Ventricular Drainage Research Articles

External Ventricular Drain: Effect of a Nursing Development Competency Program on Nurses' Knowledge and Practices

External Ventricular Drain: Effect of a Nursing Development Competency Program on Nurses' Knowledge and Practices

Determining an accurate external reference point for zeroing an external ventricular drain (EVD) as an intracranial pressure monitoring system.

Determining an accurate external reference point for zeroing an external ventricular drain (EVD) as an intracranial pressure monitoring system.

Clinical effect of external ventricular drainage under intracranial pressure monitoring in the treatment of aneurysmal subarachnoid hemorrhage patients and investigation of the mechanism of miR-146a-5p/STC1 axis in inhibiting early brain injury in aneurys.

Aneurismal subarachnoid hemorrhage (aSAH) is a common disease in the neural system, with high death rate. Our study aimed to explore the clinical effect of external ventricular drainage under intracranial pressure monitoring in the treatment of patients with aSAH and investigate the role along with mechanism of miR-146a-5p in aSAH. Ninety-six aSAH patients were allocated into control group (CG) and study group (SG). The CG was released by lumbar puncture. The SG underwent external ventricular drainage based on intracranial pressure monitoring. The prognosis, daily living ability, neurological function, S100β and NSE (neuron-specific enolase) levels and incidence of complications were monitored. Besides, a rat model of SAH was built to assess the neurobehavioral function, blood-brain barrier permeability, brain water content, neuronal apoptosis as well as inflammation. SAH cell model stimulated by oxyhemoglobin, and cell apoptosis as well as inflammation were measured. Luciferase reporter assay was implemented to explore the interaction between miR-146a-5p and STC1. Results showed higher GOS and BI scores but lower NIHSS scores, S100β and NSE levels and complication rates in SG compared with CG. Additionally, miR-146a-5p presented down-regulation in brain tissues of SAH rat model, and overexpressed miR-146a-5p reduced brain injury along with neuroinflammation in SAH rat model. Oxyhemoglobin-induced nerve cell apoptosis along with inflammation after SAH, and overexpressed miR-146a-5p repressed oxyhemoglobin-induced nerve cell apoptosis along with inflammation. STC1 is the target mRNA of miR-146a-5p, and overexpressed miR-146a-5p represses oxyhemoglobin-induced nerve cell apoptosis along with inflammation via regulating STC1 expression. In conclusion, external ventricular drainage under intracranial pressure monitoring could promote prognosis, promote daily living ability, improve neurological function, reduce S100β protein and NSE levels, and reduce the incidence of complications in patients with aSAH. Meanwhile, miR-146a-5p inhibited early brain injury and neuroinflammation in aSAH via regulating STC1 expression.

The Effect of Tranexamic Acid on Neurosurgical Intervention in Spontaneous Intracerebral Hematoma: Data From 121 Surgically Treated Participants From the Tranexamic Acid in IntraCerebral Hemorrhage-2 Randomized Controlled Trial.

An important proportion of patients with spontaneous intracerebral hemorrhage (ICH) undergo neurosurgical intervention to reduce mass effect from large hematomas and control the complications of bleeding, including hematoma expansion and hydrocephalus. The Tranexamic acid (TXA) for hyperacute primary IntraCerebral Hemorrhage (TICH-2) trial demonstrated that tranexamic acid (TXA) reduces the risk of hematoma expansion. We hypothesized that TXA would reduce the frequency of surgery (primary outcome) and improve functional outcome at 90 days in surgically treated patients in the TICH-2 data set. Participants enrolled in TICH-2 were randomized to placebo or TXA. Participants randomized to either TXA or placebo were analyzed for whether they received neurosurgery within 7 days and their characteristics, outcomes, hematoma volumes (HVs) were compared. Characteristics and outcomes of participants who received surgery were also compared with those who did not. Neurosurgery was performed in 5.2% of participants (121/2325), including craniotomy (57%), hematoma drainage (33%), and external ventricular drainage (21%). The number of patients receiving surgery who received TXA vs placebo were similar at 4.9% (57/1153) and 5.5% (64/1163), respectively (odds ratio [OR] 0.893; 95% CI 0.619-1.289; P -value = .545). TXA did not improve outcome compared with placebo in either surgically treated participants (OR 0.79; 95% CI 0.30-2.09; P = .64) or those undergoing hematoma evacuation by drainage or craniotomy (OR 1.19 95% 0.51-2.78; P -value = .69). Postoperative HV was not reduced by TXA (mean difference -8.97 95% CI -23.77, 5.82; P -value = .45). TXA was not associated with less neurosurgical intervention, reduced HV, or improved outcomes after surgery.

F.4 Anatomical assessment and comparative analysis of ventricular access points in pterional approach: a cadaveric study

Background: In early-stage transsylvian aneurysm surgery, achieving brain relaxation is crucial for the safe exposure of aneurysms; however, in cases of tight, hemorrhagic brains, ventricular drainage is often required. Although Paine/Samson initially proposed a ventricular access point in the frontal horn of the lateral ventricle, and numerous points and techniques have been described since, their consistency and success rates have not undergone rigorous evaluation through comparative cadaveric anatomical studies. Methods: We injected 2 cc agar-agar solutions with distinct colors into the lateral ventricles of twelve cadaveric brains, utilizing four described points, followed by refrigeration at 4°C for one hour for each injection. Next, the brains were sectioned in the coronal plane at 2 cm intervals for evaluation. We assessed the efficacy of the injections in reaching the ventricles and measured the ventricular dimensions, in addition to calculating the Evans’ index for each brain. Results: Injections at Paine/Samson’s point achieved a 100% success rate, followed by Hyunn’s point with a 91.6% success rate. The success rates at Temporal point and Park point were 83.3% and 58.3%, respectively. Conclusions: We emphasize the significance of direct ventricle puncture technique and our findings indicate that the classical Paine/Samson point is the most reliable among the evaluated methods.

Comparison of the Effects of Hydralazine and Labetalol on Intracranial Pressure When Used for Blood Pressure Control in Patients With Intracranial Hemorrhage: A Retrospective Study.

Background Recommendations on optimal agents to manage blood pressure (BP) in patients with an intracranial hemorrhage (ICH) are lacking. A case series suggests that hydralazine can cause intracranial pressure (ICP) elevation in an ICH. The purpose of this study was to compare the effects of intravenous (IV) hydralazine to IV labetalol on ICP in patients with ICH. Materials and methods A retrospective chart review from September 2015 to September 2021 on adults admitted to a level I trauma center with ICH, requiring an external ventricular drain or ICP monitor, and pharmacologic intervention with IV hydralazine or IV labetalol. ICP measurements and clinical interventions 0-80 minutes prior to and after medication administration were compared. Data points were excluded if multiple antihypertensive agents were administered. Results A total of 27 patients were included (three received only hydralazine, 13 only labetalol, and 11 both). Twenty-seven doses of hydralazineand 115 doses of labetalol were compared. There was no significant difference in mean ICP 0-80 minutes following hydralazine and labetalol administration (p = 0.283). Of the hydralazine doses, 29.6% received intervention for elevated ICP, while 25.2% of labetalol doses received intervention (p = 0.633). Hydralazine patients received m = 0.56 interventions for ICP, and labetalol patients received m = 0.36 interventions (p = 0.223). Of the patients that required intervention for ICP management, hydralazine patients required m = 1.88 interventions, while labetalol patients required m = 1.41 interventions (p = 0.115). Conclusion There was no significant difference in mean ICP at 0-80 minutes following administration of hydralazine or labetalol. There was also no significant difference in interventions required for elevated ICP management between groups. Larger studies are needed to confirm these findings.

Efficacy of Extended Antibiotic Cover for Ventricular Drains in Preventing Infections

Efficacy of Extended Antibiotic Cover for Ventricular Drains in Preventing Infections

Pharmacologic Venous Thromboembolism Prophylaxis in Patients with Nontraumatic Subarachnoid Hemorrhage Requiring an External Ventricular Drain.

Optimal pharmacologic thromboprophylaxis dosing is not well described in patients with subarachnoid hemorrhage (SAH) with an external ventricular drain (EVD). Our patients with SAH with an EVD who receive prophylactic enoxaparin are routinely monitored using timed anti-Xa levels. Our primary study goal was to determine the frequency of venous thromboembolism (VTE) and secondary intracranial hemorrhage (ICH) for this population of patients who received pharmacologic prophylaxis with enoxaparin or unfractionated heparin (UFH). A retrospective chart review was performed for all patients with SAH admitted to the neurocritical care unit at Emory University Hospital between 2012 and 2017. All patients with SAH who required an EVD were included. Of 1,351 patients screened, 868 required an EVD. Of these 868 patients, 627 received enoxaparin, 114 received UFH, and 127 did not receive pharmacologic prophylaxis. VTE occurred in 7.5% of patients in the enoxaparin group, 4.4% in the UFH group (p = 0.32), and 3.2% in the no VTE prophylaxis group (p = 0.08). Secondary ICH occurred in 3.83% of patients in the enoxaparin group, 3.51% in the UFH group (p = 1), and 3.94% in the no VTE prophylaxis group (p = 0.53). As steady-state anti-Xa levels increased from 0.1 units/mL to > 0.3 units/mL, there was a trend toward a lower incidence of VTE. However, no correlation was noted between rising anti-Xa levels and an increased incidence of secondary ICH. When compared, neither enoxaparin nor UFH use was associated with a significantly reduced incidence of VTE or an increased incidence of ICH. In this retrospective study of patients with nontraumatic SAH with an EVD who received enoxaparin or UFH VTE prophylaxis or no VTE prophylaxis, there was no statistically significant difference in the incidence of VTE or secondary ICH. For patients receiving prophylactic enoxaparin, achieving higher steady-state target anti-Xa levels may be associated with a lower incidence of VTE without increasing the risk of secondary ICH.

The Presence of Blood in a Strain Gauge Pressure Transducer Has a Clinical Effect on the Accuracy of Intracranial Pressure Readings.

Patients admitted with cerebral hemorrhage or cerebral edema often undergo external ventricular drain (EVD) placement to monitor and manage intracranial pressure (ICP). A strain gauge transducer accompanies the EVD to convert a pressure signal to an electrical waveform and assign a numeric value to the ICP. This study explored ICP accuracy in the presence of blood and other viscous fluid contaminates in the transducer. Preclinical comparative design study. Laboratory setting using two Natus EVDs, two strain gauge transducers, and a sealed pressure chamber. No human subjects or animal models were used. A control transducer primed with saline was compared with an investigational transducer primed with blood or with saline/glycerol mixtures in mass:mass ratios of 25%, 50%, 75%, and 100% glycerol. Volume in a sealed chamber was manipulated to reflect changes in ICP to explore the impact of contaminates on pressure measurement. From 90 paired observations, ICP readings were statistically significantly different between the control (saline) and experimental (glycerol or blood) transducers. The time to a stable pressure reading was significantly different for saline vs. 25% glycerol (< 0.0005), 50% glycerol (< 0.005), 75% glycerol (< 0.0001), 100% glycerol (< 0.0005), and blood (< 0.0005). A difference in resting stable pressure was observed for saline vs. blood primed transducers (0.041). There are statistically significant and clinically relevant differences in time to a stable pressure reading when contaminates are introduced into a closed drainage system. Changing a transducer based on the presence of blood contaminate should be considered to improve accuracy but must be weighed against the risk of introducing infection.

Racial and Ethnic Differences in Mortality and Functional Outcomes Following Aneurysmal Subarachnoid Hemorrhage.

Ischemic and hemorrhagic stroke incidence tends to be higher among minority racial and ethnic groups. The effect of race and ethnicity following an aneurysmal subarachnoid hemorrhage (aSAH) remains poorly understood. Thus, we aimed to explore the association between race and ethnicity and aSAH outcomes. Single-center retrospective review of patients with aSAH from January 2009 to March 2023. Primary outcome was in-hospital mortality. Secondary outcomes included delayed cerebral ischemia, cerebral infarction, radiographic and symptomatic vasospasm, pulmonary complications, epileptic seizures, external ventricular drain placement, and modified Rankin Scale score at discharge and 3-month follow-up. Associations between race and ethnicity and outcomes were assessed using binary and ordinal regression models, with multivariable models adjusted for significant covariates. A total of 1325 patients with subarachnoid hemorrhage presented to our center. Among them, 443 cases were excluded, and data from 882 patients with radiographically confirmed aSAH were analyzed. Distribution by race and ethnicity was 40.8% (n=360) White, 31.4% (n=277) Hispanic, 22.1% (n=195) Black, and 5.7% (n=50) Asian. Based on Hunt-Hess and modified Fisher grade, aSAH severity was similar among groups (P=0.269 and P=0.469, respectively). In-hospital mortality rates were highest for Asian (14.0%) and Hispanic (11.2%) patients; however, after adjusting for patient sex, age, health insurance, smoking history, alcohol and substance abuse, and aneurysm treatment, the overall likelihood was comparable to White patients. Hispanic patients had higher risks of developing cerebral infarction (adjusted odds ratio, 2.17 [1.20-3.91]) and symptomatic vasospasm (adjusted odds ratio, 1.64 [1.05-2.56]) than White patients and significantly worse discharge modified Rankin Scale scores (adjusted odds ratio, 1.44 [1.05-1.99]). Non-White patients also demonstrated a lower likelihood of 0 to 2 discharge modified Rankin Scale scores (adjusted odds ratio, 0.71 [0.50-0.98]). No significant interactions between race and ethnicity and age or sex were found for in-hospital mortality and functional outcomes. Our study identified significant differences in cerebral infarction and symptomatic vasospasm risk between Hispanic and White patients following aSAH. A higher likelihood of worse functional outcomes at discharge was found among non-White patients. These findings emphasize the need to better understand predisposing risk factors that may influence aSAH outcomes. Efforts toward risk stratification and patient-centered management should be pursued.

Lupus Journey: The Challenge of Obstructıve Hydrocephalus

Systemic lupus erythematosus (SLE) is a complex autoimmune condition known for its diverse clinical presentations. Neuropsychiatric SLE refers to neurological or psychiatric symptoms that arise once other potential causes have been ruled out. While hydrocephalus occurring in the context of SLE is exceedingly rare and its underlying mechanism remains elusive, its recognition is crucial for informed management decisions. A 20-year-old female patient, diagnosed with SLE, had been under our rheumatology clinic's care for two years. She recently presented with confusion, which emerged a year after her initial diagnosis. Brain tomography revealed obstructive hydrocephalus, and subsequent investigations ruled out other potential causes, linking the condition to her clinical SLE. After consulting with a neurosurgeon, a ventricular drainage catheter was inserted. In response to this hydrocephalus development, a regimen of pulse steroid therapy was administered. Following this, mycophenolate mofetil was prescribed as an immunosuppressant agent and her clinical condition was successfully stabilized.

Intracerebral hemorrhagic developing in a patient with posterior reversible encephalopathy syndrome; a case report

We describe a case of hemorrhagic posterior reversible encephalopathy syndrome (PRES) in a 19-year-old woman, who had undergone a cesarean section for epilepsy and lupus-related chronic renal failure 2 months ago, and presented to the emergency department with complaints of blurred vision. The neurological and ophthalmological examinations were normal. Despite the initial imaging being normal, subsequent magnetic resonance images showed hyperintensity in bilateral occipital lobes and cerebellum (indicative of PRES) and watershed ischemia in addition to intracerebral hemorrhage. Brain surgery was performed, external ventricular drainage was placed and she was monitored postoperatively with routine care in the intensive care unit where she remained intubated for a month, after which she died of the consequences of her condition.

Neuroendoscopy-Assisted Entire-Process Visualization Technique of Ventricular Puncture for External Ventricular Drainage.

This study aimed to investigate the feasibility, safety, and efficacy of the neuroendoscopy-assisted entire-process visualization technique (NEAEVT) of ventricular puncture for external ventricular drainage. Eighty-eight patients with cerebral hemorrhage who underwent unilateral ventricular puncture for external ventricular drainage in our hospital from June 2021 to June 2023 were analyzed. Patients were grouped according to puncture technique: NEAEVT (30 patients), freehand (30 patients), and laser-navigation-assisted (28 patients). Operation time, drainage tube placement, and catheter-related hemorrhage incidence were compared between the groups. Mean operation time significantly differed between the freehand, NEAEVT, and laser-assisted groups (17.07, 18.37, and 34.04 min, respectively; P <0.0001). The position of the drainage tube was optimal or adequate in all patients of the NEAEVT group; optimal/adequate positioning was achieved in 80% of the freehand group. No catheter-related hemorrhage occurred in the NEAEVT group. Three freehand group patients and 2 laser-assisted group patients experienced catheter-related hemorrhage. The NEAEVT of ventricular puncture is accurate and achieves ventricular drainage without significantly increasing surgical trauma, operation time, or incidence of hemorrhage.

Development of an adjustable patient-specific rigid guide to improve the accuracy of external ventricular catheter placement.

The most common method for external ventricular drain (EVD) placement is the freehand approach, which has reported inaccuracy rates of 12.3%-44.9%, especially in the case of altered ventricular anatomy. Current assistive devices require added time or equipment or do not account for shifted ventricles. To improve the accuracy of emergent EVD placement in the setting of altered ventricular anatomy, the authors designed a patient-specific EVD (PS-EVD) guide. The PS-EVD guide has a tripod base and a series of differently angled inserts that lock in place at multiple rotational positions, allowing for numerous insertion angles. For testing, the authors designed a 3D-printed phantom skull with a gelatin brain analog containing ventricles simulating normal and altered ventricular anatomy. Low-resolution CT scans of the phantom were used to calculate the insertion angle in relation to the standard perpendicular entry. The corresponding insert at the correct rotational position within the base unit was positioned over the entry point on the phantom, and the catheter was inserted. Accuracy was evaluated with repeat CT scans. With normal ventricular anatomy, as well as abnormally shifted ventricles, proper use of the PS-EVD guide led to accurate catheter insertion into the ventricle in trials, as confirmed on coronal and sagittal CT images, including cases in which a perpendicular trajectory, such as with the Ghajar guide, was insufficient. The PS-EVD guide allows consistent and accurate EVD placement in phantom skulls with both normal and altered ventricular anatomy. Further trials comparing this device to the freehand approach are required.

Incidence of Rebleed Following Cerebrospinal Fluid (CSF) Drainage in Poor Grade Subarachnoid Hemorrhage: An Institutional Experience.

The outcome of poor grade subarachnoid hemorrhage (SAH) is dismal. Some of these patients need cerebrospinal fluid (CSF) drainage procedure for the hydrocephalus and intraventricular hemorrhage (IVH) which may precipitate rebleeding. However, aneurysmal rebleed following CSF drainage procedure is controversial. Our study aimed at analyzing the effect of CSF drainage procedure on aneurysmal rebleeding. We retrospectively analyzed the records of all the consecutive patients diagnosed with poor grade aneurysmal SAH over three year period. Patients initially requiring either external ventricular drainage (EVD) or lumbar drain (LD) were included in the study group, and the rest (not requiring drainage) were included in the control group. Rebleeding was confirmed on computed tomography. The factors affecting rebleeding were analyzed. Overall 194 patients with poor grade SAH were enrolled in the study (91 males: 103 females; mean age: 50.6 years). The study group had 91 patients (83 EVD and 8 LD) while 103 patients were in the control group. Posterior circulation aneurysms, poor grade SAH, hydrocephalus, and IVH were more common in the study group P < 0.001. The rebleeding rate was 7.6% in the study group and 8.7% in the control group. On univariate analysis size >1 cm, multiplicity, multilobularity, vasospasm, and CSF drainage were significant risk factors for rebleeding (P < 0.001). On multivariate analysis aneurysm size >1 cm, CSF overdrainage >250 ml/day were significantly associated with risk of rebleeding. Ventricular drainage is essential to relieve acute hydrocephalus and drain IVH in SAH and we found no significant association between CSF drainage and rebleeding. However, rapid overdrainage of CSF can lead to aneurysm rupture, hence controlled controlled CSF drainage should be undertaken.

The Device for Intraventricular Entry guide: a novel solution to a perpetual problem.

The authors designed a low-profile device for reliable ventricular access and prospectively studied its safety, efficacy, and accuracy at a large academic center. A novel device for ventricular entry, the Device for Intraventricular Entry (DIVE) guide, was designed and created by the first and senior authors. Fifty patients undergoing external ventricular drainage (EVD) or shunt placement were prospectively enrolled for DIVE-assisted catheter placement at a single academic center. The primary outcome was the catheter tip location on postprocedural CT. Secondary outcomes included number of catheter passes, clinically significant hemorrhages, and procedure-related infections. Fifty patients were enrolled. Indications included subarachnoid hemorrhage, intraventricular hemorrhage, traumatic brain injury, hydrocephalus, pseudotumor, and postsurgical wound drainage. In total, 76% (38/50) of patients underwent right-sided placement and 24% (12/50) underwent left-sided placement. All 100% (50/50) of patients had successful cannulation with an average of 1.06 passes. Postprocedural head CT confirmed ipsilateral frontal horn or third ventricle placement (Kakarla grade 1) in 92% (46/50) of patients and placement in the contralateral lateral ventricle in 8% (4/50) (Kakarla grade 2). There were no clinically significant track hemorrhages or procedural infections. This single-center prospective study investigated the safety and efficacy of DIVE-assisted ventricular access. In total, 100% of procedures had successful ventricular cannulation, with 92% achieving Kakarla grade 1, with an average of 1.06 passes without any clinical complications.

Introducing a novel hybrid educational boot camp to augment medical student training in neurosurgery.

Neurosurgery subinternships are a critical portion of the medical student application to neurosurgery residency programs, allowing programs to assess the student's clinical knowledge, interpersonal skills, work ethic, and character. Despite how critical these auditions are, many students have a poor understanding of expectations prior to beginning these subinternships. Thomas Jefferson University hosted a combined in-person and virtual boot camp session open to all medical students interested in neurosurgery. The authors sought to determine the effectiveness of this inaugural course. A total of 304 registered participants were sent a survey assessing their attitudes toward neurosurgery subinternships, beliefs about their abilities, and their comfort with various neurosurgical skills. All participants were sent a postsession survey composed of the same questions. The mean scores for responses to pre- and postsession survey questions were recorded based on graduating year and by medical school type (US allopathic [US MD], US osteopathic [US DO], or foreign degree/international medical graduate [IMG]). Differences in means between pre- and postsession survey responses were analyzed using the Student t-test, and statistical significance was set at p < 0.05. A total of 112 presession surveys and 64 postsession surveys were completed, yielding a presession survey response rate of 36.8% and a postsession survey response rate of 21.1%. Seventy-five percent of the postsession survey respondents attended virtually, and 25% were in-person. US MD, US DO, and IMG attendees demonstrated a significantly increased understanding of the expectations of a neurosurgery subintern (p < 0.001). All students had significantly increased confidence in their ability to succeed as subinterns (US MD students and IMGs p < 0.001, US DO students p < 0.05). Regarding procedural confidence, US MD students had increased confidence in craniotomies and cranial plating (p < 0.001). When comparing responses by graduation year, students in the classes of 2024 and 2025 (rising 4th-year and rising 3rd-year medical students, respectively) demonstrated significantly increased understanding of expectations and confidence in their ability to succeed (< 0.001). Seventy-five percent of our postsession survey respondents attended virtually, and 25% were in-person. The in-person cohort had greater improvements in comfort with procedures such as craniotomies, cranial plating, and extraventricular drain placement (in-person vs Zoom mean differences: craniotomies and cranial plating, -2.29, extraventricular drain placement, -2.31) (p < 0.05). The boot camp successfully delineated the expectations of neurosurgery subinterns and enhanced the attendees' confidence in their abilities. The authors concluded that a hybrid virtual and in-person format is beneficial and feasible in increasing accessibility to information about neurosurgery subinternships.

Low-/Negative-Pressure Hydrocephalus: To Understand the Formation Mechanism from the Perspective of Clinicians.

Low-/negative-pressure hydrocephalus (LPH/NePH) is uncommon in clinical practice, and doctors are unfamiliar with it. LPH/NePH is frequently caused by other central nervous system diseases, and patients are frequently misdiagnosed with other types of hydrocephalus, resulting in delayed treatment. LPH/NePH therapy evolved to therapeutic measures based on "external ventricular drainage below atmospheric pressure" as the number of patients with LPH/NePH described in the literature has increased. However, the mechanism of LPH/NePH formation is unknown. Thus, understanding the process of LPH/NePH development is the most important step in improving diagnosis and treatment capability. Based on case reports of LPH/NePH, we reviewed theories of transcortical pressure difference, excessive cerebral venous drainage, brain viscoelastic changes, and porous elastic sponges.

An 11-month-old boy with tuberculous meningitis presenting as progressive limb weakness, fever, developmental retardation, and loss of consciousness: a case report

BackgroundTuberculous meningitis (TBM) accounts for about 1% of all tuberculosis cases and about 5% of extrapulmonary tuberculosis cases. However, it poses major importance because approximately half of those affected die or become severely disabled. Herein, the successful treatment of an 11-month-old boy with progressive limb weakness, fever, developmental retardation, and loss of consciousness due to tuberculosis, was reported.Case presentationAn 11-month-old (Iranian Turk) boy was referred to Loghman Hakim hospital for progressive limb weakness and loss of previously attained developmental milestones for the past 2 months. He also had persistent fever and loss of consciousness for about 14 to 21 days. Before being referred to our center, the patient had been diagnosed with hydrocephalus at another center due to possible acute bacterial meningitis based on a CT scan and MRI imaging. On physical examination, anterior fontanel bulging and neck stiffness were observed on the admission. His body temperature and heart rate were 38.1 C and 86 beats per minute (bpm), respectively. He had left 6 cranial nerve palsy and spastic quadriparesis with a power of grade 3/5. Other systemic examinations were normal. Endoscopic third ventriculostomy (ETV) (and leptomeningeal biopsy) revealed diffuse thickening of the floor and lateral walls of the 3rd ventricle and also a cobblestone appearance in the form of multiple white patchy lesions was detected on the floor of the 3rd ventricle. CSF analysis and polymerase chain reaction confirmed the TB meningitis. During hospitalization, a temporary EVD (external ventricular drain) was initially inserted. Eventually, defervescence was denoted 5–6 days after initiation of anti-TB medications, and a permanent ventriculoperitoneal shunt was inserted due to hydrocephalus. Gradually his truncal and limb tone and motor function improved, as did his emotional responses to his parents and ability to eat. The patient can walk without help in the 15th month following the operation and resolved hydrocephalus demonstrated on follow-up imaging.ConclusionOver half of treated TB meningitis patients die or suffer severe neurological sequelae, mainly due to late diagnosis. Hence, early diagnosis and prompt initiation of TB treatment offer the best chance of a good neurological outcome.

Severe Tick-Borne Encephalitis (TBE) in a Patient with X-Linked Agammaglobulinemia; Treatment with TBE Virus IgG Positive Plasma, Clinical Outcome and T Cell Responses

PurposeA patient with X-linked agammaglobulinemia (XLA) and severe tick-borne encephalitis (TBE) was treated with TBE virus (TBEV) IgG positive plasma. The patient’s clinical response, humoral and cellular immune responses were characterized pre- and post-infection.MethodsELISA and neutralisation assays were performed on sera and TBEV PCR assay on sera and cerebrospinal fluid. T cell assays were conducted on peripheral blood the patient and five healthy vaccinated controls.ResultsThe patient was admitted to the hospital with headache and fever. He was not vaccinated against TBE but receiving subcutaneous IgG-replacement therapy (IGRT). TBEV IgG antibodies were low-level positive (due to scIGRT), but the TBEV IgM and TBEV neutralisation tests were negative. During hospitalisation his clinical condition deteriorated (Glasgow coma scale 3/15) and he was treated in the ICU with corticosteroids and external ventricular drainage. He was then treated with plasma containing TBEV IgG without apparent side effects. His symptoms improved within a few days and the TBEV neutralisation test converted to positive. Robust CD8+ T cell responses were observed at three and 18-months post-infection, in the absence of B cells. This was confirmed by tetramers specific for TBEV.ConclusionTBEV IgG-positive plasma given to an XLA patient with TBE without evident adverse reactions may have contributed to a positive clinical outcome. Similar approaches could offer a promising foundation for researching therapeutic options for patients with humoral immunodeficiencies. Importantly, a robust CD8+ T cell response was observed after infection despite the lack of B cells and indicates that these patients can clear acute viral infections and could benefit from future vaccination programs.