Ventriculoperitoneal shunt for tuberculous meningitis-associated hydrocephalus: long-term outcomes and complications.

BACKGROUND: Hydrocephalus is a frequent complication of tuberculous meningitis (TBM), and ventriculoperitoneal shunt (VPS) has been shown to improve short-term prognosis for patients with TBM-associated hydrocephalus. However, questions remain about long-term prognosis and shunt-related complications. This study aims to provide a comprehensive assessment of both long-term prognosis and shunt-related complications in patients with TBM-induced hydrocephalus who have undergone VPS treatment. METHODS: This retrospective study analyzed the clinical data of TBM patients with hydrocephalus treated with VPS at Peking Union Medical College Hospital between December 1999 and February 2023. Both short-term outcomes at discharge and long-term outcomes during follow-up were examined. Prognosis and shunt-related complications were assessed using the modified Rankin Scale (mRS) and the Activity of Daily Living (ADL) score to evaluate neurological function and autonomic living ability, respectively. RESULTS: A total of 14 patients with TBM-associated hydrocephalus were included in this study. Of these, 92.9% (13/14) exhibited favorable short-term outcomes, while 57.1% (8/14) showed positive long-term outcomes. Initial results indicated 6 complete recoveries (CR), 7 partial recoveries (PR), and 1 treatment failure. No catheter-related complications were observed initially. Long-term results included 4 CRs, 4 PRs, and 6 treatment failures. A variety of shunt surgery-related complications were noted, including three instances of catheter obstruction, one of incision infection, one of catheter-related infection, one of acute cerebral infarction, and one of transient peritoneal irritation accompanied by diarrhea. CONCLUSIONS: VPS appears to be an effective and well-tolerated treatment for TBM-associated hydrocephalus, efficiently alleviating acute intracranial hypertension. Nonetheless, continuous long-term monitoring and proactive management are essential to mitigate the risk of catheter-related complications.

Success and complication rates of endoscopic third ventriculostomy for tuberculous meningitis: a systematic review and meta-analysis.

Because ventriculoperitoneal shunt (VPS) insertion for patients with hydrocephalus from tuberculous meningitis (TBM) can be complicated by shunt infection and malfunction, endoscopic third ventriculostomy (ETV) has been proposed as an alternative. The aim of this review was to determine the success, technical failure, and complication rates of ETV in TBM in a meta-analysis and determine which factors are predictive of outcome. The PubMed, Scopus, and CENTRAL databases were searched from inception to April 2020 for case series, cohort studies, or randomized controlled trials reporting success, technical failure, or complication rates. For studies with individual patient data available, logistic regression analysis was done to determine whether age, sex, clinical grade, and type of hydrocephalus on imaging was predictive of outcome. Eight studies with a total of 174 patients were included in the review. Using random-effects modeling, the pooled estimate of success rate was 59% (95% CI 50-68%), with low heterogeneity (I2 = 30%). The technical failure and complication rates were 5% and 15%, respectively, but these variables had moderate heterogeneity. In 36 patients with individual patient data, a non-communicating type of hydrocephalus on imaging was associated with an odds ratio of 5.90 (95% CI 1.1-32.9, p = 0.043) for success. In summary, ETV for TBM had a pooled success rate of 59%, technical failure rate of 5%, and complication rate of 15%. An imaging finding of non-communicating hydrocephalus was associated with increased success. High-quality randomized, prospective studies using VPS insertion as control are needed to further define the role of ETV in TBM.

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.

CSF protein concentration associated with ventriculoperitoneal shunt obstruction in tuberculous meningitis.

INTRODUCTION: Hydrocephalus occurs in 85% of patients with tuberculous meningitis (TBM). Ventriculoperitoneal shunt (VPS) insertion is first-line treatment for relieving increased intercranial pressure. VPS obstruction secondary to increased protein levels in cerebrospinal fluid (CSF) is a known complication. OBJECTIVE: To ascertain if there is a difference in protein levels 1) between cranial and lumbar CSF, and to quantify levels associated with VPS obstruction, and 2) obtained from lumbar puncture vs. ventricular CSF. METHOD: A 30-year retrospective analysis was undertaken. CSF protein levels were statistically analysed to determine correlation between these levels and VPS obstruction. RESULTS: Of 214 children and 376 adults who underwent VPS insertion for TBM, respectively 27.5% and 25.5% sustained blocked VPS. The mean protein level in CSF collected from the non-obstructed group was 1.76 g/l, compared to 2.94 g/l in the obstructed group. The mean CSF protein level from intraoperative ventricular vs. lumbar puncture samples in the VPS obstruction group was respectively 2.471 g/l and 2.474 g/l. CONCLUSION: Patients with increased protein levels in CSF are at a high risk of VPS blockage. In these patients, temporary measures should be employed until CSF protein levels decrease.

An unusual surgical indication for cerebral tuberculosis: status dystonicus. Case report.

Actual indications for surgery in tuberculosis are limited to obtaining a diagnosis, acquiring tissue for culture studies, treating hydrocephalus, aspiring a brain abscess, and reducing intracranial pressure in patients with multiple tuberculomas. Tuberculosis-related movement disorders are usually treated pharmacologically. We report on a child affected by post-tubercular generalized dystonia, who progressed to status dystonicus (SD) and underwent stereotactic bilateral pallidotomy. After surgery, SD resolved, and drugs were rapidly tapered. The successful reversal of SD and the motor improvement observed in our patient demonstrate the safety, feasibility, and clinical efficacy of pallidotomy in post-tuberculous-meningoencephalitis dystonia and SD.

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

BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSION: 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.

Neurological complications after tuberculous meningitis in a multi-state cohort in the United States.

BACKGROUND AND PURPOSE: To assess the rate of neurological complications and mortality after tuberculous meningitis in the United States. METHODS: The authors performed a retrospective cohort study of all patients 18years or older hospitalized for tuberculous meningitis in California between 2005 and 2010, New York between 2006 and 2012, and Florida between 2005 and 2012. Outcomes of interest were mortality and the following neurological complications: stroke, seizure, hydrocephalus requiring a ventriculoperitoneal shunt, vision impairment, and hearing impairment. Kaplan-Meier survival statistics were used to assess the cumulative rate of neurological complications and death. Cox proportional hazards regression was used to compare rates of complications in patients with and without human immunodeficiency virus (HIV) after adjustment for comorbidities. RESULTS: 806 patients with tuberculous meningitis were identified, among whom the cumulative rate of any complication or death was 55.4% (95% CI, 51.5-59.3%). More than two-thirds of complications occurred during the initial hospitalization for tuberculous meningitis. Individual neurological complications were not uncommon: the cumulative rate of stroke was 16.8% (95% CI, 14.0-20.0%), the rate of seizure was 18.8% (95% CI, 15.4-22.8%), and the rate of ventriculoperitoneal shunting was 8.4% (95% CI, 6.4-10.9%). Vision impairment occurred in 21.6% (95% CI, 18.5-25.1%) of patients and hearing impairment occurred in 6.8% (95% CI, 4.9-9.4%). The mortality rate was 21.5% (95% CI, 18.4-24.9%). Patients with HIV infection were not at increased risk of complications compared to patients without HIV (hazard ratio, 1.2; 95% CI, 0.9-1.6). CONCLUSIONS: Tuberculous meningitis is associated with significant risk of neurological complications and death in the United States.

Surgery for brain tuberculosis: a review.

The two main manifestations of brain tuberculosis that require surgery are hydrocephalus associated with tuberculous meningitis (TBMH) and brain tuberculomas. TBMH most often responds to medical therapy but surgery is required promptly for those who fail medical therapy. Both ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV) are valid options although the latter is more often successful in patients with chronic hydrocephalus than in those with acute meningitis. Patients with TBMH are more prone to complications following VP shunt than other patients. The outcome of these patients is determined by the Vellore grade (I to IV) of the patients prior to surgery with those in good grades (I and II) having a better outcome and those in the worst grade (IV) having a high mortality in excess of 80 %. Patients with brain tuberculomas present clinically with features of a brain mass, indistinguishable clinically from other pathologies. CT and MR features might provide a probable diagnosis of a tuberculoma but most often a histological diagnosis is desirable. Empiric medical therapy is reserved for a small number of patients. Although the treatment of brain tuberculomas is essentially medical, surgery is required when the diagnosis is in doubt, to reduce raised intracranial pressure or local mass effect and to obtain tissue for culture and sensitivity studies. Stereotactic biopsy, stereotactic craniotomy and excision of superficial small tuberculomas and microsurgery are all procedures used to manage brain tuberculomas. The outcome in patients with brain tuberculomas is good if the tuberculous bacillus is sensitive to the anti-tuberculous therapy. The duration of therapy is debated but we suggest at least 18 months of combination therapy with three or four anti-tuberculous drugs and continue the therapy till the tuberculoma has resolved on neuro-imaging.

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.

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

PURPOSE: 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. METHODS: Serial TCDI was performed on 20 TBM children with the aim of investigating cerebrovascular haemodynamics and the relationship between pulsatility index (PI) and ICP. RESULTS: 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. CONCLUSIONS: 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.

A randomized study of ventriculoperitoneal shunt versus endoscopic third ventriculostomy for the management of tubercular meningitis with hydrocephalus.

OBJECTIVE: This study aims at generating knowledge to understand the conditions in which either of the two procedures (endoscopic third ventriculostomy (ETV) and shunt) are better options and to develop good practice guidelines for the treatment of tubercular meningitis (TBM) hydrocephalus. METHODS: This study was conducted on 48 patients in pediatric age group (less than or equal to 18 years) of TBM hydrocephalus. The patients were randomized to one of the cerebrospinal fluid diversion procedures (ETV or shunt). The two procedures were compared for their outcome, both radiologically and clinically. RESULTS: Twenty-four cases underwent shunt, out of which 13 (68%) cases were successful. Twelve (70.3%) cases belonged to grade 3, while one case was of grade 1. In ETV group, 10 (42%) cases had a successful outcome, out of which 7 (38.8%) cases were in grade 3, while 1 case each belonged to grades 1, 2, and 4. Incidence of ETV failure was more in younger age group, i.e., <2 years (n = 7), while no such correlation with age was found in shunt cases. CONCLUSION: Though with the present study it looks like that the relative risk of ETV failure is higher than that for shunt, but the risk becomes progressively lower with time. Therefore, if patients survive the early high-risk period, they could experience a long-term survival advantage devoid of life-long shunt-related complications. Though for definitive comparison, a long-term study is needed.

CSF pseudocyst: an unusual cause of abdominal distension in a child.

Abdominal cerebrospinal fluid pseudocyst is an uncommon complication of ventriculoperitoneal (VP) shunt placement. We present the case of a 4 year old child in whom a VP shunt was placed for tubercular meningitis 5 months earlier. The clinical presentation, classic imaging findings and management of CSF pseudocyst in a child are discussed.

Tubercular temporalis abscess with skull and dural invasion.

BACKGROUND: Mycobacterium tuberculosis infection rarely penetrates both skull and dura with temporalis muscle abscess formation. METHODS: Case report and review of the literature. RESULTS: A non-immunocompromised female patient with a right temporal mass underwent surgical resection. The tubercular abscess extended from the temporalis muscle to the skull and through the dura and subdural space with dissemination of the granuloma over the arachnoid membrane. CONCLUSION: Adequate debridement with a full course of antituberculous medication is necessary for complete treatment of these lesions.

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.

Surgery in hydrocephalus of tubercular origin: challenges and management.

BACKGROUND: Hydrocephalus of tubercular origin is one of the most dreaded and difficult to manage complications of brain tuberculosis. Traditionally, the management has been ventriculoperitoneal shunting, but in recent years emerging interest is in endoscopic ventriculostomy. In this article, we discuss the management protocol of hydrocephalus in various stages of disease. METHODS: A total of 424 cases of tubercular origin hydrocephalus were managed between years 2000 and 2009. Initially the cases were managed by ventriculoperitoneal shunting, which was followed by use of endoscopic third ventriculostomy. Drug-resistant cases were also encountered and managed according to drug sensitivity. RESULTS: The results provided through evaluation of retrospective data showed a high mortality in cases of hydrocephalus of acute origin if endoscopic third ventriculostomy was performed. The cerebrospinal fluid protein level and neurological status of the patient determined the success or failure of the procedure. For better management, patients were divided into six groups and their management underlined. CONCLUSION: The cases of tubercular meningitis with aqueductal stenosis presenting in early stages should be given a trial of endoscopic third ventriculostomy where chronic burnt-out cases or cases with communicating hydrocephalus should be managed by ventriculoperitoneal shunting.

The role of ventriculoperitoneal shunt placement in patients of tubercular meningitis with hydrocephalus in poor neurological grade: a prospective study in the pediatric population and review of literature.

PURPOSE: There is still no standard protocol for management of patients of tubercular meningitis (TBM) with hydrocephalus in poor neurological grade. In general, a trial of external ventricular drain (EVD) is an accepted method of treatment to decide whether a particular patient will benefit from shunt surgery. However, recent studies suggest that ventriculoperitoneal (VP) shunt may be undertaken without the trial of an EVD. Our study prospectively evaluates the role of direct VP shunt placement in poor grade patients of TBM with hydrocephalus. METHODS: Twenty-six consecutive pediatric patients of TBM with hydrocephalus in Palur grades III and IV underwent direct VP shunt placement, without prior placement of EVD. Outcome was assessed at the end of 3 months using Glasgow Outcome Score. RESULTS: The mean age of patients was 3.3 years (range, 4 months to 11 years). Twenty-one (80.8 %) patients were in grade III and five (19.2 %) were in grade IV. Good outcome and mortality in grade IV patients was 20 % (1/5) and 60 % (3/5) respectively; whereas in grade III patients, it was 71.4 % (15/21) and 9.5 % (2/21), respectively. Thirteen patients presented with focal neurological deficit at admission, which persisted in only three patients at 3 months follow up. VP shunt-related complications were observed in six (23.5 %) patients CONCLUSIONS: Despite poor grade at admission, 71.4 % patients in grade III and 20 % patients in grade IV had a good outcome at 3 months follow-up. Direct VP shunt placement is a safe and effective option even in poor grade patients of TBM with hydrocephalus, with a low complication rate.

Childhood tubercular meningitis: an institutional experience and analysis of predictors of outcome.

Tubercular meningitis constitutes an important cause of morbidity and mortality in developing countries, and various factors determine its outcome. We studied demographic and clinical profiles of childhood tubercular meningitis, and identified predictors of outcome. This prospective study was performed in 65 children aged ≤ 18 years, hospitalized with a diagnosis of tubercular meningitis. Boys outnumbered girls. Most patients presented with a poor clinical grade. Headache and vomiting comprised common features. Cerebrospinal fluid was characterized by predominant lymphocytosis. Many patients were diagnosed for Mycobacterium tuberculosis via polymerase chain reaction. Hydrocephalus comprises a common finding via computed tomography. Low Glasgow Coma Scores, seizures, basal exudates, and infarcts predict outcomes. Children with headaches, fevers, and altered sensorium should be investigated promptly for tubercular meningitis. Timely intervention may lead to early diagnoses and reductions in morbidity and mortality.

Prognostic value of computed tomography-evident cerebral infarcts in adult patients with tuberculous meningitis and hydrocephalus treated with an external ventricular drain.

OBJECTIVE: Tuberculous meningitis (TBM) frequently is complicated by hydrocephalus and cerebral infarction. Previous studies have shown radiologic evidence of cerebral infarction in TBM to be an indicator of poor outcome in both adults and children. Our objective was to assess short-term mortality in adult patients with TBM and hydrocephalus treated with an external ventricular drain and to assess the prognostic value of cerebral infarction on admission computed tomography imaging within this cohort. METHODS: This was a retrospective case series based on an adult intensive care unit admissions database, analyzing demographic, clinical, diagnostic, and radiologic data against short-term mortality. RESULTS: A total of 25 patients managed from 2005 to 2011 were identified. Three patients were excluded. Mean age was 31 years. British Medical Research Council clinical severity grading was grade I in 9.1%, grade II in 31.8%, and grade III in 59.1%. Short-term mortality was 68.2% overall. Cerebral infarction on admission scanning was seen in 10 patients (45.5%). Prevalence of infarcts was not significantly higher in HIV-positive patients (50.0% vs. 42.9%). Mortality in the group with infarcts was 100%, compared with 41.7% in the group without infarcts. Mortality in patients with an admission Glasgow Coma Scale of 8 or less was 91.7%. Mortality in the HIV-positive group was slightly greater, but this increase did not reach statistical significance (71.4% vs. 57.1% P = 0.6). Univariate analysis showed presence of infarcts at admission, Glasgow Coma Scale ≤8 at admission and age of 30 years or more to be significantly related to mortality. There was also a statistically significantly increased mortality according to British Medical Research Council grade. CONCLUSION: TBM with hydrocephalus requiring cerebrospinal diversion carries a significant short-term mortality. Within this cohort, the group of patients who have computed tomography-evident cerebral infarcts at admission has an even worse outcome, with a significantly greater short-term mortality prevalence.

Symptomatic, paradoxical intracranial tuberculomas along non-functional ventricular catheter necessitating its removal.

Symptomatic, paradoxical intracranial tuberculomas is a rare occurrence. A case of tubercular meningitis, developing paradoxical tuberculomas alongside non-functional ventricular catheter is presented. Catheter removal facilitated removal of these paradoxical lesions, with the patient recovering to near-normal state after completing 12 months of anti-tubeculous therapy. Non-functional ventricular catheter may become the site of paradoxical tuberculomas and these lesions, if symptomatic, may require catheter removal.