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Enicker B, Aldous C. Factors associated with in-hospital mortality in HIV-infected children treated for tuberculous meningitis hydrocephalus. Childs Nerv Syst 2024; 40:695-705. [PMID: 37964056 PMCID: PMC10891234 DOI: 10.1007/s00381-023-06205-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 10/26/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE The study aimed to investigate factors associated with in-hospital mortality in children diagnosed with tuberculous meningitis (TBM) hydrocephalus and HIV co-infection undergoing cerebrospinal fluid diversion procedures and their complications. METHODS Data were collected retrospectively and prospectively between 2007 and 2022. Data collected included demographics, clinical characteristics, antiretroviral therapy (ART) status, biochemistry results, CD4 count, radiology findings, CSF diversion procedures (and complications), length of hospital stay (LOHS), and in-hospital mortality. RESULTS Thirty-one children were included, with a mean age of 6.7 ± 5.3 years and 67.7% males. Median admission Glasgow Coma Scale (GCS) was 11 (IQR 9-15). Hypertonia (64.5%) and seizures (51.6%) were frequently observed clinical characteristics. Sixty-one percent of children were on ART. Cerebral infarcts and extra-meningeal TB were diagnosed in 64.5% and 19.3% of cases, respectively. The median CD4 count was 151 (IQR 70-732) cells/µL. Surgical procedures included ventriculoperitoneal shunt (VPS) in 26 cases and endoscopic third ventriculostomy (ETV) in five children. VPS complication rate was 27%. No complications were reported for ETV. Median LOHS was 7 days (IQR 4-21). Eleven children (35.5%) died during admission. Factors associated with mortality included GCS (p = 0.032), infarcts (p = 0.004), extra-meningeal TB (p = 0.003), VPS infection (p = 0.018), low CD4 count (p = 0.009), and hyponatremia (p = 0.002). No statistically significant factors were associated with VPS complications. CONCLUSION TBM hydrocephalus in HIV-infected children carries a high mortality. Clinicians in high-prevalence settings should have a high suspicion index and institute early treatment.
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Affiliation(s)
- Basil Enicker
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, Durban, South Africa.
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Road, Congella, Durban, 4001, South Africa.
| | - Colleen Aldous
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Road, Congella, Durban, 4001, South Africa
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Raut R, Shams S, Scalia G, Umana GE, Ranganathan S, Rasheed M, Vats A, Chaurasia B. 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. Ann Med Surg (Lond) 2024; 86:881-885. [PMID: 38333284 PMCID: PMC10849454 DOI: 10.1097/ms9.0000000000001701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 12/29/2023] [Indexed: 02/10/2024] Open
Abstract
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.
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Affiliation(s)
- Rupesh Raut
- Department of Neurosurgery, Patan Hospital, Patan Academy of Health Sciences, Lalitpur
| | - Shahzad Shams
- Department of Neurosurgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Gianluca Scalia
- Neurosurgery Unit, Department of Head and Neck Surgery, Garibaldi Hospital
| | | | | | - Muddassar Rasheed
- Department of Neurosurgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Atul Vats
- James Cook University Hospital, Middlesbrough, UK
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
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Dian S, Ganiem AR, Te Brake LH, van Laarhoven A. Current Insights into Diagnosing and Treating Neurotuberculosis in Adults. CNS Drugs 2023; 37:957-972. [PMID: 37978095 DOI: 10.1007/s40263-023-01047-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/19/2023]
Abstract
Neurotuberculosis has the highest morbidity and mortality risk of all forms of extrapulmonary tuberculosis (TB). Early treatment is paramount, but establishing diagnosis are challenging in all three forms of neurotuberculosis: tuberculous meningitis (TBM), spinal TB and tuberculomas. Despite advancements in diagnostic tools and ongoing research aimed at improving TB treatment regimens, the mortality rate for neurotuberculosis remains high. While antituberculosis drugs were discovered in the 1940s, TB treatment regimens were designed for and studied in pulmonary TB and remained largely unchanged for decades. However, new antibiotic regimens and host-directed therapies are now being studied to combat drug resistance and contribute to ending the TB epidemic. Clinical trials are necessary to assess the effectiveness and safety of these treatments, addressing paradoxical responses in neurotuberculosis cases and ultimately improving patient outcomes. Pharmacokinetic-pharmacodynamic analyses can inform evidence-based dose selection and exposure optimization. This review provides an update on the diagnosis and treatment of neurotuberculosis, encompassing both sensitive and resistant antituberculosis drug approaches, drawing on evidence from the literature published over the past decade.
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Affiliation(s)
- Sofiati Dian
- Department of Neurology, Dr. Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.
- Research Centre for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia.
| | - Ahmad Rizal Ganiem
- Department of Neurology, Dr. Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Research Centre for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Lindsey Hm Te Brake
- Radboudumc Centre for Infectious Disease (RCI), Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Arjan van Laarhoven
- Radboudumc Centre for Infectious Disease (RCI), Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
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Swamy SBG, Jaikumar V, Nagaraj NM, Khandelwal S. Intracranial giant tuberculoma: A 7-year institutional experience and literature review. Clin Neurol Neurosurg 2023; 225:107593. [PMID: 36701938 DOI: 10.1016/j.clineuro.2023.107593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Intracranial tuberculomas are infrequent with a lower morbidity and mortality compared to tubercular meningitis. Giant intracranial tuberculomas are rarer but important differentials for intracranial space-occupying lesions causing focal neurological deficits depending on anatomical location and size. METHODS Histopathologically confirmed giant intracranial tuberculomas selected based on institutional size criteria (<12 Years-old: ≥25 mm; 12-18 Years-old: ≥35 mm; ≥18 Years-old: ≥40 mm) were retrospectively reviewed and analyzed for clinical features, radiology, surgical management, and outcomes in patients admitted from 2015 to 2022. RESULTS Ten patients were included (Males:Females = 3:7; Age: 8-68 Years, Average: 30.1 Years). Mean duration of symptoms was 2.84 months. Two patients demonstrated active systemic tuberculosis. Previous tubercular infections included pulmonary involvement in four, meningeal in three, and a cerebellar tuberculoma in one patient. Cerebrospinal fluid analysis in five patients demonstrated no tubercle bacilli. Seven lesions were supratentorial and three infratentorial. Giant tuberculomas demonstrated profound T2 hypointensity, sub-marginal T2 hyperintense crescents, and significant perilesional vasogenic edema. Craniotomy and excision were mainstay except in one case treated only with ventriculoperitoneal shunting. Three additional patients underwent ventriculoperitoneal shunting for hydrocephalus. One patient died from aspiration pneumonia and sepsis following a postoperative seizure. Anti-Tubercular Therapy (ATT) was advised for 18 months. Follow up ranged from 4 to 18 months. One patient was medically managed for ATT-induced hepatitis, hepatic encephalopathy, and coincidental paradoxical reaction. Remainder of patients showed complete resolution of symptomatology and absence of new symptoms till latest follow up. CONCLUSION Clinical course of giant tuberculomas differ from non-giant variants in characteristic radiology, more intensive ATT, and possibility for partial debulking/excision.
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Affiliation(s)
- Srihari Bangalore Gangadhar Swamy
- Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
| | - Vinay Jaikumar
- Affiliated with Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
| | - Nagarjun Maulyavantham Nagaraj
- Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
| | - Sandesh Khandelwal
- Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
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Siahaan AMP, Tandean S, Indharty RS, Nainggolan BWM, Susanto M. Paroxysmal sympathetic hyperactivity syndrome in tuberculous meningitis with paradoxical reaction. Int J Surg Case Rep 2022; 99:107619. [PMID: 36096085 PMCID: PMC9568713 DOI: 10.1016/j.ijscr.2022.107619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction and importance Paroxysmal sympathetic hyperactivity syndrome is frequently reported in traumatic brain injury. However, it may occur in non-traumatic brain injury, such as tuberculous meningitis with hydrocephalus. Case presentation We reported a 38-year-old male who presented with acute decrease of consciousness and hemiparesis that was developed during antitubercular drugs therapy. CT Scan showed hydrocephalus and granuloma lesion. Emergency ventriculoperitoneal shunting were performed. During treatment, the patient developed paroxysmal sympathetic syndrome during treatment that was controlled based on symptom elimination and prevention. Clinical discussion Brain tuberculosis remains a difficult problem for clinicians. Even when antitubercular drugs are administered according to protocol, paradoxical reactions can occur. If hydrocephalus develops, ventriculoperitoneal shunting is one of the options for lowering intracranial pressure. Paroxysmal sympathetic hyperactivity may occur in brain tuberculosis and should be detected as soon as possible to avoid serious morbidity. Conclusion Paroxysmal sympathetic hyperactivity may be developed in brain tuberculosis. Early identification and treatment are mandatory. Paroxysmal sympathetic hyperactivity (PSH) syndrome may be observed in non-traumatic brain injury Treatment of PSH was based on symptoms elimination and symptoms prevention. Paradoxical reaction in tuberculosis, characterized by the appearance of new clinical symptoms during antitubercular drug therapy Ventriculoperitoneal shunting to reduce intracranial pressure in hydrocephalus following meningitis tuberculosis
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Yiek SH, Wong ASH. Challenges and Controversies in the Management of Tuberculous Meningitis with Hydrocephalus: A Systematic Review and Sarawak Institution's Experience. Asian J Neurosurg 2022; 17:189-198. [PMID: 36120621 PMCID: PMC9473842 DOI: 10.1055/s-0042-1750781] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Abstract
Introduction To date, there are no standard practice guidelines available and no universal consensus regarding treatment protocol in management of tuberculous meningitis (TBM) with hydrocephalus. Over the years, diverse views have existed in neurosurgical management of TBM with hydrocephalus. Some authors advocate ventriculo-peritoneal (VP) shunt, while others suggest that external ventricular drainage (EVD) may be the preferable neurosurgical procedure for a poor-grade patient.
Method We systematically reviewed published literature and presented our institution's experience. We performed a retrospective case study in our Sarawak neurosurgical center from 2018 to 2020. We tabulated the outcome according to preoperative classifications, which were Vellore Grading (VG), Modified Vellore Grading (MVG), British Medical Research Council Classification (MRC), and others: author-defined.
Result In our center, there were 20 cases of TBM with hydrocephalus treated by EVD and VP shunt from 2018 to 2020. We systematically searched published medical literature, and 23 articles were retrieved and analyzed. Poor outcomes were observed in poor-grade patients, especially VG/MVG 3/4 and MRC 3, from both institution and systemic review data. Shunt complication rate was lower in our center as compared with published literature.
Conclusion Unfortunately, morbidity and mortality were approximately twofold higher in poor-grade as compared with good-grade patients. However, about one-third of poor-grade patients achieved a good outcome. Cerebrospinal fluid (CSF) diversion would be an unavoidable treatment for hydrocephalus. Poor-grade patients tend to have cerebral infarcts in addition to hydrocephalus. An extended duration of EVD placement could be a potential measure to assess Glasgow coma scale recovery and monitor serial CSF samples.
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Affiliation(s)
- Siew-Hong Yiek
- Department of Neurosurgery, Sarawak General Hospital, Malaysia
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Chalasani R, Goonathilake MR, Waqar S, George S, Jean-Baptiste W, Yusuf Ali A, Inyang B, Koshy FS, George K, Poudel P, Mohammed L. The Outcome of Surgical Intervention (Ventriculoperitoneal Shunt and Endoscopic Third Ventriculostomy) in Patients With Hydrocephalus Secondary to Tuberculous Meningitis: A Systematic Review. Cureus 2022; 14:e25317. [PMID: 35637922 PMCID: PMC9131440 DOI: 10.7759/cureus.25317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/05/2022] Open
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Kik CC, Spoor JKH. Pragmatism in Pediatric Neurosurgery: More Than a Pipe Dream? A Systematic Literature Review and Analysis. World Neurosurg 2022; 161:418-423. [PMID: 35505562 DOI: 10.1016/j.wneu.2021.09.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Classic randomized controlled trials (RCTs) form the cornerstone for medical guidelines and protocols. However, in neurosurgery, RCTs are not always applicable to everyday clinical practice. Pragmatic controlled trials aim to incorporate real-life data with the preservation of the methodologic quality. This study is a systematic literature review of all pediatric neurosurgical RCTs published between 2000 and 2020 and an analysis of their pragmatism. METHODS An electronic database search was performed in PubMed, EMBASE, and the Cochrane Library to identify all relevant trials. Pragmatism was evaluated retrospectively on 9 domains: eligibility, recruitment, setting, organization, flexibility (delivery and adherence), follow-up, primary outcome, and primary analysis. RESULTS Of the 1862 studies included, 15 met the inclusion criteria. On average, studies scored between equally pragmatic/explanatory and rather pragmatic (M = 3.59, standard deviation [SD] = 0.56). Lowest ratings were seen for setting (M = 2.80, SD = 1.66) and eligibility (M = 3.20, SD = 1.66). Highest scores of pragmatism were given to analysis (M = 4.67, SD = 0.82) and intervention organization (M = 4.60, SD = 1.06). There was no significant difference between studies based on number of patients included, main subject, or publication year. CONCLUSIONS Pediatric neurosurgical RCTs scored reasonably well on overall pragmatism. In the future, there will be a greater need for pragmatic controlled trials in pediatric neurosurgery to bridge the divide between real-life data and reliable methodological quality. There is an opportunity to develop further applications of pragmatism tailored to surgical interventions.
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Affiliation(s)
- Charlotte C Kik
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, The Netherlands.
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Yadav YR, Bajaj J, Ratre S, Yadav N, Parihar V, Swamy N, Kumar A, Hedaoo K, Sinha M. Endoscopic Third Ventriculostomy - A Review. Neurol India 2021; 69:S502-S513. [PMID: 35103009 DOI: 10.4103/0028-3886.332253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endoscopic third ventriculostomy (ETV) has become a proven modality for treating obstructive and selected cases of communicating hydrocephalus. OBJECTIVE This review aims to summarize the indications, preoperative workup, surgical technique, results, postoperative care, complications, advantages, and limitations of an ETV. MATERIALS AND METHODS A thorough review of PubMed and Google Scholar was performed. This review is based on the relevant articles and authors' experience. RESULTS ETV is indicated in obstructive hydrocephalus and selected cases of communicating hydrocephalus. Studying preoperative imaging is critical, and a detailed assessment of interthalamic adhesions, the thickness of floor, arteries or membranes below the third ventricle floor, and prepontine cistern width is essential. Blunt perforation in a thin floor, while bipolar cautery at low settings and water jet dissection are preferred in a thick floor. The appearance of stoma pulsations and intraoperative ventriculostomography reassure stoma and basal cistern patency. The intraoperative decision for shunt, external ventricular drainage, or Ommaya reservoir can be taken. Magnetic resonance ventriculography and cine phase-contrast magnetic resonance imaging can determine stoma patency. Good postoperative care with repeated cerebrospinal fluid drainage enhances outcomes in selected cases. Though the complications mostly occur in an early postoperative phase, delayed lethal ones may happen. Watching live surgeries, assisting expert surgeons, and practicing on cadavers and models can shorten the learning curve. CONCLUSION ETV is an excellent technique for managing obstructive and selected cases of communicating hydrocephalus. Good case selection, methodical technique, and proper training under experts are vital.
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Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Shailendra Ratre
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Nishtha Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Vijay Parihar
- Department of Neuroradiology, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Narayan Swamy
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ambuj Kumar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ketan Hedaoo
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Mallika Sinha
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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Bhushan B, Sardana V, Shringi P, Yadav SR, Maheshwari D. Role of Surgical Procedures (VP Shunt and ETV) in Tuberculous Meningitis with Hydrocephalus (TBMH): A Systematic Review. J Pediatr Neurosci 2021; 16:106-112. [PMID: 35018177 PMCID: PMC8706600 DOI: 10.4103/jpn.jpn_286_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/27/2020] [Accepted: 02/11/2021] [Indexed: 11/04/2022] Open
Abstract
Objective Hydrocephalus is one of the most common complications of tuberculous meningitis. Various cerebrospinal fluid diversion procedures, endoscopic third ventriculostomy (ETV) and shunt surgery, are performed for the management of the hydrocephalus associated with tuberculous bacterial meningitis (TBM). There is decreased clarity on the type of procedure to be done. So, this study aims at generating knowledge to understand the conditions in which either of the two procedures, ETV and shunt surgery, is a better option and to develop good practice guidelines for the treatment of tubercular meningitis hydrocephalus (TBMH). Materials and Methods A systematic search of literature was performed by using PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) for articles published from January 2001 to April 2020. A total of 15 studies were included irrespective of their design and having diagnosis with TBMH treated with ventriculoperitoneal shunt surgery (VPS) or ETV. Then, a systemic review was done regarding outcomes, complications, and recommendations made in different studies. Results The total number of patients diagnosed with TBMH was 603; among them, 348 patients had VPS and 255 patients had ETV. In the VPS group, the patient's good outcome varied from 25% to 68% and complication rate ranged from 10% to 43.8%. The average percentage of good outcome in the VPS group was 51.8%. In the ETV group, the patient's good outcome varied from 41% to 77% and complication rate ranged from 10% to 23.5%. The average percentage of good outcome in the ETV group was 68%. There was a significant difference in the average percentage of good outcome in the ETV versus the VPS shunt group (P-value was 0.008). Conclusion There was a significant difference in the average percentage of good outcome after ETV than VPS, and complication rate was also slightly lower after ETV than VPS during the chronic phase of illness. So during the acute phase of illness VPS placement is preferred whereas in the chronic burnout phase ETV is preferred because poor anatomy leads to more complications with ETV during the acute phase of the disease.
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Affiliation(s)
- Bharat Bhushan
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
| | - Vijay Sardana
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
| | - Prashant Shringi
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
| | - Seeta Ram Yadav
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
| | - Dilip Maheshwari
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
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11
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Garg R, Paliwal V. Hydrocephalus in Tuberculous Meningitis - Pearls and Nuances. Neurol India 2021; 69:S330-S335. [DOI: 10.4103/0028-3886.332275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Xiao X, Li Q, Ju Y. Giant central nervous system tuberculoma in pediatric patients: surgical case series. Childs Nerv Syst 2021; 37:2935-2941. [PMID: 33675392 PMCID: PMC8423696 DOI: 10.1007/s00381-021-05091-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/09/2021] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Xiao Xiao
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37 Guoxue Road, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Qiang Li
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37 Guoxue Road, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Yan Ju
- Department of Neurosurgery, West China Hospital of Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Rajshekhar V. Three Decades of Vellore Grading for Tuberculous Meningitis with Hydrocephalus: A Reappraisal. Neurol India 2021; 69:S569-S574. [DOI: 10.4103/0028-3886.332251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tucker EW, Marais S, Seddon JA, van Crevel R, Ganiem AR, Ruslami R, Zhang W, Sun F, Zhou X, Solomons RS, Cresswell FV, Wilmshurst J, Rohlwink U. International Survey Reveals Opportunities to Improve Tuberculous Meningitis Management and the Need for Standardized Guidelines. Open Forum Infect Dis 2020; 7:ofaa445. [PMID: 33209947 PMCID: PMC7652100 DOI: 10.1093/ofid/ofaa445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/17/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is a medical emergency, yet there are no standardized treatment guidelines for the medical or neurosurgical management of these patients and little data on neurocritical care. We conducted an international survey to understand current medical and neurosurgical TBM management and resource availability to provide baseline data needed for future multicenter trials addressing unanswered clinical research questions and the establishment of standardized guidelines. METHODS An online survey of 77 questions covering medical and neurosurgical TBM management aimed at clinicians/nurses treating TBM was distributed as an anonymous link through email invitation, international organizations' membership distribution, and direct links on organizational webpages or social media. The survey remained open for 5 months. Data were summarized with frequencies and percentages. RESULTS The survey had 222 responses from 43 countries representing 6 continents. Most respondents were from tertiary care facilities, with broad access to medical and neurosurgical resources. There was significant heterogeneity in general supportive care, and TBM-specific management demonstrated considerable divergence from current standard-of-care practices. The lack of standardized guidelines was identified as a major challenge in TBM management. General and neurocritical care were largely absent. Resources for bedside supportive care and noninvasive monitoring were broadly accessible. CONCLUSIONS These findings suggest that current TBM management could be improved by the establishment of internationally accepted treatment guidelines based on available evidence, and that numerous centers have resources available to participate in future multicenter trials, even for basic interventions, that may further improve patient outcomes globally.
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Affiliation(s)
- Elizabeth W Tucker
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Pediatric Critical Care, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
| | - Suzaan Marais
- Division of Neurology, Department of Medicine and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - James A Seddon
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ahmad Rizal Ganiem
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- Department of Neurology, Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
| | - Wenhong Zhang
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Sun
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xian Zhou
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Regan S Solomons
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Infectious Disease Institute, Mulago College of Health Sciences, Kampala, Uganda
- MRC-UVRI LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Jo Wilmshurst
- Neuroscience Institute and Department of Paediatric Neurology, University of Cape Town, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Ursula Rohlwink
- Division of Neurosurgery, Department of Surgery and Neuroscience Institute, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
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Legaspi GD, Espiritu AI, Omar AT. Success and complication rates of endoscopic third ventriculostomy for tuberculous meningitis: a systematic review and meta-analysis. Neurosurg Rev 2020; 44:2201-2209. [PMID: 32974813 DOI: 10.1007/s10143-020-01396-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/03/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Gerardo D Legaspi
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Taft Avenue, Ermita, 1000, Manila, Philippines
| | - Adrian I Espiritu
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Taft Avenue, Ermita, 1000, Manila, Philippines.,Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Taft Avenue, Ermita, 1000, Manila, Philippines
| | - Abdelsimar T Omar
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Taft Avenue, Ermita, 1000, Manila, Philippines.
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16
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Pande A, Lamba N, Mammi M, Gebrehiwet P, Trenary A, Doucette J, Papatheodorou S, Bunevicius A, Smith TR, Mekary RA. Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in pediatric and adult population: a systematic review and meta-analysis. Neurosurg Rev 2020; 44:1227-1241. [PMID: 32476100 DOI: 10.1007/s10143-020-01320-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/29/2020] [Accepted: 05/18/2020] [Indexed: 11/28/2022]
Abstract
Treatment options for hydrocephalus include endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS). Some ambiguity remains regarding indications, safety, and efficacy for these procedures in different clinical scenarios. The objective of the present study was to pool the available evidence to compare outcomes among patients with hydrocephalus undergoing ETV versus VPS. A systematic search of the literature was conducted via PubMed, EMBASE, and Cochrane Library through 11/29/2018 to identify studies evaluating failure and complication rates, following ETV or VPS. Pooled effect estimates were calculated using random effects. Heterogeneity was assessed by the Cochrane Q test and the I2 value. Heterogeneity sources were explored through subgroup analyses and meta-regression. Twenty-three studies (five randomized control trials (RCTs) and 18 observational studies) were meta-analyzed. Comparing ETV to VPS, failure rate was not statistically significantly different with a pooled relative risk (RR) of 1.48, 95%CI (0.85, 2.59) for RCTs and 1.17 (0.89, 1.53) for cohort studies; P-interaction: 0.44. Complication rates were not statistically significantly different between ETV and VPS in RCTs (RR: 1.34, 95%CI: 0.50, 3.59) but were statistically significant for prospective cohort studies (RR: 0.47, 95%CI: 0.30, 0.78); P-interaction: 0.07. Length of hospital stay was no different, when comparing ETV and VPS. These results remained unchanged when stratifying by intervention type and when regressing on age when possible. No significant differences in failure rate were observed between ETV and VPS. ETV was found to have lower complication rates than VPS in prospective cohort studies but not in RCTs. Further research is needed to identify the specific patient populations who may be better suited for one intervention versus another.
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Affiliation(s)
- Apurva Pande
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Nayan Lamba
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Mammi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Neurosurgery Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | | | - Alyssa Trenary
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Joanne Doucette
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | | | - Adomas Bunevicius
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA. .,Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Donovan J, Figaji A, Imran D, Phu NH, Rohlwink U, Thwaites GE. The neurocritical care of tuberculous meningitis. Lancet Neurol 2019; 18:771-783. [PMID: 31109897 DOI: 10.1016/s1474-4422(19)30154-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Darma Imran
- Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Ursula Rohlwink
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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18
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Matucci T, Galli L, de Martino M, Chiappini E. Treating children with tuberculosis: new weapons for an old enemy. J Chemother 2019; 31:227-245. [DOI: 10.1080/1120009x.2019.1598039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Tommaso Matucci
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Luisa Galli
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Maurizio de Martino
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Elena Chiappini
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
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19
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Aranha A, Choudhary A, Bhaskar S, Gupta LN. A Randomized Study Comparing Endoscopic Third Ventriculostomy versus Ventriculoperitoneal Shunt in the Management of Hydrocephalus Due to Tuberculous Meningitis. Asian J Neurosurg 2018; 13:1140-1147. [PMID: 30459883 PMCID: PMC6208215 DOI: 10.4103/ajns.ajns_107_18] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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.
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Affiliation(s)
- Andrew Aranha
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER) and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Ajay Choudhary
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER) and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - S Bhaskar
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER) and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - L N Gupta
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER) and Dr Ram Manohar Lohia Hospital, New Delhi, India
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20
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Wilkinson RJ, Rohlwink U, Misra UK, van Crevel R, Mai NTH, Dooley KE, Caws M, Figaji A, Savic R, Solomons R, Thwaites GE. Tuberculous meningitis. Nat Rev Neurol 2017; 13:581-598. [PMID: 28884751 DOI: 10.1038/nrneurol.2017.120] [Citation(s) in RCA: 285] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Robert J Wilkinson
- Department of Medicine, Imperial College London, Norfolk Place, London W2 1PG, UK
- The Francis Crick Institute, Midland Road, London NW1 2AT, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Republic of South Africa
| | - Ursula Rohlwink
- Division of Neurosurgery, University of Cape Town, Anzio Road, Observatory 7925, Republic of South Africa
| | - Usha Kant Misra
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Reinout van Crevel
- Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, Maryland 21287, USA
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Anthony Figaji
- Division of Neurosurgery, University of Cape Town, Anzio Road, Observatory 7925, Republic of South Africa
| | - Rada Savic
- UCSF School of Pharmacy, Department, Bioengineering, 1700 4th Street, San Francisco, California 94158, UA
| | - Regan Solomons
- Faculty of Health Sciences, Stellenbosch University, Tygerberg Hospital, Francie van Zijl Drive, Tygerberg 7505, Cape Town, Republic of South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road, Oxford OX3 9FZ, UK
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21
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Rizvi I, Garg RK, Malhotra HS, Kumar N, Sharma E, Srivastava C, Uniyal R. Ventriculo-peritoneal shunt surgery for tuberculous meningitis: A systematic review. J Neurol Sci 2017; 375:255-263. [DOI: 10.1016/j.jns.2017.02.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
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22
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Abstract
BACKGROUND Tuberculous meningitis (TBM) is the main form of tuberculosis that affects the central nervous system and is associated with high rates of death and disability. Most international guidelines recommend longer antituberculous treatment (ATT) regimens for TBM than for pulmonary tuberculosis disease to prevent relapse. However, longer regimens are associated with poor adherence, which could contribute to increased relapse, development of drug resistance, and increased costs to patients and healthcare systems. OBJECTIVES To compare the effects of short-course (six months) regimens versus prolonged-course regimens for people with tuberculous meningitis (TBM). SEARCH METHODS We searched the following databases up to 31 March 2016: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; EMBASE; LILACS; INDMED; and the South Asian Database of Controlled Clinical Trials. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials. We also checked article reference lists and contacted researchers in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) and prospective cohort studies of adults and children with TBM treated with antituberculous regimens that included rifampicin for six months or longer than six months. The primary outcome was relapse, and included studies required a minimum of six months follow-up after completion of treatment. DATA COLLECTION AND ANALYSIS Two review authors (SJ and HR) independently assessed the literature search results for eligibility, and performed data extraction and 'Risk of bias' assessments of the included studies. We contacted study authors for additional information when necessary. Most data came from single arm cohort studies without a direct comparison so we pooled the findings for each group of cohorts and presented them separately using a complete-case analysis. We assessed the quality of the evidence narratively, as using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was inappropriate with no direct comparisons between short- and prolonged-course regimens. MAIN RESULTS Four RCTs and 12 prospective cohort studies met our inclusion criteria, and included a total of 1881 participants with TBM. None of the included RCTs directly compared six months versus longer regimens, so we analysed all data as individual cohorts to obtain relapse rates in each set of cohorts.We included seven cohorts of participants treated for six months, with a total of 458 participants. Three studies were conducted in Thailand, two in South Africa, and one each in Ecuador and Papua New Guinea between the 1980s and 2009. We included 12 cohorts of participants treated for longer than six months (ranging from eight to 16 months), with a total of 1423 participants. Four studies were conducted in India, three in Thailand and one each in China, South Africa, Romania, Turkey and Vietnam, between the late 1970s and 2011.The proportion of participants classified as having stage III disease (severe) was higher in the cohorts treated for six months (33.2% versus 16.9%), but the proportion with known concurrent HIV was higher in the cohorts treated for longer (0/458 versus 122/1423). Although there were variations in the treatment regimens, most cohorts received isoniazid, rifampicin, and pyrazinamide during the intensive phase.Investigators achieved follow-up beyond 18 months after completing treatment in three out of the seven cohorts treated for six months, and five out of the 12 cohorts treated for eight to 16 months. All studies had potential sources of bias in their estimation of the relapse rate, and comparisons between the cohorts could be confounded.Relapse was an uncommon event across both groups of cohorts (3/369 (0.8%) with six months treatment versus 7/915 (0.8%) with longer), with only one death attributed to relapse in each group.Overall, the proportion of participants who died was higher in the cohorts treated for longer than six months (447/1423 (31.4%) versus 58/458 (12.7%)). However, most deaths occurred during the first six months in both treatment cohorts, which suggested that the difference in death rate was not directly related to duration of ATT but was due to confounding. Clinical cure was higher in the group of cohorts treated for six months (408/458 (89.1%) versus longer than six months (984/1336 (73.7%)), consistent with the observations for deaths.Few participants defaulted from treatment with six months treatment (4/370 (1.1%)) versus longer treatment (8/355 (2.3%)), and adherence was not well reported. AUTHORS' CONCLUSIONS In all cohorts most deaths occurred in the first six months; and relapse was uncommon in all participants irrespective of the regimen. Further inferences are probably inappropriate given this is observational data and confounding is likely. These data are almost all from participants who are HIV-negative, and thus the inferences will not apply to the efficacy and safety of the six months regimens in HIV-positive people. Well-designed RCTs, or large prospective cohort studies, comparing six months with longer treatment regimens with long follow-up periods established at initiation of ATT are needed to resolve the uncertainty regarding the safety and efficacy of six months regimens for TBM.
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Affiliation(s)
- Sophie Jullien
- Jigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Hannah Ryan
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUK
| | - Manish Modi
- Postgraduate Institute of Medical Education and ResearchDepartment of NeurologyChandigarh 160 012India
| | - Rohit Bhatia
- All India Institute of Medical SciencesDepartment of NeurologyNew DelhiIndia110029
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