Stories about: Benjamin Warf

One-time hydrocephalus operation, alternative to shunting, brings good outcomes for babies

infant hydrocephalus archival photos
(Flickr/Wikimedia Commons)

Hydrocephalus, literally “water on the brain,” is an abnormal build-up of cerebrospinal fluid in the brain cavities known as ventricles. In infants, it can be congenital (it often accompanies spina bifida, for example), or it can be caused by brain hemorrhage or infection. The usual treatment is surgery to implant a shunt, which drains the excess fluid into the abdomen, relieving pressure on the brain.

But over time, shunts nearly always fail, requiring emergency neurosurgery to repair or replace them. But emergency neurosurgery is not something that’s readily available outside of metropolitan areas. Untreated, hydrocephalus causes progressive brain damage and usually death.

What if a one-time operation could treat hydrocephalus permanently? In today’s New England Journal of Medicine, a randomized trial shows good results with a minimally invasive, relatively inexpensive shunt alternative called endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC).

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Training neurosurgeons in a rare hydrocephalus procedure, with a little help from Hollywood

ETV trainer

A 4-year-old has a progressively enlarging head and loss of developmental milestones: a clear case of hydrocephalus. He undergoes a minimally invasive endoscopic third ventriculostomy (ETV) to drain off the trapped cerebrospinal fluid.

This requires puncturing the floor of the brain’s third ventricle (fluid-filled cavity) with an endoscope — while avoiding a lethal tear in the basilar artery, which lies perilously close.

There are no good neurosurgical training models for this rare and scary operation.

“We semi-blindly poke a hole through the ventricle floor,” says Benjamin Warf, MD, director of Neonatal and Congenital Anomaly Neurosurgery at Boston Children’s Hospital. “To make the technique safer and to be able to train more people, it would be very helpful to make that hole in a way that’s less anxiety-provoking.”

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Spina bifida and hydrocephalus: Two interlinked global challenges, two plans of attack

(Photo: Crossroads Foundation https://creativecommons.org/licenses/by/2.0/legalcode)
(Photo: Crossroads Foundation)

The United Nations global Millennium Development Goals (MDGs) for 2015 aim to cut mortality among children younger than 5 by two-thirds. As 2015 approaches, there’s a sense of hope: By 2012, the 1990 base annual figure of 12 million was nearly halved, in part through curbing infectious diseases.

However, two under-recognized, highly preventable chronic conditions—spina bifida and hydrocephalus—have not declined in low- and middle-income countries. Each year, there are an estimated 200,000 new cases of infant hydrocephalus in sub-Saharan Africa alone, and 100,000 neural tube defects in India alone. As other causes of death and disability recede, data suggest that spina bifida and hydrocephalus are gaining a larger share of mortality in young children.

A multi-institution conference at Boston Children’s Hospital on April 11 sounded a global call to action, convening a mix of surgeons, pediatric neurologists, international patient advocacy groups, food fortification proponents, health economists, obstetricians, neuroscientists and others. Many innovative approaches are being explored, including two that caught Vector’s eye.

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Hydrocephalus: Tackling a global health problem

Benjamin Warf, MD, director of Neonatal and Congenital Anomalies Neurosurgery at Children’s Hospital Boston, developed a new treatment for infant hydrocephalus, or “water on the brain,” while a medical missionary in Africa, where hydrocephalus is common and usually untreated. His innovation, which has saved the lives of thousands of children, is minimally invasive, relatively inexpensive and has been taught to other surgeons in developing countries. The post below is adapted from Warf’s testimony last week before the House Subcommittee on Africa, Global Health and Human Rights (viewable on C-SPAN; jump to 17:54). John Mugamba, MD, whom Warf trained and who is currently medical director at CURE Children’s Hospital of Uganda, gave testimony in video form.

In 2000, my family and I moved to Uganda as medical missionaries to help start a specialty hospital for pediatric neurosurgery, the CURE Children’s Hospital of Uganda. At the time, there were no pediatric neurosurgical hospitals and few trained neurosurgeons in all of Africa.

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