Incidence and Predictors of Permanent Cerebro-Spinal Fluid Diversion in Patient Undergoing Posterior Fossa Tumor Surgery: Multicenter Prospective Cohort Study
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Date
2024-10-19
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Addis Ababa University
Abstract
Background: Posterior fossa tumors are frequently cause hydrocephalus, which can be obstructive or communicating. After tumor removal, only some patients require permanent Cerebro-Spinal Fluid (CSF) diversion, and the best approach to managing hydrocephalus in these cases remains debated. While some advocate for initial CSF diversion, others favor early tumor resection. In low-income settings with high patient volumes, early tumor resection is often challenging
Objective: This study aimed to assess the incidence and predictors of permanent CSF diversion following posterior fossa tumor resection among patients at BLH, MCM, and ALERT Hospitals from August 1, 2023, to September 30, 2024.
Methodology: A hospital-based, multicenter prospective cohort study was conducted from August 1, 2023, to September 31, 2024, to examine the incidence and predictors of permanent CSF diversion following posterior fossa tumor resection at BLH, MCM, and ALERT Hospitals. Data were collected from patients, attendants, surgical notes, biopsy reports, electronic records, and pre- and post-op imaging. Patients were followed in person and by phone at 1st, 3rd, and 6th months post-op. A structured questionnaire and checklist were used for data collection, and data were entered into SPSS-30 for cleaning and analysis, with demographic, radiographic, perioperative, and postoperative variables analyzed using univariate and multivariate models.
Result: This study included 52 patients, equally divided by gender, with 76.9% being adults (>18 years). Follow-up was completed for all patients at one month, 48 patients at three months, and 37 patients at six months. The overall incidence of postoperative hydrocephalus requiring permanent CSF diversion was 13%, occurring in 15% of adults and 8.3% of pediatric patients. The most common symptoms were headache (98%), nausea/vomiting (48.1%), and blurred vision (52%). Irritability was the only variable significantly associated with permanent CSF diversion (P = 0.028). Most patients had symptoms for 2-6 months before presentation. Tumors were most frequently located in the cerebellopontine angle (44.2%), with 55.8% being extra-parenchymal. The majority of tumors (53.8%) measured 3-5 cm, and 40.4% exceeded 5 cm. Preoperative hydrocephalus was present in 72.6% of patients, with 36.5% having mild and 13.5% severe hydrocephalus based on Evans Index; 44% had periventricular CSF capping on imaging. Gross Total Resection (GTR) was achieved in 77% of cases, Near Total Resection (NTR) in 7.7%, and Subtotal Resection (STR) in 15.4%. EVDs were used in 71.2% of cases, with 94.6% placed intraoperatively, stayed in place for 5-10 days in 56.8% of cases. Postoperative complications occurred in 36.5% of patients, with CSF leaks (11.5%) being the most common, followed by pseudomeningocele and ventriculitis (7.7% each), IVH (5.9%), and tumor bed hemorrhage (3.8%). Meningioma (26.9%) was the most frequent tumor type, followed by schwannoma (21.2%), medulloblastoma (17.3%), low-grade astrocytoma (15.4%), and ependymoma (5.8%).
Conclusion: The overall incidence of postoperative permanent CSF diversion is 13%, with 15% in adults and 8.3% in pediatric patients. Irritability was the only variable significantly associated with the need for postoperative permanent CSF diversion. To strengthen these findings and develop a risk prediction model for identifying high-risk patients in low-income countries, further large-scale prospective cohort studies are recommended.
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permanent cerebro-spinal fluid diversion