43 - Risk Factors for Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization (ETV/CPC) Failure In Ugandan Infants with Hydrocephalus

Publication Number: 1036.43

Marcia H. Yoshikawa, Boston Children's Hospital, Boston, MA, United States; Rutvi Vyas, Boston Children's Hospital, Boston, MA, United States; Miriah Kemigisha, CURE CHILDREN'S HOSPITAL OF UGANDA, mbale, Mbale, Uganda; Starlin Tindimwebwa, CURE CHILDRENS HOSPITAL MBALE, JINJA, Jinja, Uganda; Davis Natukwatsa, Cure Children's Hospital of Uganda, Mbale, Mbale, Uganda; Marvin Seruwu, Cure children's hospital of Uganda, Mbale, Mbale, Uganda; Moses Wabukoma, CURE Children's Hospital of Uganda, Mbale, Mbale, Uganda; Collins Akugizibwe, CURE Children's Hospital of Uganda, Mbale, Mbale, Uganda; Joshua Jayz. Magombe, NeuroKids.org, Kampala, Kampala, Uganda; Enock Kainja, Cure children's hospital of Uganda, mbale, Mbale, Uganda; Esther Nalule, Cure Children's Hospital of Uganda, Mbale, Mbale, Uganda; Simeo Ochieng, CURE Hospital, GOMA, Mukono, Uganda; Astrid G. Zazueta, Boston Children's Hospital, Boston, MA, United States; Julia Tatz, Boston Children's Hospital, Brookline, MA, United States; German Figueroa, Boston Children's Hospital, Somerville, MA, United States; Ronald Mulondo, Yale School of Medicine, New haven, CT, United States; Brian K. Nsubuga, Neurokids, Mbale, Mbale, Uganda; Humphrey Okechi, CURE Children's Hospital of Uganda, Mbale, Mbale, Uganda; Emmanuel Wegoye, CURE children's Hospital Uganda., Mbale, Mbale, Uganda; Steven J. Schiff, Yale School of Medicine, New Haven, CT, United States; Henry A.. Feldman, Boston Children's Hospital, Boston, MA, United States; Jennifer T. Queally, Boston Children's Hospital, Boston, MA, United States; P. Ellen grant, Boston Children's Hospital, Boston, MA, United States; Benjamin C.. warf, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Edith M. Kabachelor, Yale School of Medicine, New Haven, CT, United States; Sutin Jason, Boston Children's Hospital, Boston, MA, United States; Pei-Yi Lin, Boston Children's Hospital, Cambridge, MA, United States

Background: Infant hydrocephalus is a major global health issue, with 80% of cases in low- and middle-income countries. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) is the only shunt alternative proven equally effective for neurodevelopment and offers survival advantages where neurosurgical access is limited. However, ETV/CPC fails in 40% of patients. Age at surgery, prior temporary shunting, and ventricular size are established risk factors, but other predictors remain underinvestigated.

Objective: To identify risk factors for ETV/CPC failure in Ugandan infants with hydrocephalus.

Design/Methods: This prospective cohort (NCT03650101) enrolled infants < 6 months undergoing ETV/CPC. Preoperative assessments included clinical data, CT imaging for brain parenchyma and CSF volumes (BPV, CSFV), and Transcranial Doppler (TCD) of the anterior cerebral artery (ACA). CSF-corrected weight was calculated by subtracting excess intracranial CSFV from body weight. All measurements were converted to age- and sex-matched z-scores (ZS). ETV/CPC failure was defined as need for reoperation or hydrocephalus-related death. Univariate and multivariable Cox regression identified predictors of failure. Variables significantly associated with the outcome in the univariate analysis were adjusted for known risk factors. Those remaining significant after adjustment were then included in the final multivariable model.

Results: Of 300 enrolled patients, 238 (89F/149M; median[IQR] age: 77.5[80] days) underwent ETV/CPC with median follow-up of 21.1 months. Seventy-eight (32.7%) experienced ETV/CPC failure, with 97% (n=76) occurring within the first year. Univariate analysis identified age, CSFV ZS, CSF-corrected weight ZS, and TCD flow velocities as significantly associated with failure (Table1). Multivariable analysis revealed higher preoperative CSFV ZS (HR 1.16, p=0.003) and lower CSF-corrected weight ZS (HR 0.87, p=0.02) as independent predictors of ETV/CPC failure (Table2). Lower ACA diastolic flow velocity and younger age at surgery became insignificant in the multivariable analysis due to moderate correlation between the two variables (r=0.44, p< 0.001; Figure1).

Conclusion(s): This is the first report of lower CSF-corrected weight as an independent risk factor for ETV/CPC failure in Ugandan infants. These findings suggest that comprehensive preoperative assessment including nutritional status is critical for improving ETV/CPC outcomes in resource-limited settings.

Table 1. Univariate Cox proportional hazards regression analysis for surgical failure
Continuous variables presented as median [IQR]. Categorical variables presented as n (%). ETV/CPC: Endoscopic third ventriculostomy with choroid plexus cauterization, VSGS: ventriculosubgaleal shunt, CSF: cerebrospinal fluid, BPV: brain parenchymal volume, ACA: anterior cerebral artery, WFL: weight-for-length.

Table 2. Multivariable Cox proportional hazards regression analysis for surgical failure
Continuous variables presented as median [IQR]. ETV/CPC: Endoscopic third ventriculostomy with choroid plexus cauterization, CSF: cerebrospinal fluid, BPV: brain parenchymal volume, ACA: anterior cerebral artery.

Figure 1. Spearman correlation between diastolic flow velocity and age.
ACA: anterior cerebral artery; ETV/CPC: Endoscopic third ventriculostomy with choroid plexus cauterization.