The role of ventriculoperitoneal shunt placement in patients of tubercular meningitis with hydrocephalus in poor neurological grade: a prospective study in the pediatric population and review of literature

Abstract

There is still no standard protocol for management of patients of tubercular meningitis (TBM) with hydrocephalus in poor neurological grade. In general, a trial of external ventricular drain (EVD) is an accepted method of treatment to decide whether a particular patient will benefit from shunt surgery. However, recent studies suggest that ventriculoperitoneal (VP) shunt may be undertaken without the trial of an EVD. Our study prospectively evaluates the role of direct VP shunt placement in poor grade patients of TBM with hydrocephalus. Twenty-six consecutive pediatric patients of TBM with hydrocephalus in Palur grades III and IV underwent direct VP shunt placement, without prior placement of EVD. Outcome was assessed at the end of 3months using Glasgow Outcome Score. The mean age of patients was 3.3years (range, 4months to 11years). Twenty-one (80.8%) patients were in grade III and five (19.2%) were in grade IV. Good outcome and mortality in grade IV patients was 20% (1/5) and 60% (3/5) respectively; whereas in grade III patients, it was 71.4% (15/21) and 9.5% (2/21), respectively. Thirteen patients presented with focal neurological deficit at admission, which persisted in only three patients at 3months follow up. VP shunt-related complications were observed in six (23.5%) patients Despite poor grade at admission, 71.4% patients in grade III and 20% patients in grade IV had a good outcome at 3months follow-up. Direct VP shunt placement is a safe and effective option even in poor grade patients of TBM with hydrocephalus, with a low complication rate.