A randomized study comparing endoscopic third ventriculostomy versus ventriculoperitoneal shunt in the management of hydrocephalus due to tuberculous meningitis

Abstract

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.

Clinical study and management of hydrocephalus in children

“…Several studies show similar results. [13][14][15] In present study enlargement of head, bulging of fontanelle, setting sun sign are the commonest presenting signs and symptoms. Similar type of presentation is seen in various other studies also.…”

“…Similar type of presentation is seen in various other studies also. [8][9][10][11][12][13][14][15][16][17] Commonest cause of hydrocephalus in our study is Aqueductal stenosis (40%) followed by Arnold Chiari type 2 malformation (23.33%) with meningomyelocele. Similar aetiology is seen in various other studies also.…”

Outcome of Endoscopic Third Ventriculostomy: An Experience of 80 Treated Patients

“…Pericranium and wound were also closed with interrupted 2/0 Vicryl and 2/0 Prolene respectively. 1,6,11 ETV also has some complications, the most common of which are neurovascular injury, cerebrospinal fluid leakage, fever and superficial wound infection, intra cerebral hematoma, seizures altered consciousness and memory disturbance. 12,13 The data was analyzed for signs/symptoms, diagnosis, MRI/CT brain pre-operative findings and early post-operative course was studied.…”

“…Hydrocephalus is one of the commonest neurological entity . 1 It is the dilatation of ventricular system due to the imbalance of cerebrospinal fluid production and absorption. 2 The common causes of hydrocephalus are congenital, infectious, post-traumatic and tumors.…”

“…3 In developing countries tuberculous meningitis (TBM) is one of the common cause of hydrocephalus. 1 The common signs and symptoms of hydrocephalus are those of raised Intracranial pressure (ICP). That is headache, vomiting, blurring of vision or in severe causes decreased levels of conciseness.…”