Outcome of ventriculoperitoneal shunt placement in Grade IV tubercular meningitis with hydrocephalus: a retrospective analysis in 95 patients

Srikantha, Umesh; Morab, Jagadeesh V; Sastry, Savitr; Abraham, Rojin; Balasubramaniam, Anandh; Somanna, Sampath; Devi, Indira; Bangalore, C.; Pandey, Paritosh

doi:10.3171/2009.3.peds08308

Cited by 32 publications

(23 citation statements)

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“…Historically, surgical intervention was only recommended with grade 2 or 3 TBM hydrocephalus (normal or mildly altered sensorium; easily arousable) due to increased mortality and risk of poor surgical outcome in patients with grade 4 disease (deeply comatose). However, a retrospective analysis of 95 patients with grade 4-associated hydrocephalus who underwent shunt placement demonstrated favorable outcomes in 33%–45% of patients, suggesting that there may be a role for surgical intervention even in advanced TBM hydrocephalus [70]. In this study, poor neurological outcomes after shunt placement were associated with age < three years and > three days in duration of symptoms.…”

Section: Treatmentmentioning

confidence: 67%

Tuberculous Meningitis: Diagnosis and Treatment Overview

Marx

Chan

2011

Tuberculosis Research and Treatment

139

189

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Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis (TB) and has very high morbidity and mortality. TBM is typically a subacute disease with symptoms that may persist for weeks before diagnosis. Characteristic cerebrospinal fluid (CSF) findings of TBM include a lymphocytic-predominant pleiocytosis, elevated protein, and low glucose. CSF acid-fast smear and culture have relatively low sensitivity but yield is increased with multiple, large volume samples. Nucleic acid amplification of the CSF by PCR is highly specific but suboptimal sensitivity precludes ruling out TBM with a negative test. Treatment for TBM should be initiated as soon as clinical suspicion is supported by initial CSF studies. Empiric treatment should include at least four first-line drugs, preferably isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol; the role of fluoroquinolones remains to be determined. Adjunctive treatment with corticosteroids has been shown to improve mortality with TBM. In HIV-positive individuals with TBM, important treatment considerations include drug interactions, development of immune reconstitution inflammatory syndrome, unclear benefit of adjunctive corticosteroids, and higher rates of drug-resistant TB. Testing the efficacy of second-line and new anti-TB drugs in animal models of experimental TBM is needed to help determine the optimal regimen for drug-resistant TB.

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Section: Treatmentmentioning

confidence: 67%

Tuberculous Meningitis: Diagnosis and Treatment Overview

Marx

Chan

2011

Tuberculosis Research and Treatment

139

189

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“…14,20 There is recent literature supporting the role of CSF diversion even in patients in Grade IV TBM. 22 However, literature evaluating the role of CSF diversion in HIV-positive patients with TBM and hydrocephalus is scarce. Nadvi et al reported a series of 30 patients with TBM and hydrocephalus, of whom 15 were HIV positive.…”

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confidence: 99%

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

Sharma¹,

Pruthi²,

Arivazhagan³

et al. 2015

JNS

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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.

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“…This is in accordance with a previous study from our institution, which demonstrated significant improvement following shunt surgery even in poor grade patients. [8] Shunt malfunction was diagnosed by clinical examination, computed tomography (CT) scan of the head and shunt tap whenever deemed necessary. Only patients with shunt malfunction due to shunt tube block was included in the study, whereas those with improper shunt position (ventricular catheter malposition and distal tube malposition) and shunt infection were excluded from the study.…”

Section: Methodsmentioning

confidence: 99%

Factors influencing shunt malfunction in patients with tuberculous meningitis

Ambekar¹,

Srinivas²,

Pandey³

et al. 2013

IJNS

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Hydrocephalus secondary to tuberculous meningitis (TBM) is a challenging condition to treat. Though ventriculo-peritoneal (VP) shunt is an accepted modality of treatment for hydrocephalus in TBM, there is a high rate of complications associated with the same. The study was planned to evaluate various factors associated with shunt malfunction in patients undergoing VP shunt surgery for hydrocephalus due to TBM. A retrospective review of all the patients undergoing VP shunt and shunt revision for TBM between 2004 and 2008 was performed. 449 VP shunt surgeries were performed in 432 patients for hydrocephalus due to TBM. Among these 70 shunt revisions were performed in 53 patients. Shunt malfunction rate in our series was 16.2%. High cerebrospinal fluid (CSF) protein concentration (>200 mg/dL) was associated with 5 times increased incidence of shunt malfunction. Patients with hyponatremia (Na+ <130 mEq/dL) prior to surgery had a 3 times increased incidence of shunt malfunction (P < 0.05). Other factors such as duration of symptoms, presence of neurological deficits, Evan’s index, third ventricular diameter, thickness of exudates, presence of infarcts, anemia, CSF cellularity and CSF glucose concentration were not associated with increased incidence of shunt malfunction. Analysis showed that shunt viability was longest in patients with normal serum sodium levels and CSF protein concentration less than 200 mg/dL and shortest in patients with low serum sodium and CSF protein concentration more than 200 mg/dL. Patients with pre-operative hyponatremia and high CSF protein concentration have a higher incidence of shunt malfunction and need to be followed-up closely.

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Outcome of ventriculoperitoneal shunt placement in Grade IV tubercular meningitis with hydrocephalus: a retrospective analysis in 95 patients

Cited by 32 publications

References 11 publications

Tuberculous Meningitis: Diagnosis and Treatment Overview

Tuberculous Meningitis: Diagnosis and Treatment Overview

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

Factors influencing shunt malfunction in patients with tuberculous meningitis

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