Surgical outcomes and co-morbidities among all-cause paediatric hydrocephalus patients in Eastern Denmark

Surgical outcomes and co-morbidities among all-cause paediatric hydrocephalus patients in Eastern Denmark | 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 Surgical outcomes and co-morbidities among all-cause paediatric hydrocephalus patients in Eastern Denmark Anna Duc, Marveh Dokhi, Frederikke Guldberg, Elsebet Østergaard, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4489379/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 Purpose The aim of this study was to provide granular descriptions of aetiologies of hydrocephalus and concurrent conditions. Furthermore, to describe the short-term effect of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) on preoperative symptoms and to estimate the risks of shunt revision, conversion of ETV to shunt, and the risks of complications. Methods A retrospective, single-centre study was performed among children who underwent shunt insertion or ETV for hydrocephalus between December 1st, 2016 and December 31st, 2021. Information regarding course of disease, surgical treatments, and comorbidities were registered from the digital patient records. The risks of conversion of treatment modality and shunt revision were estimated as cumulative incidences (CI’s) after 30-days, 3-, and 12 months. Results A total of 89 children with either obstructive (OH) (65%) or communicating (CH) (35%) hydrocephalus were surgically treated with VPS or ETV. Neurological disorders (CH 29%, OH 26%) and genetic conditions (CH 36%, OH 16%) were frequent concurrent conditions. Increased head size (74%) and symptoms of elevated intracranial pressure (57%) were the most common preoperative symptoms. Treatment with VPS entailed a 13.7% failure rate for OH and 9.7% for CH, whereas ETV displayed 14.3% failure rate, all reflecting failure of alleviating the preoperative clinical symptoms. The cumulative 1-year risk of shunt revision was 67%, most often due to valve dysfunction (28%), disconnection (14%), and shunt displacements (12%). Conclusion The considerable risks of treatment failure and complications call for improvements in treatment based on a better understanding of the heterogenic mechanisms of disease. Hydrocephalus paediatric ventriculoperitoneal shunt endoscopic third ventriculostomy. Figures Figure 1 Background Hydrocephalus is a complex and heterogeneous condition, frequently occurring with various comorbidities, which can influence the effect of the surgical treatment. Hydrocephalus is defined as ventriculomegaly with increased intraventricular volume due to disturbance of cerebrospinal fluid (CSF) formation, flow, or absorption, potentially causing life-threatening increased intracranial pressure (ICP) [ 1 , 2 ]. Paediatric hydrocephalus encompasses congenital and acquired aetiologies, categorized as either communicating or obstructive hydrocephalus [ 3 ]. The most common causes of congenital hydrocephalus are brain malformations, spina bifida, and aqueductal stenosis [ 4 ]. The global prevalence of hydrocephalus in children under 18 years is 88/100,000 [ 5 ]. In Denmark, hydrocephalus occurs in 1.1/1000 live-born children [ 6 ]. Common surgical interventions for paediatric hydrocephalus include endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS). Insertion of VPS is highly associated with complications such as obstruction, infection, or failure [ 7 ], with a high revision rate of 42.6% within 3 years after initial shunt placement [ 8 ], and a cumulative 1-year risk of 50% in children under 2 years [ 9 ]. ETV sometimes combined with choroid plexus cauterization, has emerged as the primary surgical approach for visible obstruction in recent years [ 10 , 11 ][ 12 ]. Factors influencing the choice between ETV and VPS include aetiology, age, anatomy, and surgeon expertise. While both procedures have demonstrated promising results, a significant debate persists regarding their comparative effectiveness and safety in paediatric patients [ 13 – 16 ]. Re-evaluating surgical outcomes is crucial, focusing on clinical improvement. While the risk of shunt revision and treatment modality conversion are common measures for outcome, they do not necessarily reflect clinical effect on preoperative symptoms [ 9 , 17 ]. Thus, lack of shunt revision would be designated as a successful outcome; however, such “success” does not necessarily reflect positive effect on preoperative symptoms. Especially not if the preoperative symptoms were not clearly assigned to increased ICP. Describing concurrent comorbidities is important, as they may confound the primary outcome and predispose to complications such as shunt infections or revisions. Hydrocephalus treatment is still limited to two relatively simple surgical principles despite the diversity in aetiologies, age, clinical and anatomical presentations. Accounting for these factors may help in the choice of the best possible first-time treatment option for each patient. Purpose Based on these considerations, this study aimed to provide granular descriptions of various aetiologies of hydrocephalus and concurrent conditions, while assessing short- and long-term treatment outcomes. Short-term failure was measured as the immediate clinical response during admission after primary treatment. Furthermore, risk of shunt revision or conversion of ETV to VPS within a follow-up period of 1 year was estimated for all. The subset of patients with available data were included in a sub analysis of the risk of ETV-conversion/shunt revision up to 13 years after primary surgical intervention. Methods Study design This study is a single-centre, retrospective observational study. Data source In the Capital Region of Denmark, medical records are stored as electronic health records (EHR) (Epic®,). The EHR was implemented on December 1st, 2016, containing all records from healthcare personnel, laboratory data, and imaging studies performed since the implementation. Study population All congenital hydrocephalus patients aged 0–18 years at the time of first surgery, who underwent shunt insertion, shunt revision, or endoscopic third ventriculostomy for hydrocephalus at the University Hospital of Copenhagen between December 1st, 2016, and December 31st, 2021, were included. Patients were identified from the surgical work board in the EHR. Only patients with available clinical information from the point of diagnosis to 12 months after primary surgery were included. If available, information on later treatment failures were collected for a sub analysis of treatment failure beyond the first postoperative year. Patients with incomplete clinical information on follow-up were excluded, which was either due to home address abroad or replacement of the file system in 2016. Data collection We recorded patient demographics including date of birth, sex, onset age, pre-operative symptoms, comorbidities, results from genetic analyses, hydrocephalus subtype, and aetiology. Furthermore, treatment details including age of initial surgery, treatment modality, clinical outcome, surgical complications, and revisions were recorded. Outcomes The main outcome was treatment failure defined as persistent or worsened clinical symptoms or the need for additional surgery within the same hospital admission. This was distinguished from treatment success defined as resolution or improvement of symptoms following the hospital stay. Statistical analyses We estimated the risks of insufficient clinical effect of VPS on obstructive hydrocephalus (OH) versus communicating hydrocephalus (CH) as an odds ratio with 95% confidence intervals using Fischer’s Exact Probability Test. We estimated the cumulative incidence (CI) for shunt revision after 30-days, 3-, and 12 months. Genetic analyses Some patients had extensive genetic analyses performed based on their clinical presentations. These included whole exome sequencing (WES) for both children and their parents, often referred to as trios, whole genome sequencing (WGS), chromosome microarray, chromosome analysis, as well as specific gene or panel analyses targeting specific gene(s). All analyses were according to local protocols. Ethics The legal office at Copenhagen University Hospital and the regional Scientific Ethics Committee’s approved the study. Personal data was pseudo-anonymized to ensure data protection. The data was handled and stored in accordance with regulations set by The Danish Data Protection Agency and the General Data Protection Regulations (GDPR). Results A total of 128 patients with congenital hydrocephalus were identified and screened for eligibility. Thirty-nine did not meet the inclusion criteria of available clinical information from the point of diagnosis to 12 months after the primary surgery, resulting in 89 patients. They were classified into 58 patients with OH and 31 with CH. Table 1 presents demographic and clinical data of those. Table 1 Patient characteristics for children treated for hydrocephalus Obstructive hydrocephalus Communicating hydrocephalus Aqueductal stenosis Tumor Cyst Perinatal IVH Chiari Dandy Walker Total Idiopathic MMC Perinatal IVH Total N % N % N % N % N % N % N % N % N % N % N % N 14 15.7 28 31.5 6 6.7 3 3.4 2 2.2 5 5.6 58 65.2 16 18.0 6 6.7 9 10.1 31 34.8 Sex (Female) 9 64.3 10 35.7 4 66.7 2 66.7 0 0.0 3 60.0 28 48.3 7 43.8 4 66.7 3 33.3 14 45.2 Age group distribution Prenatal 4 28.6 2 7.1 1 16.7 2 66.7 0 0.0 2 40.0 11 19.0 1 6.3 4 66.7 1 11.1 6 19.4 < 1 year (months) 6 42.9 5 17.9 4 66.7 1 33.3 2 100.0 2 40.0 20 34.5 9 56.3 2 33.3 7 77.8 18 58.1 1–2 years (months) 0 0.0 5 17.9 1 16.7 0 0.0 0 0.0 1 20.0 7 12.1 1 6.3 0 0.0 0 0.0 1 4.5 3–10 years 2 14.3 10 35.7 0 0.0 0 0.0 0 0.0 0 0.0 12 20.7 5 31.3 0 0.0 0 0.0 5 22.7 10–17 years 2 14.3 6 21.4 0 0.0 0 0.0 0 0.0 0 0.0 8 13.8 0 0.0 0 0.0 0 0.0 0 0.0 Median age (years) Age range (years) 3.5 prenatal-15 5.9 prenatal-16 0.6 prenatal-1 0.1 prenatal-0 0.4 0–1 0.8 prenatal-1 1.9 prenatal-16 1.5 prenatal-5 0.1 prenatal-0 0.1 prenatal-0 3.3 prenatal-5 Pre-operative symptoms Increased head size 9 64.3 6 21.4 6 100.0 2 66.7 1 50.0 4 80.0 28 48.3 15 93.8 3 50.0 5 55.6 23 74.2 Symptoms of high ICP 8 57.1 20 71.4 2 33.3 0 0.0 1 50.0 2 40.0 33 56.9 5 31.3 1 16.7 5 55.6 11 35.5 Delayed motor skills 3 21.4 3 10.7 3 50.0 1 33.3 0 0.0 2 40.0 12 21.8 8 50.0 0 0.0 0 0.0 8 25.8 Delayed cognitive development 4 28.6 1 3.6 0 0.0 0 0.0 0 0.0 0 0.0 5 8.6 3 18.8 0 0.0 0 0.0 3 9.7 Failure to thrive 1 7.1 6 21.4 2 33.3 0 0.0 0 0.0 0 0.0 9 15.5 3 18.8 0 0.0 1 11.1 4 12.9 Reduced vision 2 14.3 9 32.1 1 16.7 0 0.0 0 0.0 0 0.0 12 20.7 2 12.5 0 0.0 0 0.0 2 6.5 Reduced hearing 1 7.1 1 3.6 0 0.0 0 0.0 0 0.0 0 0.0 2 3.4 0 0.0 Comorbidities Neurological diseases 7 50.0 3 10.7 2 33.3 0 0.0 1 50.0 2 40.0 15 25.9 3 18.8 1 16.7 5 55.6 9 29.0 Chronic heart, lung, & kidney diseases 2 14.3 3 10.7 0 0.0 0 0.0 0 0.0 0 0.0 5 8.6 0 0.0 2 33.3 0 0.0 2 6.5 Genetic conditions 2 14.3 3 10.7 0 0.0 0 0.0 0 0.0 4 80.0 9 15.5 5 31.3 0 0.0 3 33.3 8 35.5 Neuropsychiatric diseases 0 0.0 2 7.1 0 0.0 0 0.0 1 50.0 0 0.0 3 5.2 3 18.8 0 0.0 1 11.1 4 12.9 Bone and connective tissue diseases 0 0.0 0 0.0 1 16.7 0 0.0 0 0.0 0 0.0 1 1.7 0 0.0 1 16.7 1 11.1 2 6.5 Immune deficiency 0 0.0 0 0.0 Recurring infections (pneumonia, sinusitis) 0 0.0 0 0.0 Abbreviations: IVH, intraventricular hemorrhage; MMC, myelomeningocele; ICP, intracranial pressure. Aetiology As seen from Table 1 , tumour and idiopathic aqueductal stenosis (AS) comprised the most frequent causes of OH, whereas idiopathic and perinatal intraventricular haemorrhage (IVH) were the most common causes of CH. Sex and age The sex distribution showed a slight preponderance for males (51.7% for OH and for 54.8% for CH). The mean onset age for OH was notably younger at 1.9 years compared to CH at 3.3 years. All subgroups contained patients diagnosed with hydrocephalus prenatally, except Chiari malformations (CM) with 0.4 years as the youngest age at diagnosis. AS and tumour had the broadest age range for diagnosis from prenatal to 15 years and prenatal to 16 years, respectively. Preoperative symptoms The most frequent preoperative symptom across the aetiologic subgroups was macrocephaly, except in tumour patients, accounting for 74.2% with CH and 48.3% with OH. In tumour patients, symptoms of elevated ICP were the most frequent symptom (71.4%), followed by reduced vision (32.1%), failure to thrive, and macrocephaly (21.4%). Symptoms of elevated ICP were considerably more frequent in patients with OH (56.9%) compared to CH (35.5%). Patients with AS primarily presented with elevated ICP (57.1%) and increased head circumference (64.3%). The occurrence of delayed motor skills was seen almost equally in patients with OH (21.8%) and patients with CH (25.8%). Reduced vision was observed in three subgroups of OH: tumour (32.1%), intracranial cysts (16.7%), AS (14.3%), and idiopathic hydrocephalus regarding CH. Patients with AS (28.6%) and idiopathic CH (18.8%) were often described with delayed cognitive development. Only two patients displayed reduced hearing, one with AS (7.1%) and one tumour patient (3.6%). The obstructive (15.5%) and the communicating hydrocephalus group (12.9%) almost equally displayed failure to thrive. Comorbidities Neurologic and neurodevelopmental The most frequent comorbidities were neurological diseases, occurring in 25.9% of patients with OH and 29.0% of patients with CH. Neurological diseases encompassed epilepsy, tetraplegia, dyskinetic cerebral palsy, paresis, dystonia, and cranial nerve palsies. Neurological comorbidity was present in all subgroups, the only exception being OH due to perinatal IVH. Among the 89 patients, seven were diagnosed with neuropsychiatric disorders: four with attention deficit and hyperactivity disorder (ADHD) and three with infantile autism combined with intellectual disability. Of patients with ADHD, two were in the tumour group, and two had idiopathic CH. The autism patients each presented with distinct underlying aetiology comprising; CM, idiopathic CM, and perinatal IVH with CH. Comorbidities outside CNS Seven patients had chronic heart, lung, or kidney disease (14%). Three tumour patients had hydronephrosis, asthma, and tracheal stenosis, respectively. Among the subgroup of AS, one had nephrotic syndrome, and another patient presented with asthma and aortic stenosis. Of the patients with myelomeningocele (MMC), one had anal atresia and pulmonary hypoplasia, and another had both bowel atresia and renal agenesis. Genetic conditions Of the 89 patients, 36 (40.4%) underwent genetic testing, 16 with OH and 20 with CH. Of the 36 patients tested, 15 (43.2%) presented with one or two genetic findings. Among these, eight patients had CH and seven had OH. Three patients displayed distinct copy number variations: trisomy 8 mosaicism, a 2 Mb deletion involving the ZIC2 gene on chromosome 13, and a 3.2 Mb deletion on chromosome 3, whose direct association with hydrocephalus remains uncertain. The remaining patients had different pathogenic single gene variants. Two had a COL4A1 variant associated with hydrocephalus and cerebral hemorrhage. Crouzon syndrome associated with hydrocephalus was observed in one patient with a pathogenic variant in FGFR2 . One patient had neurofibromatosis type 1 and one patient was mosaic for a variant in NF2 , associated with neurofibromatosis type 2. A homozygous PLG variant caused plasminogen deficiency in one patient and one patient had a PTEN variant associated with macrocephaly and autism syndrome. A pathogenic variant in G6PD was found in a male patient, but it was uncertain if it explained the hydrocephalic phenotype. Additional findings in four patients included heterozygous variants in PDGFB and FLNC in both sibs of a twin pair, a SHOX deletion, and a 45,X/46,XY mosaicism. However, these variations were not established as the direct cause of hydrocephalus. Furthermore, one patient with several structural brain abnormalities including subependymal heterotopia and demyelination and one patient with PHACE syndrome did not undergo genetic testing. Treatment modalities Table 2 presents the distribution of the primary treatment modality varied among the subgroups. In cases of OH, 51 patients (88%) received a VPS, while the remaining seven (12%) underwent ETV. All 31 with CH received a shunt. Table 2 The frequency of either ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy (ETV) as first surgical intervention for patients with either obstructive or communicating hydrocephalus. Obstructive hydrocephalus (%) Communicating hydrocephalus (%) Total VPS 51 (62) 31 (38)) 82 (100) ETV 7 (100) 0 (0.0) 7 (100) Total 58 31 89 Failure rates Table 3 presents failure rates for short-term treatment outcome in hydrocephalus subgroups after initial treatment. The overall failure rate regardless of treatment type was 12.4%. Shunt failure rates were higher for OH (13.7%) compared to CH (9.7%). Patients treated endoscopically had a failure rate of 14.3%, however based on only one event with AS at the age of 14 when operated. Table 3 Failure rates measured as persistent or worsening of clinical symptoms and/or repeated surgery within the same hospital admission for patients with obstructive (OH) and communicating hydrocephalus (CH), according to treatment modality of primary surgery (ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy (ETV)). Total (%) Failure (%) Odd's ratio (95% CI) P-value All surgical interventions 89 (100) 11 (12.4) - - - VPS on OH 51 (57) 7 (13.7) 0.68 (0.16–2.82) 0.74 VPS on CH 31 (35) 3 (9.7) ETV on OH 7 (8) 1 (14.3) - - - Shunt revisions All included were followed for at least one year after initial shunt placement. The analysis included 76 patients, excluding 13 individuals with a follow-up of less than 1 year. 51 underwent revision within follow-up (67%), of which 12 (23%) had one revision, 7 (14%) had 2 revisions and 4 (8%) had 3 or more revisions (Table 4 ). The median revision rate was 2.9 during follow-up (range 0–8), and median time from primary shunt operation until first revision was 23.4 months (range 1 day − 83 months). Table 4 The number of patients who underwent shunt revision (51 patients, 67%) with a follow-up period of at least one year, listed as the number of shunt revisions within the first year after initial insertion. Thirteen patients, who were followed for less than one year, were excluded. Revisions within 1 year No. % 0 28 55 1 12 23 2 7 14 3+ 4 8 Total 51 100.0 Causes of shunt revision are presented in Table 5 . Apart from elective shunt revision due to growth (24%), the most frequent causes were mechanical shunt dysfunction (28%), mostly due to obstruction of the valve. Disconnection (14%) and shunt displacements (12%) were other frequents causes. Four patients had displacement of the ventricular catheter and two patients of the abdominal catheter. The four patients with over drainage (8%) underwent revisions by switching to higher pressure valves (adjustable or non-adjustable). Table 5 The causes of initial peritoneal shunt revision in 51 paediatric hydrocephalus patients with the percentage distribution of each cause. No. % Shunt dysfunction 14 27.5 Elective change of shunt due to growth 13 25.5 Disconnection 7 13.7 Displacement 6 11.8 Infection 5 9.8 Over drainage 4 7.8 Other 2 3.9 Total 51 100.0 Discussion This retrospective single-centre study, with granular descriptions of 89, surgically treated paediatric hydrocephalus patients, highlights the extreme heterogenic aetiologic composition of paediatric hydrocephalus. The patients had many comorbidities, of which genetic conditions and neurological disorders were most frequent. Among patients tested for underlying genetic variation 40.0% of CH patients presented with genetic conditions versus 43.8% for OH. The results revealed that 12.4% had no clinical improvement or worsening of symptoms after treatment. During the follow-up period of 1–13 years, 67% underwent shunt revision and approximately half occurred within the first year after shunt placement (not including elective revisions due to growth). Comorbidities & genetic conditions Our study describes various comorbidities associated with hydrocephalus, primarily involving the central nervous system. Neurological disorders, particularly epilepsy, were the most common comorbidities in our study population. We found gene variants explaining hydrocephalus in 10 of 89 patients (11.2%), or in 27.8% of 36 patients with one or more genetic tests. Genetic conditions were heterogeneous and included both copy number and single gene variants, phenotypically manifesting with e.g. craniosynostosis, cerebral haemorrhage or plasminogen deficiency. We did not investigate how comorbidities impact mortality. A Danish nationwide register-based cohort study with follow-up from 1996–2015 reported that the non-tumour-related cumulative mortality remains high, primarily due to prevalent comorbidities. Shunt related deaths occurred mostly in those with severe comorbidities and postoperative infections. Only 3.2% of deaths were related to shunt malfunctions [ 9 ]. This is in line with findings in a retrospective study by Hannah et. al., who found that 76% of paediatric hydrocephalus mortality was caused by medical comorbidities, including respiratory complications of preterm birth, sepsis, and sudden death from epilepsy, rather than hydrocephalus itself [ 18 ]. Comorbidities coexisting with hydrocephalus correlate with mortality, making it crucial to address and manage these comorbidities for improved patient outcomes. Treatment modalities and complications Treating hydrocephalus is crucial to avoid severe neurologic complications and death, but the optimal treatment, especially in infants, remains discussed [ 14 , 19 – 26 ]. Few comparisons on surgical outcomes exist, primarily limited to retrospective studies [ 27 – 30 ]. Ventriculoperitoneal shunt VPS is a frequently performed neurosurgical procedure, especially in children [ 31 – 33 ]. However, it poses risks like shunt malfunction, migration, over drainage, infection, CSF leak [ 31 , 32 , 34 , 35 ], and abdominal complications, including pseudocyst formation, bowel perforation, and ileus [ 31 – 33 ]. Mechanical complications frequently cause shunt failure, accounting for up to 60% of overall complications [ 36 – 38 ]. Children under two years of age primarily experience mechanical failure due to ventricular catheter obstruction (63.2%), followed by distal catheter occlusion (23.5%), migration (8.8%), disconnection, (1.4%) and breaking of the shunt apparatus (1.4%) [ 37 ]. Ventricular catheter obstruction was most prevalent in infants below 1 month of age. In line with the literature, most of the revisions in this study were due to mechanical issues, including shunt dysfunction, disconnection, displacement, and over drainage. Infection represents a leading causes of shunt failure[ 39 – 41 ] and estimated as the most expensive [ 42 ]. In conclusion, only little improvement was found in our study based on data from 2016–2022, as compared to findings in the previously mentioned nationwide Danish cohort study based on data from 1996–2015. Endoscopic third ventriculostomy Only seven patients were treated with ETV as first choice in our study. By fenestrating the floor of the third ventricle and thereby draining cerebrospinal fluid to the basal cistern, shunt-related risks are eliminated [ 36 ]. While VPS treats both OH and [ 43 ], ETV is often recommended as the primary surgical treatment for OH [ 44 ]. However, ETV is a technically more complex procedure with higher risk of injury of adjacent structures or surgically induced haemorrhages [ 36 ]. Neurological complications in ETV range from 3–4%, while long-term complications are typically below 1% [ 45 , 46 ]. Even though our findings point toward ETV as a good alternative to VPS for OH, even in young children, the number of patients is insufficient to make firm conclusions. However, due to high revision rate for shunt hardware, ETV has also been advocated as a feasible or even superior treatment method in low- and middle-income countries [ 47 , 48 ]. Postoperative outcomes We found high shunt revision rates and a considerable risk of insufficient effect after primary surgery. Around half of the revisions occurred within the first year after initial surgery, with a median time from primary placement to first revision of 23.4 months. The success rate aligns with paediatric surgical series, in which shunt failures occur in 14% of patients within first month, and failure rates range from 4–50% within first year [ 31 ]. Kulkarni et. al. presented the first multi-centre, prospective comparison of ETV and VPS for infant hydrocephalus, reporting superior success rates for shunts at 3, 6, and 12 months, focusing on clinical outcome [ 49 ]. Baldauf et. al reported an overall success rate of 43% with AS and age above 1 year as positive prognostic factors [ 24 ]. A systematic review by Javadpur et. al. reported higher success rate for patients diagnosed with AS but insignificant effect of age comparing ETV in infants [ 23 ]. Customizing treatment involves considering age, aetiology, comorbidities, and possible complications. Limitation and strength of the study Strength of this study includes detailed granular clinical information of all patients and a complete baseline-follow-up of at least one year after primary surgery, although the limited sample size from single-centre data acquisition weakens statistical power. However, the majority of our results and conclusions align with other publications. Retrieving clinical information from non-standardized chart notes poses risks of inaccuracies in assessment of clinical information including presenting and outcome symptoms. However, revision rates are often used as a surrogate for outcome devoid of any information on symptoms and functionality. As surprisingly few publications report on true clinical outcome, this study adds important information on neurological outcome and co-morbidities. The transition to a new electronic health record system resulted in missing or insufficient data, making the study susceptible to selection bias. This predominantly affected the older paediatric group, as data before 2016 regarding disease and treatment were unavailable. Therefore, many patients in our study population were young. Conclusion The results of this study illustrate the extensive diversity in symptoms, aetiology, comorbidities, and outcomes of paediatric hydrocephalus. The heterogeneity possibly stems from various underlying factors, such as congenital anomalies, infections, or acquired conditions, requiring individualized treatment. The vast array of genetic aetiologies contributing to hydrocephalus necessitates extensive genetic screening to understand the diverse causes and underlying pathogenic mechanisms. Improved subclassification may pave the way for individualized treatment and lower failure rates of the primary surgery. Declarations Ethical approval The study has been approved by the hospital board as well as by The Regional Research Ethics Committees (H-22040623). Competing interests The authors have no conflicts of interest to declare that are relevant to the content of this article. Authors' contributions M.D. and A.D. drafted the primary manuscript with contributions from F.G. A.D. calculated all statistics under supervision from a biostatistician. T.M. was responsible for conceptualization, idea and supervision. All authors actively contributed to the interpretation of the results and the revisions of the primary manuscript. All authors approved the final version of the manuscript. Funding The authors have no relevant financial or non-financial interests to disclose. Availability of data and materials Data and program codes will not be available according to the Danish data agency. References Kahle KT, Kulkarni AV, Limbrick DD, Warf BC (2016) Hydrocephalus in children. 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Eur J Pediatr Neurol 26:7–14. https://doi.org/10.1016/j.ejpn.2020.02.011 Tully HM, Doherty D, Wainwright M (2022) Mortality in pediatric hydrocephalus. Dev Med Child Neurol 64:112–117. https://doi.org/10.1111/dmcn.14975 Fritsch MJ, Kienke S, Ankermann T et al (2005) Endoscopic third ventriculostomy in infants. J Neurosurg Pediatr 103:50–53. https://doi.org/10.3171/ped.2005.103.1.0050 Balthasar AJR, Kort H, Cornips EMJ et al (2007) Analysis of the success and failure of endoscopic third ventriculostomy in infants less than 1 year of age. Child’s Nerv Syst 23:151–155. https://doi.org/10.1007/s00381-006-0219-z Wagner W, Koch D (2005) Mechanisms of failure after endoscopic third ventriculostomy in young infants. J Neurosurg Pediatr 103:43–49. https://doi.org/10.3171/ped.2005.103.1.0043 Gorayeb RP, Cavalheiro S, Zymberg ST (2004) Endoscopic third ventriculostomy in children younger than 1 year of age. J Neurosurg Pediatr 100:427–429. https://doi.org/10.3171/ped.2004.100.5.0427 Javadpour M, Mallucci C, Brodbelt A et al (2001) The Impact of Endoscopic Third Ventriculostomy on the Management of Newly Diagnosed Hydrocephalus in Infants. Pediatr Neurosurg 35:131–135. https://doi.org/10.1159/000050406 Baldauf J, Oertel J, Gaab MR, Schroeder HWS (2007) Endoscopic third ventriculostomy in children younger than 2 years of age. Child’s Nerv Syst 23:623–626. https://doi.org/10.1007/s00381-007-0335-4 Kulkarni AV, Drake JM, Kestle JRW et al (2010) Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score. J Neurosurg Pediatr 6:310–315. https://doi.org/10.3171/2010.8.peds103 Kulkarni AV, Sgouros S, Leitner Y, Constantini S (2018) International Infant Hydrocephalus Study (IIHS): 5-year health outcome results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus. Child’s Nerv Syst 34:2391–2397. https://doi.org/10.1007/s00381-018-3896-5 Drake JM, Kulkarni AV, Kestle J (2009) Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in pediatric patients: a decision analysis. Child’s Nerv Syst 25:467–472. https://doi.org/10.1007/s00381-008-0761-y Kulkarni AV, Hui S, Shams I, Donnelly R (2010) Quality of life in obstructive hydrocephalus: endoscopic third ventriculostomy compared to cerebrospinal fluid shunt. Child’s Nerv Syst 26:75–79. https://doi.org/10.1007/s00381-009-0983-7 Rasul FT, Marcus HJ, Toma AK et al (2013) Is endoscopic third ventriculostomy superior to shunts in patients with non-communicating hydrocephalus? A systematic review and meta-analysis of the evidence. Acta Neurochir (Wien) 155:883–889. https://doi.org/10.1007/s00701-013-1657-5 Kulkarni AV (2011) Erratum: Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score. J Neurosurg Pediatr 7:221. https://doi.org/10.3171/2010.8.PEDS103a Wu Y, Green NL, Wrensch MR et al (2007) VENTRICULOPERITONEAL SHUNT COMPLICATIONS IN CALIFORNIA. Neurosurgery 61:557–563. https://doi.org/10.1227/01.NEU.0000290903.07943.AF Chung J-J, Yu J-S, Kim JH et al (2009) Intraabdominal Complications Secondary to Ventriculoperitoneal Shunts: CT Findings and Review of the Literature. Am J Roentgenol 193:1311–1317. https://doi.org/10.2214/AJR.09.2463 MISAKI K, UCHIYAMA N, HAYASHI Y, HAMADA J (2010) Intracerebral Hemorrhage Secondary to Ventriculoperitoneal Shunt Insertion -Four Case Reports-. Neurol Med Chir (Tokyo) 50:76–79. https://doi.org/10.2176/nmc.50.76 Sufianov AA, Sufianova GZ, Iakimov IA (2010) Endoscopic third ventriculostomy in patients younger than 2 years: outcome analysis of 41 hydrocephalus cases. J Neurosurg Pediatr 5:392–401. https://doi.org/10.3171/2009.11.PEDS09197 Braga MHV, de Carvalho GTC, Brandão RACS et al (2009) Early shunt complications in 46 children with hydrocephalus. Arq Neuropsiquiatr 67:273–277. https://doi.org/10.1590/S0004-282X2009000200019 Di Rocco C, Massimi L, Tamburrini G (2006) Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications? Child’s Nerv Syst 22:1573–1589. https://doi.org/10.1007/s00381-006-0194-4 Di Rocco C, Marchese E, Velardi F (1994) A survey of the first complication of newly implanted CSF shunt devices for the treatment of nontumoral hydrocephalus. Child’s Nerv Syst 10:321–327. https://doi.org/10.1007/BF00335171 Drake JM, Kestle JRW, Tuli S (2000) CSF shunts 50 years on - past, present and future. Child’s Nerv Syst 16:800–804. https://doi.org/10.1007/s003810000351 Mansoor N, Solheim O, Fredriksli OA, Gulati S (2021) Shunt complications and revisions in children: A retrospective single institution study. Brain Behav 11. https://doi.org/10.1002/brb3.2390 Tervonen J, Leinonen V, Jääskeläinen JE et al (2017) Rate and Risk Factors for Shunt Revision in Pediatric Patients with Hydrocephalus—A Population-Based Study. World Neurosurg 101:615–622. https://doi.org/10.1016/j.wneu.2017.02.030 Hasanain A, Abdullah A, Alsawy M et al (2019) Incidence of and Causes for Ventriculoperitoneal Shunt Failure in Children Younger Than 2 Years: A Systematic Review. J Neurol Surg Cent Eur Neurosurg 80:026–033. https://doi.org/10.1055/s-0038-1669464 Walters BC, Hoffman HJ, Hendrick EB, Humphreys RP (1984) Cerebrospinal fluid shunt infection. J Neurosurg 60:1014–1021. https://doi.org/10.3171/jns.1984.60.5.1014 Khan B, Hamayun S, Haqqani U et al (2021) Early Complications of Ventriculoperitoneal Shunt in Pediatric Patients With Hydrocephalus. https://doi.org/10.7759/cureus.13506 . Cureus Juhler M, Hansen TS, Novrup HVG et al (2022) Hydrocephalus Study Design: Testing New Hypotheses in Clinical Studies and Bench-to-Bedside Research. World Neurosurg 161:424–431. https://doi.org/10.1016/j.wneu.2021.12.100 Beems T, Grotenhuis JA (2004) Long-term complications and definition of failure of neuroendoscopic procedures. Child’s Nerv Syst 20:868–877. https://doi.org/10.1007/s00381-004-0945-z Schroeder HWS, Oertel J, Gaab MR (2004) Incidence of complications in neuroendoscopic surgery. Child’s Nerv Syst 20:878–883. https://doi.org/10.1007/s00381-004-0946-y González-López P, Gómez-Revuelta C, Puchol Rizo M et al (2023) Development and evaluation of a 3d printed training model for endoscopic third ventriculostomy in low-income countries. Brain Spine 3:101736. https://doi.org/10.1016/j.bas.2023.101736 Jesuyajolu DA, Zubair A, Nicholas AK et al (2022) Endoscopic third ventriculostomy versus ventriculoperitoneal shunt insertion for the management of pediatric hydrocephalus in African centers – A systematic review and meta-analysis. Surg Neurol Int 13:467. https://doi.org/10.25259/SNI_747_2022 Kulkarni AV, Sgouros S, Constantini S (2016) International Infant Hydrocephalus Study: initial results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus. Child’s Nerv Syst 32:1039–1048. https://doi.org/10.1007/s00381-016-3095-1 Additional Declarations No competing interests reported. Supplementary Files PedHCSupplementaryMaterialAnnaDuc.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-4489379","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318927092,"identity":"ac8266d7-959c-4404-8e6e-5ae9aa7e1bb1","order_by":0,"name":"Anna Duc","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYNACNgRTDkQcAKMzRGoxJl1LYgOExq2Ff3bvwQ8MZYflGaTbr0nzVNxJ397efvHAxx13GPjOHMCqReLOuWQJhnOHDRtkzpRJ85x5ljvnzJmCgzPPPGOQPNuA3ZobOQYSjG2HExgkctKkedsO586QyEk4DGQwGJzHrkP+Ro7xD4SWf4fTJeTf4NdicCPHDGpL+jFp3obDCRIS7AcgWnA4zBCoxSLhXLphm0QOs+WcY4cNZ/DkMByc2XaYRxKH9+WADrvxocxanl8i/eGNNzWH5SXYjz/+8LHtsBzfmQTsLgMBkBQbA48BEw+Yy2MAJnGrhwP2B4w/oAwiVI+CUTAKRsEIAgCbUmbKhzXbJwAAAABJRU5ErkJggg==","orcid":"","institution":"Afdeling for Hjerne- og Nervekirurgi","correspondingAuthor":true,"prefix":"","firstName":"Anna","middleName":"","lastName":"Duc","suffix":""},{"id":318927093,"identity":"a4429cd5-7a3a-4710-923a-64d2b322851f","order_by":1,"name":"Marveh Dokhi","email":"","orcid":"","institution":"Afdeling for Hjerne- og Nervekirurgi","correspondingAuthor":false,"prefix":"","firstName":"Marveh","middleName":"","lastName":"Dokhi","suffix":""},{"id":318927094,"identity":"6fa321ab-5870-4671-a508-781cbf9a49da","order_by":2,"name":"Frederikke Guldberg","email":"","orcid":"","institution":"Afdeling for Hjerne- og Nervekirurgi","correspondingAuthor":false,"prefix":"","firstName":"Frederikke","middleName":"","lastName":"Guldberg","suffix":""},{"id":318927095,"identity":"f3a28bda-6519-44c3-89cf-870a1b16636b","order_by":3,"name":"Elsebet Østergaard","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Elsebet","middleName":"","lastName":"Østergaard","suffix":""},{"id":318927096,"identity":"f5032ed9-c275-4f9b-bb3f-1a53fc70235d","order_by":4,"name":"Carl Larsen","email":"","orcid":"","institution":"Afdeling for Hjerne- og Nervekirurgi","correspondingAuthor":false,"prefix":"","firstName":"Carl","middleName":"","lastName":"Larsen","suffix":""},{"id":318927097,"identity":"256bf94b-9215-42b8-9356-81a1f5cf70d9","order_by":5,"name":"Marianne Juhler","email":"","orcid":"","institution":"Afdeling for Hjerne- og Nervekirurgi","correspondingAuthor":false,"prefix":"","firstName":"Marianne","middleName":"","lastName":"Juhler","suffix":""},{"id":318927098,"identity":"eb96b464-1527-4917-90a7-6bc1f279584f","order_by":6,"name":"Tina Nørgaard Munch","email":"","orcid":"","institution":"Statens Serum Institut","correspondingAuthor":false,"prefix":"","firstName":"Tina","middleName":"Nørgaard","lastName":"Munch","suffix":""}],"badges":[],"createdAt":"2024-05-28 08:36:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4489379/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4489379/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59606007,"identity":"021611d1-6a92-45f7-9e03-947784e39ee6","added_by":"auto","created_at":"2024-07-03 18:51:08","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83611,"visible":true,"origin":"","legend":"\u003cp\u003eThe main subclassification of hydrocephalus in obstructive and communicating hydrocephalus delineates into distinct aetiologies. Each row represents an underlying aetiology, and subcategories are indented to show the hierarchy within each subtype of hydrocephalus.\u003c/p\u003e","description":"","filename":"floatimage111.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4489379/v1/be5ad3458bece643f5081a22.jpeg"},{"id":59607638,"identity":"05cb97cb-ab79-42b0-9938-a478b6d95533","added_by":"auto","created_at":"2024-07-03 19:07:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1006726,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4489379/v1/d3c1c719-49d6-4cf7-a259-8dfc5d91e953.pdf"},{"id":59606006,"identity":"6fe8bd92-d4b4-4639-afe2-ca9f1dd02dcb","added_by":"auto","created_at":"2024-07-03 18:51:08","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12722,"visible":true,"origin":"","legend":"","description":"","filename":"PedHCSupplementaryMaterialAnnaDuc.docx","url":"https://assets-eu.researchsquare.com/files/rs-4489379/v1/f0d6e755deaff42f5aba0018.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical outcomes and co-morbidities among all-cause paediatric hydrocephalus patients in Eastern Denmark","fulltext":[{"header":"Background","content":"\u003cp\u003eHydrocephalus is a complex and heterogeneous condition, frequently occurring with various comorbidities, which can influence the effect of the surgical treatment. Hydrocephalus is defined as ventriculomegaly with increased intraventricular volume due to disturbance of cerebrospinal fluid (CSF) formation, flow, or absorption, potentially causing life-threatening increased intracranial pressure (ICP) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Paediatric hydrocephalus encompasses congenital and acquired aetiologies, categorized as either communicating or obstructive hydrocephalus [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The most common causes of congenital hydrocephalus are brain malformations, spina bifida, and aqueductal stenosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The global prevalence of hydrocephalus in children under 18 years is 88/100,000 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Denmark, hydrocephalus occurs in 1.1/1000 live-born children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCommon surgical interventions for paediatric hydrocephalus include endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS). Insertion of VPS is highly associated with complications such as obstruction, infection, or failure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], with a high revision rate of 42.6% within 3 years after initial shunt placement [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and a cumulative 1-year risk of 50% in children under 2 years [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. ETV sometimes combined with choroid plexus cauterization, has emerged as the primary surgical approach for visible obstruction in recent years [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Factors influencing the choice between ETV and VPS include aetiology, age, anatomy, and surgeon expertise. While both procedures have demonstrated promising results, a significant debate persists regarding their comparative effectiveness and safety in paediatric patients [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRe-evaluating surgical outcomes is crucial, focusing on clinical improvement. While the risk of shunt revision and treatment modality conversion are common measures for outcome, they do not necessarily reflect clinical effect on preoperative symptoms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Thus, lack of shunt revision would be designated as a successful outcome; however, such \u0026ldquo;success\u0026rdquo; does not necessarily reflect positive effect on preoperative symptoms. Especially not if the preoperative symptoms were not clearly assigned to increased ICP. Describing concurrent comorbidities is important, as they may confound the primary outcome and predispose to complications such as shunt infections or revisions. Hydrocephalus treatment is still limited to two relatively simple surgical principles despite the diversity in aetiologies, age, clinical and anatomical presentations. Accounting for these factors may help in the choice of the best possible first-time treatment option for each patient.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eBased on these considerations, this study aimed to provide granular descriptions of various aetiologies of hydrocephalus and concurrent conditions, while assessing short- and long-term treatment outcomes. Short-term failure was measured as the immediate clinical response during admission after primary treatment. Furthermore, risk of shunt revision or conversion of ETV to VPS within a follow-up period of 1 year was estimated for all. The subset of patients with available data were included in a sub analysis of the risk of ETV-conversion/shunt revision up to 13 years after primary surgical intervention.\u003c/p\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study is a single-centre, retrospective observational study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData source\u003c/h2\u003e \u003cp\u003eIn the Capital Region of Denmark, medical records are stored as electronic health records (EHR) (Epic\u0026reg;,). The EHR was implemented on December 1st, 2016, containing all records from healthcare personnel, laboratory data, and imaging studies performed since the implementation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eAll congenital hydrocephalus patients aged 0\u0026ndash;18 years at the time of first surgery, who underwent shunt insertion, shunt revision, or endoscopic third ventriculostomy for hydrocephalus at the University Hospital of Copenhagen between December 1st, 2016, and December 31st, 2021, were included. Patients were identified from the surgical work board in the EHR. Only patients with available clinical information from the point of diagnosis to 12 months after primary surgery were included. If available, information on later treatment failures were collected for a sub analysis of treatment failure beyond the first postoperative year. Patients with incomplete clinical information on follow-up were excluded, which was either due to home address abroad or replacement of the file system in 2016.\u003c/p\u003e \u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eWe recorded patient demographics including date of birth, sex, onset age, pre-operative symptoms, comorbidities, results from genetic analyses, hydrocephalus subtype, and aetiology. Furthermore, treatment details including age of initial surgery, treatment modality, clinical outcome, surgical complications, and revisions were recorded.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe main outcome was treatment failure defined as persistent or worsened clinical symptoms or the need for additional surgery within the same hospital admission. This was distinguished from treatment success defined as resolution or improvement of symptoms following the hospital stay.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eWe estimated the risks of insufficient clinical effect of VPS on obstructive hydrocephalus (OH) versus communicating hydrocephalus (CH) as an odds ratio with 95% confidence intervals using Fischer\u0026rsquo;s Exact Probability Test. We estimated the cumulative incidence (CI) for shunt revision after 30-days, 3-, and 12 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eGenetic analyses\u003c/h2\u003e \u003cp\u003eSome patients had extensive genetic analyses performed based on their clinical presentations. These included whole exome sequencing (WES) for both children and their parents, often referred to as trios, whole genome sequencing (WGS), chromosome microarray, chromosome analysis, as well as specific gene or panel analyses targeting specific gene(s). All analyses were according to local protocols.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The legal office at Copenhagen University Hospital and the regional Scientific Ethics Committee\u0026rsquo;s approved the study. Personal data was pseudo-anonymized to ensure data protection. The data was handled and stored in accordance with regulations set by The Danish Data Protection Agency and the General Data Protection Regulations (GDPR).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 128 patients with congenital hydrocephalus were identified and screened for eligibility. Thirty-nine did not meet the inclusion criteria of available clinical information from the point of diagnosis to 12 months after the primary surgery, resulting in 89 patients. They were classified into 58 patients with OH and 31 with CH. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents demographic and clinical data of those.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics for children treated for hydrocephalus\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"23\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c21\" colnum=\"21\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c22\" colnum=\"22\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c23\" colnum=\"23\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"14\" nameend=\"c15\" namest=\"c2\"\u003e \u003cp\u003eObstructive hydrocephalus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c23\" namest=\"c16\"\u003e \u003cp\u003eCommunicating hydrocephalus\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAqueductal stenosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTumor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eCyst\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ePerinatal IVH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eChiari\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003eDandy Walker\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e \u003cp\u003eIdiopathic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e \u003cp\u003eMMC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c21\" namest=\"c20\"\u003e \u003cp\u003ePerinatal IVH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c23\" namest=\"c22\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e65.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex (Female)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e43.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e45.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"23\" nameend=\"c23\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge group distribution\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrenatal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 year (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e34.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e56.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e77.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e58.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2 years (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;17 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian age (years)\u003c/p\u003e \u003cp\u003eAge range (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3.5 prenatal-15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5.9 prenatal-16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.6 prenatal-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.1 prenatal-0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e0.8 prenatal-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e1.9 prenatal-16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e \u003cp\u003e1.5 prenatal-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e \u003cp\u003e0.1 prenatal-0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c21\" namest=\"c20\"\u003e \u003cp\u003e0.1 prenatal-0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c23\" namest=\"c22\"\u003e \u003cp\u003e3.3 prenatal-5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"23\" nameend=\"c23\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePre-operative symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased head size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e55.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms of high ICP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e56.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e55.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed motor skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e25.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed cognitive development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailure to thrive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced hearing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"23\" nameend=\"c23\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurological diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e25.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e55.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic heart, lung, \u0026amp; kidney diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenetic conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuropsychiatric diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone and connective tissue diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmune deficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurring infections (pneumonia, sinusitis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c22\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c23\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"23\"\u003eAbbreviations: IVH, intraventricular hemorrhage; MMC, myelomeningocele; ICP, intracranial pressure.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAetiology\u003c/h2\u003e \u003cp\u003eAs seen from Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, tumour and idiopathic aqueductal stenosis (AS) comprised the most frequent causes of OH, whereas idiopathic and perinatal intraventricular haemorrhage (IVH) were the most common causes of CH.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSex and age\u003c/h2\u003e \u003cp\u003eThe sex distribution showed a slight preponderance for males (51.7% for OH and for 54.8% for CH). The mean onset age for OH was notably younger at 1.9 years compared to CH at 3.3 years. All subgroups contained patients diagnosed with hydrocephalus prenatally, except Chiari malformations (CM) with 0.4 years as the youngest age at diagnosis. AS and tumour had the broadest age range for diagnosis from prenatal to 15 years and prenatal to 16 years, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative symptoms\u003c/h2\u003e \u003cp\u003eThe most frequent preoperative symptom across the aetiologic subgroups was macrocephaly, except in tumour patients, accounting for 74.2% with CH and 48.3% with OH. In tumour patients, symptoms of elevated ICP were the most frequent symptom (71.4%), followed by reduced vision (32.1%), failure to thrive, and macrocephaly (21.4%). Symptoms of elevated ICP were considerably more frequent in patients with OH (56.9%) compared to CH (35.5%). Patients with AS primarily presented with elevated ICP (57.1%) and increased head circumference (64.3%). The occurrence of delayed motor skills was seen almost equally in patients with OH (21.8%) and patients with CH (25.8%).\u003c/p\u003e \u003cp\u003eReduced vision was observed in three subgroups of OH: tumour (32.1%), intracranial cysts (16.7%), AS (14.3%), and idiopathic hydrocephalus regarding CH. Patients with AS (28.6%) and idiopathic CH (18.8%) were often described with delayed cognitive development. Only two patients displayed reduced hearing, one with AS (7.1%) and one tumour patient (3.6%). The obstructive (15.5%) and the communicating hydrocephalus group (12.9%) almost equally displayed failure to thrive.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eComorbidities\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eNeurologic and neurodevelopmental\u003c/h2\u003e \u003cp\u003eThe most frequent comorbidities were neurological diseases, occurring in 25.9% of patients with OH and 29.0% of patients with CH. Neurological diseases encompassed epilepsy, tetraplegia, dyskinetic cerebral palsy, paresis, dystonia, and cranial nerve palsies. Neurological comorbidity was present in all subgroups, the only exception being OH due to perinatal IVH. Among the 89 patients, seven were diagnosed with neuropsychiatric disorders: four with attention deficit and hyperactivity disorder (ADHD) and three with infantile autism combined with intellectual disability. Of patients with ADHD, two were in the tumour group, and two had idiopathic CH. The autism patients each presented with distinct underlying aetiology comprising; CM, idiopathic CM, and perinatal IVH with CH.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eComorbidities outside CNS\u003c/h2\u003e \u003cp\u003eSeven patients had chronic heart, lung, or kidney disease (14%). Three tumour patients had hydronephrosis, asthma, and tracheal stenosis, respectively. Among the subgroup of AS, one had nephrotic syndrome, and another patient presented with asthma and aortic stenosis. Of the patients with myelomeningocele (MMC), one had anal atresia and pulmonary hypoplasia, and another had both bowel atresia and renal agenesis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eGenetic conditions\u003c/h2\u003e \u003cp\u003eOf the 89 patients, 36 (40.4%) underwent genetic testing, 16 with OH and 20 with CH. Of the 36 patients tested, 15 (43.2%) presented with one or two genetic findings. Among these, eight patients had CH and seven had OH. Three patients displayed distinct copy number variations: trisomy 8 mosaicism, a 2 Mb deletion involving the \u003cem\u003eZIC2\u003c/em\u003e gene on chromosome 13, and a 3.2 Mb deletion on chromosome 3, whose direct association with hydrocephalus remains uncertain.\u003c/p\u003e \u003cp\u003eThe remaining patients had different pathogenic single gene variants. Two had a \u003cem\u003eCOL4A1\u003c/em\u003e variant associated with hydrocephalus and cerebral hemorrhage. Crouzon syndrome associated with hydrocephalus was observed in one patient with a pathogenic variant in \u003cem\u003eFGFR2\u003c/em\u003e. One patient had neurofibromatosis type 1 and one patient was mosaic for a variant in \u003cem\u003eNF2\u003c/em\u003e, associated with neurofibromatosis type 2. A homozygous \u003cem\u003ePLG\u003c/em\u003e variant caused plasminogen deficiency in one patient and one patient had a \u003cem\u003ePTEN\u003c/em\u003e variant associated with macrocephaly and autism syndrome. A pathogenic variant in \u003cem\u003eG6PD\u003c/em\u003e was found in a male patient, but it was uncertain if it explained the hydrocephalic phenotype.\u003c/p\u003e \u003cp\u003eAdditional findings in four patients included heterozygous variants in \u003cem\u003ePDGFB\u003c/em\u003e and \u003cem\u003eFLNC\u003c/em\u003e in both sibs of a twin pair, a \u003cem\u003eSHOX\u003c/em\u003e deletion, and a 45,X/46,XY mosaicism. However, these variations were not established as the direct cause of hydrocephalus. Furthermore, one patient with several structural brain abnormalities including subependymal heterotopia and demyelination and one patient with PHACE syndrome did not undergo genetic testing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTreatment modalities\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the distribution of the primary treatment modality varied among the subgroups. In cases of OH, 51 patients (88%) received a VPS, while the remaining seven (12%) underwent ETV. All 31 with CH received a shunt.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe frequency of either ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy (ETV) as first surgical intervention for patients with either obstructive or communicating hydrocephalus.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstructive\u003c/p\u003e \u003cp\u003ehydrocephalus (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunicating hydrocephalus (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (38))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eETV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eFailure rates\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents failure rates for short-term treatment outcome in hydrocephalus subgroups after initial treatment. The overall failure rate regardless of treatment type was 12.4%. Shunt failure rates were higher for OH (13.7%) compared to CH (9.7%). Patients treated endoscopically had a failure rate of 14.3%, however based on only one event with AS at the age of 14 when operated.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFailure rates measured as persistent or worsening of clinical symptoms and/or repeated surgery within the same hospital admission for patients with obstructive (OH) and communicating hydrocephalus (CH), according to treatment modality of primary surgery (ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy (ETV)).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFailure (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eOdd's ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll surgical\u003c/p\u003e \u003cp\u003einterventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVPS on OH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(0.16\u0026ndash;2.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVPS on CH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (9.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eETV on OH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eShunt revisions\u003c/h2\u003e \u003cp\u003eAll included were followed for at least one year after initial shunt placement. The analysis included 76 patients, excluding 13 individuals with a follow-up of less than 1 year. 51 underwent revision within follow-up (67%), of which 12 (23%) had one revision, 7 (14%) had 2 revisions and 4 (8%) had 3 or more revisions (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The median revision rate was 2.9 during follow-up (range 0\u0026ndash;8), and median time from primary shunt operation until first revision was 23.4 months (range 1 day \u0026minus;\u0026thinsp;83 months).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe number of patients who underwent shunt revision (51 patients, 67%) with a follow-up period of at least one year, listed as the number of shunt revisions within the first year after initial insertion. Thirteen patients, who were followed for less than one year, were excluded.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevisions within 1 year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCauses of shunt revision are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Apart from elective shunt revision due to growth (24%), the most frequent causes were mechanical shunt dysfunction (28%), mostly due to obstruction of the valve. Disconnection (14%) and shunt displacements (12%) were other frequents causes. Four patients had displacement of the ventricular catheter and two patients of the abdominal catheter. The four patients with over drainage (8%) underwent revisions by switching to higher pressure valves (adjustable or non-adjustable).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe causes of initial peritoneal shunt revision in 51 paediatric hydrocephalus patients with the percentage distribution of each cause.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShunt dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective change of shunt due to growth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisconnection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisplacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOver drainage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective single-centre study, with granular descriptions of 89, surgically treated paediatric hydrocephalus patients, highlights the extreme heterogenic aetiologic composition of paediatric hydrocephalus. The patients had many comorbidities, of which genetic conditions and neurological disorders were most frequent. Among patients tested for underlying genetic variation 40.0% of CH patients presented with genetic conditions versus 43.8% for OH. The results revealed that 12.4% had no clinical improvement or worsening of symptoms after treatment. During the follow-up period of 1\u0026ndash;13 years, 67% underwent shunt revision and approximately half occurred within the first year after shunt placement (not including elective revisions due to growth).\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eComorbidities \u0026amp; genetic conditions\u003c/h2\u003e \u003cp\u003eOur study describes various comorbidities associated with hydrocephalus, primarily involving the central nervous system. Neurological disorders, particularly epilepsy, were the most common comorbidities in our study population. We found gene variants explaining hydrocephalus in 10 of 89 patients (11.2%), or in 27.8% of 36 patients with one or more genetic tests. Genetic conditions were heterogeneous and included both copy number and single gene variants, phenotypically manifesting with e.g. craniosynostosis, cerebral haemorrhage or plasminogen deficiency.\u003c/p\u003e \u003cp\u003eWe did not investigate how comorbidities impact mortality. A Danish nationwide register-based cohort study with follow-up from 1996\u0026ndash;2015 reported that the non-tumour-related cumulative mortality remains high, primarily due to prevalent comorbidities. Shunt related deaths occurred mostly in those with severe comorbidities and postoperative infections. Only 3.2% of deaths were related to shunt malfunctions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This is in line with findings in a retrospective study by Hannah et. al., who found that 76% of paediatric hydrocephalus mortality was caused by medical comorbidities, including respiratory complications of preterm birth, sepsis, and sudden death from epilepsy, rather than hydrocephalus itself [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Comorbidities coexisting with hydrocephalus correlate with mortality, making it crucial to address and manage these comorbidities for improved patient outcomes.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eTreatment modalities and complications\u003c/h2\u003e \u003cp\u003eTreating hydrocephalus is crucial to avoid severe neurologic complications and death, but the optimal treatment, especially in infants, remains discussed [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Few comparisons on surgical outcomes exist, primarily limited to retrospective studies [\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eVentriculoperitoneal shunt\u003c/h2\u003e \u003cp\u003eVPS is a frequently performed neurosurgical procedure, especially in children [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, it poses risks like shunt malfunction, migration, over drainage, infection, CSF leak [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and abdominal complications, including pseudocyst formation, bowel perforation, and ileus [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Mechanical complications frequently cause shunt failure, accounting for up to 60% of overall complications [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Children under two years of age primarily experience mechanical failure due to ventricular catheter obstruction (63.2%), followed by distal catheter occlusion (23.5%), migration (8.8%), disconnection, (1.4%) and breaking of the shunt apparatus (1.4%) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Ventricular catheter obstruction was most prevalent in infants below 1 month of age. In line with the literature, most of the revisions in this study were due to mechanical issues, including shunt dysfunction, disconnection, displacement, and over drainage. Infection represents a leading causes of shunt failure[\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] and estimated as the most expensive [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In conclusion, only little improvement was found in our study based on data from 2016\u0026ndash;2022, as compared to findings in the previously mentioned nationwide Danish cohort study based on data from 1996\u0026ndash;2015.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eEndoscopic third ventriculostomy\u003c/h2\u003e \u003cp\u003eOnly seven patients were treated with ETV as first choice in our study. By fenestrating the floor of the third ventricle and thereby draining cerebrospinal fluid to the basal cistern, shunt-related risks are eliminated [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. While VPS treats both OH and [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], ETV is often recommended as the primary surgical treatment for OH [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, ETV is a technically more complex procedure with higher risk of injury of adjacent structures or surgically induced haemorrhages [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Neurological complications in ETV range from 3\u0026ndash;4%, while long-term complications are typically below 1% [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Even though our findings point toward ETV as a good alternative to VPS for OH, even in young children, the number of patients is insufficient to make firm conclusions. However, due to high revision rate for shunt hardware, ETV has also been advocated as a feasible or even superior treatment method in low- and middle-income countries [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative outcomes\u003c/h2\u003e \u003cp\u003eWe found high shunt revision rates and a considerable risk of insufficient effect after primary surgery. Around half of the revisions occurred within the first year after initial surgery, with a median time from primary placement to first revision of 23.4 months. The success rate aligns with paediatric surgical series, in which shunt failures occur in 14% of patients within first month, and failure rates range from 4\u0026ndash;50% within first year [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKulkarni et. al. presented the first multi-centre, prospective comparison of ETV and VPS for infant hydrocephalus, reporting superior success rates for shunts at 3, 6, and 12 months, focusing on clinical outcome [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Baldauf et. al reported an overall success rate of 43% with AS and age above 1 year as positive prognostic factors [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A systematic review by Javadpur et. al. reported higher success rate for patients diagnosed with AS but insignificant effect of age comparing ETV in infants [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Customizing treatment involves considering age, aetiology, comorbidities, and possible complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eLimitation and strength of the study\u003c/h2\u003e \u003cp\u003eStrength of this study includes detailed granular clinical information of all patients and a complete baseline-follow-up of at least one year after primary surgery, although the limited sample size from single-centre data acquisition weakens statistical power. However, the majority of our results and conclusions align with other publications.\u003c/p\u003e \u003cp\u003eRetrieving clinical information from non-standardized chart notes poses risks of inaccuracies in assessment of clinical information including presenting and outcome symptoms. However, revision rates are often used as a surrogate for outcome devoid of any information on symptoms and functionality. As surprisingly few publications report on true clinical outcome, this study adds important information on neurological outcome and co-morbidities. The transition to a new electronic health record system resulted in missing or insufficient data, making the study susceptible to selection bias. This predominantly affected the older paediatric group, as data before 2016 regarding disease and treatment were unavailable. Therefore, many patients in our study population were young.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this study illustrate the extensive diversity in symptoms, aetiology, comorbidities, and outcomes of paediatric hydrocephalus. The heterogeneity possibly stems from various underlying factors, such as congenital anomalies, infections, or acquired conditions, requiring individualized treatment. The vast array of genetic aetiologies contributing to hydrocephalus necessitates extensive genetic screening to understand the diverse causes and underlying pathogenic mechanisms. Improved subclassification may pave the way for individualized treatment and lower failure rates of the primary surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been approved by the hospital board as well as by The Regional Research Ethics Committees (H-22040623).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.D. and A.D. drafted the primary manuscript with contributions from F.G.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA.D. calculated all statistics under supervision from a biostatistician.\u003c/p\u003e\n\u003cp\u003eT.M. was responsible for conceptualization, idea and supervision.\u003c/p\u003e\n\u003cp\u003eAll authors actively contributed to the interpretation of the results and the revisions of the primary manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData and program codes will not be available according to the Danish data agency. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKahle KT, Kulkarni AV, Limbrick DD, Warf BC (2016) Hydrocephalus in children. Lancet 387:788\u0026ndash;799. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(15)60694-8\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(15)60694-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBothwell SW, Janigro D, Patabendige A (2019) Cerebrospinal fluid dynamics and intracranial pressure elevation in neurological diseases. Fluids Barriers CNS 16:9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12987-019-0129-6\u003c/span\u003e\u003cspan address=\"10.1186/s12987-019-0129-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKartal MG, Algin O (2014) Evaluation of hydrocephalus and other cerebrospinal fluid disorders with MRI: An update. 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Surg Neurol Int 13:467. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.25259/SNI_747_2022\u003c/span\u003e\u003cspan address=\"10.25259/SNI_747_2022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulkarni AV, Sgouros S, Constantini S (2016) International Infant Hydrocephalus Study: initial results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus. Child\u0026rsquo;s Nerv Syst 32:1039\u0026ndash;1048. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00381-016-3095-1\u003c/span\u003e\u003cspan address=\"10.1007/s00381-016-3095-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\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":"Hydrocephalus, paediatric, ventriculoperitoneal shunt, endoscopic third ventriculostomy.","lastPublishedDoi":"10.21203/rs.3.rs-4489379/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4489379/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003ePurpose\u003c/b\u003e The aim of this study was to provide granular descriptions of aetiologies of hydrocephalus and concurrent conditions. Furthermore, to describe the short-term effect of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) on preoperative symptoms and to estimate the risks of shunt revision, conversion of ETV to shunt, and the risks of complications.\u003c/p\u003e \u003cp\u003eMethods\u003c/p\u003e \u003cp\u003eA retrospective, single-centre study was performed among children who underwent shunt insertion or ETV for hydrocephalus between December 1st, 2016 and December 31st, 2021. Information regarding course of disease, surgical treatments, and comorbidities were registered from the digital patient records. The risks of conversion of treatment modality and shunt revision were estimated as cumulative incidences (CI\u0026rsquo;s) after 30-days, 3-, and 12 months.\u003c/p\u003e \u003cp\u003eResults\u003c/p\u003e \u003cp\u003eA total of 89 children with either obstructive (OH) (65%) or communicating (CH) (35%) hydrocephalus were surgically treated with VPS or ETV. Neurological disorders (CH 29%, OH 26%) and genetic conditions (CH 36%, OH 16%) were frequent concurrent conditions. Increased head size (74%) and symptoms of elevated intracranial pressure (57%) were the most common preoperative symptoms. Treatment with VPS entailed a 13.7% failure rate for OH and 9.7% for CH, whereas ETV displayed 14.3% failure rate, all reflecting failure of alleviating the preoperative clinical symptoms. The cumulative 1-year risk of shunt revision was 67%, most often due to valve dysfunction (28%), disconnection (14%), and shunt displacements (12%).\u003c/p\u003e \u003cp\u003eConclusion\u003c/p\u003e \u003cp\u003eThe considerable risks of treatment failure and complications call for improvements in treatment based on a better understanding of the heterogenic mechanisms of disease.\u003c/p\u003e","manuscriptTitle":"Surgical outcomes and co-morbidities among all-cause paediatric hydrocephalus patients in Eastern Denmark","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-03 18:51:03","doi":"10.21203/rs.3.rs-4489379/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":"f3ac6201-e8f3-45ba-bfd1-ec05c703866d","owner":[],"postedDate":"July 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-03T18:51:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-03 18:51:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4489379","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4489379","identity":"rs-4489379","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}