive function.[ 11 , 23 , 27 ]

Neurocognitive outcome was better in secondary hydrocephalus when the cause was treated, opposite to congenital hydrocephalus with a high rate of psychomotor retardation. This fact can be explained by the early onset in congenital hydrocephalus and especially by the associated brain lesions.[ 7 ] Aside these endogenous factors, we can notice also the diagnostic delay common in Africa. Indeed, time is crucial for psychomotor development: early diagnosis and treatment may reduce residual neuronal degeneration. Despite the small patients seen in control after one year, the high percentage of psychomotor retardation (61.8%) gave an idea about significant morbidity of infantile hydrocephalus. This rate would probably be higher if all patients had been seen; as well as long-term mortality. This high rate of outpatient control of no attendance is explained first by medical facilities farness for patients, who are mainly rural but by the minimization of those appointment by parents either for economic reasons or discouragement due to absence of substantial psychomotor improvement expected. A feeling of fatality or reorientation toward traditional medicine then sets in. The management of hydranencephaly raised ethical problems. There is debate between abstinence and surgical treatment; therefore, indications are mainly individual.[ 2 , 5 , 6 , 10 , 13 ] In our practice, we are doing shunt firstly to treat the macrocephalus.

CONCLUSION

This study confirms the trend of the predominance of congenital causes of hydrocephalus in Africa, even if maternal infections can be involved in the development of some of them. The diagnosis remains late. Most patients are treated by shunt despite the availability of endoscopic ventriculocisternostomy. The morbimortality of this pathology remains important, especially concerning neurocognitive outcomes.

Declaration of patient consent

Patients’ consent not required as patients’ identities were not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Ba MC, Kpélao E, Thioub M, Kouara M, Thiam AB, Ndoye N. Post meningitic hydrocephalus of the infant in Dakar. Afr J Neurol Sci. 2012. 31: 8-14

2. Bae JS, Jang MU, Park SS. Prolonged survival to adulthood of an individual with hydranencephaly. Clin Neurol Neurosurg. 2008. 110: 307-9

3. Bauman N, Poenaru D. Hydrocephalus in Africa : A surgical perspective. Ann Afr Surg. 2008. 2: 30-7

4. Broalet MY, N’dri Oka D, Konan L, Diakité I, Konan S, Ba Zézé V. Childhood hydrocephalus: experience of a West African hospital. Neurochirurgie. 2011. 57: 264

5. Cecchetto G, Milanese L, Giordano R, Viero A, Suma V, Manara R. Looking at the missing brain: Hydranencephaly case series and literature review. Pediatr Neurol. 2013. 48: 152-8

6. Covington C, Taylor H, Gill C, Padaliya B, Newman W, Smart JR, Charles PD. Prolonged survival in hydranencephaly: A case report. Tenn Med. 2003. 96: 423-4

7. Dhandapani M, Yagnick NS, Mohanty M, Ahuja CK, Dhandapani S. Clinical outcome, cognitive function, and quality of life after endoscopic third ventriculostomy versus ventriculo-peritoneal shunt in non-tumor hydrocephalus. Neurol India. 2021. 69: S556-60

8. Fatigba OH, Noudamadjo A, Allode SA, Savi de Tové KM, Ayivi B. Etiologic and prognosis factors of non tumoral pediatric hydrocephalus at departmental teaching hospital of Borgou (Bénin). Rev CAMES. 2011. 12: 18-21

9. Guidetti B, Giuffrè R, Palma L, Fontana M. Hydrocephalus in infancy and childhood our experience of CSF shunting. Childs Brain. 1976. 2: 209-25

10. Hodé L, Gandaho HJ, Yekpe FP, Alihonou T, Houessou GF, Hadonou AA. Hydranencephaly at Cotonou: 3 cases reports. AJNS. 2013. 32: 65-71

11. Mataró M, Junqué C, Poca MA, Sahuquillo J. Neuropsychological findings in congenital and acquired childhood hydrocephalus. Neuropsychol Rev. 2001. 11: 169-78

12. Mohanty A, Biswas A, Satish S, Praharaj SS, Sastry KV. Treatment options for dandy-walker malformation. J Neurosurg. 2006. 105: 348-56

13. Pant S, Kaur G, De JK. Hydranencephaly. Kathmandu Univ Med J (KUMJ). 2010. 8: 83-6

14. Peacock WJ, Currer TH. Hydrocephalus in childhood: A study of 440 cases. S Afr Med J. 1984. 66: 323-4

15. Salem-Memou S, Chavey S, Elmoustapha H, Mamoune A, Moctar A, Salihy S. Hydrocephalus in newborns and infants at the Nouakchott National Hospital. Pan Afr Med J. 2020. 36: 184

16. Salvador SF, Henriques JC, Munguambe M, Vaz RM, Barros HP. Hydrocephalus in children less than 1 year of age in northern Mozambique. Surg Neurol Int. 2014. 5: 175

17. Schrander-Stumpel C, Fryns JP. Congenital hydrocephalus: Nosology and guidelines for clinical approach and genetic counselling. Eur J Pediatr. 1998. 157: 355-62

18. Simeone RM, Rasmussen SA, Mei JV, Dollard SC, Frias JL, Shaw GM. A pilot study using residual newborn dried blood spots to assess the potential role of cytomegalovirus and Toxoplasma gondii in the etiology of congenital hydrocephalus. Birth Defects Res A Clin Mol Teratol. 2013. 97: 431-6

19. Spennato P, Mirone G, Nastro A, Buonocore MC, Ruggiero C, Trischitta V. Hydrocephalus in Dandy-Walker malformation. Childs Nerv Syst. 2011. 27: 1665-81

20. Tully HM, Capote RT, Saltzman BS. Maternal and infant factors associated with infancy-onset hydrocephalus in Washington State. Pediatr Neurol. 2015. 52: 320-5

21. Tully HM, Dobyns WB. Infantile hydrocephalus: A review of epidemiology, classification and causes. Eur J Med Genet. 2014. 57: 359-68

22. Verhagen JM, Schrander-Stumpel CT, Krapels IP, de DieSmulders CE, van Lint FH, Willekes C. Congenital hydrocephalus in clinical practice: A genetic diagnostic approach. Eur J Med Genet. 2011. 54: e542-7

23. Warf B, Ondoma S, Kulkarni A, Donnelly R, Ampeire M, Akona J. Neurocognitive outcome and ventricular volume in children with myelomeningocele treated for hydrocephalus in uganda. J Neurosurg Pediatr. 2009. 4: 564-70

24. Warf BC. Pediatric hydrocephalus in East Africa: Prevalence, causes, treatments, and strategies for the future. World Neurosurg. 2010. 73: 296-300

25. Warf BC. Hydrocephalus in Uganda: The predominance of infectious origin and primary management with endoscopic third ventriculostomy. J Neurosurg. 2005. 102: 1-15

26. Zabsonré DS, Ouattara O, Dao I, Sanou A, Yameogo WS, Kabré A. Etiologies of hydrocephalus among children at the Yalgado ouedraogo University Hospital (YO-CHU) of Burkina Faso. AJNS. 2021. 40: 12-7

27. Zielińska D, Rajtar-Zembaty A, Starowicz-Filip A. Cognitive disorders in children’s hydrocephalus. Neurol Neurochir Pol. 2017. 51: 234-9

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