Changing Landscape of Hydrocephalus Treatment in Pakistan: A Brief History and Bibliometric Analysis

Abstract

Introduction

Hydrocephalus is estimated to affect 85 per 100,000 people around the world and despite recent advancements in surgical techniques and treatment options, it remains a major public health issue in low- and middle-income countries such as Pakistan. We did a bibliometric analysis on the trends of hydrocephalus research in Pakistan from Dr. Jooma bringing ventriculoperitoneal (VP) shunts in his personal baggage for his patients and Dr. Bhatti developing his own shunts till the development of new centers and introduction of endoscopic techniques.

Materials and Methods

We conducted a retrospective bibliometric study analyzing the trends of hydrocephalus treatment in Pakistan. All published articles in national or international journals from 1995 to 2024 were included. Descriptive statistics were computed for all variables. Trends in the type of intervention and etiology were analyzed using the chi-square test. Statistical significance was determined using a p-value threshold of < 0.05. Data were distributed in tables and were visualized using bar charts. All analyses were performed using SPSS version 27.

Results

A total of 102 hydrocephalus-related studies were published in Pakistan during the study period. Descriptive analysis showed multiple etiologies (23.5%) as the most common cause, followed by congenital (21.6%), infectious (20.6%), and acquired (15.7%) factors. VP shunt remained the predominant intervention (40%), with a rising trend in endoscopic procedures. Most studies were observational (52.9%) and published in local journals, primarily the Pakistan Journal of Neurological Surgery (40.2%). Research output was concentrated in Karachi (39%), especially at the Aga Khan University Hospital (22.5%). Male authors outnumbered female authors across all years, highlighting a persistent gender gap in neurosurgical research.

Discussion

Hydrocephalus in Pakistan presents unique challenges and opportunities for research. This study provides essential insights into hydrocephalus research and management trends over the past 3 decades. The predominance of congenital and infectious etiologies, the continued importance of shunt procedures, the evolving adoption of endoscopic procedures, and the concentration of clinical research in major urban centers illustrate the important trends in hydrocephalus. Future studies should focus on comparing the effectiveness and cost-effectiveness of different interventional approaches in the Pakistani health care setup, identifying potential risk factors for developing hydrocephalus, and devising targeted prevention strategies. Collaborative efforts, inclusive research practices, and a commitment to addressing gender disparities will be pivotal in shaping the future landscape of hydrocephalus management and research in the region. Further, addressing the challenges of neurosurgical workforce shortages, resource constraints, and infection rates is critical to improving outcomes for hydrocephalus patients in Pakistan.

Keywords

endoscopic third ventriculostomy - hydrocephalus - hydrocephalus history in Pakistan - neurosurgery in Pakistan - VP shunt

Introduction

Despite recent advancements in treatment options and surgical techniques, hydrocephalus remains a major public health concern in low- and middle-income countries (LMICs) such as Pakistan, where limited neurosurgical access, late diagnoses, and financial barriers impact care.[1] [2] [3] It is estimated to affect 85 per 100,000 people around the world, with the highest prevalence among the elderly (175 per 100,000) and children (88 per 100,000). In LMICs, newborns face an even higher incidence (123 per 100,000 births), often due to congenital malformations and infections.[2] [3] [4] [5] While hydrocephalus research in Pakistan has grown, a comprehensive analysis of evolving trends, key interventions, and study impact remains lacking.

Bibliometric analysis is a powerful tool for evaluating research trends by assessing publication volume, authorship patterns, institutional contributions, and citation impact. This study focuses on the evolving landscape of hydrocephalus research in Pakistan, particularly trends in surgical interventions over the years, the number of publications, and shifts in research priorities. By mapping these developments, it aims to identify gaps, highlight key advancements, and provide insights to guide future research and policy decisions.

Brief History of Hydrocephalus Management in Pakistan

Neurosurgery in Pakistan started in the year 1951 when the country was only 4 years old and still trying to consolidate its resources. The first center was established in Jinnah Hospital, Karachi, by Dr. Omar Vali Jooma, and remained the only neurosurgery center in the region for several years.[6] Patients with hydrocephalus used to be diagnosed either clinically, or by cerebral angiography or ventriculograms, and treated with limited resources.[7] Dr. Jooma used to bring Spitz–Holter shunts from the United States in his baggage to be implanted in selected patients, while most other patients received a subcutaneous rubber drain connecting the ventricles to the peritoneal cavity, similar to the one described by Mikulicz in 1893.[8] Patients suspected of obstructive hydrocephalus underwent either a Torkildsen procedure or a ventriculocisternal shunt, which required using a rubber drain to connect the lateral ventricle to the cisterna magna.[9] These procedures were only offered in two centers up until the mid-1970s.

It is interesting to note that at around the same time, Pakistani-origin neurosurgeon Dr. Ayub Omayya had introduced the Omayya reservoir in the United States.[10] In the late 1970s, Dr. Iqtidar Hussain Bhatti developed his own design for a ventriculoperitoneal (VP) shunt and named it the Bhatti shunt. This was Pakistan's first approved implantable device and was designed to address central nervous system infections, as tuberculous meningitis and ventriculitis were very common in those days. The Bhatti shunt, apart from a subcutaneous silicone tube connecting the ventricles with the peritoneum, also featured a one-way valve and a reservoir for direct intraventricular administration of antibiotics.[11] However, despite being a local product, it never gained widespread adoption, and most shunts used in the country were still brought in personal luggage either from India (Chhabra shunts) or from the United States (Medtronic). Trade was still officially restricted between India and Pakistan, so Chhabra shunts were smuggled in personal baggage. In the 1990s, Huw Baven Griffith visited Pakistan and performed the country's first ventricular endoscopic procedure when he did a choroid plexus coagulation at Jinnah Hospital, Karachi.[12] [13] Endoscopy initially failed to gain popularity, but it has only recently achieved widespread acceptance.

Three decades later, a survey of neurosurgical centers across Pakistan shows that most people living in the country are now within a couple of hours from a neurosurgery center and the majority of centers not only have a functioning computed tomography scan but also offer VP shunt insertions for hydrocephalus, and quite a few also offering endoscopic third ventriculostomies (ETVs).[14]

Materials and Methods

We conducted a retrospective bibliometric study analyzing the trends of hydrocephalus treatment in Pakistan. All published articles in national or international journals from 1995 to 2024 were included. A search string (hydrocephalus, treatment, management, VP shunt, etc.) was used on various databases including PubMed, Scopus, and Google Scholar for articles related to hydrocephalus treatment published by authors affiliated with institutes in Pakistan.

Publications in peer-reviewed national and international journals, focused on hydrocephalus treatment, authors affiliated with Pakistani institutes, and set in Pakistani institutes including the local population were included. However, studies lacking an explicit focus on hydrocephalus, letters to the editor, studies without original data, and authors affiliated with international institutes or not focused on Pakistani population were excluded.

Data Extraction and Analysis

Data were extracted in an Excel sheet, where different variables were recorded by two researchers, to ensure accuracy. Variables included etiology of hydrocephalus, type of intervention used, city/origin of publication, author metrics (first author affiliation, number of female and male authors), choice of journals, and study design ([Supplementary Material], available in the online version).

Descriptive statistics were computed for all variables. Trends in the type of intervention and etiology were analyzed using the chi-square test. Statistical significance was determined using a p-value threshold of < 0.05. Data were distributed in tables and were visualized using bar charts. All analyses were performed using SPSS version 27.

Results

A total of 102 studies were published in the study period across the country. Descriptive analysis was done for all variables. Hydrocephalus was mostly caused by multiple etiologies, including a combination of tumors, infections, aqueductal stenosis, and congenital malformations (23.5%). This was closely followed by congenital (21.6%), infectious (20.6%), and acquired factors (15.7%). Other identified causes include neoplastic (7.8%), normal pressure hydrocephalus (NPH) (5.9%), and traumatic (1%). In 3.9% of the studies, the etiology was not otherwise specified ([Fig. 1]).

Fig. 1 Overall etiology of hydrocephalus. Multiple etiology refers to a patient developing hydrocephalus due to multiple ongoing conditions including tumors, infections, aqueductal stenosis, and congenital malformations. NOS, not otherwise specified; NPH, normal pressure hydrocephalus.

VP shunt insertion remained the most commonly performed procedure across the years (40%), although more recently, a growing number of publications were noted on endoscopic procedures ([Figs. 2] and [3]). Most papers on hydrocephalus (39%) were published from just one city (Karachi), and almost a quarter (22.5%) of all hydrocephalus-related publications from Pakistan came from a single center, the Aga Khan University Hospital in Karachi, followed by Lady Reading Hospital in Peshawar (14.7%). The number of authors per study ranged from 1 to 10, with a mean of 4.5, dominated by male authors. [Fig. 4] shows that male authors consistently outnumber female authors, with slight fluctuations over time. The gender gap in neurosurgical research remains evident. The majority of studies were observational (52.9%), followed by case reports/series (27.5%), cross-sectional (8.8%), and experimental studies (6.9%).

Fig. 2 Frequency of intervention types, with shunt procedure showing overall predominance. Combined/specialized interventions refer to patients having complex disease requiring VP shunt, external ventricular drainage, myelomeningocele repair, septum pellucidotomy, and craniectomy. ETV, endoscopic third ventriculostomy; NOS, not otherwise specified; VP, ventriculoperitoneal.

Fig. 3 Trends of intervention over the years with an increase in endoscopic procedures in recent years. ETV, endoscopic third ventriculostomy; NOS, not otherwise specified; VP, ventriculoperitoneal.

Fig. 4 Trends in male and female authorship over time.

Among the 102 published papers, we observed a clear distribution of 60% local and 40% international journals, while most of number of studies were published in the Pakistan Journal of Neurological Surgery (40.2%) followed by the Journal of Pakistan Medical Association (14.7%) and Journal of Ayub Medical College (5.9%).

Discussion

This bibliometric analysis provides a comprehensive outlook on hydrocephalus research in Pakistan over nearly 3 decades. The study analyzed 102 publications and explored the multifaceted causes of hydrocephalus, prevailing treatment trends, geographical research distribution, study typologies, and authorship demographics. The study underscores advancements in minimally invasive surgical intervention by identifying that shunt procedures remain the predominant intervention (40%), with a growing trend toward endoscopic techniques (25.5%). Moreover, it identifies that most hydrocephalus research in the country originates from one city, and more specifically, just two centers in the country. These findings match those for other bibliometric analyses published for neurosurgery from Pakistan.[15] Further, it also sheds light on gender disparities among authors.

Our results depicted multifactorial etiology as the most common indication for treatment, with congenital and infectious causes also predominant. The predominance of congenital and postinfectious hydrocephalus is consistent with global trends, where congenital hydrocephalus remains a significant health care burden.[1] [2] [3] [4] The notably high incidence of postinfectious hydrocephalus underscores the ongoing burden of preventable infections in the region, possibly attributed to inadequate vaccination coverage, poverty and overcrowding, poor maternal health, and inadequate neonatal care. Also, the limited access to health care facilities and delayed medical intervention further complicate the management. In contrast, high-income countries (HICs) report lower incidences of infection-related hydrocephalus, likely suggestive of advancements in prenatal diagnostics and cutting-edge health care infrastructure. However, it is commonly associated with congenital anomalies, neoplasms, or as a sequel of subarachnoid hemorrhage.[2] [16] On the other side, the relatively lower prevalence of acquired (15.7%), postneoplastic (7.8%), and posttraumatic hydrocephalus (1%) may reflect the variations in national health care infrastructure with differences in diagnostic modalities or health care access. NPH is more commonly a condition of geriatrics, and 5.9% prevalence suggests underdiagnosis, at least in the published studies.

The primary surgical modalities for hydrocephalus were found to be VP shunting and ETV. The choice between the two depends on various factors, including patient age, hydrocephalus etiology, and anatomical considerations. Moreover, the treatment approaches also vary between regions within Pakistan, influenced by the availability of resources and expertise. The high cost of neurosurgical procedures and implanted devices is a significant financial barrier for many families in Pakistan, further compounded by a lack of health insurance and government support, even though the situation has significantly improved in the last decade.[17]

Our analysis depicted that shunt-based procedures emerged as the mainstay of treatment (40%), similar to global practice. The findings highlight its continued significance and underscore the need for training and sterile resources to ensure safe and effective implementation. However, studies have reported increasing rates of shunt failure and associated complications such as the incidence of shunt infections. This is attributed to the limited sterile operating environment and postoperative care resources.[18] [19] [20] At the same time, the increasing trend in endoscopic procedures suggests a growing interest in minimally invasive techniques, which may offer advantages in terms of reduced morbidity and improved outcomes. The trend aligns with that of other LMICs and HICs.[21] However, the widespread adoption of endoscopic procedures in Pakistan may still be restricted by cost and accessibility.

The majority of publications on hydrocephalus originated from just one city (Karachi followed by Peshawar and Lahore). These cities host major medical centers and universities, providing the necessary infrastructure, resources, and academic environments conducive to clinical research. For the said reasons, the tertiary care centers in these cities entertain a large and diverse patient population that also facilitates clinical studies. This geographical distribution of research also highlights the substantial disparities in Pakistan. Neurosurgical services are concentrated in urban zones, leaving rural areas underserved. Patients from rural and remote areas often travel long distances to reach the urban hubs and face multiple challenges in seeking specialized care. The distribution further highlights the scarcity of trained neurosurgeons in Pakistan, particularly pediatric neurosurgeons. This paucity exacerbates the burden on already burdened health care facilities and delays timely intervention in hydrocephalus patients.[17] [21] Building capacity is crucial for the effective management of hydrocephalus and is a timely necessity to minimize the burden of hydrocephalus in Pakistan.

The landscape of hydrocephalus publications in Pakistan is characterized by high proportion of observational studies (52.9%), followed by case reports and series (27.5%), which provide valuable insights into clinical presentations and treatment outcomes but may lack the rigor and generalizability of good quality data or randomized controlled trials (RCTs). The trend observed may be due to resource constraints such as trained research personnel, grants, standardization etc., and making RCTs challenging to conduct. The trend also depicted a clear 60/40 distribution between local and international journals with the Pakistan Journal of Neurological Surgery being the top journal in terms of publication output. We noticed a significant shift from the 77% publication rate in local journals observed in the previous bibliometric analysis.[22] This change suggests an overall improvement in research quality, greater adherence to international publication standards, and enhanced global recognition of Pakistani neurosurgical research.

The analysis of authorship trends in neurosurgical publications on hydrocephalus in Pakistan highlights a persistent gender disparity. As shown in the graph, male authors have consistently outnumbered female authors, with an average of 3.8 male authors per study compared with just 0.7 female authors. While there is a slight increase in female authorship over time, the gap remains significant. This disparity is despite the overwhelming majority of medical students in Pakistan being female. A national study on medical students' perceptions of neurosurgery in Pakistan also found that female students identified greater barriers to entering the field, citing concerns about work–life balance and a lack of female role models.[23] Although the slow rise in female authorship suggests a gradual shift, targeted efforts such as mentorship programs and supportive policies are essential to fostering a more inclusive neurosurgical research landscape.

The observation of this study puts forth the current landscape of hydrocephalus in Pakistan, highlighting the significant implications for neurosurgical practice and research. Understanding the etiological patterns and treatment outcomes can inform policymakers and relevant authorities to make decisions leading to improved resource allocation, enhanced training programs, and better, specialized health care centers. Since the majority of the cases of hydrocephalus are attributed to congenital conditions, taking the potential steps to increase trained neurosurgeons and promoting specialization in pediatric neurosurgery can swiftly tackle the problem at the root cause, improving access to newborn care. One such example is the CURE Protocol, a program that trains local neurosurgeons in resource-limited settings and offers a promising model to replicate in Pakistan.[24] Furthermore, the increasing shift from shunt to endoscopic procedures suggests a dynamic transition toward minimally invasive strategies, which should be again supported by training programs and potential investments in necessary equipment. Additionally, addressing geographical disparities in research output by encouraging collaborative efforts between smaller and larger institutes could potentially improve neurosurgical care. Additionally, steps should be taken to foster public–private partnerships, such as the collaboration between government and private hospitals, nonprofit organizations, and international partners, which can enhance resource allocation and improve the quality of neurosurgical care.

Future research should focus on evaluating the long-term treatment outcomes of various treatment modalities for hydrocephalus, particularly shunt versus endoscopic procedures in the Pakistani population and settings. They should also explore the impact of public health interventions on reducing postinfectious hydrocephalus and devise effective strategies to overcome it. Additionally, efforts should be made to identify the factors restricting women from pursuing neurosurgery and taking part in research, while also developing strategies to promote gender equity in surgical academia. A national hydrocephalus, shunt, or ETV registry can certainly help further understand both short- and long-term outcomes of these patients.

Limitations

This study has certain limitations. As a retrospective bibliometric analysis, it relies solely on published data, which may be subject to publication bias. Additionally, the search strategy may not have captured all hydrocephalus-related research, particularly from non-pubmed indexed jounals. Also, with the varying publication types, this study did not assess the quality of the clinical studies included, which may vary considerably. Moreover, data bias may exist as reliance on data reported from tertiary care centers may not accurately represent the wide range of patient population; hence, the findings of the studies cannot be generalized. Finally, despite identifying trends in treatment modalities, no statistical significance was observed over time; therefore, no definitive conclusions about evolving practice can be drawn.

Conclusion

Hydrocephalus in Pakistan presents unique challenges and opportunities for research. This study provides essential insights into hydrocephalus research and management trends over the past 3 decades. The predominance of congenital and infectious etiologies, the continued importance of shunt procedures, the evolving adoption of endoscopic procedures, and the concentration of clinical research in major urban centers illustrate the important trends in hydrocephalus. Future studies should focus on comparing the effectiveness and cost-effectiveness of different interventional approaches in the Pakistani health care setup, identifying potential risk factors for developing hydrocephalus, and devising targeted prevention strategies. Collaborative efforts, inclusive research practices, and a commitment to addressing gender disparities will be pivotal in shaping the future landscape of hydrocephalus management and research in the region. Further, addressing the challenges of neurosurgical workforce shortages, resource constraints, and infection rates is critical to improving outcomes for hydrocephalus patients in Pakistan.

Conflict of Interest

None declared.

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Publikationsverlauf

Artikel online veröffentlicht:
04. Juni 2025