Understanding barriers to pediatric hydrocephalus management: an international survey

PURPOSE: A pediatric neurosurgeon's approach to the treatment of hydrocephalus can vary but often includes ventriculoperitoneal (VP) shunt insertion or endoscopic third ventriculostomy (ETV). However, there are several suspected barriers to accessible hydrocephalus care, particularly regarding endoscopy. The aim of this study was to characterize neurosurgical approaches and perceived barriers to pediatric hydrocephalus treatment globally. METHODS: An online survey targeting a non-random sample of pediatric neurosurgeons was distributed via international neurosurgery mailing lists. Demographics including age, sex, level of training, years of practice, and country of residence were collected. Likert-scale and multiple-choice questions were used to determine surgical indications, surgeon preferences, surgeon training, and access to endoscopy. Fisher's exact test was used to compare frequencies between high- and low-income countries. RESULTS: Forty-five neurosurgeons from 29 countries with a mean age of 49.2 ± 10.4 (mean ± S.D.) years, all treating pediatric hydrocephalus, responded to the survey. Overall, 64.4% (n = 29/45) were from high-income countries (HICs) and 35.6% (n = 16/45) were from low- and middle-income countries (LMICs). Regarding VP shunt insertion, 41.4% of HIC respondents and 81.3% (p = 0.013) of LMIC respondents acknowledged barriers to treatment. Barriers to VP shunt insertion included equipment access, specifically hardware availability reported by 10.3% of HIC respondents and 43.8% of LMIC respondents (p = 0.021). Regarding ETV, 51.7% of HIC surgeons and 93.8% of LMIC surgeons (p = 0.007) reported a barrier. Barriers to ETV included equipment access, specifically endoscope/balloon catheter availability, reported by 34.5% of HIC respondents and 81.3% of LMIC respondents (p = 0.005). Respondents also reported surgeon/staff training problems, patient financial insecurity, and operating room (OR) access but no significant differences were found between the two economic groups for ETV or VP shunt insertion. Furthermore, 81.3% of LMIC respondents and 44.8% (p = 0.027) of HIC respondents expressed the desire to treat more patients endoscopically. CONCLUSION: LMICs face more perceived barriers to the treatment of pediatric hydrocephalus than HICs. These perceived barriers are more frequent in endoscopic treatment, in comparison to VP shunt insertion in both economic groups, largely due to improper access to endoscopic equipment. Future studies should focus on leveraging neurosurgical collaborations to improve care worldwide.