Preoperative risk and postoperative outcome from subdural fluid collections in African infants with postinfectious hydrocephalus.

This study investigated the incidence of postoperative subdural collections in a cohort of African infants with postinfectious hydrocephalus. The authors sought to identify preoperative factors associated with increased risk of development of subdural collections and to characterize associations between subdural collections and postoperative outcomes. The study was a post hoc analysis of a randomized controlled trial at a single center in Mbale, Uganda, involving infants (age < 180 days) with postinfectious hydrocephalus randomized to receive either an endoscopic third ventriculostomy plus choroid plexus cauterization or a ventriculoperitoneal shunt. Patients underwent assessment with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III; sometimes referred to as BSID-III) and CT scans preoperatively and then at 6, 12, and 24 months postoperatively. Volumes of brain, CSF, and subdural fluid were calculated, and z-scores from the median were determined from normative curves for CSF accumulation and brain growth. Linear and logistic regression models were used to characterize the association between preoperative CSF volume and the postoperative presence and size of subdural collection 6 and 12 months after surgery. Linear regression and smoothing spline ANOVA were used to describe the relationship between subdural fluid volume and cognitive scores. Causal mediation analysis distinguished between the direct and indirect effects of the presence of a subdural collection on cognitive scores. Subdural collections were more common in shunt-treated patients and those with larger preoperative CSF volumes. Subdural fluid volumes were linearly related to preoperative CSF volumes. In terms of outcomes, the Bayley-III cognitive score was linearly related to subdural fluid volume. The distribution of cognitive scores was significantly different for patients with and those without subdural collections from 11 to 24 months of age. The presence of a subdural collection was associated with lower cognitive scores and smaller brain volume 12 months after surgery. Causal mediation analysis demonstrated evidence supporting both a direct (76%) and indirect (24%) effect (through brain volume) of subdural collections on cognitive scores. Larger preoperative CSF volume and shunt surgery were found to be risk factors for postoperative subdural collection. The size and presence of a subdural collection were negatively associated with cognitive outcomes and brain volume 12 months after surgery. These results have suggested that preoperative CSF volumes could be used for risk stratification for treatment decision-making and that future clinical trials of alternative shunt technologies to reduce overdrainage should be considered. NCT01936272 (clinicaltrials.gov)

本研究调查了一组患有感染后脑积水的非洲婴儿术后硬膜下积液的发生率。作者试图确定与硬膜下积液发生风险增加相关的术前因素，并描述硬膜下积液与术后结果之间的关联。 该研究是对乌干达姆巴莱一个中心的一项随机对照试验的事后分析，涉及患有感染后脑积水的婴儿（年龄<180天），这些婴儿被随机分配接受内镜下第三脑室造瘘术加脉络丛烧灼术或脑室腹腔分流术。患者在术前以及术后6个月、12个月和24个月时接受贝利婴幼儿发展量表第三版（Bayley - III；有时也称为BSID - III）评估和CT扫描。计算了脑、脑脊液和硬膜下液的体积，并根据脑脊液积聚和脑生长的标准曲线确定了中位数的z分数。使用线性和逻辑回归模型来描述术前脑脊液体积与术后6个月和12个月硬膜下积液的存在及大小之间的关联。使用线性回归和平滑样条方差分析来描述硬膜下液体积与认知评分之间的关系。因果中介分析区分了硬膜下积液的存在对认知评分的直接和间接影响。 硬膜下积液在接受分流术治疗的患者以及术前脑脊液体积较大的患者中更为常见。硬膜下液体积与术前脑脊液体积呈线性相关。在结果方面，Bayley - III认知评分与硬膜下液体积呈线性相关。在11至24个月龄时，有硬膜下积液的患者和无硬膜下积液的患者的认知评分分布存在显著差异。硬膜下积液的存在与术后12个月较低的认知评分和较小的脑体积相关。因果中介分析证明了有证据支持硬膜下积液对认知评分既有直接影响（76%）又有间接影响（通过脑体积，24%）。 发现较大的术前脑脊液体积和分流手术是术后硬膜下积液的危险因素。硬膜下积液的大小和存在与术后12个月的认知结果和脑体积呈负相关。这些结果表明，术前脑脊液体积可用于治疗决策的风险分层，并且应考虑未来对替代分流技术进行临床试验以减少过度引流。 NCT01936272（clinicaltrials.gov）