Hydrocephalus In Tuberculous Meningitis Research Articles

Factors associated with in-hospital mortality in HIV-infected children treated for tuberculous meningitis hydrocephalus

PurposeThe study aimed to investigate factors associated with in-hospital mortality in children diagnosed with tuberculous meningitis (TBM) hydrocephalus and HIV co-infection undergoing cerebrospinal fluid diversion procedures and their complications.MethodsData were collected retrospectively and prospectively between 2007 and 2022. Data collected included demographics, clinical characteristics, antiretroviral therapy (ART) status, biochemistry results, CD4 count, radiology findings, CSF diversion procedures (and complications), length of hospital stay (LOHS), and in-hospital mortality.ResultsThirty-one children were included, with a mean age of 6.7 ± 5.3 years and 67.7% males. Median admission Glasgow Coma Scale (GCS) was 11 (IQR 9–15). Hypertonia (64.5%) and seizures (51.6%) were frequently observed clinical characteristics. Sixty-one percent of children were on ART. Cerebral infarcts and extra-meningeal TB were diagnosed in 64.5% and 19.3% of cases, respectively. The median CD4 count was 151 (IQR 70–732) cells/µL. Surgical procedures included ventriculoperitoneal shunt (VPS) in 26 cases and endoscopic third ventriculostomy (ETV) in five children. VPS complication rate was 27%. No complications were reported for ETV. Median LOHS was 7 days (IQR 4–21). Eleven children (35.5%) died during admission. Factors associated with mortality included GCS (p = 0.032), infarcts (p = 0.004), extra-meningeal TB (p = 0.003), VPS infection (p = 0.018), low CD4 count (p = 0.009), and hyponatremia (p = 0.002). No statistically significant factors were associated with VPS complications.ConclusionTBM hydrocephalus in HIV-infected children carries a high mortality. Clinicians in high-prevalence settings should have a high suspicion index and institute early treatment.

The first historical description of chronic subdural hematoma: A tale of inaccurate interpretation, inaccurate quoting and inaccurate requoting

ABSTRACT Most historical articles have named Johann Jacob Wepfer as the first author to describe a case of chronic subdural hematoma (CSDH). However, the question arises whether these cases truly describe CSDH. Two other names that appear in literature as the first authors to describe a case of CSDH are Thomas Willis and Giovanni Battista Morgagni. In our attempt to find the first description of a CSDH, we studied the original cases described by Willis, Wepfer, and Morgagni. The cases described by Willis and Wepfer cannot be interpreted as cases of CSDH. Willis’s university scholar is more likely to have experienced venous infarction with an underlying septic thrombosis than a CSDH. Wepfer’s cases seem to represent an intraparenchymal hemorrhage from the rupture of a branch or branches of the internal carotid artery, a subarachnoid hemorrhage complicated with hydrocephalus, and a hydrocephalus in tuberculous meningitis. Morgagni’s case described in Letter III, Article 20 in the Sedibus in 1761 seems to be the first accurate historical description of a CSDH, and we believe it should be cited as such. With these early cases of alleged CSDH, we emphasize the importance of misquotation and blind copying of references, which are important citation errors.

Three Decades of Vellore Grading for Tuberculous Meningitis with Hydrocephalus: A Reappraisal.

This review documents the evolution of the Vellore grading system for tuberculous meningitis and hydrocephalus (TBMH), its evaluation by different authors, and analyzes the need for further modification in light of the published literature. Published literature was searched in PubMed and Google Scholar using the search terms, "tuberculous meningitis hydrocephalus" and "Vellore grading." The retrieved articles were reviewed by the author and the appropriate ones were chosen for inclusion in the study. Vellore grade (1-4, with 1 being the best grade and 4 being the worst grade) was found to be the sole statistically significant factor associated with outcome following VP shunt or ETV in several studies. Additionally, Vellore grades also correlate with the likelihood of success following ETV. However, the use of response to external ventricular drainage (EVD) in managing Vellore grade 4 patients has remained contentious as a small but significant proportion of patients have a good outcome following shunt, irrespective of their response to the EVD. The latter findings suggest that grade 4 patients might not constitute a homogenous group. It is proposed that grade 4 be subdivided into grades 4a and 4b, which might help in prognostication and in surgical management of the hydrocephalus in patients with TBMH. Vellore grading has proved its utility as a prognostic tool and can aid surgical decision-making. However, management of patients in grade 4 might be better rationalized with its division into grades 4a and 4b.

Frequency of Hydrocephalus in Patients with Chronic Meningitis due to Mycobacterium Tuberculosis

Background: Tuberculosis is one of the causes of chronic meningitis which may lead to hydrocephalus. Uncertainty and doubtdominate all aspects of tuberculous meningitis.Objectives: To determine the frequency of hydrocephalus in tuberculous meningitis patients.Material & Methods: This was observational descriptive study conducted at department of neurosurgery and neurology ladyreading hospital Peshawar from Jan,2016 to Dec,2018. In this study there were total 93 cases of TBM with 95% confidencelevel,2.2% margin of error according to WHO calculator. Diagnosis was based on clinical features, CSF analysis and CT/MRI brain.Tuberculous meningitis patients of age range 15 to 50 years of either gender were included in this study. All those patients havingSOL in brain and other causes of meningitis were excluded from this study.The symptoms were fever, headache, and weight lossand neck rigidity with or without fits. These cases then underwent CSF analysis under aseptic measures. The findings to label TBMon CSF were low glucose (< 40 mg/dl), increased protein content (> 100 mg/dl) and high WBC count with predominance oflymphocytes. The data was analyzed with the help of SPSS version 23.Effect modifiers were stratified and and post stratificationChi-Square test was applied with P-value < 0.05 as significant. The cases of TBM were divided according to standard BMRC scaleinto three stages.Results: In this study there were total 93 cases with mean age of 37.11± 08.67 years. There were 54 (58.06%) males and 39(41.94%) females. Maximum cases were seen in stage II of TBM which affected 65 (69.89%) cases. Hydrocephalus was seen in 61(65.59%) of the cases. Hydrocephalus was significantly high in male gender as compared to females where it affected 39 (72.22%)of cases. It was also more common in cases that had age group 15-29 years affecting 40 (67.79%) of cases.Conclusion: Hydrocephalus is a common complication of tuberculous meningitis and it is predominantly seen in in male patients,stage II and III of TBM.Keywords: TBM, Hydrocephalus, Meningitis

SHUNT MALFUNCTION IN TUBERCULOUS MENINGITIS- WHETHER GRADE AND CSF PICTURE AFFECT OUTCOME

BACKGROUND Tuberculosis remains a major global problem and a public health issue of considerable magnitude. The World Health Organisation (WHO) estimates that one third of the world’s population is infected with mycobacterium tuberculosis, with the highest prevalence of tuberculosis in Asia. Shunt surgery for hydrocephalus associated with tuberculous meningitis has proven to be highly efficacious. Few studies have addressed the issue of outcome of shunt surgery and impact of CSF (Cerebrospinal fluid) picture in post tuberculous meningitis hydrocephalus shunt surgery. MATERIAL AND METHODS The study was a prospective study conducted in Department of Neurosurgery, PGIMER, Dr. RML Hospital, New Delhi. The duration of follow up was of 6 months. 70 patients were enrolled in the study. All patients who underwent ventriculo-peritoneal shunt surgery for hydrocephalus with tuberculous meningitis in Neurosurgery department at PGIMER & Dr.RML hospital were included in the study. All the patients who had hydrocephalus following tuberculous meningitis were evaluated using Modified Vellore grading of TBM and hydrocephalus. All the patients who underwent ventriculo-peritoneal shunt surgery had have their CSF analysis (cytology, protein, sugar, Gram stain, ZN stain, India ink and aerobic culture) done. Outcome of the surgery were evaluated based on Glasgow outcome score (GOS), radiological parameters and complications. Statistical analysis was performed by the SPSS program for Windows, version 17.0. RESULTS The age of patients enrolled into the study varied from 2 months to 87 years with 44.3% of patients in 1-5 years age group. Patients were divided into 4 grades according to Modified Vellore Grading. Grades at the time of admission were compared with the final Glasgow outcome scale. At the time of admission 6 patients were in Grade I, 13 patients in Grade II, 45 patients in Grade III and 6 patients in Grade IV. GOS was 5 in Grade I, 4.69 +/- in Grade II, 4.50 +/- IN Grade III and 2.17+/- in Grade IV. Outcome was compared according to Cerebrospinal fluid (CSF) cell count, sugar and protein levels but none was found to be significant. Number of shunt revisions were compared to CSF cell count and sugar level but none was found to be significant. Mean FH/ID ratio before surgery was 60.89% which was reduced to 43.70% after 6 months follow up. CONCLUSION Ventriculo-peritoneal shunt surgery is a safe and effective treatment modality to treat tuberculous meningitis with hydrocephalus in all grades of patients except in Grade IV. CSF protein, sugar levels and cell count neither affect the outcome nor increase the risk of shunt malfunction

A Randomized Study Comparing Endoscopic Third Ventriculostomy versus Ventriculoperitoneal Shunt in the Management of Hydrocephalus Due to Tuberculous Meningitis.

Objectives:The objective of this study was to compare safety and efficacy of endoscopic third ventriculostomy (ETV) versus ventriculoperitoneal (VP) shunt in the treatment of hydrocephalus in tuberculous meningitis (TBM) and to assess clinical and radiological profiles of patients with TBM that would be better suited to either VP shunt or ETV.Methods:This study was a single-center randomized prospective study on 52 patients with TBM hydrocephalus in the pediatric age group (<18 years of age). Patients included in the study were randomized into undergo either VP shunt or ETV. Both groups were followed up for a minimum of 5 months and assessed for success and failure rates as well as procedural complications and neurologic sequelae.Results:Twenty-six patients underwent ETV with a success rate of 65.4% with six of nine failures occurring within the first 16 days after surgery (median time to failure – 3 days). In the VP shunt group, there was a success rate of 61.54% and a median time to failure of 50 days. Modified Vellore grading was found to be a significant factor in determining outcome in both ETV and VP shunt groups with high-grade TBM consistently associated with poor outcome (odds ratio = 4.2).Conclusions:ETV can be performed effectively in young children including infants, as well as those with communicating hydrocephalus, high cerebrospinal fluid (CSF) cell counts, and protein levels with a lower rate of failure than that of VP shunt. Hence, ETV should be attempted as the first-choice CSF diversion procedure in hydrocephalus secondary to TBM where technical expertise and experience with this procedure is available as it avoids the myriad of lifelong complications associated with shunts.

Undernutrition as Risk Factor of Hydrocephalus Prevalence in Children with Tuberculous Meningitis

Background : Hydrocephalus is the most frequent neurological complication in children with tuberculous meningitis. Tuberculosis infection cannot be separated from nutritional status. Children with undernutrition have decreased immunity thus could affect clinical manifestation of tuberculous meningitis. This study was conducted to identify the relationship between undernutrition and the prevalence of hydrocephalus in tuberculous meningitis. Methods : An analytic observational study was carried out to 38 medical records of children with tuberculous meningitis in Dr. Hasan Sadikin General Hospital from 2007 to 2015. Variables that were studied included gender, age, advanced stage of disease, motoric paralysis, history of seizure, nutritional status and hydrocephalus. The collected data were analyzed using Chi-Square test. Results : Out of 21 subjects with undernutrition, 11 subjects were found to have hydrocephalus. The analysis using chi-square was statistically significant (p=0.009). Prevalence ratio=4.45 (CI 95% 1.14−45.43), meaning tuberculous meningitis children with undernutrition were at risk of hydrocephalus 4.45 times greater than children with normal nutritional status. Conclusions : Undernutrition may increase the risk of hydrocephalus in children with tuberculous meningitis. [AMJ.2017;4(1):143–7] DOI : 10.15850/amj.v4n1.1036

Hydrocephalus in tuberculous meningitis—How fast does it develop?

To the Editor,A 3.5-y-old female child presented on 29 November 2012 with swelling of the left knee joint of 3-month duration, fever of 1-month duration, and 1 episode of generalized tonic–clonic c...

Hydrocephalus in tuberculous meningitis: Incidence, its predictive factors and impact on the prognosis

Hydrocephalus is one of the most common complications of tuberculous meningitis. The present study evaluated the incidence, predictive factors and impact of hydrocephalus on overall prognosis of tuberculous meningitis. In a prospective cohort study, all patients fulfilling the inclusion criteria of tuberculous meningitis underwent clinical and cerebrospinal fluid evaluation, together with magnetic resonance imaging of the brain. Patients were treated with antituberculosis drugs and dexamethasone. Follow up neuroimaging was done after 6 months. Hydrocephalus was assessed using Evan's index. Of 80 patients with tuberculous meningitis, 52(65%) had hydrocephalus at presentation. During follow up, 8 new patients developed hydrocephalus. Factors associated with hydrocephalus included advanced stage of disease, severe disability, duration of illness>2 months, diplopia, seizures, visual impairment, papilledema, cranial nerve palsy, hemiparesis, CSF total cell count>100/cu.mm, CSF protein>2.5g/l. Neuroimaging factors that were significantly associated with hydrocephalus included basal exudates, tuberculoma and infarcts. Multivariate analysis revealed visual impairment, cranial nerve palsy and the presence of basal exudates as significant predictors of hydrocephalus. In 13 patients, with early tuberculous meningitis, there was complete resolution of hydrocephalus. Hydrocephalus was significantly associated with mortality and poor outcome. Hydrocephalus occurs in approximately two-third of patients with tuberculous meningitis and has an unfavorable impact on the prognosis. Hydrocephalus in early stages of tuberculous meningitis may resolve completely.

Effects of the implantation of Ommaya reservoir in children with tuberculous meningitis hydrocephalus: a preliminary study

The role of Ommaya reservoir implantation in children with tuberculous meningitis hydrocephalus (TBMH) has been seldomly reported. Therefore, we performed this study to determine the role of the Ommaya reservoir in the treatment of children with TBMH. We retrospectively analyzed the effects of Ommaya reservoir implantation in 12 children with TBMH. Intracapsular puncture of the reservoir was performed for draining the cerebrospinal fluid and the TBM was treated by intraventricular injection of isoniazid. The ideal treatment outcome was observed in nine (75 %) of the 12 children; two (16.7 %) children developed serious disabilities and one of them (8.3 %) eventually died. The treatment method was effective for all six (100 %) children with Palur grade II TBM but showed no effect in three (50 %) children with grade III and IV TBM. The number of leukocytes in the cerebrospinal fluid decreased to 20 × 10(6)/L (75 %) within 2 weeks after implantation of the reservoirs. Finally, the Ommaya reservoirs in eight children were removed but were retained in four children. Four children had to undergo ventriculoperitoneal shunt. Ommaya reservoir implantation has been shown to be effective in treating children with TBMH. This method may be largely suitable for children with early grade II TBM or partly in children with grade III TBM who have mild or moderate hydrocephalus that can alleviate after short-term treatment. Thus, a good proportion of children who undergo Ommaya reservoir implantation can avoid ventriculoperitoneal shunt surgery.

Role of modified external ventricular drainage in the management of children with tuberculous meningitis hydrocephalus

To explore the role of modified external ventricular drainage (mEVD) in the treatment of tuberculous meningitis obstructive hydrocephalus in children. The records were retrospectively reviewed for 30 pediatric patients of tuberculous meningitis with hydrocephalus (TBMH) undergoing surgery between January 2007 and December 2010. The procedures included ventricular abdomen subcutaneous drainage (mEVD) (n = 6), Ommaya reservoir (n = 9) and ventriculoperitoneal shunt (VPS) (n = 15). White cell count and protein content of cerebrospinal fluid were measured repeatedly. And their clinical outcomes were assessed at 6 months post-operation. External drainage was extracted for 4 of 6 TBMH patients after 4 - 6 months of mEVD. Neither intracranial infections nor serious postoperative complications occurred. Two of 6 TBMH received VPS substituting for mEVD. No statistically significant difference in white cell count, protein content of cerebrospinal fluid and outcome was found between the mEVD and VPS groups. Ventricular abdomen subcutaneous drainage is both safe and efficacious in the management of children with tuberculous meningitis hydrocephalus. This approach may avoid possible complications and long-term indwelling shunt so that it is worthy of further clinical application.

Are linear measurements and computerized volumetric ratios determined from axial MRI useful for diagnosing hydrocephalus in children with tuberculous meningitis?

This study aimed to evaluate linear measurements and computerized volumetric ratios on axial magnetic resonance imaging (MRI) scans against the diagnosis of hydrocephalus in children with tuberculous meningitis (TBM). MRI scans and clinical notes of children with culture positive TBM were reviewed. Patients with surgical drainage of ventricles were considered positive for hydrocephalus. Alternatively, predefined radiological criteria of hydrocephalus in combination with any clinical criteria were considered positive for hydrocephalus. Axial T2-weighted MRI scans were used for measurement by a radiologist. Linear measurements included the Evans index, frontal-occipital horn ratio, and frontal-occipital horn width ratio. Computer-assisted segmentation of the MRI volume was performed on a slice-by-slice basis using the number of pixels comprising each region to calculate the ratios: ventricular volume: brain volume and cerebrospinal fluid (CSF)/(brain + CSF) for all slices and for a single slice at the level of the lateral ventricles. Twenty-two children (mean age 3.7years) comprised ten patients with a 'final' diagnosis of hydrocephalus (six communicating, four non-communicating). None of the linear measurements showed a statistical correlation with the 'final' diagnosis of hydrocephalus. The frontal-occipital horn width ratio (FOHWR) (p = 0.09) was the closest to demonstrate statistical significance. The highest sensitivity was attained with FOR (90%) followed by FOHWR (85%). The highest specificity was reached with FOHWR (70%). Volumetric ratios were inferior to linear measures. Linear measures of hydrocephalus in TBM were more reliable than volumetric ratios. Hydrocephalus can be quantified most reliably using the FOHWR. This is useful for serial follow-up and for research of TBM.

Intraoperative ventriculo-stomographic evaluation of endoscopic cerebrospinal fluid diversion and flow restoration procedures

Purpose. This prospective study was designed for intra-operative demonstration of cerebrospinal fluid (CSF) flow in ventricles and cisternal spaces before and after neuroendoscopic procedure. The aim of this study was to evaluate site of obstruction of CSF flow and subsequent stomal or aqueductal patency after endoscopic third ventriculostomy (ETV) or aqueductoplasty in patients with hydrocephalus of diverse aetiology.Method. Seventeen patients with hydrocephalus due to diverse aetiology underwent ETV (n = 15) and aqueductoplasty (n = 2) or cysto-ventrticulostomy (n = 1) or transaqueductal removal of neurocysticercus cyst (NCC) (n = 1). Intra-operatively, radio-opaque contrast agent (iohexol) instillation into the third ventricle was used for qualitative evaluation of obstruction and post-procedure CSF flow across the stoma into cisternal spaces.Result: 11 male and 6 female patients ranging from 3 to 50 years of age were included in the study. Post-procedure intra-operative ventriculo-stomography (IOVSG) showed free flow of dye across the endoscopic stoma (n = 13) or aqueduct (n = 2) into cisternal spaces. Diagnosis of fourth ventricular NCC was made in one patient with panventriculomegaly. In two patients of tuberculous meningitis hydrocephalus, poor flow of contrast in the prepontine area and basal cisterns was seen on IOVSG. They were subjected to ventriculoperitoneal shunt insertion in the same sitting. Cine MRI confirmed the patency of stoma or aqueduct in follow-up period in all patients with successful endoscopic procedure.Conclusion. IOVSG is a simple and safe technique that helps in confirming the adequacy of endoscopic procedure during surgery and thereby facilitates intra-operative decision about further management.

PO16-TU-14 Clinical outcome of Filipino children with tuberculous meningitis hydrocephalus in a Tertiary hospital: three year review

PO16-TU-14 Clinical outcome of Filipino children with tuberculous meningitis hydrocephalus in a Tertiary hospital: three year review

Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy

Endoscopic third ventriculostomy (ETV) is increasingly being used as an alternative treatment for post-tuberculous meningitis (TBM) hydrocephalus. The aim of this study was to affirm the role of ETV in patients with TBM hydrocephalus and also to study the usefulness of cine phase-contrast MR imaging (cine MR imaging) for functional assessment of the ETV stoma. An additional goal was to identify factors that influence the outcome of ETV, so as to define patients with TBM hydrocephalus in whom ETV is warranted. Twenty-six patients with TBM hydrocephalus treated with ETV were evaluated clinically and with cine MR imaging postoperatively. The duration of follow-up ranged from 1 to 15 months. The authors evaluated flow void changes in the floor of the third ventricle and analyzed parameters from the preoperative data, which they then used as a basis for comparison between endoscopically successful and endoscopically unsuccessful cases. The overall success rate of ETV in TBM hydrocephalus was 73.1% in this case series. Cine MR imaging showed a sensitivity of 94.73% and specificity of 71.42% for the functional assessment of third ventriculostomy in these patients, with the efficacy being maintained during follow-up. The outcome of ETV showed a statistically significant correlation with the stage of illness and presence of intraoperative cisternal exudates. Although duration of symptoms and duration of preoperative antituberculous therapy (ATT) appeared to influence the outcome, their correlation with outcome was not statistically significant. Endoscopic third ventriculostomy should be considered as the first surgical option for CSF diversion (that is, before shunt surgery) in patients with TBM hydrocephalus. Cine MR imaging is a highly effective noninvasive tool for the postoperative functional assessment of stomata. Patients who presented with a history of longer duration and those who were administered preoperative ATT for a longer period had a better outcome of endoscopic treatment. Outcome was poorer in patients who presented with higher stages of illness and in those in whom cisternal exudates were observed intraoperatively.

Shunting in tuberculous meningitis: a neurosurgeon’s nightmare

I read with interest the original paper by Sil et al. entitled “Shunting in tuberculous meningitis: a neurosurgeon’s nightmare” [Childs Nerv Syst (2008) 24:1029–1032]. I am delighted and congratulate the authors on presenting their valuable work on shunting in tuberculous meningitis, which is indeed a difficult decision-making process and associated with a variable outcome. They conclude that early shunting is the best option to prevent long-term neurological sequelae. Tuberculous meningitis still continues to be a grave problem in Indian population at large, especially in children. It frequently forms an important differential diagnosis for childhood chronic meningitis. The sequelae can be devastating and contributes significantly to the economic burden of the family as well as the nation. The CSF diversion procedure is largely based on the Palur’s grading system for tubercular meningitis. In the era prior to effective antitubercular medication, there was a little choice for the clinician apart from a shunt procedure for hydrocephalus. The potential ill effects of shunt infection and a relatively high incidence of repeated shunt blockade have always been worrisome and precluded easy decision making for shunt insertion. Following an effective antitubercular medication and steroids for tubercular meningitis, aggressive neurosurgical intervention was largely avoided and a wait and watch policy was adopted. However, in absence of an objective criterion, the uniformity for cerebrospinal fluid (CSF) diversion procedure is still questionable among neurosurgical fraternity and ranges from close neurological observation to a delayed time interval for CSF diversion procedure. An intellectual indifference and a false sense of security could occur on the part of the clinician which could result in delay for intervention, especially since the symptomatology of meningitis secondary to vasculitis and arachnoiditis versus raised intracranial pressure tend to overlap and/or coexist. There is little controversy about the role of shunt in noncommunicating hydrocephalus in tuberculous meningitis which is confirmed readily on serial imaging. The decision for shunt insertion in communicating hydrocephalus could be difficult and needs to be appropriately measured. The neurosurgeon’s role in tuberculous meningitis is largely restricted to the cerebrospinal fluid diversion procedures as mentioned by the authors. The selection of the patient for cerebrospinal fluid diversion is important for optimal outcome [1, 2]. The outcome of CSF diversion procedure is more gratifying if the timing of intervention is appropriate. The decision to perform a CSF diversion procedure is a sum product of the clinical profile of the patient and radiological imaging. It is a function of time. It requires to be stressed that the clinical history of the patient is paramount. This is reflected by the author’s results in which Palur grade II patients had a better outcome. The moderate hydrocephalus in Palur grades I and II should be closely monitored clinically for the need of possible early intervention to maximize the neurological outcome and prevent potential irreversible morbidity. Nature and homeostatic mechanisms allow a certain time frame for optimal outcome. The neurosurgeon should be Childs Nerv Syst (2008) 24:1383–1384 DOI 10.1007/s00381-008-0741-2

Factors affecting the outcome of neuroendoscopy in patients with tuberculous meningitis hydrocephalus: a preliminary study

Background In recent years, ETV has been found to be effective in patients with TBMH; however, its precise selection criteria are yet to be established. We carried out this study to identify the factors affecting the outcome of ETV in TBMH. Methods Fourteen patients with TBMH (11 male patients and 3 female patients; mean age, 15.7 years; range, 9 months to 40 years) formed the study group. Various preoperative (clinical grade, ventricular morphology, basal exudates, and CNS tuberculoma) and perioperative (ependymal tubercles, third ventricular floor anatomy, exudates, and adhesions) factors were studied with regard to the result of ETV. Endoscopic third ventriculostomy could be performed on 13 patients; however, an unidentifiable third ventricular floor anatomy precluded ETV in the remaining patient. Endoscopic third ventriculostomy was assigned as “failed” if the patient needed shunt, required EVD, or died in the postoperative period. The average follow-up period for the patients was 5 months. Results Endoscopic third ventriculostomy was successful in 9 of the 14 (64.2%) patients subjected to neuroendoscopy. Statistical analysis did not show any significant association of ventricular morphology ( P = .109), basal enhancement on CT ( P = .169), CNS tuberculoma ( P = .169), and clinical grade ( P = .057) with the result of ETV, probably because of the small number of cases. However, patients with severe hyponatremia, extra-CNS tuberculosis, an unidentifiable third ventricular floor anatomy, and adhesions in the prepontine cistern had a failed ETV. Patients with tuberculoma in the brain had a successful ETV. Conclusions Endoscopic third ventriculostomy is likely to fail in the presence of advanced clinical grade, extra-CNS tuberculosis, dense adhesions in prepontine cisterns, and an unidentifiable third ventricular floor anatomy. Tuberculoma in the brain in cases of TBMH may be associated with a successful ETV.

Role of neuroendoscopy in the management of patients with tuberculous meningitis hydrocephalus

The role of neuroendoscopy in patients of tuberculous meningitis with hydrocephalus (TBMH) is not yet established. We present details of endoscopic morphology, and analyze outcome of Neuroendoscopy performed in 28 patients (15 males and 13 females, average age 23 years) of TBMH in last 2.5 years. Endoscopic procedures performed included endoscopic third ventriculostomy (ETV) alone (n=19), ETV with monroplasty (n=2), and septostomy (n=2), ETV with decompression/biopsy of tuberculoma (n=2) and with abscess drainage (n=1). Outcome was assessed on the basis of clinico-radiological improvement, need for external shunt and complications. Outcome was satisfactory in 14 (50%), acceptable in five (18%) and unsatisfactory in nine (32%) patients. Overall, 19 (68%) patients benefited from endoscopic intervention. Cerebrospinal fluid (CSF) leak (n=2) and per-operative bleeding (n=1) were the only complications encountered. Endoscopy appears to be helpful in a considerable number of patients with TBMH, and should be considered as the first surgical option for CSF diversion surgery in these patients. External shunt should be reserved for those who fail the endoscopic CSF diversion.

Shunt surgery for hydrocephalus in tuberculous meningitis: a long-term follow-up study

Hydrocephalus is a common complication of tuberculous meningitis. Case studies of 114 patients with tuberculous meningitis and hydrocephalus, who underwent shunt surgery between July, 1975, and June, 1986, were reviewed to evaluate the long-term outcome and to outline a management protocol for these patients based on the results. Seven factors were studied in each case: 1) age at admission; 2) grade on admission (I to IV, classified by the authors; Grade I being the best and Grade IV being the worst); 3) duration of alteration of sensorium; 4) cerebrospinal fluid (CSF) cell content at initial examination; 5) CSF protein levels at initial examination; 6) number of shunt revisions required; and 7) the necessity for bilateral shunts. During a long-term follow-up period ranging from 6 months to 13 years (mean 45.6 months), the mortality rate was 20% for patients in Grade I; 34.7% for patients in Grade II; 51.9% for patients in Grade III; and 100% for patients in Grade IV. Only the grade at the time of admission was found to be statistically significant in determining final outcome (p less than 0.001). Based on these results, the authors advocate early shunt surgery for Grade I and II patients. For patients in Grade III, surgery may be performed either if external ventricular drainage causes an improvement in sensorium or without selection. All patients in Grade IV should undergo external ventricular drainage and only those who show a significant change in their neurological status within 24 to 48 hours of drainage, should have shunt surgery.

Hydrocephalus in tuberculous meningitis in children: Treatment with acetazolamide and repeated lumbar puncture

Increased intracranial pressure was found in 36 of 49 children with tuberculous meningitis. Four patients who presented with acute onset died early. Eight patients with obstructive hydrocephalus were treated surgically. In the 24 patients who had communicating hydrocephalus and were treated with acetazolamide and repeated lumbar punctures, treatment was successful in all but two, in whom shunt surgery was needed.