Management of hydrocephalus in patients with tuberculous meningitis

Frequency of success and complications of primary endoscopic third ventriculostomy in infants with obstructive hydrocephalous

OBJECTIVES

To determine the success rate and complications of primary endoscopic third ventri-culostomy (ETV) in infants with obstructive hydrocephalous.

METHODS

This case series was conducted at the Department of Neurosurgery, Medical and Teaching Institute, Lady Reading Hospital Peshawar from July 2016 to June 2018. All consecutive patients with age less than one year who underwent ETV for primary obstructive hydrocephalous, of both gender, were included in the study. The patients were followed up to six months after surgery. The data was entered in a specially designed Performa. Patients' data was analyzed using SPSS version 21.0.

RESULTS

We had total 21 patients with age less than one year during the study period. Male patients were 11 (52.4%). Success rate of ETV at six months of follow up was 12 (57.1%). Post-op complications observed were in 9.52% (2/21) cases. One patient had cerebrospinal fluid CSF) leak and the other had significant bleed.

CONCLUSION

ETV is successful in 57.1% of infants with obstructive type of hydrocephalous. The post op complications in case of ETV are lower than Ventriculo-peritoneal shunts. Therefore, ETV can be offered to infants having obstructive hydrocephalous.

Endoscopic third ventriculostomy and ventriculoperitoneal shunt for patients with noncommunicating hydrocephalus: A PRISMA-compliant meta-analysis

BACKGROUND

The surgical methods of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VS) for patients with noncommunicating hydrocephalus have rapidly increased in the past 2 decades. However, there is controversy regarding the efficacy and safety of these 2 surgical methods for noncommunicating hydrocephalus. The purpose of this study was to identify whether ETV is safer and more efficacious than VS for patients with noncommunicating hydrocephalus.

METHODS

We performed electronic searches in PubMed, Embase, China National Knowledge Internet, and the Cochrane Library to identify studies published up to February 03, 2018. The study summary results included improvement of symptoms, major complications, hematoma, infection, reoperation, mortality, duration of surgery, and hospital stay. Odds ratios (ORs) or standard mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using random-effects models.

RESULTS

We identified 10 observational studies (4 prospective and 6 retrospective studies) with data collected from 2017 patients with noncommunicating hydrocephalus. First, there was no significant difference between ETV and VS for symptom improvement (OR: 0.83; 95%CI: 0.46-1.50; P = .534). Second, ETV was associated with lower incidence of major complications when compared with VS (OR: 0.31; 95%CI: 0.17-0.56; P < .001). Third, ETV has little or no significant effect on hematoma (OR: 0.65; 95%CI: 0.22-1.92; P = .433) and mortality (OR: 0.90; 95%CI: 0.11-7.72; P = .926). Fourth, ETV were associated with lower incidence of infection (OR: 0.20; 95%CI: 0.06-0.69; P = .010) and reoperation (OR: 0.22; 95%CI: 0.08-0.56; P = .002). Finally, patients who received ETV had shorter duration of surgery (SMD: -1.71; 95%CI: -3.16 to -0.27; P = .020) and hospital stay (SMD: -0.91; 95%CI: -1.45 to -0.38; P = .001).

CONCLUSIONS

This meta-analysis provides robust evidence that ETV has greater benefits in terms of major complications, infection, reoperation, duration of surgery, and hospital stay than VS for patients with noncommunicating hydrocephalus.

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.

Modified external ventricular drainage in pediatric tuberculous meningitis: is it possible to avoid ventriculoperitoneal shunt placement?

OBJECTIVE

Ventriculoperitoneal shunting is the current mainstay of treatment for children with tuberculous meningitis with hydrocephalus. However, ventriculoperitoneal shunting is highly associated with complications, and more importantly, long-term, indwelling shunt devices may adversely affect children's spirits and psychological health. Therefore, there is clearly a need to explore methods of CSF diversion to avoid ventriculoperitoneal shunting.

METHODS

We studied 6 cases of children with tuberculous meningitis with hydrocephalus in whom external drainage from the ventricle to the subcutaneous abdomen was adopted. Outcomes were assessed over a 6- to 9-month follow-up period based on improvements in radiological features, such as ventricular morphology, as well as the need for ventriculoperitoneal shunting and any complications.

RESULTS

The drainage tubes were removed in 4 cases 4-6 months after the modified external ventricular drainage surgery, and 2 patients went on to receive a ventriculoperitoneal shunt. All patients' CSF protein and cell counts returned to normal, and imaging showed improved ventricular morphology and no intracranial secondary infection.

CONCLUSION

In our preliminary study, the modified ventricular drainage device can produce satisfactory outcomes and relatively safe effects and may help some patients to avoid ventriculoperitoneal shunt placement.