ventriculoperitoneal shunt ( vps ) remains the most common treatment for hydrocephalus world over even though it is associated with several short- and long - term complications .
as shunt system continues to evolve over the years to improve the outcome of the procedure ; surgeons have also devised other alternative and safer techniques for the treatment of hydrocephalus . the advent of endoscopes ushered in the endoscopic third ventriculostomy ( etv ) technique and later endoscopic choroid plexus cauterization ( cpc ) as alternatives to shunting for hydrocephalus in 1995 . even then , there had been reported low success rate when used alone in some patients . hence , the recent popularization of combined etv + cpc technique as a relatively safe means of increasing the overall treatment outcome success and avoiding the need for a shunt in infants with hydrocephalus . despite of the recent advances in technology , vps remains the most widely performed procedure for hydrocephalus in infants .
various shunt valve designed have been developed to improve the success rate of shunting for hydrocephalus .
the general trends in developed country are the use of programmable shunt valves . in low - income country like nigeria , however , low cost , fixed pressure shunt valve system is widely used .
this study was undertaken as an audit of infant hydrocephalus management in our institutions where fixed - pressure slit - in spring chhabra ventriculoperitoneal shunt device is traditionally used .
this study included infants ( < 12 months ) with hydrocephalus managed in our neurosurgical division over 3 years .
our institution has a facility for transcranial ultrasound , computed tomographic scan , and magnetic resonant imaging machines .
data were collected retrospectively through review of case files , imaging reports , ward records , operative notes , and follow - up clinic charts .
information on demography , etiology , type and onset of hydrocephalus , treatment offered , complication , and outcome of care were retrieved using a predesigned pro forma .
the main outcome measures were developmental milestones attained for age , complications , and death .
data were entered into 2011 ibm spss ( statistical package for social sciences ) software for windows , version 20 ; armonk , ny ( ibm inc . ) .
fifty - eight infants constituting 76% of a total of 76 patients with hydrocephalus were treated between 2012 and 2014 .
there were 33 males ( 57% ) and 25 females ( 43% ) with male to female ratio of 1.3:1 . age of patient ranged between 3 and 12 months with a median age of 3 months ( standard deviation of 4.2  2 months ) .
the most common age group in this study was 16 months 33 ( 57% ) , while the 712 months age group had the least frequency 9 ( 15% ) [ table 1 ] .
demographic and etiological distribution , cases ( n=58 ) a large proportion had an undetermined cause of their hydrocephalus 18 ( 31% ) . of those with an identifiable congenital cause , the majority was due to chiari ii malformation 14 ( 24% ) while intraventricular hemorrhage ( ivh ) was the most common acquired cause 10 ( 17% ) [ table 1 and figure 1 ] . in general ,
congenital hydrocephalus was more common 40 ( 69% ) than acquired type 18 ( 31% ) [ figures 24 ] .
diagnosis and frequency of occurrence classification of hydrocephalus based on the time of onset typical hydrocephalus neglected congenital hydrocephalus the majority of the patients 27 ( 47% ) had communicating hydrocephalus , whereas noncommunicating type was seen in 17 ( 29% ) .
vps was the neurosurgical treatment offered in most of the cases 53 ( 91% ) , followed by 3 ( 3.4% ) etv , and 2 ( 1.7% ) ventriculosubgaleal ( vsg ) shunt [ figure 5 ] , respectively [ table 2 ] .
( b ) postconversion of ventriculosubgaleal shunt to ventriculoperitoneal shunt type of hydrocephalus , surgical treatment , and complication , cases ( n=58 ) infection was found to be the most common postoperative complication 7 ( 12% ) in this series , followed by distal obstruction 5 ( 8.6% ) while migration of shunt was the least complication experienced by patients 1 ( 1.7% ) .
one of the deaths was due to respiratory arrest in an infant with chiari ii malformation while the other patient was a preterm with ivh .
as at last follow up , most patients 38 ( 65.5% ) were assessed has having satisfactory outcome based on developmental milestones attained for age .
a total of 76 patients with hydrocephalus were treated in our facility in 3 years between january 2012 and december 2014 under review .
poverty , stigmatization , traditional beliefs , and poor awareness of the amenability of hydrocephalus to orthodox medicine remain strong negative factors preventing hospital presentation in sub - sahara africa . on the other hand ,
approximately 69,000 annual hospital admissions for hydrocephalus were recorded in the united states where awareness and access to health care are much better .
this series recorded a slight male preponderance in the incidence of hydrocephalus [ table 1 ] with a male to female ratio of 1.3:1 which is similar to the reports in other parts of nigeria and america .
hydrocephalus is predominantly a disease of infants ; hence , the age range of 312 months with a median age of 3 months found in these studies .
the most common age group in this study was 16 months 33 ( 57% ) , the cranial sutures are yet to fuse at this early age and pressure created by accumulation of cerebrospinal fluid ( csf ) in the ventricles causes a back pressure effect on the cranium , widening the sutures , and expanding the head circumference ( mega cranium ) ; a feature pathognomonic of hydrocephalus in childhood .
chiari ii malformation in infants with lumbosacral myelomeningocele was the most common cause of hydrocephalus , followed by ivh in these infants [ table 1 and figure 1 ] .
this is a reversal of the etiological pattern reported by kulkarni et al . where ivh was the most common , followed by aqueductal stenosis . in our series
, however , the precise cause of the disease could not be determined in a significant number of cases 19 ( 32.7% ) .
this is mostly due to financial constraints , which limited imaging and other necessary investigations that could have been done to confirm the diagnosis . in nigeria ,
national insurance scheme is yet to cover all citizens , especially the informal sector and the rural dwellers . hence , hospital bills are settled out of pocket with individual patient taking full responsibility for his or her hospital bills . for the same reason
, indigent parents generally find it difficult to finance the care of their sick child [ figure 4 ] . besides , hospital is usually the last point of call after exhausting their meager resources - seeking alternative healthcare at traditional homes and faith healing homes .
in general , congenital hydrocephalus was more common than acquired type , and the majority of patients had communicating hydrocephalus , [ figure 2 ] .
vps was the neurosurgical treatment offered in most of the cases 53 ( 91% ) , followed by 3 ( 3.4% ) etv , and 2 ( 1.7% ) vsg , respectively [ table 2 ] .
endoscopic procedure is a relatively new technique in our practice , the 3 patients who had etv had good outcome without complications .
good outcome from etv among childhood hydrocephalus has been previously reported in nigeria and other part of the world .
there are on - going controversies on the efficacy of etv in infant hydrocephalus management . a retrospective ,
multicenter north american study has suggested etv + cpc as a relatively safe procedure with improve treatment success . in nigeria ,
a success rate of 75% has been reported with etv + cpc in childhood hydrocephalus .
our unit practice is likely to move toward etv as preferred procedure in suitable infants following this audit .
vsg procedure was undertaken for 3 of our patients with ivh as a temporizing measure .
all of these were subsequently converted to vps when the csf became clear [ figure 5 ] .
infection was found to be the most common postoperative complication 7 ( 12% ) , in this series , followed by distal obstruction 5 ( 8.6% ) while migration of shunt was the least complication experienced by 1 patient ( 1.7% ) .
the prevalence of infection ( 12% ) record in this study falls within the variable rates of 2.2%39% reported in earlier studies . and
it tallies with the overall infection rate of 11.7% reported by simon et al . in a study of over 7000 children after
even though it is higher than 6.98% observed by wu et al . in a similar study in china .
's study were done before the advent of antibiotics impregnated shunts which explain why the infection rate was close to our findings . aside from type of shunt implanted , other predisposing factors to shunt infection include age of patients at shunt insertion , cause of hydrocephalus and perioperative antibiotics , operative room traffic , duration of the shunt placement operation , experience of the neurosurgeon , and cause of hydrocephalus .
further studies of the role of these variables in etiology of shunt infections will be a valuable future research direction .
double gloving , prophylactic antibiotics , shunt impregnated with antibiotics usually rifampicin and clindamycin are reported to reduce shunt infections .
most commonly implicated organisms in shunt - associated infections are coagulase - negative staphylococcus and staphylococcus aureus and other skin bacteria followed by gram - negative bacteria .
there is need to improve surgical intervention in the form of etv in suitable patients . subsidizing cost of care
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
 background : hydrocephalus is a leading cause of disability among children worldwide . the outcome depends on morphology and whether insult is pre- or post - natal . 
 there has been improvement in morbidity in developed countries due to improved surgical care . a paucity of trained personnel impacts negatively on care and outcome of infants with hydrocephalus in many low - income countries resulting poorer outcome . 
 we conducted an audit of patients with hydrocephalus managed in our institution to determine common etiology and outcome.object:the objective of this retrospective review was to conduct an audit of hydrocephalus care in our institution.materials and methods : information was retrieved from case notes , ward records , imaging results , operation notes , and follow - up clinic charts . 
 type of hydrocephalus , onset , treatment offered , outcome , complications , and follow - up duration were documented.results:management of 58 infants with complete data was analyzed . 
 most hydrocephalus 40 ( 69% ) were congenital with 14 ( 35% ) occurring in association with myelomeningocele and 8 patients confirmed with aqueductal stenosis . 
 ventriculoperitoneal shunts insertion 53 ( 91% ) was the most common treatment modality.conclusions:there is need to improve surgical intervention in the form of endoscopic third ventriculostomy in suitable patients . 
 subsiding cost of care may be considered for indigent patients . 
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