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

Prognostic Model to Predict Outcome of Adult Patients with Tuberculous Meningitis Undergoing Ventriculoperitoneal Shunt Surgery: A Prospective Observational Study

BACKGROUND

The prognosis of adult patients with tuberculous meningitis undergoing ventriculoperitoneal (VP) surgery is not well known. Prognostic models developed to predict the prognosis might help clinicians immensely.

METHODS

This was a prospective study. Adult patients (≥18 years) with tuberculous meningitis undergoing VP shunt surgery were included in the study. Patients were followed for 6 months. The primary outcome was death and the secondary outcome was a composite outcome of death plus disability. Prognostic models were developed using binary logistic regression. The model performance was assessed using discrimination and calibration. Internal validation of the model was performed using bootstrap. The models were plotted on a nomogram and e-calculator for bedside use.

RESULTS

Of 92 patients, 28 (30.4%) died and 36 (39.1%) experienced a composite poor outcome. The final model showed Medical Research Council grade III, papilledema, seizures, and size of the temporal horn to be predictors of poor outcome. The models showed good discrimination: area under the curve of 83.7% (95% confidence interval, 75.1%-92.3%; P < 0.001) for death and area under the curve of 84.7% (95% confidence interval, 75.9%-93.5%; P < 0.001) for composite poor outcome. Both the models showed good calibration; the Hosmer-Lemeshow test P value of 0.448 for death and 0.093 for composite outcome. The model remained valid after performing a bootstrap procedure, thus signifying internal validation.

CONCLUSIONS

About 39% of adult patients with tuberculous meningitis die or remain disabled after VP shunt surgery. Medical Research Council grade III illness, papilledema, seizures, and size of hydrocephalus are the most important baseline predictors that can help in prognostication. The nomograms developed may help the treating physician with prognostication.

Extensive Physiotherapy Rehabilitation for Pulmonary Tuberculosis and Tuberculous Meningitis With Ventriculoperitoneal Shunting: A Case Report

Tuberculous meningitis (TBM), an advanced form of extrapulmonary tuberculosis (TB), is caused by Mycobacterium tuberculosis infection of the meninges surrounding the brain and spinal cord. If it is not promptly and effectively treated, it can result in serious inflammatory reactions and neurological problems. TBM frequently leads to joint stiffness, discomfort, respiratory difficulties, swallowing difficulties, neurological deficits, and muscular weakness. Physiotherapy intervention is essential in treating these issues, as it provides individualized treatment strategies and programs that enhance muscle strength, motor coordination, and overall mobility. Acute TB is a disease that spreads through the bloodstream due to the presence of TB bacteria. The mild, nonspecific clinical presentation, which typically mimics the central organ involved, makes diagnosis challenging. This case study explains how to enhance function, quality of life, and functional capacity. It examines a 43-year-old man who reports respiratory issues, swallowing difficulties, and generalized weakness. MRI results indicate a defect in the right parietal region, along with slight soft tissue swelling above it. A four-week physical therapy rehabilitation program was created based on the patient's limitations identified during the initial intensive care unit (ICU) phase. The primary objectives of physiotherapy were to promote postural balance, preserve joint integrity, initiate early bed mobility, enhance sensation by improving respiratory patterns and secretion mobilization, and assist the patient with transfers and activities of daily living (ADLs).

Cerebrospinal Fluid Parameters Predicting Contralateral Isolated Lateral Ventricle in Adult Tuberculous Meningitis with Hydrocephalus Post-Ventriculoperitoneal Shunt

OBJECTIVE

Hydrocephalus, a major complication in tuberculous meningitis (TBM) patients, often necessitates treatment via ventriculoperitoneal shunt (VPS). However, post-VPS, some patients develop a complication called contralateral isolated lateral ventricle (CILV), leading to persistent hydrocephalus symptoms. This study aims to evaluate cerebrospinal fluid (CSF) parameters in predicting CILV occurrence post-VPS in adult TBM patients.

METHODS

A retrospective analysis was conducted, focusing on the relationship between preoperative CSF parameters and the development of CILV in 40 adult TBM patients who underwent VPS. The study compared CSF parameters from lumbar puncture after admission with those from ventricular CSF post-external ventricular drainage tube insertion.

RESULTS

CILV was observed in 6 of the 40 patients following VPS. Statistical analysis showed no significant difference between the CSF parameters obtained via lumbar and ventricular punctures. Notably, the mean CSF glucose level in patients with CILV was significantly lower (1.92 mmol/L) compared to the non-CILV group (3.03 mmol/L). Conversely, the median adenosine deaminase (ADA) level in the CILV group was higher (5.69 U/L) compared to the non-CILV group (3.18 U/L). The optimal cutoff values for CSF glucose and ADA levels were 1.90 mmol/L and 4.80 U/L, respectively, with a sensitivity of 66.67% and 83.33% and a specificity of 88.24% and 79.41%.

CONCLUSIONS

The study identified elevated ADA levels and decreased glucose levels in CSF as potential risk factors for CILV development in adult TBM patients post-VPS. These findings suggest the necessity for more tailored surgical approaches, in patients with altered CSF parameters to mitigate the risk of CILV.

Neuroinfectious Emergencies

OBJECTIVE

This article describes nervous system infections and complications that lead to neurologic emergencies.

LATEST DEVELOPMENTS

New research on the use of dexamethasone in viral and fungal infections is reviewed. The use of advanced MRI techniques to evaluate nervous system infections is discussed.

ESSENTIAL POINTS

Neurologic infections become emergencies when they lead to a rapid decline in a patient's function. Emergent complications may result from neurologic infections that, if not identified promptly, can lead to permanent deficits or death. These complications include cerebral edema and herniation, spinal cord compression, hydrocephalus, vasculopathy resulting in ischemic stroke, venous thrombosis, intracerebral hemorrhage, status epilepticus, and neuromuscular respiratory weakness.

Comparison of ventriculoperitoneal shunt versus endoscopic third ventriculostomy in managing hydrocephalus due to tuberculous meningitis: a randomized controlled trial with a 30-day follow-up

Background

Hydrocephalus is a significant complication arising from tuberculous meningitis (TBM). While ventriculoperitoneal shunt (VPS) remains the primary surgical approach for TBM-related hydrocephalus, there is a rising trend in the use of endoscopic third ventriculostomy (ETV).

Materials and methods

This randomized controlled trial, conducted from February 2018 to July 2019, enroled 60 patients aged 20-50 with TBM-related hydrocephalus. Patients underwent either VPS or ETV. Both groups were followed up for a minimum of 30 days, evaluating clinical outcomes and modifications in the modified Vellore grading system. Glasgow Coma Scale (GCS) assessments were conducted at 7-days and 30-day post-surgery for both groups.

Results

The mean GCS scores were comparable between the two groups on the 7th and 30th postoperative days. The association between modified Vellore Grade and treatment modality did not show statistically significant differences (P=1.0 and P=0.3) on the seventh and thirtieth postoperative days respectively.

Conclusions

Both VPS and ETV demonstrate efficacy in managing hydrocephalus secondary to TBM in adult patients. Our 30-day outcomes did not reveal discernible differences between the two procedures. Therefore, considering technical expertise and experience with ETV, it may be considered as the primary choice for cerebrospinal fluid (CSF) diversion in TBM-associated hydrocephalus, owing to its avoidance of several lifelong complications linked with VPS.

Overview of management of infection-related movement disorders with focus on specific-infections

Infections are important treatable causes of secondary movement disorders (MD) that can have heterogeneous presentations. According to various studies, infection-related movement disorders (IRMD) account for around 10-20% of secondary MD. Certain infections have a predilection for causing various MD, and some MD phenomenologies, such as acute cerebellar ataxia and opsoclonus-myoclonus-ataxia syndromes (OMAS), suggest a strong possibility of an underlying infectious cause. The underlying pathophysiology is multifaceted, including direct neuronal damage due to neurotropism, granulomas, abscesses causing structural damage, and inflammatory and autoimmune responses triggered by infections. Understanding the prevalence, spectrum, and pattern of these IRMD and common infections that are responsible helps in early diagnosis, and instituting appropriate, timely treatment, thereby improving the overall prognosis and avoiding unnecessary investigations. In this review, we aim to provide a brief overview of common infections associated with MD, common clinical presentations of IRMD, their underlying pathophysiology, and overall approach to their treatment, with a focus on specific treatments of prevalent and treatable IRMD.

Migration of the distal ventriculoperitoneal shunt catheter into the stomach with or without trans-oral extrusion: A systematic literature review and meta-analysis

BACKGROUND

Intra-gastric migration of the distal ventriculoperitoneal shunt (VPS) catheter clinically presenting with or without trans-oral extrusion is one of the rare complications of VPS catheter insertion.

AIM

To identify the demographics, clinical presentation, clinical findings, and results of surgical therapy offered for the treatment of intra-gastric migration of the distal VPS catheter, clinically presented with or without trans-oral extrusion.

METHODS

An online search was performed for the extraction/retrieval of the published/ available literature pertaining to the above-mentioned VPS complication. Manuscripts were searched from PubMed, PMC (PubMed Central), ResearchGate, and Google Scholar databases using various terminology relating to the VPS complications. The first case of migration of a VPS catheter into the stomach was reported in the year 1980, and the data were retrieved from 1980 to December 2022. Cases were categorized into two groups; Group A: Cases who had migration of the distal VPS catheter into the stomach and clinically presented with trans-oral extrusion of the same, and Group B: Cases who had migration of the distal VPS catheter into the stomach, but presented without trans-oral extrusion.

RESULTS

A total of n = 46 cases (n = 27; 58.69% male, and n = 19; 41.3% females) were recruited for the systematic review. Group A included n = 32, and Group B n = 14 cases. Congenital hydrocephalus was the indication for the primary VPS insertion for approximately half of the (n = 22) cases. Approximately sixty percent (n = 27) of them were children ≤ 5 years of age at the time of the diagnosis of the complication mentioned above. In seventy-two percent (n = 33) cases, this complication was detected within 24 mo after the VPS insertion/last shunt revision. Clinical diagnosis was evident for the entire group A cases. Various diagnostic modalities were used to confirm the diagnosis for Group B cases. Various surgical procedures were offered for the management of the complication in n = 43 cases of both Groups. In two instances, intra-gastric migration of the distal VPS catheter was detected during the autopsy. This review documented four deaths.

CONCLUSION

Intra-gastric migration of the peritoneal end of a VPS catheter is one of the rare complications of VPS catheter implantation done for the treatment of hydrocephalus across all age groups. It was more frequently reported in children, although also reported in adults and older people. A very high degree of clinical suspicion is required for the diagnosis of a case of an intra-gastric migration of the distal VPS catheter clinically presenting without trans-oral extrusion.

Management of ventriculoperitoneal shunt complications in children: A review of 34 cases

OBJECTIVES

The primary objective of this study was to analyse the demographics of the children who presented with ventriculoperitoneal shunt (VPS) complications. The secondary objectives were to review the clinical characteristics, surgical procedures performed for the management of VPS complications and the final outcome.

MATERIALS AND METHODS

This is a single-institution observational study that included children below 12 years of age who required VPS revisions during the study period.

RESULTS

During the study period of 10 years, n = 336 VPS catheters were implanted for the treatment of hydrocephalus in children. Forty (11.90%) children developed various VPS complications and required VPS revisions in the follow-up period. A total of n = 30 (8.92%) children (n = 21 boys and n = 9 girls) were selected/recruited for the present study, and they required n = 34 revision procedures. The mean interval from VPS insertion to the diagnosis of the complication was 7.29 months. VPS complications that required revisions occurred in the following order of frequency: (1) VPS catheter, cerebrospinal fluid (CSF) or shunt tract infection n = 8 (2.38%); (2) malfunction of distal VPS catheter n = 7 (2.08%); (3) coiling of distal VPS catheter at abdominal area n = 6 (1.78%); (4) extrusion of VPS catheter n = 5 (1.48%); (5) CSF leak from abdominal wound site/umbilicus n = 4 (1.19%); (6) malfunction of ventricular catheter n = 3 (0.89%) and (7) CSF pseudocyst peritoneal cavity n = 1 (0.29%). Surgical procedures were performed for the treatment of abovementioned complications in the following order of frequency: (1) revision of distal VPS catheter n = 14 (4.16%), (2) removal of entire VPS catheter ± external ventricular drainage (EVD) n = 7 (2.08%), (3) distal VPS catheter converted as EVD n = 6 (1.78%), (4) revision of proximal VPS catheter n = 3 (0.89%), (5) revision of entire VPS catheter n = 3 (0.89%) and (6) CSF pseudocyst excision n = 1 (0.29%). This study also documented n = 2 (6.6%) deaths during the post-operative period.

CONCLUSION

VPS insertion done for the treatment of hydrocephalus in infants and children was associated with various complications. Seventy per cent of the complications occurred within the first 6 months after the VPS insertion. Two-thirds of the complications were related to the distal VPS catheter.

The Outcome of Surgical Intervention (Ventriculoperitoneal Shunt and Endoscopic Third Ventriculostomy) in Patients With Hydrocephalus Secondary to Tuberculous Meningitis: A Systematic Review

The objective of this study is to analyze the outcome of the safety and efficiency of the surgical interventions (ventriculoperitoneal shunt [VPS] and endoscopic third ventriculostomy [ETV]) in patients with hydrocephalus due to tuberculous (TB) meningitis. A systematic literature search has been conducted using PubMed, Google Scholar, PMC, and ScienceDirect databases from 2001 to 2022 April. A total of 16 studies have been included, irrespective of their design. These studies include patients diagnosed with hydrocephalus secondary to TB meningitis (TBM) treated with VPS or ETV. A systematic review was conducted to determine the efficiency of surgical procedures based on the outcomes and complications associated with these procedures. A total of 2207 patients (aged one month to 68 years) have been included in this study, out of which 1723 underwent VPS and 484 underwent ETV. The overall success rate in the VPS group varied from 21.1% to 77.5%. The overall success rate in the ETV group ranged from 41.1% to 77%. The overall complications rate in the VPS group varied from 10% to 43.8%, and the complications rate in the ETV group varied from 3.8% to 22.5%. After ruling out the significant differences in the average percentages of outcomes and complications followed by VPS and ETV, ETV is suggested in patients with chronic phases of illness because the chances of ETV failure are high during the initial stage. The uncertainty of the ETV gradually decreases over time. To attain favourable long-term outcomes with ETV in patients with TBM hydrocephalus (TBMH), ETV should be performed after chemotherapy, anti-tubercular treatment, and steroids. In addition, ETV is considered beneficial over VP shunt as associated long-term complications are significantly less compared to VP shunt. In contrast, VP shunt is suggested as a modified Vellore grading which shows a more favourable outcome in patients with acute illness than ETV.

Neuro-ophthalmic manifestations of tuberculosis

Neuro-ophthalmic features are a known association in tuberculosis, especially common in central nervous system tuberculosis (CNS-TB). They are mostly the result of the visual pathway and/or ocular motor and other cranial nerve involvement. Furthermore, toxic optic neuropathy and paradoxical response to anti-tubercular drugs (ATT) are also not uncommon. The etiopathogenesis is by the complex interplay of various factors like exudates, vasculitis, arachnoiditis, presence of tuberculomas, hydrocephalus, brain infarcts and/or immune-mediated reaction. The entity often poses a diagnostic dilemma for the ophthalmologists/neuro-ophthalmologists and may lead to irreversible vision loss. The presence of neuro-ophthalmic features not only affect the visual outcome but are also predictors of systemic morbidity of the disease. Therefore, understanding and knowledge about this entity are necessary for the comprehensive management of the disease. While various forms of TB including CNS-TB have been well-dealt with in literature, little is discussed specifically about the neuro-ophthalmic manifestations of tuberculosis. Therefore, the purpose of this review is to highlight current understanding of the types of neuro-ophthalmic involvement in tuberculosis, its etiopathogenesis, diagnosis and management.

Strategies for the diagnosis and management of meningitis in HIV-infected adults in resource limited settings

INTRODUCTION

The incidence of human immunodeficiency virus-1 (HIV-1) associated meningitis has been declining in the post-combination antiretroviral treatment (ART) era, although survival rates remain low for the common causes like tuberculosis and cryptococcal disease. Diagnosis and treatment of meningitis in HIV-1 is complicated by atypical clinical presentations, limited accuracy of diagnostic tests, access to diagnostic tests, and therapeutic agents in low- and middle-income countries (LMIC) and immune reconstitution inflammatory syndrome (IRIS).

AREAS COVERED

We provide an overview of the common etiologies of meningitis in HIV-1-infected adults, suggest a diagnostic approach based on readily available tests, and review specific chemotherapeutic agents, host-directed therapies, supportive care, timing of ART initiation, and considerations in the management of IRIS with a focus on resource-limited settings. They identify key knowledge gaps and suggest areas for future research.

EXPERT OPINION

Evidence-based management of HIV-1-associated meningitis is sparse for common etiologies. More readily available and sensitive diagnostic tests as well as standardized investigation strategies are required in LMIC. There is a lack of availability of recommended drugs in areas of high HIV-1 prevalence and a limited pipeline of novel chemotherapeutic agents. Host-directed therapies have been inadequately studied.

Harnessing cerebrospinal fluid circulation for drug delivery to brain tissues

Initially thought to be useful only to reach tissues in the immediate vicinity of the CSF circulatory system, CSF circulation is now increasingly viewed as a viable pathway to deliver certain therapeutics deeper into brain tissues. There is emerging evidence that this goal is achievable in the case of large therapeutic proteins, provided conditions are met that are described herein. We show how fluid dynamic modeling helps predict infusion rate and duration to overcome high CSF turnover. We posit that despite model limitations and controversies, fluid dynamic models, pharmacokinetic models, preclinical testing, and a qualitative understanding of the glymphatic system circulation can be used to estimate drug penetration in brain tissues. Lastly, in addition to highlighting landmark scientific and medical literature, we provide practical advice on formulation development, device selection, and pharmacokinetic modeling. Our review of clinical studies suggests a growing interest for intra-CSF delivery, particularly for targeted proteins.

Neurotuberculosis: an update

Tuberculous (TB) meningitis (TBM), accounting for 70-80% of cases of neurotuberculosis, is one of the most severe forms of extrapulmonary tuberculosis. Two-thirds of new TB cases come from eight countries. Polymorphisms in toll-interleukin-1 receptor domain and in leukotriene A4 hydrolase (LTA4H) gene, affect the risk of inflammation in TBM. The common site of tuberculoma in children is cerebellum, and they may rarely develop tuberculous encephalopathy which has a high mortality. Young females with a high cerebrospinal fluid (CSF) protein have an increased predisposition to develop optochiasmatic arachnoiditis. Spinal TB meningitis may mimic transverse myelitis or Guillain-Barre syndrome. An extra-neural focus of TB should be sought clinically and radiologically as it may indicate safer and more accessible sites for diagnostic samplings. Cartridge-based nucleic acid amplification test (CBNAAT), also known as Genexpert test, is a polymerase chain reaction (PCR)-based method for detection of TB which also detects rifampicin resistance as it targets the rpob gene of mycobacteria. Line probe assays, based on PCR and reverse hybridization methods, identify mutations associated with drug resistance within a week. TBM being a paucibacillary disease, often evades a definite diagnosis and empirical treatment for a minimum of 9 months is warranted based on clinical judgement. All TBM patients should receive adjunctive corticosteroids, even those with HIV infection. Drug resistance is strongly associated with previous treatment and bedaquiline as well as delamanid have received approvals for multidrug resistant (MDR) TB. The key principle of managing MDR TB is never to add a single drug to a failing regimen. Correct combination and duration of most effective second line drugs in MDR TB require further modifications. Early shunting should be considered in those with hydrocephalus failing medical management. The single most important determinant of outcome is the stage of TBM at which treatment has been started.

Giant central nervous system tuberculoma in pediatric patients: surgical case series

Central nervous system tuberculoma is rare and challenging situation. Clinical records of patients with pathologically proven tuberculoma were retrospectively reviewed. Clinical presentation, lesion location, radiological characteristics, perioperative and surgical management, and outcome is summarized and analyzed. Eight patients were included and there was one girl. Age ranged from 3 to 14 years with mean age 9.8 years. Clinical duration ranged from 20 days to 2 years, and 3 patients had previous lung tuberculosis with anti-TB treatment. The lesion was in cerebellum in 6 cases, including 1 involving basal ganglia and 1 involving thalamus. The lesion was in basal ganglia, thalamus, and third ventricle in 1 case, and in T12-L1 spinal cord in another. Cerebellar lesion was resected via paramedian suboccipital approach in 5 patients, basal ganglia lesion via trans-cortical frontal horn approach in 2 patients, and intra-spinal lesion via trans-laminar approach in 1 patient. Follow-up ranged from 10 to 24 months. Of the 8 patients, 6 returned to normal life. One patient had cerebellar lesion resected and the thalamic lesion reduced in size after anti-TB treatment. One patient died from TB spreading. Our data showed that most patients can be successfully treated by resection of the lesion. Low T2 signal, ring shaped enhancement and peripheral edema strongly suggest tuberculoma. Empirical anti-TB treatment should be initiated perioperatively.

Etiology of Non-Traumatic Seizures in Children Admitted to PICU: An Eight-Year Retrospective Study

Purpose

Seizure is a serious neurological symptom in the pediatric intensive care unit (PICU), yet data on etiologies of non-traumatic childhood seizures in China are scarce. We aimed to investigate the etiological trends of seizures in children admitted to the PICU in our tertiary center.

Patients and Methods

We performed a retrospective analysis of all patients (aged 29 days to 14 years) with non-traumatic seizures, admitted to the PICU of Xiangya Hospital from 2010 to 2017. Etiological analysis was performed to compare data between 2010–2013 and 2014–2017.

Results

The study included 318 patients (male: female = 1.27:1) with mean age of 5.4 ± 4.0 years. The most frequent causes observed were CNS infections (109/318, 34.3%), unknown reason epilepsy (96/318, 30.2%), and immune (56/318, 17.6%). Comparison of the 2010–2013 and 2014–2017 periods revealed a significant decrease in the percentage of CNS infections [48.8% (59/121) vs 25.4% (50/197), p < 0.001] and a significant increase in the incidence of unknown reason epilepsy [(24/121, 19.8%) vs (72/197, 36.5%), p < 0.001] and immune causes [(12/121, 9.9%) vs (44/197, 22.3%), p = 0.005].

Conclusion

CNS infections were the most common cause of seizures during 2010–2013, while non-infectious diseases such as epilepsy and immune disorders represented the leading causes during 2014–2017. Continuous improvement in medical technology and understanding of disease patterns would greatly improve early diagnosis and therapeutic management of such conditions.

Meningitis and encephalitis management in the ICU

PURPOSE OF REVIEW

Management of patients with meningitis and encephalitis oftentimes requires ICU level of care. This article is an update on management for meningitis and encephalitis with focus on clinical care in the ICU. Information provided is based on a review of recent studies with focus on studies since 2017.

RECENT FINDINGS

Advances in diagnostic and treatment approach for different pathogens are presented. Nosocomial meningitis now constitutes a major part of brain infections seen in ICUs in the developed world. Advances in ICU care of central nervous system (CNS) infections include application of newer diagnostic methods, improved understanding and delivery of antibiotics to the CNS, infection prevention for nosocomial infections, and application of neuromonitoring where indicated.

SUMMARY

Advances in diagnostics and therapeutic approach to CNS infections are continually made. For intensivists, focus on neuromonitoring and brain resuscitation in critically ill patients with CNS infections may present a path to enhance preservation of brain function and improve outcomes. VIDEO ABSTRACT: http://links.lww.com/COCC/A22.

Early Mortality among Immunocompetent Patients of Tuberculous Meningitis: A Prospective Study

Most deaths in tuberculous meningitis occur in the early part of the illness. We assessed the determinants of early deaths, occurring within 2 months of intensive therapy. We prospectively included consecutive newly diagnosed adults with HIV-negative tuberculous meningitis. Patients were given WHO-recommended antituberculosis treatment and were followed up for 9 months. We enrolled 152 patients. A total of 26 deaths were recorded during 2 months. The logistic regression analysis revealed that papilledema (P = 0.029, odds ratio (OR) = 4.8 [1.2-19.8]), increasing age (P = 0.001, OR = 1.07 [1.03-1.1]), stage-III disease (Glasgow coma scale score ≤ 10; P = 0.01, OR = 4.2 [1.4-12.3]), and hydrocephalus (P = 0.003, OR = 8.4 [2.1-33.6]) were independently associated with death. In addition, cerebral infarcts (P = 0.012, OR = 5.6 [1.5-21.3]), paraparesis (P = 0.004, OR = 8.8 [2.02-38.1]), and age (P = 0.005, OR = 1.05 [1.02-1.09]) were associated with poor functional outcome. In conclusion, disease severity predicts early deaths in tuberculous meningitis.

Checklists to guide the supportive and critical care of tuberculous meningitis

The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.

Checklists to guide the supportive and critical care of tuberculous meningitis

The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.

An Electrical Model of Hydrocephalus Shunt Incorporating the CSF Dynamics

The accumulation of cerebrospinal fluid (CSF) in brain ventricles and subarachnoid space is known as hydrocephalus. Hydrocephalus is a result of disturbances in the secretion or absorption process of CSF. A hydrocephalus shunt is an effective method for the treatment of hydrocephalus. In this paper, at first, the procedures of secretion, circulation, and absorption of CSF are studied and subsequently, the mathematical relations governing the pressures in different interacting compartments of the brain are considered. A mechanical-electrical model is suggested based on the brain physiology and blood circulation. In the proposed model, hydrocephalus is modeled with an incremental resistance (Ro) and hydrocephalus shunt, which is a low resistance path to drain the accumulated CSF in the brain ventricles, is modeled with a resistance in series with a diode. At the end, the simulation results are shown. The simulation results can be used to predict the shunt efficiency in reducing CSF pressure and before a real shunt implementation surgery is carried out in a patient's body.

The neurocritical care of tuberculous meningitis

Tuberculous meningitis is the most severe form of tuberculosis and often causes critical illness with high mortality. Two primary management objectives are reducing intracranial pressure, and optimising cerebral perfusion, while killing the bacteria and controlling intracerebral inflammation. However, the evidence base guiding the care of critically ill patients with tuberculous meningitis is poor and many patients do not have access to neurocritical care units. Invasive intracranial pressure monitoring is often unavailable and although new non-invasive monitoring techniques show promise, further evidence for their use is required. Optimal management regimens of neurological complications (eg, hydrocephalus and paradoxical reactions) and of hyponatraemia, which frequently accompanies tuberculous meningitis, remain to be elucidated. Advances in the field of tuberculous meningitis predominantly focus on diagnosis, inflammatory processes, and antituberculosis chemotherapy. However, clinical trials are required to provide robust evidence guiding the most effective supportive, therapeutic, and neurosurgical interventions for tuberculous meningitis that will improve morbidity and mortality.

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.

Treatment of Tuberculous Meningitis and Its Complications in Adults

PURPOSE OF REVIEW

Tuberculous meningitis (TBM) is a global health problem. In this review, we systematically evaluate the evidence for current and emerging antimicrobials, host-directed therapies and supportive managements.

RECENT FINDINGS

Current antimicrobial regimes do not factor the differing ability of drugs to cross the blood-brain barrier. Rifampicin may be more effective at higher doses yet the most recent clinical trial failed to demonstrate survival benefit at 15 mg/kg/day. Dose finding studies suggest that higher doses still may be safe and more effective. Fluoroquinolones are currently listed as important second-line agents in drug-resistant TBM; however, a survival benefit as a first-line agent has yet to be shown. Linezolid may be a promising antimicrobial with good central nervous system penetrance. Dexamethasone reduces mortality in HIV-uninfected individuals yet evidence for its use in HIV co-infection is lacking. Aspirin has anti-inflammatory and anti-thrombotic properties. Small studies have demonstrated efficacy in reducing stroke but further research is required to better understand its effect on controlling the host inflammatory response. Discovery of genetic polymorphisms may direct individualized immune therapies and mediators of the innate immune response may provide targets for the development of novel therapies. There is at present no significant evidence base to guide management of hydrocephalus in HIV co-infection. Further clinical trial data is required to improve treatment outcomes in TBM in particularly in regard to the value of high-dose rifampicin, newer antimicrobials with improved central nervous system penetration and host-directed therapies. Supportive measures in particular the management of hydrocephalus in HIV co-infection should be an area for future research.

Tuberculous meningitis

Tuberculosis remains a global health problem, with an estimated 10.4 million cases and 1.8 million deaths resulting from the disease in 2015. The most lethal and disabling form of tuberculosis is tuberculous meningitis (TBM), for which more than 100,000 new cases are estimated to occur per year. In patients who are co-infected with HIV-1, TBM has a mortality approaching 50%. Study of TBM pathogenesis is hampered by a lack of experimental models that recapitulate all the features of the human disease. Diagnosis of TBM is often delayed by the insensitive and lengthy culture technique required for disease confirmation. Antibiotic regimens for TBM are based on those used to treat pulmonary tuberculosis, which probably results in suboptimal drug levels in the cerebrospinal fluid, owing to poor blood-brain barrier penetrance. The role of adjunctive anti-inflammatory, host-directed therapies - including corticosteroids, aspirin and thalidomide - has not been extensively explored. To address this deficit, two expert meetings were held in 2009 and 2015 to share findings and define research priorities. This Review summarizes historical and current research into TBM and identifies important gaps in our knowledge. We will discuss advances in the understanding of inflammation in TBM and its potential modulation; vascular and hypoxia-mediated tissue injury; the role of intensified antibiotic treatment; and the importance of rapid and accurate diagnostics and supportive care in TBM.