Psychomotor Performance in Children Operated for Hydrocephalus: About 79 Cases

Case Report

Austin J Pediatr. 2015; 2(2): 1024.

Psychomotor Performance in Children Operated for Hydrocephalus: About 79 Cases

Gandaho HJ1,2*, Alao MJ3, Houinsou-Hans I2, Alassane L2, Djrolo G2, Hans Moevi AA2, Kpadonou T4 and Koumakpayi Adeoti S3

1Department of Neurosurgery, Military Teaching Hospital, Cotonou, Benin Republic

2Department of Traumatology, Orthopedics and Reconstructive Surgery, University Hospital CNHUHKM, Cotonou, Benin Republic

3Department of Pediatrics and Medical Genetics, University Hospital CNHU-HKM, Cotonou, Benin, CNHU-HKM, Cotonou, Benin Republic

4Department of physical medicine and rehabilitation, University Hospital CNHU-HKM, Cotonou, Benin Republic *

*Corresponding author:Hugues J Gandaho, Department of Neurosurgery, Military Teaching Hospital, Cotonou, Benin Republic

Received: November 23, 2015; Accepted: December 02, 2015; Published: December 04, 2015

Abstract

Introduction: Ventricle enlargement is characteristic of hydrocephalus and responsible of brain compression including ischemic disorders and alterations of the myelinisation. Delayed management of children hydrocephalus could induce definitive psychomotor impairment. Our aim was to assess children that have been operated for hydrocephalus in psychomotor field before and after operation.

Patients and Methods: It was a retrospective, cross sectional and analytical survey. The study was conducted on children operated from 2003 through 2009. These children were reevaluated in 2013. Sometimes, clinical data were obtained from their parents or relatives. The Denver test was used for final neurological evaluation.

Results: From 2003 through 2009, 357 children were managed for hydrocephalus. Seventy nine cases were included for this study. In 35 cases (44.33%) families’ monthly incomes were below the minimum salary fixed by the government. Prior to surgical procedure, 57.2% of these children had macrocrania (>3 SD). Only three children (3.79%) underwent surgery within one month after admission. With a medium follow up of 7.8 years, 41 of operated children (51.9%) are still alive and 19 (24.05%) were symptomatic psychomotor delay were identified in 18 cases, whereas major functions impairments were present in 14 cases. Twenty three (56.1%) were attending schools.

Conclusion: In this report, difficulties in management of children with hydrocephalus could be responsible of psychomotor impairments. More effort must be done regarding the initial evaluation, surgical management and social integration.

Keywords: Hydrocephalus; Psychomotor impairment; School

Introduction

Hydrocephalus is a disorder of production and absorption of cerebrospinal fluid. It causes enlargement of ventricular system which lead to direct compression of cerebral parenchyma. According to the causes, the anatomic level or obstruction, and the duration of the disease, impairments may occur such as ischemia, basal ganglia destruction or parenchyma necrosis [1-3].

In neonates or young patients, morphologic and functional impairments of cerebral structures could compromise mental functions, pathways organization and good psychomotor development [4]. In developing countries especially in African sub Saharan countries, most children with hydrocephalus suffered from meningitis in neonatal period [5-8]. In Benin republic, this pathology counted for about 15% of patients attending neurosurgical consultations. So far, children with hydrocephalus represented more than 60% of the pediatric neurosurgical disorders [9]. To this reason, in this present study, we aims to determine the clinical patterns and neuro-imaging aspects of children with hydrocephalus in Cotonou, Benin in order to have a better understanding of their quality of life after neurosurgical procedure.

Patients and Methods

The study was done in Department of Neurosurgery in the Military Teaching Hospital and Department of Pediatrics in the National Teaching Hospital of Cotonou, both committed in surgical care for children with hydrocephalus.

It was a retrospective, descriptive and analytic study regarding children that underwent surgical management of hydrocephalus from September 2003 through August 2009. These children were aged from one day to ten years old, and had been included according to selected variables upon epidemiology, clinical, therapeutic and follow up data. A minimum of one year follow-up was requested after neurosurgical procedure before inclusion. Data had been collected from patient’s files and were completed with psychomotor pattern based on Denver test during final neurological assessment [10-12]. More questions were asked for better description of cultural and social profile, various disabilities, including challenges in social insertion. In some other cases, missing data were obtained through phone call. Neuro-imaging data of ventricular system were obtained by cerebral ultrasounds (n=75) and CT scan (n=35). MRI was done in only one case. These help determining EVANS ratio which is the distance between outer margins of frontal horns divided by distance between inner table of calvarium on the same slice. Normal value ranged from 0.3 through 0.4 [2]. By reference to the normal developmental age, a six month extra time period was considered before looking on neurological development delayed. All data were analyzed with SPSS 21software. Chi-square test was used for proportion comparison and a p-value of 0.05 was considered as significant. Parents gave written consent and data were managed according to good practice in clinical research.

Results

During the period of the study, 357 patients had ventricularperitoneal shunt, and 79 parents had given their consent in participating in the study. The sex-ratio was 1.2. The mean age at first admission was nine months (min = 27 days and max = nine years) and 61cases (78.2%) were in infants. Children at school age and neonate were respectively 1.26% and 19.2%. In 60 cases (76%) first neurosurgical consultation was obtained at least one month after the beginning of the disorders. In eight cases (10.3%) this delay was = one year. Regarding economic conditions, 45 parents (56.96%) were self-employed workers, enrolled in private companies or without job. Twenty one (26.58%) were civil servants and are eligible for the national health system assurance. In most cases (n = 63; 80%) the highest parents’ income varied from 40 000 to 120 000 CFA franc (240 US Dollars). Six families (10%) had income higher than 120 000 CFA franc, and six others had income lower than 40000 FCFA or no income at all. Medical histories revealed fetal infections (n=62; 78.51%), preterm birth (12.65%) and birth asphyxia (8.86%). Main etiologies are documented in (Table 1). Meningitis (74.7%) and cerebral malformations (16.5%) represented the leading causes of hydrocephalus. All the children came with macrocrania. Variation of cranial circumpherence was higher than 3 standard deviations in 45 cases (57.2%) and was situated between 2 and 3 SD in 34cases (42.8%). Neurological disorders were axial hypotonia (n=40; 50.6%), poor control of vesical sphincter (n = 14; 17.7%). On anatomic based, hydrocephalus was tetra ventricular in 49 cases (62.02%) and tri or bi ventricular respectively in 30.37 % and 7.59 % of the cases. Calculated EVANS ratio ranged from 0.71 to 1 in 65 cases (82.85%) and 0.51 to 0.70 in 9 cases (11.42%). In five children, the ratio was in the subnormal range. The global average value was 0.81 (min = 0.48 - max = 1). Regarding management following their admission, only three cases (3.79%) underwent surgery before one month following admission. Sixty children (76%) were operated between one month and one year, while 16 children (20.25%) had surgeries one year after operative decision. At the completion of this study, medium post-operative follow up was 7.8 years (min = 1 year; max = 10 years). Sixty two children (78%) had single neurosurgical procedure and kept their first shunt device. Twenty five children (31.64%) disclosed complications such as meningitis (n=11; 26.8%), infection either cutaneous necrosis at the operating site (n=8; 19.5%) and malnutrition (14.7%).

Table 1: Etiologies of children hydrocephalus.





  

    
Pathologies

    
Patients

    
%

  

  

    
Meningitis

    
59

    
74.7

  

  

    
Cerebral malformation

    
13

    
16.5

  

  

    
Hemorrage

    
5

    
6.3

  

  

    
Tumor

    
2

    
2.5

  

  

    
Total

    
79

    
100,0

  










Table 1:  Etiologies of children hydrocephalus.

Seventeen children (21.51%) had benefited from a shunt revision. Thirty eight children out of 79 (48.10%) died from shunt dysfunctions (n=18), infections at operating site (n=14) or under nutrition (n=6). Final neurological evaluation was based on 41 clinical controls in the department with 38 reports collected from parents. Nineteen children (24.05%) were free of neurological disorder. Sixty other children had

shown various psychomotor impairments. Out of 41 that were alive children, 23 (56.1%) were able to attend normal schools. Twelve children (52%) were doing well at school and 11 (47.82%) had bad school performances. Delayed in neurological abilities were identified in 18 cases, while major functions impairments were present in 14 cases such as lack of walking after three years (n=7); blindness (n=3), dysarthria and inability in scholar duty (n=4).

Discussion

Hydrocephalus counted for 63.4% of pediatric consultations and represents a major challenge for Benin health system [1]. Over the period of study, 357 children were operated for hydrocephalus and 79 (22.12%) received neurological evaluation in our facilities. In this study, infants represented 78.2% of the cases, as usually reported [5, 6]. Early onset of hydrocephalus is responsible of massive neuronal destructions. Through a routine neuro pediatrics evaluation in 18 children ranged from 1 to 8 years old with previous history of isolated fetal mild ventriculomegaly. Gomez-Ariga reported five cases of neurological disorders: three had language impairment and two had either left hemiparesis or intellectual retardation [13]. In this study, circumstances were dominated by infectious contexts (n=60; 75.9%) and meningitis (n=59; 74.7%) was the main cause, followed by congenital malformation as found in 13 cases (16.5%). This predominance of infection was previously reported especially in low income countries [7, 14-16]. The occurrence time of hydrocephalus in children comes from the importance of ventricular enlargement that is responsible of reduction of cerebral mantle. This increases immediately EVANS ratio (0.81 instead of 0.3). This is pathognomonic of major cerebral anatomical changes and characteristic in infant that had suffered from meningitis, leading to poor outcome [8,17,18]. On a therapeutic aspect, delay in surgery is at the origin of major complications such as chronic infectious, under nutrition and cutaneous necrosis near shunt device. All these increase revision rate with negative impact on quality of surgery. Qura-Tul-Ain and al. had reported the rates of 11.2% and 16% respectively regarding shunt infection and dysfunction [15]. In term of psychomotor development, 23 out of 41 alive children (56.09%) had combined disorders or sequela, such as motor disability, cognitive and psycho affective impairments. Three children (7.31%) had no psychomotor impairment and had good result at school. The major fear in this condition is psychomotor delay as reported in literature [19,20]. Complications are fewer in high income resources countries compared to developing world [20-22]. In our study, long term outcome gave 56.1% of survivors and most of them (n = 20; 86.95 %) are still going to normal schools with no specific help. Our results were consistent with what have been reported in the past [20-25].

Conclusion

Hydrocephalus is at risk whenever new born or infant experience acute infection of nervous system. Long term follow up in Benin republic is characterized by a low rate of survival (51.9%) and various impairments on survivors such as motor deficit (68.29%), cognitive (31.7%) and psycho affective (12.19) disorders. There is a low rate of schooling (56.1%) in survivor children.

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Citation: Gandaho HJ, Alao MJ, Houinsiu-Hans I, Alassane L, Djrolo G, et al. Psychomotor Performance in Children Operated for Hydrocephalus: About 79 Cases. Austin J Pediatr. 2015; 2(2): 1024. ISSN: 2381-8999