The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings

What is it about?

Paediatric hydrocephalus is a common disease world-wide that is often treated by neurosurgeons. The disease occurs most commonly in geographic regions where there are the fewest neurosurgeons available to assist, and thus represents a large source of untreated neurosurgical disease worldwide. The CURE protocol was developed in Mbale, Uganda as a clinical tool to assist neurosurgical providers in decision making for evidence-based treatment of paediatric hydrocephalus focusing on endoscopy as primary surgical treatment rather than the standard shunt. In this study we evaluated the effectiveness of this evidence-based algorithm by studying its use and resulting patient outcomes at two separate centres in sub-Saharan Africa. We compared 730 children in Uganda managed by local neurosurgeons highly experienced in the protocol and 96 children in Nigeria managed by a local neurosurgeon trained in the protocol. Interestingly, while the ages of the patients were similar between the two groups the aetiologies of hydrocephalus were significantly different, with the majority of Ugandan cases resulting from previous infection and the majority of Nigerian cases resulting from congenital causes. Ultimately, using the protocol both centres were able to treat over half of children with newly diagnosed hydrocephalus without requiring a shunt. By being managed entirely without a shunt the children are at lower long term risk for emergencies such as shunt failure which is often fatal in sub-Saharan africa. Use of the CURE Protocol in two centres with different populations and surgeon experience yielded similar 6-month results, with over half of all children remaining shunt-free. Where feasible, this could represent a better public health strategy in low-resource settings than primary shunt placement.

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