Tuberculous Hydrocephalus Research Articles

Clinical Chronicle: The Use of Ventriculo-Atrial Shunt in Tuberculous Hydrocephalus Treatment

Tuberculous meningitis (TBM) is the predominant bacterial meningitis form in children under 13, with an incidence of 8.6 per 100,000 before age 15. Tuberculous Hydrocephalus (TH), often presenting with hydrocephalus, poses a significant challenge in Indonesia for both children and adults. The commonly used Ventriculo-peritoneal (VP)-shunt procedure for TH, though prevalent, is associated with multiple complications. As an alternative, the Ventriculo-atrial (VA)-shunt procedure has been explored, but reports on its use in TH in Indonesia are lacking. This case report details a 1-year-old girl with TH who initially underwent a VP-shunt procedure, which proved unsuccessful. Subsequently, the VA-shunt procedure was employed, leading to a complete recovery. Our findings contribute valuable insights into the potential effectiveness of the VA-shunt as an alternative intervention for TH, especially in the Indonesian medical landscape.

Diagnosis and Management of Tuberculous Meningitis in Children- an Update

UPDATE ON THE DIAGNOSIS AND MANAGEMENT OF TUBERCULOUS MENINGITIS IN CHILDREN: Ronald van Toorn, Regan Solomons Seminars in Pediatric Neurology Volume 21, Issue 1, March 2014, Pages 12-18 Tuberculous meningitis (TBM), the most devastating manifestation of tuberculosis, is often missed or overlooked because of nonspecific symptoms and difficulties in diagnosis. It continues to be an important cause of neurologic handicap in resource-poor countries. Owing to the suboptimal performance of diagnostic tests of TBM, diagnosis relies on thorough history, clinical examination, and relevant investigations. The development of affordable, accurate diagnostic tests for TBM in resource-poor settings remains a priority. Short intensified treatment is safe and effective in both human immunodeficiency virus (HIV)-infected and HIV-uninfected children. Treatment of tuberculous hydrocephalus depends on the level of the cerebrospinal fluid obstruction. Corticosteroids reduce risk of neurodisability and death in HIV-uninfected children. Thalidomide should be considered in children compromised by tuberculosis abscesses and tuberculous-related optochiasmic arachnoiditis. In resource-poor countries, home-based TBM treatment after initial in-hospital stabilization is feasible in carefully selected patients. Early diagnosis and treatment of TBM is the single most important factor determining outcome.

A comparative study of Outcome in Ventriculoperitoneal Shunt and Endoscopic Third Ventriculostomy in Cases of Tubercular Meningitis with Hydrocephalus in Pediatric Patients

Introduction: Tuberculous meningitis (TBM) is becoming a rare illness in industrialized nations, but it is still widespread in underdeveloped nations. Ventriculoperitoneal shunt surgery is the GOLD Standard and is time tested procedure. Shunts, however, are associated with multiple problems. Material and Method: This is an observational study that compares the outcome of Endoscopic Third Ventriculostomy (ETV) with Ventriculoperitoneal shunt in patients of TBM with hydrocephalus at a 6-month follow-up. This study was done at a single tertiary care center. Data was collected from the patient records as per selection criteria. 100 consecutive cases in each ETV and Shunt group fulfilling selection criteria were included in the study. The two procedures were compared for their clinical outcome based on modified Vellore grade at 6 months of follow-up. Discussion: Evaluation of outcome at 6 months revealed an overall success rate of 68.5%. The success rate was higher for shunt (71%) as compared to ETV (66 %). However, the difference between the two groups was not significant statistically. For children with advanced TBM and elevated ICP, shunt surgery may not be necessary. While some authors have considered the potential of delaying surgery for these kids, others have argued that even a single positive outcome warrants shunt placement for every kid with tuberculous hydrocephalus. Conclusion: In pediatric cases of TBM with Hydrocephalus ETV should be considered as a first-line treatment in lower grades of TBM. Though for definitive comparison, a long-term randomized study is needed, and the study to look into factors responsible for the failure of ETV in TBM cases needs to be identified to formulate an ETV success score.

Tuberculosis of the central nervous system in children.

Central nervous system tuberculosis (CNS TB) in children is still a socioeconomic problem in developing countries. It has varied manifestations, symptoms are nonspecific, diagnosis can be challenging, and treatment may be difficult. It is often missed or overlooked. Among the various pathological entities, tuberculous meningitis is the most common and devastating manifestation. The resultant vasculitis, infarction, and hydrocephalus can be life-threatening. It can have grave cognitive, intellectual, and endocrine sequelae if not treated in time resulting in handicap, especially in resource constraint countries. Early diagnosis and treatment of tuberculous meningitis is the single most important factor determining outcome. Tuberculous hydrocephalus needs to be recognized early, and cerebrospinal fluid diversion procedure needs to be performed in adequate time to prevent morbidity or mortality in some cases. Tuberculous pachymeningitis and arachnoiditis are rare in children. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Drug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. Heightened clinical suspicion, early diagnosis, appropriate antituberculous treatment, and surgery in relevant situation are essential for a gratifying outcome and preventing complications.

Ventriculo-peritoneal shunt surgery for tuberculous meningitis: A systematic review

BackgroundVentriculo-peritoneal shunt surgery is one of the most commonly performed surgery for the management of tuberculous hydrocephalus. There is decreased clarity on issues regarding the indication as well as timing of cerebrospinal fluid diversion procedures in tuberculous meningitis. We systematically analysed published literature on this subject with an objective to assess the value of cerebrospinal fluid diversion procedures in tuberculous meningitis. MethodsA systematic search of literature was performed using PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) for articles published till August 2016. All original studies, irrespective of their design, enrolling at least 10 patients with tuberculous meningitis and hydrocephalus, and in whom the outcome following ventriculo-peritoneal shunt was described, were included in this review. Data was extracted on a pre-formed data extraction sheet. Primary outcome was defined using Glasgow outcome scale (GOS). ResultsNineteen studies, comprising of 1038 patients, were included in the review. A majority of patients were children. Good outcome (GOS 5 and 4), following ventriculo-peritoneal shunt, was observed in 58.26% of patients; 78.57% of patients in grade I, 65.35% in grade II and 67.97% in grade III achieved a good outcome while only 31.51% in grade IV could achieve a good outcome. On subgroup analysis, 61.08% of HIV-negative patients achieved a good outcome as compared to only 25% of HIV-positive patients. There were 18.03% deaths in the HIV-negative group as compared to 66.67% deaths in the HIV-positive group after shunt surgery. The rate of complications following ventriculo-peritoneal shunt was 22.11%; shunt blockage, leading to shunt revision, was the most common complication. Majority of included studies were clinically and methodologically heterogeneous. ConclusionOutcome, following ventriculo-peritoneal shunt, depends on the clinical severity of tuberculous meningitis. HIV-infected patients have a worse prognosis when compared with HIV uninfected patients. Compared to children, corresponding data is sparse for adult patients with tuberculous meningitis.

The value of transcranial Doppler imaging in children with tuberculous meningitis.

Transcranial Doppler imaging (TCDI) is potentially a valuable investigational tool in children with tuberculous meningitis (TBM), a condition often complicated by pathology relevant to Doppler imaging such as raised intracranial pressure (ICP) and cerebral vasculopathies. Serial TCDI was performed on 20 TBM children with the aim of investigating cerebrovascular haemodynamics and the relationship between pulsatility index (PI) and ICP. We observed a poor correlation between ICP and PI in children with communicating hydrocephalus (p = 0.72). No decline in PI was noted following 7 days of medical therapy for communicating hydrocephalus (p = 0.78) despite a concomitant decline in ICP. Conversely, a decline in PI was noted in all four children with non-communicating hydrocephalus who underwent cerebrospinal fluid diversion. High blood flow velocities (BFV) in all the basal cerebral arteries were observed in 14 children (70 %). The high BFV persisted for 7 days suggesting stenosis due to vasculitis rather than functional vasospasm. Complete middle cerebral artery (MCA) occlusion, subnormal mean MCA velocities (<40 cm/s) and PIs (<0.4) correlated with radiologically proven large cerebral infarcts. TCDI-derived PI is not a reliable indicator of raised ICP in children with tuberculous hydrocephalus. This may be attributed to individual variation of tuberculous vascular disease, possibly compromising cerebral vascular compliance and resistance. Basal artery stenosis secondary to vasculitis is observed during the acute stage of TBM in the majority of children.

Efficacy of cerebrospinal fluid lavage replacement in severe tuberculous hydrocephalus

Efficacy of cerebrospinal fluid lavage replacement in severe tuberculous hydrocephalus

Update on the Diagnosis and Management of Tuberculous Meningitis in Children

Tuberculous meningitis (TBM), the most devastating manifestation of tuberculosis, is often missed or overlooked because of nonspecific symptoms and difficulties in diagnosis. It continues to be an important cause of neurologic handicap in resource-poor countries. Owing to the suboptimal performance of diagnostic tests of TBM, diagnosis relies on thorough history, clinical examination, and relevant investigations. The development of affordable, accurate diagnostic tests for TBM in resource-poor settings remains a priority. Short intensified treatment is safe and effective in both human immunodeficiency virus (HIV)-infected and HIV-uninfected children. Treatment of tuberculous hydrocephalus depends on the level of the cerebrospinal fluid obstruction. Corticosteroids reduce risk of neurodisability and death in HIV-uninfected children. Thalidomide should be considered in children compromised by tuberculosis abscesses and tuberculous-related optochiasmic arachnoiditis. In resource-poor countries, home-based TBM treatment after initial in-hospital stabilization is feasible in carefully selected patients. Early diagnosis and treatment of TBM is the single most important factor determining outcome.

Commentary

Ventriculo-peritoneal shunt surgery is one of the most commonly performed surgery for the management of tuberculous hydrocephalus. There is decreased clarity on issues regarding the indication as well as timing of cerebrospinal fluid diversion procedures in tuberculous meningitis. We systematically analysed published literature on this subject with an objective to assess the value of cerebrospinal fluid diversion procedures in tuberculous meningitis.A systematic search of literature was performed using PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) for articles published till August 2016. All original studies, irrespective of their design, enrolling at least 10 patients with tuberculous meningitis and hydrocephalus, and in whom the outcome following ventriculo-peritoneal shunt was described, were included in this review. Data was extracted on a pre-formed data extraction sheet. Primary outcome was defined using Glasgow outcome scale (GOS).Nineteen studies, comprising of 1038 patients, were included in the review. A majority of patients were children. Good outcome (GOS 5 and 4), following ventriculo-peritoneal shunt, was observed in 58.26% of patients; 78.57% of patients in grade I, 65.35% in grade II and 67.97% in grade III achieved a good outcome while only 31.51% in grade IV could achieve a good outcome. On subgroup analysis, 61.08% of HIV-negative patients achieved a good outcome as compared to only 25% of HIV-positive patients. There were 18.03% deaths in the HIV-negative group as compared to 66.67% deaths in the HIV-positive group after shunt surgery. The rate of complications following ventriculo-peritoneal shunt was 22.11%; shunt blockage, leading to shunt revision, was the most common complication. Majority of included studies were clinically and methodologically heterogeneous.Outcome, following ventriculo-peritoneal shunt, depends on the clinical severity of tuberculous meningitis. HIV-infected patients have a worse prognosis when compared with HIV uninfected patients. Compared to children, corresponding data is sparse for adult patients with tuberculous meningitis.

Endoscopy for tuberculous hydrocephalus

The role of endoscopy in hydrocephalus due to infectious aetiology is unclear. Tuberculous hydrocephalus is a useful model to study because it presents particular challenges and the pathophysiology of the cerebrospinal fluid disturbance is well known. We present the results of 24 endoscopic operations in tuberculous meningitis. Endoscopic third ventriculostomy (ETV) was attempted in 17 patients: seven were successful, five failed, and five were not completed due to abnormal anatomy. There were five fenestration procedures, three of which were successful. Endoscopic biopsy of two tuberculomas failed to yield a bacteriological result. These operations were more difficult to perform than for hydrocephalus due to other aetiologies. Although ETV is technically possible in this situation, it is imperative that the patients are adequately selected for the procedure to ensure optimal treatment and that the surgeon has experience with difficult cases.

‘Does cerebral perfusion pressure influence outcome in children with tuberculous meningitis?’

Developmental Medicine & Child NeurologyVolume 46, Issue 5 p. 358-360 Free Access ‘Does cerebral perfusion pressure influence outcome in children with tuberculous meningitis?’ P Nourse MBChB MRCP, P Nourse MBChB MRCPSearch for more papers by this authorJF Schoeman MBChB MMed FCP MD, JF Schoeman MBChB MMed FCP MDSearch for more papers by this authorP-L Van Der Merwe MBChB MMed FCP MD, Corresponding Author P-L Van Der Merwe MBChB MMed FCP MD aCorrespondence to: Department of Paediatrics and Child Health Faculty of Medicine, Stellenbosch University Tygerberg Children's Hospital, South Africa E-mail: plvdm@sun.ac.zaSearch for more papers by this author P Nourse MBChB MRCP, P Nourse MBChB MRCPSearch for more papers by this authorJF Schoeman MBChB MMed FCP MD, JF Schoeman MBChB MMed FCP MDSearch for more papers by this authorP-L Van Der Merwe MBChB MMed FCP MD, Corresponding Author P-L Van Der Merwe MBChB MMed FCP MD aCorrespondence to: Department of Paediatrics and Child Health Faculty of Medicine, Stellenbosch University Tygerberg Children's Hospital, South Africa E-mail: plvdm@sun.ac.zaSearch for more papers by this author First published: 13 February 2007 https://doi.org/10.1111/j.1469-8749.2004.tb00500.xCitations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 Humphries MJ, Teoh R, Lau J, Gabriel M. (1990) Factors of prognostic significance in Chinese children with tuberculous meningitis. Tubercle 71: 161– 168. 2 Schoeman JF, Le Roux D, Bezuidenhout PB, Donald PR. (1985) Intracranial pressure monitoring in tuberculous meningitis: clinical and computerized correlation. Dev Med Child Neurol 27: 644– 654. 3 Schoeman J, Van Zyl L, Laubscher J, Donald E (1997) Effect of corticosteroids on intracranial pressure, computerized tomographic findings, and clinical outcome in young children with tuberculous meningitis. Pediatrics 99: 226– 231. 4 Dastur DK, Lalitha VS. (1970) The brain and meninges in tuberculous meningitis -- gross pathology in 100 cases and pathogenesis. Neurol India 18: 86– 100. 5 Goitein, KJ, Amit Y, Mussaffi H. (1983) Intracranial pressure in central nervous system infections and cerebral ischaemia of infancy. Arch Dis Child 58: 184– 186. 6 Nussbaum E, Galant SP. (1983) Intracranial pressure monitoring as a guide to prognosis in the nearly drowned, severely comatose child. J Pediatr 102: 215– 218. 7 Frewen TC, Han VK, Amacher AL, Del Maestro RF, Sibbald WJ. (1985) Cerebral resuscitation therapy in paediatric near drowning. J Pediatr 106: 615– 617. 8 Minns RA, Barlow KM. (1999) The relation between intracranial pressure and outcome in non-accidental head injury. Dev Med Child Neurol 41: 220– 225. 9 Schoeman JF, Laubscher JA, Donald PR. (2000) Serial lumbar CSF pressure measurements and cranial computed tomographic findings in childhood tuberculosis meningitis. Childs Nerv Syst 16: 203– 209. 10 Medical Research Council. (1948) Streptomycin treatment of tuberculous meningitis. Lancet 1: 582– 596. 11 Brown JK. (1991) Mechanisms of production of raised intracranial pressure. In: RA Minns, editor. Problems of Intracranial Pressure in Childhood. Clinics in Developmental Medicine No. 113/114. London : Mac Keith Press. p 33. 12 Schoeman J, Donald P, Van Zyl L, Keet M, Wait J. (1991) Tuberculous hydrocephalus: comparison of different treatments with regard to ICP, ventricular size and clinical outcome. Dev Med Child Neurol 33: 396– 405. 13 Rosner MJ, Sheila D, Rosner RN, Johnson RN. (1995) Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 83: 949– 962. 14 Kirkham FJ. (1991) Intracranial pressure and cerebral blood flow in non-traumatic coma in childhood. In: RA Minns, editor. Problems of Intracranial Pressure in Childhood. Clinics in Developmental Medicine No. 113/114. London : Mac Keith Press. p 300– 305. Citing Literature Volume46, Issue5May 2004Pages 358-360 ReferencesRelatedInformation

Serial lumbar CSF presure measurements and cranial computed tomographic findings in childhood tuberculous meningitits.

Intracranial pressure (ICP) was monitored in 218 consecutive children with hydrocephalus secondary to tuberculous meningitis (TBM). All children underwent cranial computerized tomographic (CT) scanning and continuous lumbar cerebrospinal (CSF) pressure monitoring on admission. Noncommunicating hydrocephalus (37 children), as determined by air encephalography, was treated by ventriculoperitoneal (VP) shunting and communicating hydrocephalus (181 children), by means of daily acetazolamide and frusemide. Response of ICP to treatment in the group with communicating hydrocephalus was assessed by means of repeated CSF pressure monitoring and CT scanning. One hundred and eighty-five of the 218 patients survived the 1st month of treatment. The aim of this study was the retrospective determination of (1) the relationship between ICP measurements and CT findings on admission and (2) the characteristics of the ICP recording which correlated best with the CT criteria of compensated hydrocephalus after the 1st month of treatment. No relationship was found between the level of baseline CSF pressure and the degree of hydrocephalus, as demonstrated by CT scanning, on admission. Seventy-five per cent of the patients with communicating hydrocephalus that survived the 1st month of treatment complied with the CT criteria for compensated hydrocephalus. All these patients had a baseline CSF pressure below 15 mmHg and absence of high-amplitude B waves on the pressure recording done at the end of the 1st month. In this study repeated lumbar CSF pressure monitoring proved to be an effective instrument to assess the response of communicating tuberculous hydrocephalus to medical treatment and also accurately predicted the timing of compensation of the hydrocephalus.

Serial CT Scanning in Childhood Tuberculous Meningitis: Prognostic Features in 198 Cases

Serial cranial computed tomographic (CT) scanning and intracranial pressure monitoring were performed on 198 children with stage II and III tuberculous meningitis. The aims of the study were to document the course of tuberculous hydrocephalus during medical and surgical treatment, as well as the prognostic significance of parenchymal changes in the brain as demonstrated by CT. Lumbar cerebrospinal fluid pressure was monitored continuously for a 1-hour period in all patients on admission and at weekly intervals in patients with communicating hydrocephalus for the 1st month of treatment. Cranial CT scanning was done on admission and repeated in survivors after 1 month and again after 6 months of antituberculous therapy. The raised intracranial pressure of 112 children with communicating hydrocephalus, as demonstrated by air-encephalography, was treated medically (with daily acetazolamide and furosemide) for 1 month. Thirty-one children with noncommunicating hydrocephalus were referred for immediate ventriculoperitoneal shunting. No significant difference was found in the eventual ventricular size or clinical outcome between the two treatment groups. Lumbar cerebrospinal fluid pressure changes in the children with communicating hydrocephalus closely followed changes in the degree of hydrocephalus during the course of treatment. The main cause of permanent neurologic disability was basal ganglia infarction, which occurred unilaterally in 21% and bilaterally in 10% of patients on admission and developed in a further 22% of children during treatment. A prominent subarachnoid space, which was seen on the CT scan of 36% of patients after the 1st month of treatment and which reverted to normal, probably relates to the poor nutritional state of these patients on admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberculous Hydrocephalus: Comparison of Different Treatments With Regard to Icp, Ventricular Size and Clinical Outcome

The effect of different treatment regimes on intracranial pressure (ICP), degree of hydrocephalus and clinical outcome was evaluated in 81 children with tuberculous meningitis. 24 children underwent CSF shunting, while 57 with communicating hydrocephalus were randomly assigned to three treatment groups: antituberculous drugs only; or additional intrathecal hyaluronidase or oral acetazolamide and furosemide in addition to antituberculous treatment. The addition of acetazolamide and furosemide was significantly more effective in achieving normal ICP than antituberculous drugs alone. No difference was found in mortality or number of disabled survivors between groups. Of those surviving, nearly two-thirds with stage II tuberculous meningitis were mildly disabled and nearly one-half with stage III were severely disabled at follow-up, emphasising the need for early diagnosis of tuberculous meningitis in the young child.