Features of Somatic Pathology in Children with Hydrocephalus Before and After Ventriculoperitoneal Shunting Operations

The dissertation is devoted to the study of the features of somatic pathology in children with hydrocephalus at the prehospital stage and after ventriculoperitoneal shunting operations. The research covers questions of pathophysiology, clinical manifestations, and treatment of hydrocephalus, as well as the development of algorithms for differential diagnosis between manifestations of surgical hydrocephalus and accompanying somatic pathology of internal organs. Clinical, laboratory, ultrasonic, and radiological examination methods applied for early detection of hydrocephalus and its complications are considered.

The work analyzes the morbidity of internal organs in children with hydrocephalus in comparison with the general pediatric population, identifies significant diagnostic signs that allow determining indications for imaging examination methods (CT, MRI), and develops a system of dispensary observation and follow-up of children after ventriculoperitoneal shunting operations, taking into account the risk of postoperative complications and accompanying somatic pathology.

Relevance of the Problem. For many decades, the problem of treating children with hydrocephalus (H) has attracted the close attention of neurosurgeons, neuropathologists, and pediatricians (Arendt A.A., 1948; Purin V.P., Zhukova T.P., 1976; Simerensky B.P., 1984, 1985; Khachatryan V.A., 1991, 1998; Orlov Yu.A., 1996; Stein S.C. et al, 1981; Abdullah J., 2001). Despite active study of the problem of hydrocephalus, questions regarding the accompanying pediatric (somatic) pathology remain insufficiently explored.

The incidence of hydrocephalus ranges from 0.28 to 3.0 per 1,000 newborns (Yakunin Yu.A. et al., 1979; Zinenko D.Yu., 1996; Amacher A.L., Wellington J., 1984). According to Khachatryan V.A. et al. (1998), hydrocephalus is noted in 1-4 per 1,000 live newborns. In children over the age of 3, the frequency of diagnosed hydrocephalus increases to 1% (Bashkirov M.V. et al., 1999; Kariev M.Kh., Kariev G.M., 1998; Botash R.Kh., 2001; Heinsbergen I et al, 2001). Hydrocephalus as a separate syndrome accounts for up to 30% of all congenital malformations of the brain (Onegin E.V., 1998; C. Schrander-Stumpel et al., 1998; Davies A.F. et al., 2000).

It is important to emphasize that the main trend of modern medicine is the development and improvement of "active" methods of correcting hydrocephalus, including surgical treatment, primarily ventriculoperitoneal shunting operations (VPS). Annually, 100,000 to 200,000 VPS operations are performed worldwide (Khachatryan V.A., 1991; Kang J.-K., 1999; Cochrane D.D., 2003). In our city, VPS has been applied since 1980, and their number increases each year (Khachatryan V.A. et al., 1998; Iova A.S., Garmashov Yu.A., 2003).

The success of surgical treatment of hydrocephalus depends on many factors, among which particularly important are the variant of the pathological process course, constitutional features of the child's organism, the presence of intercurrent diseases, adequacy of surgical treatment, the course of postoperative complications, and the features of dispensary observation.

To date, the questions of diagnosing various manifestations of hydrocephalus and developing an algorithm for selecting treatment tactics for children with accompanying somatic pathology remain poorly covered in the literature. The latter includes functional disorders of the gastrointestinal tract, including dyspeptic syndrome of various genesis; endocrine-metabolic disturbances causing delayed or precocious physical and sexual development; as well as delays in psychomotor, speech, and intellectual development. The diagnosis of complications of ventriculoperitoneal shunting operations and visceral pathology in children with hydrocephalus after VPS, manifesting as intestinal paresis, hydrocele of the testis, abdominal pain, dyspepsia, development of shunt nephritis, and others, deserves attention. There is no clear program for observing these children in the pediatric department.

The goal of the research includes improving the results of treatment of children with hydrocephalus, in particular through its early detection and differential diagnosis of manifestations of accompanying somatic pathology.

Research Tasks

To achieve the stated goal, it is necessary to solve the following tasks:

1). To identify the frequency and features of internal organ pathology in children with hydrocephalus and to compare them with indicators of morbidity in the general pediatric population of Saint Petersburg.

2). To establish significant signs of initial manifestations of the hypertensive-hydrocephalic syndrome that allow determining indications for using imaging examination methods — computed tomography (CT) or magnetic resonance imaging (MRI). To develop an algorithm for possible early diagnosis of hydrocephalus in children with accompanying somatic pathology for timely provision of neurosurgical care to these patients.

3). To determine a differentiated approach to observing children who have undergone ventriculoperitoneal shunting operations for predicting the course of hydrocephalus, taking into account the risk of developing probable postoperative complications. To develop recommendations for dispensary observation of patients with hydrocephalus after ventriculoperitoneal shunting operations, taking into account the accompanying somatic pathology.

Scientific Novelty

On the basis of comprehensive dynamic research of accompanying somatic pathology in children with congenital and acquired hydrocephalus, it was found that the overall morbidity of children with hydrocephalus is several times higher than in the pediatric population of Saint Petersburg. It was noted that patients with hydrocephalus have gastrointestinal diseases 2-4 times more often, endocrine-metabolic disorders 3-6 times more often, urinary system morbidity indicators 1.5-4 times higher, bronchial asthma 3-4 times more often, and congenital heart defects 4 times more frequently. Only 22% of the examined children had no accompanying pathology.

The developed diagnostic table of signs allows identifying hydrocephalus in children with accompanying somatic pathology in a pediatric department. Diagnostic coefficients have been proposed that determine the need for specialized imaging examination methods — CT, MRI.

On a large clinical material, features of manifestations of hydrocephalus of various genesis and postoperative complications after VPS in children have been identified.

Practical Significance

Through systematic study of a sufficiently large and well-verified clinical material, a socioeconomic characterization of families of children with hydrocephalus at the time of diagnosis, prior to surgical treatment, has been provided.

The spectrum of somatic pathology in children with hydrocephalus at the prehospital stage has been determined.

The most frequent manifestations of hydrocephalus requiring surgical treatment in children with accompanying somatic pathology before ventriculoperitoneal shunting operations have been systematized. A diagnostic algorithm for early identification of hydrocephalus has been proposed.

The reasons for delayed neurosurgical care for children with hydrocephalus have been analyzed.

A scheme for postoperative observation after ventriculoperitoneal shunting operations in polyclinic conditions and differential diagnosis of VPS complications have been developed.

Dissertation Defense

Five printed works have been published on the topic of the dissertation research. The results of the research were reported at the I All-Russian Conference on Pediatric Neurosurgery (Moscow, 2003), the VII International Symposium "New Technologies in Neurosurgery" (Saint Petersburg, 2004), the Russian Conference "Combined Treatment of Brain Tumors" (Yekaterinburg, 2004), and the VI Far Eastern International Conference of Neurosurgeons and Neurologists (Khabarovsk, 2004).

Implementation of research results in practice: the main provisions are used in the practical work of the State Research Neurosurgical Institute named after Professor A.L. Polenov, City Hospital No. 19 named after Rauhfus, the clinics of Saint Petersburg State Pediatric Medical Academy, 19 children's polyclinics of Saint Petersburg, and 36 city polyclinic of Minsk. The dissertation materials formed the basis of lectures for attendees of the Department of Pediatrics with courses of perinatology and endocrinology of the Faculty of Advanced Training and the Faculty of Professional Development of the State Educational Institution of Higher Professional Education "Saint Petersburg State Pediatric Medical Academy."

Main Provisions for Defense:

1. Hydrocephalus frequently (78%) is accompanied by visceral organ pathology. Timely diagnosis and correction of hydrocephalus improves the prognosis of the course of accompanying internal organ pathology in children with hydrocephalus, leading to improved quality of life for the patient.

2. The compiled table of prognostically significant signs allows determining the probability of surgical hydrocephalus at the prehospital stage and referring the patient for specialized imaging examination (CT, MRI) and consultation with a pediatric neurosurgeon.

3. The proposed system of dispensary observation and rehabilitation of children who have undergone ventriculoperitoneal shunting operations should take into account the risk of complications and their prognosis, the course of accompanying somatic pathology, and should provide for an individual plan of preventive vaccinations.

Structure and Volume of the Dissertation

The dissertation consists of an introduction, 4 chapters, a conclusion, findings, practical recommendations, 5 appendices, and a reference list including 163 sources: 82 domestic and 81 foreign.