Neurocognitive outcomes and changes in brain and CSF volume after treatment of post-infectious hydrocephalus in Ugandan infants by shunting or ETV/CPC: a randomized prospective trial

 描述（由申请人提供）：我们估计撒哈拉以南非洲（SSA）每年有250，000名新生儿发生脑积水，最常见的是新生儿感染。大多数人难以获得治疗。我们开发并验证了一种新的手术治疗婴儿脑积水的方法，该方法结合了内窥镜下第三脑室造口术和脉络丛烧灼术（ETV/CPC），避免了大多数情况下的分流依赖。我们之前在乌干达CURE儿童医院（CCHU）的合作工作支持分流术放置和ETV/CPC之间在5年生存率和神经认知发育方面的平衡。ETV/CPC可以防止那些没有紧急分流功能障碍的患者对分流系统的依赖，这是令人信服的，但我们不知道哪种治疗方法可以优化大脑发育。随着人道主义努力，以改善获得照顾妊高征婴儿在SSA前进，我们寻求确认最佳的治疗选择范例。使用CT成像数据，我们发现脑和CSF体积是神经认知结果的重要多变量判别因素。该方法有望作为脑积水治疗疗效的客观指标。从我们的R-21资助的初步数据（1 R21 TW 009612）ETV/CPC与分流术治疗妊高征的随机对照试验（RCT）（ClinicalTrials.gov注册NCT 01936272）显示无重要差异（通过意向治疗或实际接受的治疗）在安全性、有效性或发育结局方面，从而支持研究的完成和在24个月大时最大脑生长期的随访的延长。本R 01旨在实现以下目标：1）进一步发展CCHU作为临床脑积水研究的独立研究中心; 2）检验ETV/CPC治疗妊高征在神经认知发育方面优于或等于分流术的假设; 3）将脑/CSF体积指标与神经认知发育相关联; 4）评估术前脑/CSF体积指标指导治疗选择的实用性。将延长并完成R- 21研究中启动的RCT。在100例所需患者中，迄今为止已入组77例，其中40例随访6个月，无失访。对于所有100例患者，将在术前和术后6个月、12个月和24个月完成CT成像，以进行脑和CSF体积评估。还将在术前以及术后6、12和24个月时使用Bayley婴儿发育量表（BSID-III）完成神经认知评估。神经认知结局将与术前和术后脑/CSF体积和治疗方式相关。脑和CSF体积的变化也将与治疗方式相关。研究的完成将确定这两种治疗之间的发育结果是否存在重要差异。值得注意的是，证明ETV/CPC的优效性或无重要差异将导致选择ETV/CPC作为首选初始治疗。CCHU的研究能力将得到进一步发展。

 DESCRIPTION (provided by applicant): We estimate 250,000 new infants develop hydrocephalus, most commonly following neonatal infection, in sub- Saharan Africa (SSA) each year. Most have poor access to treatment. We have developed and validated a novel operative treatment for infant hydrocephalus combining endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) that avoids shunt dependence in the majority. Our prior collaborative work at CURE Children's Hospital of Uganda (CCHU) supports equipoise between shunt placement and ETV/CPC in regard to 5-year survival and neurocognitive development. That ETV/CPC prevents shunt dependence among those with no urgent access for shunt malfunction is compelling, but we do not know which treatment optimizes brain development. Going forward with humanitarian efforts to improve access to care for PIH infants in SSA, we seek to confirm the optimal treatment selection paradigm. Using data from CT imaging, we have found that both brain and CSF volume are significant multivariate discriminators of neurocognitive outcome. This method is promising as an objective measure of hydrocephalus treatment efficacy. Preliminary data from our R-21 funded (1R21TW009612) randomized controlled trial (RCT) of ETV/CPC vs. shunt for PIH treatment (ClinicalTrials.gov registration NCT01936272) have shown no important differences (either by intention-to-treat or actual treatment received) at this point in regard to safety, efficacy, or developmental outcome, thereby supporting completion of the study and extension of the follow up through the period of maximal brain growth at 24 months of age. This R01 proposes to accomplish the following aims: 1) further develop CCHU as an independent site for clinical hydrocephalus research; 2) test the hypothesis that treatment of PIH by ETV/CPC is better than or equal to shunting in regard to neurocognitive development; 3) correlate brain/CSF volume metrics with neurocognitive development; 4) assess the utility of preoperative brain/CSF volume metrics to guide treatment selection. The RCT initiated in the R- 21 study will be extended and completed. Of 100 required patients, 77 have been enrolled thus far with 6- month follow-up in 40 and none lost to follow-up. For all 100 patients, CT imaging preoperatively and at 6, 12, and 24 months postoperatively will be completed for brain and CSF volumetric assessment. Neurocognitive assessment with the Bayley Scales of Infant Development (BSID-III) will also be completed preoperatively, and at 6, 12, and 24 months post-operatively. Neurocognitive outcome will be correlated with pre- and post- operative brain/CSF volumes and treatment modality. Changes in brain and CSF volumes will also be correlated with treatment modality. Completion of the study will determine whether there is an important difference in developmental outcome between these two treatments. Significantly, demonstrating superiority of ETV/CPC or no important difference will lead to selecting ETV/CPC as the preferred initial treatment. Research capacity at CCHU will be further developed.