Analysis of variation in radiological parameters in congenital hydrocephalus after ventriculoperitoneal shunt placement and its association with the functional outcome

Analysis of variation in radiological parameters in congenital hydrocephalus after ventriculoperitoneal shunt placement and its association with the functional outcome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of variation in radiological parameters in congenital hydrocephalus after ventriculoperitoneal shunt placement and its association with the functional outcome Tehniat Khaliq, Shafin bin amin, Jahan jarwar, Rabbia Aqeel, allah bux This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6306501/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Cerebrospinal fluid (CSF) buildup in the brain's ventricular system is a hallmark of congenital hydrocephalus, which can result in elevated intracranial pressure and possible neurological damage. The major surgical procedure for removing extra CSF and releasing pressure is still ventriculoperitoneal (VP) shunting. It is still up for debate, nevertheless, whether functional results and radiological improvements following shunting are related. The objective of this research is to examine the relationship between neurological outcomes and changes in Evans' ratio, cortical mantle thickness (CMT), frontal horn to inter caudate distance (FH/ID) ratio, and temporal horn size after surgery. Methods: Fifty patients with congenital hydrocephalus who had VP shunting participated in this retrospective cross-sectional study, which was carried out at Jinnah Postgraduate Medical Centre in Karachi. Preoperative and postoperative radiological measurements were among the data gathered from medical records during a one-year follow-up. The chi-square test was used to determine the significance of the statistical analysis, which was carried out using SPSS 23.0. Results: Significant decreases in ventricular size were indicated by significant decreases in Evans' ratio (58% of patients, p = 0.00051). While 14% showed further thinning, 28% of patients showed a rise in CMT, indicating possible brain tissue recovery. Thirty percent of instances had an improvement in the FH/ID ratio, whereas 56 percent saw no change. Although there were differences in response, 34% of patients experienced a decrease in temporal horn size. Conclusion: Although VP shunting successfully shrinks the ventricle, there is still inconclusive evidence linking it to neurological improvement. The results indicate that ventricular size by itself is not a reliable prognostic indicator, underscoring the necessity of multimodal evaluations that consider cerebral perfusion and white matter integrity to improve patient care and make more accurate predictions. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction A disease known as hydrocephalus is defined by an abnormal buildup of cerebrospinal fluid (CSF) in the brain's ventricles, which can be caused by either excessive CSF production or poor absorption. It may develop later in life (acquired) or be present from birth (congenital) [ 1 ]. Congenital hydrocephalus is further divided into two categories: non-communicative hydrocephalus, which happens when CSF drainage channels are blocked, and communicating hydrocephalus, in which the ventricular system is unharmed. Congenital hydrocephalus is brought on by several risk factors, such as infections, genetic disorders, preterm birth, and structural abnormalities such as Chiari malformations, Dandy-Walker malformations, neural tube defects, cerebral aqueduct stenosis, and corpus callosum agenesis [ 2 – 3 ]. Pharmacological methods such as acetazolamide and surgical procedures like endoscopic third ventriculostomy and ventriculoperitoneal (VP) shunt implantation are used to treat hydrocephalus. The most popular and successful treatment among these is still VP shunt insertion [ 4 ]. To assist CSF drainage, a catheter is inserted into the brain's ventricular system, with its distal end placed in the peritoneal cavity. VP shunting improves neurological function and decreases ventricular size; these improvements are frequently assessed using radiological markers. These postoperative radiological findings, however, vary widely, which has sparked continuous discussion on their relationship to long-term functional outcomes [ 5 ]. Evans' index, the frontal horn to inter caudate distance (FH/IHD) ratio, temporal horn size, and cortical mantle thickness (CMT) are some of the important radiological characteristics that are used to evaluate hydrocephalus and forecast prognosis. The degree of parenchymal thinning brought on by prolonged ventricular enlargement is reflected in CMT; higher thinning is linked to worse neurological outcomes [ 6 ]. A common indicator of ventricular enlargement is Evans' index, which is determined by dividing the greatest width of the frontal horns by the maximum biparietal diameter. Higher values of this index signify more severe hydrocephalus and a poorer prognosis [ 7 ]. Another measure of ventricular volume is the FH/IHD ratio; larger values indicate more ventricular dilatation and the detrimental consequences it has on deep brain structures and neurodevelopment [ 8 ]. A common early indicator of hydrocephalus is temporal horn enlargement, which usually occurs before other ventricular areas dilate. After shunt surgery, persistent temporal horn dilatation could indicate poor shunt function or insufficient CSF diversion [ 9 ]. Although these radiological markers offer important information on the course of hydrocephalus and the effectiveness of treatment, there is ongoing discussion regarding their prognostic utility. A more thorough approach to patient evaluation is required, as some research indicates that gains in neurological function do not necessarily follow ventricular size reduction following shunting [ 10 – 11 ]. To improve understanding of prognosis in the management of hydrocephalus, this study intends to examine changes in these radiological markers and their relationship to functional results. Methodology Study design: The study was conducted in the neurosurgery department of Jinnah Post Graduate Medical Centre, a tertiary care hospital in Karachi, using a retrospective cross-sectional research methodology. It comprised 50 congenital hydrocephalus patients who were prospectively recruited and monitored for a year between 02-08-2021 and 02-08-2022. Participants were chosen at random from the neurosurgery department of Jinnah Post-Gradual Medical Center in Karachi. Criteria for inclusion: Patients with congenital hydrocephalus, regardless of gender (male or female), have voluntarily consented after being informed that their personal information will be kept anonymous and that no publications will utilize it. Exclusion criteria: Patients without consent, adult populations, patients admitted in other facilities apart from Jinnah Postgraduate Medical Center, children with other congenital defects, and people who do not meet the requirements for congenital hydrocephalus are among the exclusion criteria. Methods of Data Collection: With institutional review board consent, data was gathered at the neurosurgery department. Each patient's age, gender, and the cause of their hydrocephalus were gathered from their hospital records, along with information about their history and radiological tests, which included measurements of the temporal horn's size, Evan's ratio, FH/ID ratio, and cortical mantle thickness. Data Analysis: Using SPSC 23.0, the data was examined after a year of patient follow-up. Descriptive statistics (mean, standard deviation) were employed to compile participant attributes such as cortical mantle thickness, Evan's ratio, FH/ID ratio, and temporal horn size. Results 1. Study Population and Demographics: The study included 50 individuals in all, whose mean age was 6.8 months. There was a greater percentage of females in the study population, as evidenced by the fact that 18 (36%) of the participants were male and 32 (64%) were female. Evans ratio, cortical mantle thickness, FH/ID ratio, and temporal horn size were the four main radiological characteristics that were the focus of the analysis, and changes were evaluated throughout a one-year follow-up period. The overview of observed changes in all outcomes is highlighted in Table No. 1. Table no.1 Summary of Observed Changes in Outcomes Outcome Increase (%) No Change (%) Decrease (%) Cortical Mantle Thickness 28% 58% 14% Evans Ratio 28% 14% 58% FH/ID Ratio 14% 56% 30% Temporal Horn Size 34% Varied 0% 2. Changes in Evans Ratio In 29 individuals, the Evans ratio, a crucial measure of ventricular enlargement dropped, indicating a general decrease in ventriculomegaly. Seven patients (14%) had no discernible change, whereas 14 patients (28%) displayed an increase, suggesting possible hydrocephalus development. These changes were confirmed to be non-random by the chi-square test, which revealed a highly significant difference (p = 0.00051). Although a small percentage of patients showed worsening ventricular dilatation, the large percentage of patients who experienced a decrease indicates an overall favorable outcome. The variations in the Evans ratio are shown in Table No. 2 and Graph No. 1. Table no.2: Evans Ratio Change Type Number of Patients Percentage (%) Increase 14 28% No Change 7 14% Decrease 29 58% Significance p = 0.00051 Highly Significant 3. Changes in Cortical Mantle Thickness In 14 patients (28%), cortical mantle thickness, a measure of brain parenchymal preservation increased, suggesting possible neuroprotection or brain tissue recovery. On the other hand, 7 patients (14%) showed a decline, indicating a development of cortical thinning associated with hydrocephalus. 29 individuals, or 58% of the total, did not exhibit any discernible change. The validity of these findings was supported by statistical analysis, which showed a highly significant difference (p = 0.00051). Although the decrease in 14% of cases is still concerning, the increase in cortical thickness in 28% of patients is a positive sign. Figure No. 2 and Table No. 3 display the thickness of the cortical mantle. Table no.3 Cortical Mantle Thickness Changes Change Type Number of Patients Percentage (%) Increase 14 28% No Change 29 58% Decrease 7 14% Significance p = 0.00051 Highly Significant 4. Changes in FH/ID Ratio Fifteen patients (30%) had a decrease in the frontal horn to interhemispheric distance (FH/ID) ratio, indicating improved ventricular dimensions. Throughout the trial, 28 patients (56%) exhibited no discernible change, while 7 individuals (14%) displayed an increase. A significant difference was confirmed by the chi-square test (p = 0.00118), suggesting that variations in the FH/ID ratio followed a significant pattern. Compared to the Evans ratio and cortical thickness, the FH/ID ratio may be less vulnerable to short-term fluctuations, as indicated by the high percentage of patients (56%) who showed no change. Figure No. 3 and Table No. 4 display the fd/ihd ratio. Table no.4: FH/ID Ratio Changes Change Type Number of Patients Percentage (%) Increase 7 14% No Change 28 56% Decrease 15 30% Significance p = 0.00118 Significant 5. Changes in Temporal Horn Size 17 patients (34%) had a decrease in temporal horn size, indicating an improvement in the distribution of CSF. The outcomes of the remaining patients, however, were inconsistent, making it difficult to distinguish between those who had an increase and those who did not. The absence of a significant chi-square result precludes drawing firm conclusions about the overall effect, even if a size reduction is usually advantageous. To evaluate the clinical importance of temporal horn size changes, more research is required that includes exact categorization. Changes in temporal horn size are displayed in Table No. 5 and Figure No. 4. Table No. 5: Temporal Horn Size Changes Change Type Number of Patients Percentage (%) Reduced 17 34% Other Variations 33 Varied Significance Not Statistically Significant - 6. Interpretation of Chi-Square Test Results To ascertain if the observed changes in the Evans ratio, cortical mantle thickness, and FH/ID ratio were statistically significant rather than random fluctuations, the chi-square (χ²) test was employed. The findings demonstrated that all three measures changed significantly throughout the follow-up period, confirming that there were significant changes in ventricular size, brain tissue thickness, and CSF distribution. A robust trend of improvement was confirmed by extremely significant changes (p < 0.00051) in the Evans ratio and cortical mantle thickness. Although most patients (56%), the FH/ID ratio also showed substantial volatility (p = 0.00118), indicating that this parameter may be less sensitive to short-term impacts. Chi-square test results are displayed in Table No. 6. Table No. 6: Chi-Square Test Results Outcome Chi-Square Value (χ²) p-Value Evans Ratio 15.16 0.00051 Cortical Mantle Thickness 15.16 0.00051 FH/ID Ratio 13.48 0.00118 Discussion To better understand the impact of several radiological measures in post-ventriculoperitoneal shunt (VP) implantation in congenital hydrocephalus and how they relate to functional results, we conducted this study. Evans ratio, cortical mantle thickness (CMT), (fd/ihd) ratio, and temporal horn size were the main focus of this investigation, which was carried out in a tertiary care hospital. The findings showed notable variations in these indices over 12 months, with differing degrees of influence on the preservation of brain tissue and the reduction of ventricular size. An essential indicator for forecasting ventricular hypertrophy is the Evans ratio. The majority of the patients in our study had an overall decrease in ventricular volume in addition to improved functional results. Tisell et al. have reported similar results, demonstrating a decrease in ventricular size but no discernible improvement in cognitive outcomes [ 7 ]. Furthermore, Novak et al. demonstrated a comparable improvement in ventricular volume and neurological results, but they also emphasized the importance of other parameters, such as cerebral perfusion and periventricular edema, in enhancing neurological outcomes rather than only the Evans index [ 12 ]. Limbrick et al., on the other hand, demonstrated a comparable decrease in ventricular size but no improvement in functional outcomes [ 11 ]. This implies that there is no correlation between cognitive reaction and ventricular size alone. The extremely statistically significant difference (p = 0.00051), however, indicates that these results were not the result of chance. Another endpoint that was evaluated for our study was Cmt. It is a sign of ventricular enlargement-induced cerebral compression. A third of the population showed a rise in CMT, according to our survey, while the majority showed no change. In a similar vein, Vinchon et al. showed a stronger neurological response and a notable rise in CMT [ 10 ]. McGovern et al. [ 6 ] demonstrated a partial manifestation of this impact, demonstrating a decrease in ventricular size without improving neurological state. Given that patients with chronic hydrocephalus did not exhibit any improvement in their neurological state following shunt surgery, this underscored the importance of prompt intervention. As McAlister et al. [ 13 ] show, this effect is also important in situations when CMT was not raised after surgery. In a similar vein, Kulkarni et al. reported neurological improvement despite no change in CMT. Chong et al. also observed this effect, showing that although some patients had changes in CMT, others did not, indicating the involvement of other factors like cerebral perfusion and white matter integrity [ 5 , 14 ]. Another measure of ventricular capacity was the Fh/ihd ratio. The bulk of the patients in our study showed no response, whereas one-third of the population responded favourably. These results are consistent with those of Coenen et al., who found high preoperative FH/ID ratios were associated with neurodevelopmental impairment. However, postoperative alterations did not always indicate functional recovery because deep brain areas may sustain irreparable damage even with CSF diversion [ 15 ]. Kim et al. also exhibited similar results, demonstrating that improvement in neurological state is not predicted by the extent of reduction. Furthermore, he emphasizes that the fh/ihd ratio should be assessed in conjunction with periventricular edema and white matter integrity rather than being utilized as a stand-alone metric [ 16 ]. Greater percentages of the unchanging ratio, however, imply that this statistic may not be as sensitive as others. A common early sign of hydrocephalus is temporal horn growth. While some patients experienced a decrease in temporal horn size, the majority of our patients experienced a range of outcomes. Kulkarni et al. recently brought attention to these discrepancies by showing that shunt revision rates are increased by prolonged post-operative temporal horn dilatation [ 5 ]. []. Similarly, Novak et al. said that this metric is not a reliable indicator of neurological condition because of the irregularities they found in it [ 12 ]. Changes in temporal horn size were not statistically significant, in contrast to Evans' ratio and CMT, indicating that this metric by itself could not be a trustworthy prognostic indicator as proposed by Novak et al. Limitations It is important to recognize the limitations of our study, even if it offers important insights into the link between radiological measures and functional outcomes after ventriculoperitoneal (VP) shunt installation in congenital hydrocephalus. First off, we only used a small sample size and only one tertiary care hospital for our study. This could restrict our findings' applicability to broader, more varied groups. Our findings need to be confirmed by bigger cohorts in future multicentre research. Second, our study only tracked patients for a year after surgery, which might not be enough time to record long-term neurological effects and problems from the shunt. Over time, some functional gains or deteriorations might become apparent. Thirdly, we mostly used standard MRI and CT data, which might not adequately represent changes in the microstructure of the brain, cerebral perfusion, or white matter integrity. More sophisticated methods like phase-contrast MRI, functional MRI, or diffusion tensor imaging (DTI) may offer a more thorough picture of brain recovery following a shunt. Last but not least, we did not fully analyze confounding clinical variables, such as patient comorbidities, shunt revisions, intracranial pressure (ICP) monitoring, and genetic impacts. Future research must include a more thorough clinical evaluation because these factors may have a substantial impact on both radiological alterations and functional recovery. Conclusion The limits of utilizing ventricular size alone to predict functional recovery are highlighted by this study, which also emphasizes the heterogeneity in radiological responses after VP shunt insertion. Although metrics like Evans' ratio, CMT, FH/ID ratio, and temporal horn size offer insightful information, there is still inconclusive evidence linking them to therapeutic improvement. To improve prognosis and customize hydrocephalus treatment to meet the needs of each patient, multimodal assessment techniques that integrate radiographic, clinical, and biomarker-based evaluations are crucial. Abbreviations CMT cortical mantle thickness Fd/ihd frontal horn to interhemispheric distance Vp ventriculoperitoneal shunt Icp intracranial pressure Csf cerebrospinal fluid Declarations Ethics approval and consent to participate: This research was approved by the institutional review board at Jinnah Postgraduate Medical Center on 6 th November 2023 and the reference number is F.2/81/2023-GENL/185/JPMC. Consent for publication: The consent was taken from the patients' parents and those who refused were omitted from the study. Availability of Data and Material: Not Applicable Competing interests: The authors declare that they have a competing interest Funding: The authors received no extramural funding for this meta-analysis. Acknowledgements: Not applicable Author’s Contributions: TK and SBA assisted in the data collection process, JJ carried out the analysis, SBA, RA, and AB did the manuscript writing, TK edited the manuscript. References Tully HM, Capote RT, Saltzman BS (2015) Maternal and infant factors associated with infancy-onset hydrocephalus in Washington State. Pediatr Neurol 52(3):320–325. 10.1016/j.pediatrneurol.2014.10.030 Huang Y-H, Wu Q-J, Chen Y-L et al (2018) Trends in the prevalence of congenital hydrocephalus in 14 cities in Liaoning Province, China from 2006 to 2015 in a population-based birth defect registry from the Liaoning Women and Children’s Health Hospital. Oncotarget 9(18):14472–14480 Zhang J, Williams MA, Rigamonti D (2006) Genetics of human hydrocephalus. J Neurol 253(10):1255–1266 Kahle KT, Kulkarni AV, Limbrick DD et al (2016) Hydrocephalus in children. Lancet 387(10020):788–799 Kulkarni AV, Donnelly R et al (2018) Predicting shunt failure in pediatric hydrocephalus. J Neurosurg Pediatr 21(3):214–223 McGovern RA, Casella DP et al (2022) Ventricular volume and outcome after shunt placement. Neurosurgery 90(4):550–558 Tisell M, Tullberg M, Hellström P et al (2006) Shunt surgery in idiopathic normal pressure hydrocephalus: Outcome and CSF dynamics. J Neurosurg 105(5):812–818 Riva-Cambrin J et al (2012) The relationship between ventricular size and neurocognitive outcomes in pediatric hydrocephalus. Neurosurgery 71(2):289–295 Garton HJL, Piatt JH et al (2018) CSF dynamics and functional outcome in congenital hydrocephalus. J Neurosurg Pediatr 22(4):455–462 Vinchon M et al (2019) Cognitive outcome in congenital hydrocephalus: Influence of treatment parameters. Childs Nerv Syst 35(7):1145–1153 Limbrick DD et al (2017) Shunt outcomes and neurological function in congenital hydrocephalus. J Pediatr Neurosurg 53(3):119–127 Nowak KR et al (2022) The role of MRI biomarkers in predicting functional recovery after VP shunting. J Neurosurg Pediatr 29(2):220–229 McAllister JP (2008) Pathophysiology of congenital and neonatal hydrocephalus. Semin Pediatr Neurol 15(1):50–58. 10.1016/j.spen.2008.03.008 Chong CS et al (2020) White matter integrity and functional recovery in hydrocephalus. J Neurosurg 132(4):987–995 Coenen VA et al (2021) Functional neuroimaging in hydrocephalus: Advances and future directions. Neurosurg Rev 44(2):653–665 Kim DS, Choi JU, Huh R (2007) The causal relationship of the hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 42(3):174–178 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6306501","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":448801850,"identity":"af50cba6-49b5-40b1-811c-d14257b5146f","order_by":0,"name":"Tehniat Khaliq","email":"","orcid":"","institution":"Jinnah Postgraduate Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Tehniat","middleName":"","lastName":"Khaliq","suffix":""},{"id":448801852,"identity":"a79a9af2-b3a3-45f3-b6ca-c7b92ad51880","order_by":1,"name":"Shafin bin 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shunt placement and its association with the functional outcome","fulltext":[{"header":"Introduction","content":"\u003cp\u003eA disease known as hydrocephalus is defined by an abnormal buildup of cerebrospinal fluid (CSF) in the brain's ventricles, which can be caused by either excessive CSF production or poor absorption. It may develop later in life (acquired) or be present from birth (congenital) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Congenital hydrocephalus is further divided into two categories: non-communicative hydrocephalus, which happens when CSF drainage channels are blocked, and communicating hydrocephalus, in which the ventricular system is unharmed. Congenital hydrocephalus is brought on by several risk factors, such as infections, genetic disorders, preterm birth, and structural abnormalities such as Chiari malformations, Dandy-Walker malformations, neural tube defects, cerebral aqueduct stenosis, and corpus callosum agenesis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Pharmacological methods such as acetazolamide and surgical procedures like endoscopic third ventriculostomy and ventriculoperitoneal (VP) shunt implantation are used to treat hydrocephalus. The most popular and successful treatment among these is still VP shunt insertion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. To assist CSF drainage, a catheter is inserted into the brain's ventricular system, with its distal end placed in the peritoneal cavity. VP shunting improves neurological function and decreases ventricular size; these improvements are frequently assessed using radiological markers. These postoperative radiological findings, however, vary widely, which has sparked continuous discussion on their relationship to long-term functional outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Evans' index, the frontal horn to inter caudate distance (FH/IHD) ratio, temporal horn size, and cortical mantle thickness (CMT) are some of the important radiological characteristics that are used to evaluate hydrocephalus and forecast prognosis. The degree of parenchymal thinning brought on by prolonged ventricular enlargement is reflected in CMT; higher thinning is linked to worse neurological outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A common indicator of ventricular enlargement is Evans' index, which is determined by dividing the greatest width of the frontal horns by the maximum biparietal diameter. Higher values of this index signify more severe hydrocephalus and a poorer prognosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Another measure of ventricular volume is the FH/IHD ratio; larger values indicate more ventricular dilatation and the detrimental consequences it has on deep brain structures and neurodevelopment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A common early indicator of hydrocephalus is temporal horn enlargement, which usually occurs before other ventricular areas dilate. After shunt surgery, persistent temporal horn dilatation could indicate poor shunt function or insufficient CSF diversion [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although these radiological markers offer important information on the course of hydrocephalus and the effectiveness of treatment, there is ongoing discussion regarding their prognostic utility. A more thorough approach to patient evaluation is required, as some research indicates that gains in neurological function do not necessarily follow ventricular size reduction following shunting [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To improve understanding of prognosis in the management of hydrocephalus, this study intends to examine changes in these radiological markers and their relationship to functional results.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design:\u003c/h2\u003e \u003cp\u003e The study was conducted in the neurosurgery department of Jinnah Post Graduate Medical Centre, a tertiary care hospital in Karachi, using a retrospective cross-sectional research methodology. It comprised 50 congenital hydrocephalus patients who were prospectively recruited and monitored for a year between 02-08-2021 and 02-08-2022. Participants were chosen at random from the neurosurgery department of Jinnah Post-Gradual Medical Center in Karachi.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCriteria for inclusion:\u003c/h3\u003e\n\u003cp\u003ePatients with congenital hydrocephalus, regardless of gender (male or female), have voluntarily consented after being informed that their personal information will be kept anonymous and that no publications will utilize it.\u003c/p\u003e\n\u003ch3\u003eExclusion criteria:\u003c/h3\u003e\n\u003cp\u003ePatients without consent, adult populations, patients admitted in other facilities apart from Jinnah Postgraduate Medical Center, children with other congenital defects, and people who do not meet the requirements for congenital hydrocephalus are among the exclusion criteria.\u003c/p\u003e\n\u003ch3\u003eMethods of Data Collection:\u003c/h3\u003e\n\u003cp\u003eWith institutional review board consent, data was gathered at the neurosurgery department. Each patient's age, gender, and the cause of their hydrocephalus were gathered from their hospital records, along with information about their history and radiological tests, which included measurements of the temporal horn's size, Evan's ratio, FH/ID ratio, and cortical mantle thickness.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003eUsing SPSC 23.0, the data was examined after a year of patient follow-up. Descriptive statistics (mean, standard deviation) were employed to compile participant attributes such as cortical mantle thickness, Evan's ratio, FH/ID ratio, and temporal horn size.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e1. Study Population and Demographics:\u003c/h2\u003e\n \u003cp\u003eThe study included 50 individuals in all, whose mean age was 6.8 months. There was a greater percentage of females in the study population, as evidenced by the fact that 18 (36%) of the participants were male and 32 (64%) were female. Evans ratio, cortical mantle thickness, FH/ID ratio, and temporal horn size were the four main radiological characteristics that were the focus of the analysis, and changes were evaluated throughout a one-year follow-up period. The overview of observed changes in all outcomes is highlighted in \u003cstrong\u003eTable No. 1.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable no.1 Summary of Observed Changes in Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIncrease (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo Change (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDecrease (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCortical Mantle Thickness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEvans Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFH/ID Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTemporal Horn Size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003e2. Changes in Evans Ratio\u003c/h3\u003e\n\u003cp\u003eIn 29 individuals, the Evans ratio, a crucial measure of ventricular enlargement dropped, indicating a general decrease in ventriculomegaly. Seven patients (14%) had no discernible change, whereas 14 patients (28%) displayed an increase, suggesting possible hydrocephalus development. These changes were confirmed to be non-random by the chi-square test, which revealed a highly significant difference (p\u0026thinsp;=\u0026thinsp;0.00051). Although a small percentage of patients showed worsening ventricular dilatation, the large percentage of patients who experienced a decrease indicates an overall favorable outcome. The variations in the Evans ratio are shown in \u003cstrong\u003eTable No. 2 and Graph No. 1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable no.2: Evans Ratio\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChange Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncrease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecrease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSignificance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.00051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHighly Significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3. Changes in Cortical Mantle Thickness\u003c/h2\u003e\n \u003cp\u003eIn 14 patients (28%), cortical mantle thickness, a measure of brain parenchymal preservation increased, suggesting possible neuroprotection or brain tissue recovery. On the other hand, 7 patients (14%) showed a decline, indicating a development of cortical thinning associated with hydrocephalus. 29 individuals, or 58% of the total, did not exhibit any discernible change. The validity of these findings was supported by statistical analysis, which showed a highly significant difference (p\u0026thinsp;=\u0026thinsp;0.00051). Although the decrease in 14% of cases is still concerning, the increase in cortical thickness in 28% of patients is a positive sign. \u003cstrong\u003eFigure No. 2 and Table No. 3\u003c/strong\u003e display the thickness of the cortical mantle.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable no.3 Cortical Mantle Thickness Changes\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tabc\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChange Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncrease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecrease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSignificance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.00051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHighly Significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e4. Changes in FH/ID Ratio\u003c/h2\u003e\n \u003cp\u003eFifteen patients (30%) had a decrease in the frontal horn to interhemispheric distance (FH/ID) ratio, indicating improved ventricular dimensions. Throughout the trial, 28 patients (56%) exhibited no discernible change, while 7 individuals (14%) displayed an increase. A significant difference was confirmed by the chi-square test (p\u0026thinsp;=\u0026thinsp;0.00118), suggesting that variations in the FH/ID ratio followed a significant pattern. Compared to the Evans ratio and cortical thickness, the FH/ID ratio may be less vulnerable to short-term fluctuations, as indicated by the high percentage of patients (56%) who showed no change. \u003cstrong\u003eFigure No. 3 and Table No. 4\u003c/strong\u003e display the fd/ihd ratio.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable no.4: FH/ID Ratio Changes\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tabd\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChange Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncrease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecrease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSignificance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.00118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e5. Changes in Temporal Horn Size\u003c/h2\u003e\n \u003cp\u003e17 patients (34%) had a decrease in temporal horn size, indicating an improvement in the distribution of CSF. The outcomes of the remaining patients, however, were inconsistent, making it difficult to distinguish between those who had an increase and those who did not. The absence of a significant chi-square result precludes drawing firm conclusions about the overall effect, even if a size reduction is usually advantageous. To evaluate the clinical importance of temporal horn size changes, more research is required that includes exact categorization. Changes in temporal horn size are displayed in \u003cstrong\u003eTable No. 5 and Figure No. 4.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable No. 5: Temporal Horn Size Changes\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tabe\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChange Type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReduced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther Variations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaried\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSignificance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot Statistically Significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e6. Interpretation of Chi-Square Test Results\u003c/h2\u003e\n \u003cp\u003eTo ascertain if the observed changes in the Evans ratio, cortical mantle thickness, and FH/ID ratio were statistically significant rather than random fluctuations, the chi-square (\u0026chi;\u0026sup2;) test was employed. The findings demonstrated that all three measures changed significantly throughout the follow-up period, confirming that there were significant changes in ventricular size, brain tissue thickness, and CSF distribution. A robust trend of improvement was confirmed by extremely significant changes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.00051) in the Evans ratio and cortical mantle thickness. Although most patients (56%), the FH/ID ratio also showed substantial volatility (p\u0026thinsp;=\u0026thinsp;0.00118), indicating that this parameter may be less sensitive to short-term impacts. Chi-square test results are displayed in \u003cstrong\u003eTable No. 6.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable No. 6: Chi-Square Test Results\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tabf\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChi-Square Value (\u0026chi;\u0026sup2;)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEvans Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCortical Mantle Thickness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFH/ID Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo better understand the impact of several radiological measures in post-ventriculoperitoneal shunt (VP) implantation in congenital hydrocephalus and how they relate to functional results, we conducted this study. Evans ratio, cortical mantle thickness (CMT), (fd/ihd) ratio, and temporal horn size were the main focus of this investigation, which was carried out in a tertiary care hospital. The findings showed notable variations in these indices over 12 months, with differing degrees of influence on the preservation of brain tissue and the reduction of ventricular size.\u003c/p\u003e \u003cp\u003eAn essential indicator for forecasting ventricular hypertrophy is the Evans ratio. The majority of the patients in our study had an overall decrease in ventricular volume in addition to improved functional results. Tisell et al. have reported similar results, demonstrating a decrease in ventricular size but no discernible improvement in cognitive outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, Novak et al. demonstrated a comparable improvement in ventricular volume and neurological results, but they also emphasized the importance of other parameters, such as cerebral perfusion and periventricular edema, in enhancing neurological outcomes rather than only the Evans index [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Limbrick et al., on the other hand, demonstrated a comparable decrease in ventricular size but no improvement in functional outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This implies that there is no correlation between cognitive reaction and ventricular size alone. The extremely statistically significant difference (p = 0.00051), however, indicates that these results were not the result of chance. Another endpoint that was evaluated for our study was Cmt. It is a sign of ventricular enlargement-induced cerebral compression. A third of the population showed a rise in CMT, according to our survey, while the majority showed no change. In a similar vein, Vinchon et al. showed a stronger neurological response and a notable rise in CMT [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. McGovern et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] demonstrated a partial manifestation of this impact, demonstrating a decrease in ventricular size without improving neurological state. Given that patients with chronic hydrocephalus did not exhibit any improvement in their neurological state following shunt surgery, this underscored the importance of prompt intervention. As McAlister et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] show, this effect is also important in situations when CMT was not raised after surgery. In a similar vein, Kulkarni et al. reported neurological improvement despite no change in CMT. Chong et al. also observed this effect, showing that although some patients had changes in CMT, others did not, indicating the involvement of other factors like cerebral perfusion and white matter integrity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother measure of ventricular capacity was the Fh/ihd ratio. The bulk of the patients in our study showed no response, whereas one-third of the population responded favourably. These results are consistent with those of Coenen et al., who found high preoperative FH/ID ratios were associated with neurodevelopmental impairment. However, postoperative alterations did not always indicate functional recovery because deep brain areas may sustain irreparable damage even with CSF diversion [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Kim et al. also exhibited similar results, demonstrating that improvement in neurological state is not predicted by the extent of reduction. Furthermore, he emphasizes that the fh/ihd ratio should be assessed in conjunction with periventricular edema and white matter integrity rather than being utilized as a stand-alone metric [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Greater percentages of the unchanging ratio, however, imply that this statistic may not be as sensitive as others. A common early sign of hydrocephalus is temporal horn growth. While some patients experienced a decrease in temporal horn size, the majority of our patients experienced a range of outcomes. Kulkarni et al. recently brought attention to these discrepancies by showing that shunt revision rates are increased by prolonged post-operative temporal horn dilatation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. []. Similarly, Novak et al. said that this metric is not a reliable indicator of neurological condition because of the irregularities they found in it [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Changes in temporal horn size were not statistically significant, in contrast to Evans' ratio and CMT, indicating that this metric by itself could not be a trustworthy prognostic indicator as proposed by Novak et al.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eIt is important to recognize the limitations of our study, even if it offers important insights into the link between radiological measures and functional outcomes after ventriculoperitoneal (VP) shunt installation in congenital hydrocephalus. First off, we only used a small sample size and only one tertiary care hospital for our study. This could restrict our findings' applicability to broader, more varied groups. Our findings need to be confirmed by bigger cohorts in future multicentre research. Second, our study only tracked patients for a year after surgery, which might not be enough time to record long-term neurological effects and problems from the shunt. Over time, some functional gains or deteriorations might become apparent. Thirdly, we mostly used standard MRI and CT data, which might not adequately represent changes in the microstructure of the brain, cerebral perfusion, or white matter integrity. More sophisticated methods like phase-contrast MRI, functional MRI, or diffusion tensor imaging (DTI) may offer a more thorough picture of brain recovery following a shunt. Last but not least, we did not fully analyze confounding clinical variables, such as patient comorbidities, shunt revisions, intracranial pressure (ICP) monitoring, and genetic impacts. Future research must include a more thorough clinical evaluation because these factors may have a substantial impact on both radiological alterations and functional recovery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe limits of utilizing ventricular size alone to predict functional recovery are highlighted by this study, which also emphasizes the heterogeneity in radiological responses after VP shunt insertion. Although metrics like Evans' ratio, CMT, FH/ID ratio, and temporal horn size offer insightful information, there is still inconclusive evidence linking them to therapeutic improvement. To improve prognosis and customize hydrocephalus treatment to meet the needs of each patient, multimodal assessment techniques that integrate radiographic, clinical, and biomarker-based evaluations are crucial.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCMT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecortical mantle thickness\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eFd/ihd\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efrontal horn to interhemispheric distance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eVp\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eventriculoperitoneal shunt\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIcp\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintracranial pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCsf\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecerebrospinal fluid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was approved by the institutional review board at Jinnah Postgraduate Medical Center on 6\u003csup\u003eth\u003c/sup\u003e November 2023 and the reference number is F.2/81/2023-GENL/185/JPMC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe consent was taken from the patients' parents and those who refused were omitted from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have a competing interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no extramural funding for this meta-analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTK and SBA assisted in the data collection process, JJ carried out the analysis, SBA, RA, and AB did the manuscript writing, TK edited the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTully HM, Capote RT, Saltzman BS (2015) Maternal and infant factors associated with infancy-onset hydrocephalus in Washington State. Pediatr Neurol 52(3):320\u0026ndash;325. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pediatrneurol.2014.10.030\u003c/span\u003e\u003cspan address=\"10.1016/j.pediatrneurol.2014.10.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang Y-H, Wu Q-J, Chen Y-L et al (2018) Trends in the prevalence of congenital hydrocephalus in 14 cities in Liaoning Province, China from 2006 to 2015 in a population-based birth defect registry from the Liaoning Women and Children\u0026rsquo;s Health Hospital. Oncotarget 9(18):14472\u0026ndash;14480\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang J, Williams MA, Rigamonti D (2006) Genetics of human hydrocephalus. J Neurol 253(10):1255\u0026ndash;1266\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKahle KT, Kulkarni AV, Limbrick DD et al (2016) Hydrocephalus in children. Lancet 387(10020):788\u0026ndash;799\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulkarni AV, Donnelly R et al (2018) Predicting shunt failure in pediatric hydrocephalus. J Neurosurg Pediatr 21(3):214\u0026ndash;223\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGovern RA, Casella DP et al (2022) Ventricular volume and outcome after shunt placement. Neurosurgery 90(4):550\u0026ndash;558\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTisell M, Tullberg M, Hellstr\u0026ouml;m P et al (2006) Shunt surgery in idiopathic normal pressure hydrocephalus: Outcome and CSF dynamics. J Neurosurg 105(5):812\u0026ndash;818\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiva-Cambrin J et al (2012) The relationship between ventricular size and neurocognitive outcomes in pediatric hydrocephalus. Neurosurgery 71(2):289\u0026ndash;295\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarton HJL, Piatt JH et al (2018) CSF dynamics and functional outcome in congenital hydrocephalus. J Neurosurg Pediatr 22(4):455\u0026ndash;462\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVinchon M et al (2019) Cognitive outcome in congenital hydrocephalus: Influence of treatment parameters. Childs Nerv Syst 35(7):1145\u0026ndash;1153\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLimbrick DD et al (2017) Shunt outcomes and neurological function in congenital hydrocephalus. J Pediatr Neurosurg 53(3):119\u0026ndash;127\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNowak KR et al (2022) The role of MRI biomarkers in predicting functional recovery after VP shunting. J Neurosurg Pediatr 29(2):220\u0026ndash;229\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcAllister JP (2008) Pathophysiology of congenital and neonatal hydrocephalus. Semin Pediatr Neurol 15(1):50\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.spen.2008.03.008\u003c/span\u003e\u003cspan address=\"10.1016/j.spen.2008.03.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChong CS et al (2020) White matter integrity and functional recovery in hydrocephalus. J Neurosurg 132(4):987\u0026ndash;995\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoenen VA et al (2021) Functional neuroimaging in hydrocephalus: Advances and future directions. Neurosurg Rev 44(2):653\u0026ndash;665\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim DS, Choi JU, Huh R (2007) The causal relationship of the hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 42(3):174\u0026ndash;178\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6306501/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6306501/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eCerebrospinal fluid (CSF) buildup in the brain's ventricular system is a hallmark of congenital hydrocephalus, which can result in elevated intracranial pressure and possible neurological damage. The major surgical procedure for removing extra CSF and releasing pressure is still ventriculoperitoneal (VP) shunting. It is still up for debate, nevertheless, whether functional results and radiological improvements following shunting are related. The objective of this research is to examine the relationship between neurological outcomes and changes in Evans' ratio, cortical mantle thickness (CMT), frontal horn to inter caudate distance (FH/ID) ratio, and temporal horn size after surgery.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003e Fifty patients with congenital hydrocephalus who had VP shunting participated in this retrospective cross-sectional study, which was carried out at Jinnah Postgraduate Medical Centre in Karachi. Preoperative and postoperative radiological measurements were among the data gathered from medical records during a one-year follow-up. The chi-square test was used to determine the significance of the statistical analysis, which was carried out using SPSS 23.0.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eSignificant decreases in ventricular size were indicated by significant decreases in Evans' ratio (58% of patients, p\u0026thinsp;=\u0026thinsp;0.00051). While 14% showed further thinning, 28% of patients showed a rise in CMT, indicating possible brain tissue recovery. Thirty percent of instances had an improvement in the FH/ID ratio, whereas 56 percent saw no change. Although there were differences in response, 34% of patients experienced a decrease in temporal horn size.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eAlthough VP shunting successfully shrinks the ventricle, there is still inconclusive evidence linking it to neurological improvement. The results indicate that ventricular size by itself is not a reliable prognostic indicator, underscoring the necessity of multimodal evaluations that consider cerebral perfusion and white matter integrity to improve patient care and make more accurate predictions.\u003c/p\u003e","manuscriptTitle":"Analysis of variation in radiological parameters in congenital hydrocephalus after ventriculoperitoneal shunt placement and its association with the functional outcome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 20:16:16","doi":"10.21203/rs.3.rs-6306501/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fefcce42-9999-462f-86ce-f9f677e35bc9","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T08:43:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-08 20:16:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6306501","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6306501","identity":"rs-6306501","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}