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ORIGINAL ARTICLE
Year : 2015  |  Volume : 18  |  Issue : 4  |  Page : 172-176

Sonographic pattern of hydrocephalus among the under five children in Sokoto North Western Nigeria


1 Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Radiology, University of Ilorin, Ilorin, Nigeria
3 Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication16-Feb-2016

Correspondence Address:
Sule Ahmed Saidu
Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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DOI: 10.4103/1118-8561.176584

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  Abstract 

Background: Hydrocephalus among children is an important medical problem in view of its neurological sequelae in the growing child. This situation is compounded by the acute shortage of neurosurgeons in third world countries like Nigeria; hence, the need for its early detection and proper management. Objective: Evaluation of the ultrasound (US) appearances in children under 5 years of age presenting with clinical signs of raised intracranial pressure suggestive of hydrocephalus. Patients and Methods: A retrospective review of transfontanelle US scans done in 64 children (39 boys and 25 girls) attending the Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria over a period of 2 years was carried out. The patients had a mean age of 5.0 ± 4.6 months (range: 1–60 months) at the time of their US examination. Some of the clinical indications for US scan included: Congenital hydrocephalus, encephalocele, meningomyelocele, and meningitis. All scans were performed through the anterior fontanelle using SIUI Apogee 800 PLUS scanner with a curvilinear probe using multi-frequency transducer of 2–5 MHz. Results: Fifty-two patients (81.3%) had hydrocephalus of congenital origin. Eleven cases (17.2%) had postmeningitic hydrocephalus while only 1 case (1.6%) was posthemorrhagic. Twenty-five patients (48.0%) of the congenital cases were due to cerebral aqueduct stenosis. Eleven (21.2%) of the congenital cases were from obstruction at the exit foramina of Luschka and Magendie resulting in the communicating type of hydrocephalus. Conclusion: Hydrocephalus is a known cause of neurological morbidity among infants in developing countries. Majority of the cases are congenital in origin and most commonly due to cerebral aqueduct stenosis. Transfontanelle US is cheap, affordable, nonhazardous, and more accessible than other imaging modalities. It should serve as the first-line investigation of infants with suspected hydrocephalus for early detection and monitoring of progression to determine those cases that would require shunt operation.

Keywords: Children, hydrocephalus, pattern, sonographic, under five


How to cite this article:
Saidu SA, Maaji SM, Nzeh DA, Shehu BB, Ismail NJ. Sonographic pattern of hydrocephalus among the under five children in Sokoto North Western Nigeria. Sahel Med J 2015;18:172-6

How to cite this URL:
Saidu SA, Maaji SM, Nzeh DA, Shehu BB, Ismail NJ. Sonographic pattern of hydrocephalus among the under five children in Sokoto North Western Nigeria. Sahel Med J [serial online] 2015 [cited 2019 Sep 23];18:172-6. Available from: http://www.smjonline.org/text.asp?2015/18/4/172/176584


  Introduction Top


Significant advancement has been achieved in the technique of cerebral transfontanelle ultrasonography over the years.[1] It permits early diagnosis of intracranial abnormalities and follow-up of high-risk children during the early years of life.[2]

It comes in handy in the developing world where advanced and indeed expensive radiological modalities such as computerized tomography (CT) and magnetic resonance imaging (MRI) are considered expensive and not readily available. Ultrasonography is noninvasive, simple, mobile, and cheap.[3]

CT, on the other hand, though more precise and complex, may require anesthesia for the procedure and transportation to the regional centers that have the facility. In addition, CT exposes the child to the hazard of ionizing radiation. MRI, which does not have the danger of ionizing radiation, and is the best imaging modality to provide functional and anatomical information,[4] is even more expensive and rarer.

It is evident that a preliminary ultrasound (US) examination may reduce, postpone or even render unnecessary these more complex and costly examinations and yet achieve, given recent improvements in US technology, a spatial resolution that is now comparatively highly competitive.[5],[6]

Some of the intracranial pathologies that may be diagnosed include hydrocephalus, intracranial infections, intracranial hemorrhage, periventricular leukomalacia, brain tumors and meningomyelocele.[1],[2],[7],[8]

Sonographic monitoring also facilitates the decision on conservative or neurosurgical treatment of hydrocephalus.[2]

This study was undertaken to analyze the pattern of hydrocephalus among children <5 years of age in Sokoto, Nigeria using ultrasonography with a view to suggesting better ways of managing the disease.


  Patients and Methods Top


A retrospective cross-sectional descriptive study of patients attending the Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria for transfontanelle ultrasonography over a period of 2 years (October 2003–October 2005) was carried out.

Some of the clinical indications for the US scan referral included: Big head, raised intracranial pressure, congenital hydrocephalus, encephalocoele, meningomyelocele, and meningitis.

All the scans were done through the anterior fontanelle using an SIUI Apogee 800 plus US machine, usually with a multi-frequency sector transducer of range 2–5 MHz. Occasionally, a linear multi-frequency transducer, 5–11 MHz, was used to further examine the patient's brain, especially the superficial structures, where necessary. The patient was made to sit on his or her mother's or adult relation's laps. The coupling gel was then applied over the anterior fontanelles. The patient's brain was then scanned in the sagittal, and/or parasagittal, as well as the straight and, angled coronal planes. The images were then recorded accordingly. Diagnosis of hydrocephalus was made when the diameter of the occipital horn exceeded 16 mm, and that of the body of the lateral ventricle was >3 mm on the sagittal views, whereas the third ventricle should normally measure <2 mm in its widest diameter on coronal views.[9] Any associated lesions, for example, encephalocoeles were subsequently examined to visualize their contents and diagnose them.

The data collected was crosschecked for accuracy and analyzed using the Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) version 20.0. The results were cross-tabulated as frequency tables. Mean standard deviation, and ranges were used as appropriate to describe continuous variables.


  Results Top


There were 64 children (39 boys and 25 girls) with a male: female ratio of 3:2.

The patients had a mean age of 5.0 ± 4.6 months (range = 1–60 months) at the time of their US examination.

The patients were divided into five groups according to their ages in months; 0–12, 13–24, 25–36, 37–48, and 49–60. [Table 1] shows that an overwhelming number of patients in the study, 61 (95.3%), were in their infancy followed by the 13–24 months age group with 2 patients (3.1%).
Table 1: Age distribution of patients

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Fifty-two (81.3%) of the patients had hydrocephalus of congenital origin, as shown in [Table 2]. Eleven cases (17.2%) had postmeningitic hydrocephalus while only one case (1.6%) was posthemorrhagic.
Table 2: Causes of hydrocephalus

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Twenty-five (48.1%) of the congenital cases were due to cerebral aqueduct of Sylvius stenosis. Eleven (21.2%) of the congenital cases were from obstruction at the exit  Foramina of Luschka More Details and Magendie resulting in communicating hydrocephalus. A detail of the congenital etiological factors is as shown in [Table 3]. [Figure 1] and [Figure 2] show US images of congenital and postmeningitic hydrocephalus, respectively.
Table 3: Etiology of congenital hydrocephalus

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Figure 1: (a) Coronal ultrasound scan showing severe dilatation of the right and left lateral ventricles and 3rd ventricle in a male child with a communicating type of congenital hydrocephalus. (b) Ultrasound scan of the same child in Figure 1a shows severely dilated 3rd and 4th ventricles. (c) Parasagittal ultrasound scan of the same child as [Figure 1]a shows severely dilated right lateral ventricle

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Figure 2: (a) Coronal ultrasound scan of a female child showing severely dilated right and left lateral ventricles due to hydrocephalus from meningitis. (b) Parasagittal ultrasound scan of the same child as [Figure 2]a shows severe dilatation of the right lateral ventricle due to hydrocephalus from meningitis. (c) Parasagittal ultrasound scan of the same child as Figure 2a shows severe dilatation of the left lateral ventricle due to hydrocephalus from meningitis

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  Discussion Top


Hydrocephalus or increased intracranial content of cerebrospinal fluid is one of the most common central nervous system anomalies in children.[9] It may be congenital or acquired. The congenital causes include aqueductal stenosis, agenesis of the corpus callosum, neural tube defect, and chromosomal abnormalities while among the acquired ones are intraventricular hemorrhage and infections such as meningitis.[10],[11],[12]

Hydrocephalus has an incidence of about 0.3–0.8 cases/1000 live births and other anomalies such as encephalocoeles, Arnold  Chiari malformation More Details, arachnoid cysts, and holoprosencephaly are frequently associated with it.[10],[12],[13]

In this study, we found that 5.8% of our patients had associated encephalocoeles and cranial meningoceles whereas one patient (1.9%) also had both cranial meningocele and posterior cranial fossa arachnoid cyst, as shown in [Table 3].

In advanced cases, the cortical mantle may become thinned and in some cases markedly. The attendant neurosurgical complications and sequelae pose a great challenge to the clinician because of their effects on the neurological integrity of the patient.[14]

An overwhelming proportion of our patients were below 1 year of age. We believe that this is related to the early suspicion of intracranial pathology in such infants in hospital-based deliveries, with prompt referral for the cranial US.[15] The numbers were noted to be less in older children since some surgical intervention would have been undertaken. Some could have also died at home from neglect as suggested by Binitie.[16] We found a higher proportion of male patients than females. This concurs with the study by Bajpai et al.[17]

Majority (81.3%) of our patients had hydrocephalus of congenital origin followed by the postmeningitic variety. Nzeh et al. and Bajpai et al.,[11],[17] also found the congenital variety as the most preponderant in their studies. Only a small percentage of posthemorrhagic cases were found in our study, which we believe may be related to the lower incidence of intracranial hemorrhage in developing countries, attributed to possible environmental and genetic factors.[8] In addition, the lack of a well-established preterm neonatal US screening service in the hospital may be responsible for our rather very low finding of 1.6% for posthemorrhagic hydrocephalus. It is noteworthy, however, that a study in Blantyre, Malawi found a majority of postmeningitic hydrocephalus of 51.5%.[18] Hydrocephalus was also found to be the most common complication of meningitis in other studies in Nigeria.[19],[20]

Hydrocephalus secondary to obstructio n at the level of the cerebral aqueduct of Sylvius was the predominant type of the congenital group, in our study. This agrees with findings in the literature.[11],[12],[21] Congenital communicating hydrocephalus (from foramina of Luschka and Magendie obstruction) was the next in preponderance. Nzeh et al.,[12] however, found a higher proportion of encephalocoeles than congenital communicating hydrocephalus. We had a lower percentage of encephalocoeles, and all the cases we found were associated with hydrocephalus, unlike in the former study,[11] where majority of the encephalocoeles occurred alone.

The neurological morbidity and mortality associated with hydrocephalus in infancy or childhood makes it imperative for early diagnosis to be made to effect prompt intervention. In order to significantly influence the perinatal outcome of these intracranial abnormalities, transabdominal and/or transvaginal antenatal or fetal ultrasonography is encouraged.[22] Advancement in the technique with the evolution of three-dimensional technology make it easier to define the lesions,[22],[23] so that antenatal correction can be undertaken. Otherwise, immediate postnatal intervention may be done after team consultation and preparation for the appropriate mode of delivery.[24] This ensures that the untoward sequelae and complications that would otherwise result are nipped in the bud.


  Conclusion Top


Transfontanelle ultrasonography is useful technique for the early diagnosis of hydrocephalus in infancy and early childhood. It is radiation free and relatively inexpensive which makes it invaluable in the developing world where MRI is unaffordable and not readily available.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jurine N, Allard D, Portafaix M. Transfontanelle cerebral echography. Neurochirurgie 1986;32:537-46.  Back to cited text no. 1
    
2.
Dittrich M, Dinkel E, Peters H. Sonographic diagnosis of the central nervous system in the neonate and infant – Pathomorphology, indications and value. Ultraschall Med 1983;4:174-81.  Back to cited text no. 2
    
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Santa M, Sulla I, Fagul'a J, Santová I. CT-scan or two-dimensional echoencephalography in neonatal intracranial pathology? Zentralbl Neurochir 1989;50:78-83.  Back to cited text no. 3
    
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Marchiano A, Biasi S, Damascelli B. Ultrasonography. In: Damascelli B, editor. Basic Concepts in Diagnostic Imaging. New York: Raven Press, Ltd.; 1991. p. 125-30.  Back to cited text no. 5
    
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Han BK, Babcock DS, McAdams L. Bacterial meningitis in infants: Sonographic findings. Radiology 1985;154:645-50.  Back to cited text no. 7
    
8.
Nzeh DA, Ajayi OA. Sonographic diagnosis of intracranial hemorrhage and periventricular leukomalacia in premature African neonates. Eur J Radiol 1997;26:77-82.  Back to cited text no. 8
    
9.
Siegel MJ. Neonatal intracranial problems. In: Sanders RC, Winter T, editors. Clinical Sonography: A Practical Guide. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2007. p. 341-64.  Back to cited text no. 9
    
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Grumbach K. Obstetric ultrasound. In: Sutton D, Young JW, editors. A Concise Textbook of Clinical Imaging. 2nd ed. Missouri: Mosby-Year Book, Inc.; 1995. p. 714-8.  Back to cited text no. 10
    
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Nzeh DA, Erinle SA, Saidu SA, Pam SD. Transfontanelle ultrasonography: An invaluable tool in the assessment of the infant brain. Trop Doct 2004;34:226-7.  Back to cited text no. 11
    
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Nzeh DA, Saidu SA, Erinle SA, Pam SD. Sonographic diagnosis of congenital brain malformations: The Ilorin experience. Niger Postgrad Med J 2006;13:57-60.  Back to cited text no. 12
    
13.
Pomschar A, Koerte I, Peraud A, Heinen F, Herber-Jonat S, Reiser M, et al. Hydrocephalus in childhood: Causes and imaging patterns. Radiologe 2012;52:813-20.  Back to cited text no. 13
    
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Bazán-Camacho AJ, García-Almeida E, Jiménez-Valdés ML. A study of the evolution of ventricular dilatations using transfontanellar ultrasonography. Rev Neurol 2004;39:1109-12.  Back to cited text no. 14
    
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Nzeh DA, Pam SD, Erinle SA, Saidu SA. Ultrasound diagnosis of hydrocephalus among infants in Nigeria. West Afr J Ultrasound 2001;2:13-6.  Back to cited text no. 15
    
16.
Binitie OP. Congenital malformations of the central nervous system at the Jos University Teaching Hospital, Jos Plateau State of Nigeria. West Afr J Med 1992;11:7-12.  Back to cited text no. 16
    
17.
Bajpai M, Kataria R, Bhatnagar V, Agarwala S, Gupta DK, Bharadwaj M, et al. Management of hydrocephalus. Indian J Pediatr 1997;64 6 Suppl: 48-56.  Back to cited text no. 17
    
18.
Adeloye A, Khare R. Ultrasonographic study of children suspected of hydrocephalus at the Queen Elizabeth Central Hospital in Blantyre, Malawi. East Afr Med J 1997;74:267-70.  Back to cited text no. 18
    
19.
Nzeh D, Oyinloye OI, Odebode OT, Akande H, Braimoh K. Ultrasound evaluation of brain infections and its complications in Nigerian infants. Trop Doct 2010;40:178-80.  Back to cited text no. 19
    
20.
Eze KC, Enukegwu SU, Odike AI. Brain sonography in African infants with complicated sporadic bacterial meningitis. Niger Med J 2013;54:320-4.  Back to cited text no. 20
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Babcock DS, editor. Cranial sonography: Congenital anomalies. In: Neonatal and Pediatric Ultrasonography. 1st ed. Edinburgh: Churchill-Livingstone; 1989. p. 1-5.  Back to cited text no. 21
    
22.
Monteagudo A, Timor-Tritsch IE, Mayberry P. Three-dimensional transvaginal neurosonography of the fetal brain: 'Navigating' in the volume scan. Ultrasound Obstet Gynecol 2000;16:307-13.  Back to cited text no. 22
    
23.
Timor-Tritsch IE, Monteagudo A, Mayberry P. Three-dimensional ultrasound evaluation of the fetal brain: The three horn view. Ultrasound Obstet Gynecol 2000;16:302-6.  Back to cited text no. 23
    
24.
Kurjak A, Gogolja D, Kogler A, Latin V, Rajhvajn B. Ultrasound diagnosis and perinatal management of surgically correctable fetal malformations. Ultrasound Med Biol 1984;10:443-55.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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