Management of post-tubercular hydrocephalus

Tuberculous meningitis with good outcome following appropriate timing of ventriculoperitoneal shunting for hydrocephalus

Background

Tuberculous meningitis is often associated with hydrocephalus. However, the appropriate timing for shunt placement to treat hydrocephalus remains controversial.

Case Presentation

A 43‐year‐old man presented with high fever and disturbance of consciousness. Cerebrospinal fluid (CSF) findings showed pleocytosis, increased protein levels, and hypoglycemia with an elevated pressure of 30 cm H₂O. Brain magnetic resonance imaging revealed cerebral infarctions and hydrocephalus resulting in suspicion of tuberculous meningitis. A few days after admission, external ventricular drainage was carried out for acute hydrocephalus. Four antitubercular drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) as well as dexamethasone sodium phosphate were given. The CSF polymerase chain reaction test for tuberculosis was found to be positive 2 weeks later. Once CSF protein levels improved, a ventriculoperitoneal shunting operation was undertaken.

Conclusions

When tuberculous meningitis is suspected, treatment with antitubercular drugs should be initiated prior to definitive diagnosis, and a shunt surgery should be carried out in a timely manner.

Outcome of Ventriculoperitoneal Shunt Surgery in Human Immunodeficiency Virus-Positive Patients on Combination Antiretroviral Therapy with Tuberculosis Meningitis and Hydrocephalus

BACKGROUND

In 2000, we advised against insertion of a ventriculoperitoneal shunt (VPS) in human immunodeficiency virus (HIV)-positive patients with tuberculous meningitis (TBM) complicated by hydrocephalus. However, this was in the era when combination antiretroviral therapy (ART) was not freely available in South Africa. In this subsequent preliminary report, we describe the outcome of ventriculoperitoneal shunting in patients with TBM and hydrocephalus who are HIV positive and receiving ART.

METHODS

We compared a group of 15 HIV-positive patients with TBM and hydrocephalus on ART with a retrospective control group of 15 patients (demographically and clinically matched) but not on ART. All patients were otherwise managed similarly and evaluated at 1 month after VPS insertion.

RESULTS

In historical controls, 10 patients died (66.7%) and no patient showed any improvement 1 month after shunting. In contrast, in the current group on ART, 4 patients died (26.7%), with 11 patients (73.3%) having a good outcome. Eight of 12 patients with grade 3 TBM had a good outcome, whereas all 3 with grade 1 TBM made a good recovery.

CONCLUSIONS

The outcome of VP shunting in HIV-positive patients with TBM and hydrocephalus is markedly improved in patients on ART. Based on limited data from this study, we recommend that better grades of TBM (1 and 2) undergo immediate VPS surgery. Patients with grade 4 TBM should undergo a trial of external ventricular drainage and those who improve should undergo a definitive procedure. Further research is required for patients with grade 3 TBM to identify characteristics associated with better outcomes to allow for effective use of limited resources.

Infections in the immunocompromised child

Prevention and management of opportunistic infections in children is particularly relevant in an era demonstrating an increased prevalence of immunocompromising conditions. The presence of an unusual organism which results in serious infection in a child should therefore always raise the consideration of immune compromise. The more common opportunistic infections have become easier to recognize in recent times due to improved awareness and more refined diagnostic testing. Targeted treatment is usually followed by long-term prophylactic medication. The impact of these conditions on patient outcome is of clear significance and certainly warrants further discussion.

Functional outcomes in adults with tuberculous meningitis admitted to the ICU: a multicenter cohort study

BACKGROUND

Tuberculous meningitis (TBM) is a devastating infection in tuberculosis endemic areas with limited access to intensive care. Functional outcomes of severe adult TBM patients admitted to the ICU in nonendemic areas are not known.

METHODS

We conducted a retrospective multicenter cohort study (2004-2016) of consecutive TBM patients admitted to 12 ICUs in the Paris area, France. Clinical, biological, and brain magnetic resonance imaging (MRI) findings at admission associated with a poor functional outcome (i.e., a score of 3-6 on the modified Rankin scale (mRS) at 90 days) were identified by logistic regression. Factors associated with 1-year mortality were investigated by Cox proportional hazards modeling.

RESULTS

We studied 90 patients, of whom 61 (68%) had a score on the Glasgow Coma Scale ≤ 10 at presentation and 63 (70%) required invasive mechanical ventilation. Brain MRI revealed infarction and hydrocephalus in 38/75 (51%) and 25/75 (33%) cases, respectively. A poor functional outcome was observed in 55 (61%) patients and was independently associated with older age (adjusted odds ratio (aOR) 1.03, 95% CI 1.0-1.07), cerebrospinal fluid protein level ≥ 2 g/L (aOR 5.31, 95% CI 1.67-16.85), and hydrocephalus on brain MRI (aOR 17.2, 95% CI 2.57-115.14). By contrast, adjunctive steroids were protective (aOR 0.13, 95% CI 0.03-0.56). The multivariable adjusted hazard ratio of adjunctive steroids for 1-year mortality (47%, 95% CI 37%-59%) was 0.23 (95% CI 0.11-0.44). Among survivors at 1 year, functional independence (mRS of 0-2) was observed in 27/37 (73%, 95% CI 59%-87%) cases.

CONCLUSIONS

A poor functional outcome in adult TBM patients admitted to the ICU in a nonendemic area is observed in 60% of cases and is independently associated with elevated cerebrospinal fluid protein level and hydrocephalus. Our data also suggest a protective effect of adjunctive steroids, with reduced disability and mortality, irrespective of immune status and severity of disease at presentation. One-year follow-up revealed functional independence in most survivors.

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.

Role of endoscopic third ventriculostomy in tuberculous meningitis with hydrocephalus

Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM). It can be purely obstructive, purely communicating, or due to combinations of obstruction in addition to defective absorption of cerebrospinal fluid (CSF). Endoscopic third ventriculostomy (ETV) as an alternative to shunt procedures is an established treatment for obstructive hydrocephalus in TBM. ETV in TBM hydrocephalus can be technically very difficult, especially in acute stage of disease due to inflamed, thick, and opaque third ventricle floor. Water jet dissection can be helpful in thick and opaque ventricular floor patients, while simple blunt perforation is possible in thin and transparent floor. Lumbar peritoneal shunt is a better option for communicating hydrocephalus as compared to VP shunt or ETV. Intraoperative Doppler or neuronavigation can help in proper planning of the perforation to prevent neurovascular complications. Choroid plexus coagulation with ETV can improve success rate in infants. Results of ETV are better in good grade patients. Poor results are observed in cisternal exudates, thick and opaque third ventricle floor, acute phase, malnourished patients as compared to patients without cisternal exudates, thin and transparent third ventricle floor, chronic phase, well-nourished patients. Some of the patients, especially in poor grade, can show delayed recovery. Failure to improve after ETV can be due to blocked stoma, complex hydrocephalus, or vascular compromise. Repeated lumbar puncture can help faster normalization of the raised intracranial pressure after ETV in patients with temporary defect in CSF absorption, whereas lumbar peritoneal shunt is required in permanent defect. Repeat ETV is recommended if the stoma is blocked. ETV should be considered as treatment of choice in chronic phase of the disease in obstructive hydrocephalus.

Tubercular meningitis with hydrocephalus with HIV co-infection: role of cerebrospinal fluid diversion procedures

OBJECT Hydrocephalus is one of the commonest complications of tubercular meningitis (TBM), and its incidence is increasing with the HIV epidemic. Literature evaluating the role of ventriculoperitoneal shunts in HIV-positive patients with TBM and their long-term prognosis is scarce. METHODS Between June 2002 and October 2012, 30 HIV-positive patients with TBM and hydrocephalus underwent ventriculoperitoneal shunt placement. Thirty age-, sex-, and grade-matched HIV-negative patients with TBM and hydrocephalus were randomly selected as the control group. Outcome was analyzed at discharge (short-term outcome) and at follow-up (long-term outcome). Univariate and multivariate analyses were performed to look for predictors of outcome; p < 0.05 was considered significant. RESULTS There were no differences in the clinical, radiological, or biochemical parameters between the 2 groups. Short-term outcome was better in the HIV-negative group (76.7% improvement) than in the HIV-positive group (70%). However, the long-term outcome in HIV-positive patients was very poor (66.7% mortality and 76.2% poor outcome) compared with HIV-negative patients (30.8% mortality and 34.6% poor outcome). Seropositivity for HIV is an independent predictor of poor outcome both in univariate and multivariate analyses (p = 0.038). However, in contrast to previous reports, of 5 patients with TBM in good Palur grades among the HIV-positive patients, 4 (80%) had good outcome following shunt placement. CONCLUSIONS The authors recommend that shunt treatment should not be performed in HIV-positive patients in poor Palur grade with hydrocephalus. A trial of external ventricular drainage should be undertaken in such patients, and shunt treatment should be performed only if there is any improvement. However, HIV-positive patients in good Palur grades should undergo VP shunt placement, as these patients have better outcomes than previously reported.

Acute presentation of craniopharyngioma in children and adults in a Danish national cohort

We aimed to study the occurrence of acute-onset symptoms at initial presentation in a national Danish cohort of patients with childhood- or adult-onset craniopharyngioma, and to investigate potential risk factors for acute presentation. Medical records of 189 consecutive patients (39 children, 150 adults) presenting with craniopharyngioma during the period 1985-2004 were reviewed, and data regarding initial symptoms, neuroimaging results, vision and pituitary function were systematically collected. Acute symptoms preceding hospital admission were noted. Subgroup analyses were based on age, gender and calendar year period. Potential risk factors for acute presentation were analysed through uni- and multivariate analyses. Acute symptoms were reported in 24 (13%) patients. Acute visual symptoms, headache, nausea or vomiting were most frequently reported, and acute symptoms were more frequent among children (28%) than among adults (9%) (P < 0.01). There were no differences according to sex or calendar year period. Hydrocephalus was present in half of childhood cases and one-fifth of adult patients (P < 0.001). Intra-tumour haemorrhage was seen in two cases. Acute symptoms were more frequent among patients with tumours occupying the third ventricle (P < 0.01), radiologic signs of calcification (P < 0.05) or hydrocephalus (P < 0.01). In multivariate analysis, however, only childhood onset (P < 0.05) and calcification (P < 0.05) were independent risk factors for acute presentation. Craniopharyngioma presented with acute symptoms in 13% of patients. Childhood onset and radiologic signs of calcification were independent risk factors for acute presentation. Intra-tumour haemorrhage was rare.

A review of the neurological and neurosurgical implications of tuberculosis in children

Tuberculous involvement of the central nervous system (CNS) and vertebral column is the most lethal and disabling form of tuberculosis (TB). Several factors contribute to poor outcome, including cerebrovascular involvement with ischemia, hydrocephalus, direct parenchymal injury and formation of abscess and inflammation in the brain and spinal cord, hyponatremia, seizures, and delayed diagnosis. Spinal spondylitis from TB and associated spinal deformity is the leading cause of paraplegia in developing countries. The evidence for supportive treatment of TB infection of the CNS is limited, leading to substantial differences in management protocols. Many of the treatment approaches used in TB infection of the CNS have been extrapolated from treatment of other acute neurological disorders such as bacterial meningitis and traumatic brain injury. We review data from the available literature and highlight questions relating to the neurological and neurosurgical care of children with TB infection of the CNS and vertebral column.

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

BACKGROUND

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.

MATERIAL AND METHODS

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.

RESULTS

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 > 2.5 g/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.

CONCLUSION

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.

Ventriculocholecysto shunt: a solution to recurrent shunt complications in comorbid post-tubercular hydrocephalus with tubercular adhesive peritonitis

BACKGROUND

Tuberculosis is still a killer disease and a nightmare in developing countries. Post-tubercular hydrocephalus remains one of the most severe complications, with many diversion procedure methods. How common is the occurrence of co-morbid post tubercular hydrocephalus with tubercular peritonitis is still not known. This is a frustrating cause of repeated shunt complications and revisions.

METHODS

We discuss the management of two cases that were the cause of nearly 50 % of our shunt revisions due to the comorbidities of post-tubercular hydrocephalus and tubercular adhesive peritonitis. We performed the ventriculocholecysto (VC) shunt. This procedure diverts CSF from the ventricular system to the gall bladder.

RESULTS

The two children are disease free and did not require a revision in the 3.4-year follow-up period.

CONCLUSION

The VC shunt is a simple procedure. It improved the quality of life of these children who otherwise would have had a very morbid period during shunt revisions and the active disease. These children did not require further revisions and can grow normally.