Role of neuroendoscopy in the management of patients with tuberculous meningitis hydrocephalus

Surgery for Central Nervous System Tuberculosis in Children

Tuberculosis (TB) is the second most common cause of death due to a single infectious agent worldwide after COVID-19. Central nervous system tuberculosis is widely prevalent in the world, especially in the developing countries and continues to be a socioeconomic problem. It is highly devastating form of tuberculosis leading to unacceptable levels of morbidity and mortality despite appropriate antitubercular therapy. The clinical symptoms are varied and nonspecific. They can be easily overlooked. Tuberculous meningitis is the most common presentation and its sequelae viz. vasculitis, infarction and hydrocephalus can be devastating. The ensuing cognitive, intellectual, and endocrinological outcome can be a significant source of morbidity and mortality, especially in resource constrained countries. Early diagnosis and treatment of tuberculous meningitis and institution of treatment is helpful in limiting the course of disease process. The diagnosis of CNS tuberculosis remains a formidable diagnostic challenge. The microbiological methods alone cannot be relied upon. CSF diversion procedures need to be performed at the appropriate time in order to achieve good outcomes. Tuberculous pachymeningitis and arachnoiditis are morbid sequelae of tuberculous meningitis. Tuberculomas present as mass lesions in the craniospinal axis. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Tuberculosis of the spinal cord is seen similar to intracranial tuberculosis in pathogenesis but with its own unique clinical manifestations and management. Multidrug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. Heightened clinical suspicion is paramount to ensure prompt investigation. Early diagnosis and treatment are essential to a gratifying outcome and prevent complications.

The Neuro-Ophthalmology of Tuberculosis

Tuberculosis (TB) is a global health concern and central nervous system (CNS) TB leads to high mortality and morbidity. CNS TB can manifest as tubercular meningitis, tuberculoma, myelitis, and arachnoiditis. Neuro-ophthalmological involvement by TB can lead to permanent blindness, ocular nerve palsies and gaze restriction. Visual impairment is a dreaded complication of tubercular meningitis (TBM), which can result from visual pathway involvement at different levels with varying pathogenesis. Efferent pathway involvement includes cranial nerve palsies and disorders of gaze. The purpose of this review is to outline the various neuro-ophthalmological manifestations of TB along with a description of their unique pathogenesis and management. Optochiasmatic arachnoiditis and tuberculomas are the most common causes of vision loss followed by chronic papilloedema. Abducens nerve palsy is the most commonly seen ocular nerve palsy in TBM. Gaze palsies with deficits in saccades and pursuits can occur due to brainstem tuberculomas. Corticosteroids are the cornerstone in the management of paradoxical reactions, but other immunomodulators such as thalidomide and infliximab are being explored. Toxic optic neuropathy caused by ethambutol necessitates careful monitoring and immediate drug discontinuation. Cerebrospinal fluid diversion through ventriculo-peritoneal shunting may be required in patients with hydrocephalus in stage I and II of TBM to prevent visual impairment. Early diagnosis and prompt management are crucial to prevent permanent disability. Prevention strategies, public health initiatives, regular follow-up and timely intervention are essential in reducing the burden of CNS TB and its neuro-ophthalmological complications.

Role of Surgical Procedures (VP Shunt and ETV) in Tuberculous Meningitis with Hydrocephalus (TBMH): A Systematic Review

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.

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.

Neuroendoscopic lavage for ventriculitis: Case report and literature review

BACKGROUND

Ventriculitis, one of the difficulties in neurosurgical treatment, is a significant cause of death and morbidity in patients with hydrocephalus. Neuroendoscopy is widely used in the treatment of non-communicable hydrocephalus. The advantages of neuroendoscopy may play a decisive role in the treatment of ventriculitis.

CASE REPORT AND METHODS

We report a 34-year-old male patient with refractory fever and rapid progressive disturbance of consciousness due to ventriculitis caused by intraventricle rupture in a left colliculus abscess. He received intravenous (IV) antibiotics and saline neuroendoscopic lavage (NEL) combined with septostomy and endoscopic third ventriculostomy leading to rapid recovery and remission of symptoms. We also reviewed the use of NEL for ventriculitis in PubMed from 1970 to January 20, 2019.

RESULTS

In our review, 93 cases (including the present report) were treated with NEL; 91 cases of infection subsided, and 7 patients died.

CONCLUSION

NEL may be an effective method for the treatment of ventriculitis.

Advances in the Diagnosis and Management of Tubercular Meningitis in Children

Tubercular meningitis (TBM) continues to be a common cause of neuromorbidity in children. There is no single diagnostic method that can rapidly detect Mycobacterium tuberculosis (M.tb) in TBM patients with high sensitivity and specificity. Newer diagnostic modalities like Xpert/RIF assay and Loop mediated isothermal amplification assay (LAMP) have gained an essential stand in molecular diagnostics due to their high specificity, modest sensitivity in cerebrospinal fluid (CSF) and quick availability of results. Intensified drug regimens using high dose rifampicin, fluoroquinolone and aspirin appear to be useful adjunct therapy but more pediatric clinical trials on large scale are needed to determine their appropriate place in pediatric TBM. The emergence of multi and extreme drug resistant M.tb strains further challenges the standard therapy. In this review authors summarize challenges of the currently used diagnostic methods and treatment for TBM and discuss the recent advances.

Neuroendoscopy for post-infective hydrocephalus in children

The treatment of hydrocephalus has changed in recent years with better imaging and introduction of endoscopic procedures as well as enhanced shunts. Indications of endoscopic third ventriculostomy (ETV) are now more refined with better quantification of outcome. This article reviews the current state of neuroendoscopy for infective hydrocephalus in children. The roles of third ventriculostomy as a primary procedure or after shunt malfunction, endoscopic interventions in multiloculated hydrocephalus and introduction of intraventricular lavage to salvage severely infected children are evaluated.

Tuberculosis of the central nervous system in children

BACKGROUND

Central nervous system tuberculosis (CNS TB) in children is still a socioeconomic problem in developing countries. It has varied manifestations, symptoms are nonspecific, diagnosis can be challenging, and treatment may be difficult. It is often missed or overlooked. Among the various pathological entities, tuberculous meningitis is the most common and devastating manifestation. The resultant vasculitis, infarction, and hydrocephalus can be life-threatening. It can have grave cognitive, intellectual, and endocrine sequelae if not treated in time resulting in handicap, especially in resource constraint countries. Early diagnosis and treatment of tuberculous meningitis is the single most important factor determining outcome. Tuberculous hydrocephalus needs to be recognized early, and cerebrospinal fluid diversion procedure needs to be performed in adequate time to prevent morbidity or mortality in some cases. Tuberculous pachymeningitis and arachnoiditis are rare in children. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Drug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted.

AIM

The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized.

CONCLUSION

Heightened clinical suspicion, early diagnosis, appropriate antituberculous treatment, and surgery in relevant situation are essential for a gratifying outcome and preventing complications.

Endoscopic Treatment of Hydrocephalus with Minimal Resources: Resource Utilization and Indigenous Innovation in Developing Countries like India

CONTEXT

Neuroendoscopic surgeries need specialized equipments, unavailable in neurosurgical departments of majority of public healthcare institutions of India. Aims: Neuroendoscopic treatment of hydrocephalus in the setting of minimal resources using utilization of available resources, inter-departmental co-ordination and indigenous innovations.

METHODS

Study was carried out at a public sector institute of India with scarce resources. Senior author (DKJ) used indigenously designed stainless steel working sheath along with equipments of 'awake endoscopic intubation system' of department of neuroanesthesia and 18 cm, 4 mm, 0° rigid telescope for neuroendoscopic surgeries for various intraventricular pathologies.

RESULTS

Thirty-four neuroendoscopic surgeries in 32 patients were done over last 3 years. There were 18 males and 14 females with average age of 23 years. It included hydrocephalus due to tubercular meningitis (n = 19), neurocysticercosis (NCC) (n = 4), intra-ventricular (n = 2) and para-ventricular (n = 2) space occupying lesions, aqueduct stenosis with (n = 2) or without (n = 1) shunt malfunction and one case each of pyogenic meningitis and right cerebellar infarction. Endoscopic third ventriculostomy (ETV) (n = 28), septostomy (n = 6), removals of cystic lesions (n = 3) and biopsies of intraventricular lesions (n = 2) were done in a total of 34 neuroendoscopic surgeries. Overall there were four failures of ETVs, which were managed by ventriculo-peritoneal shunts. Two mortalities in the study group were unrelated to the surgical procedures.

CONCLUSION

Indigenous innovations and interdisciplinary co-ordination are the way ahead to tackle resource scarcity in public sector healthcare institutions of India in the scenario of plenty of neuroendoscopic trainings opportunities for young neurosurgeons and paucity of equipments required.

A Randomized Study Comparing Endoscopic Third Ventriculostomy versus Ventriculoperitoneal Shunt in the Management of Hydrocephalus Due to Tuberculous Meningitis

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.

Role of endoscopic third ventriculostomy in tuberculous meningitis with hydrocephalus

Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM). It can be purely obstructive, purely communicating, or due to combinations of obstruction in addition to defective absorption of cerebrospinal fluid (CSF). Endoscopic third ventriculostomy (ETV) as an alternative to shunt procedures is an established treatment for obstructive hydrocephalus in TBM. ETV in TBM hydrocephalus can be technically very difficult, especially in acute stage of disease due to inflamed, thick, and opaque third ventricle floor. Water jet dissection can be helpful in thick and opaque ventricular floor patients, while simple blunt perforation is possible in thin and transparent floor. Lumbar peritoneal shunt is a better option for communicating hydrocephalus as compared to VP shunt or ETV. Intraoperative Doppler or neuronavigation can help in proper planning of the perforation to prevent neurovascular complications. Choroid plexus coagulation with ETV can improve success rate in infants. Results of ETV are better in good grade patients. Poor results are observed in cisternal exudates, thick and opaque third ventricle floor, acute phase, malnourished patients as compared to patients without cisternal exudates, thin and transparent third ventricle floor, chronic phase, well-nourished patients. Some of the patients, especially in poor grade, can show delayed recovery. Failure to improve after ETV can be due to blocked stoma, complex hydrocephalus, or vascular compromise. Repeated lumbar puncture can help faster normalization of the raised intracranial pressure after ETV in patients with temporary defect in CSF absorption, whereas lumbar peritoneal shunt is required in permanent defect. Repeat ETV is recommended if the stoma is blocked. ETV should be considered as treatment of choice in chronic phase of the disease in obstructive hydrocephalus.

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.

Role of endoscopy in recalcitrant intraventricular tuberculoma-innovative novel treatment adjunct

INTRODUCTION

Intraventricular tuberculomas are rare entities. To the best of our knowledge, only 14 cases have been reported in English literature. Medical management of cerebral tuberculomas is well accepted. Intraventricular tuberculomas may be recalcitrant for unclear reasons. An effective management protocol for this entity is unclear. To the best of our knowledge, the definitive indication, timing, and possible role of surgery in these lesions have not been discussed in literature.

MATERIALS AND METHODS

A 27-year-old nursing professional who was undergoing treatment for miliary tuberculosis at another center presented to us in 2008 with right hemiparesis, deteriorating vision, and progressive decline in consciousness. In addition to antituberculous therapy (ATT), she underwent multiple CSF diversion procedures for the obstructive hydrocephalus secondary to a recalcitrant third ventricular tuberculoma. Finally, she underwent endoscopic decompression of the lesion with a very good clinical response at 1-year follow-up.

DISCUSSION

We discuss a patient with recalcitrant intraventricular tuberculoma managed using neuroendoscopy along with the standard antituberculous therapy. We also discuss in detail the technique we utilized for endoscopic management of this lesion.

CONCLUSION

Being a rare entity, a consensus for management of these lesions is not possible, but we have demonstrated that neuroendoscopic management of these rare entities is an option giving the advantage of definitive diagnosis when required, hastening the resolution, and clearing the CSF pathway.

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.

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.

Ventriculocholecysto shunt: a solution to recurrent shunt complications in comorbid post-tubercular hydrocephalus with tubercular adhesive peritonitis

BACKGROUND

Tuberculosis is still a killer disease and a nightmare in developing countries. Post-tubercular hydrocephalus remains one of the most severe complications, with many diversion procedure methods. How common is the occurrence of co-morbid post tubercular hydrocephalus with tubercular peritonitis is still not known. This is a frustrating cause of repeated shunt complications and revisions.

METHODS

We discuss the management of two cases that were the cause of nearly 50 % of our shunt revisions due to the comorbidities of post-tubercular hydrocephalus and tubercular adhesive peritonitis. We performed the ventriculocholecysto (VC) shunt. This procedure diverts CSF from the ventricular system to the gall bladder.

RESULTS

The two children are disease free and did not require a revision in the 3.4-year follow-up period.

CONCLUSION

The VC shunt is a simple procedure. It improved the quality of life of these children who otherwise would have had a very morbid period during shunt revisions and the active disease. These children did not require further revisions and can grow normally.

Endoscopic third ventriculostomy

Endoscopic third ventriculostomy (ETV) is considered as a treatment of choice for obstructive hydrocephalus. It is indicated in hydrocephalus secondary to congenital aqueductal stenosis, posterior third ventricle tumor, cerebellar infarct, Dandy-Walker malformation, vein of Galen aneurism, syringomyelia with or without Chiari malformation type I, intraventricular hematoma, post infective, normal pressure hydrocephalus, myelomeningocele, multiloculated hydrocephalus, encephalocele, posterior fossa tumor and craniosynostosis. It is also indicated in block shunt or slit ventricle syndrome. Proper Pre-operative imaging for detailed assessment of the posterior communicating arteries distance from mid line, presence or absence of Liliequist membrane or other membranes, located in the prepontine cistern is useful. Measurement of lumbar elastance and resistance can predict patency of cranial subarachnoid space and complex hydrocephalus, which decides an ultimate outcome. Water jet dissection is an effective technique of ETV in thick floor. Ultrasonic contact probe can be useful in selected patients. Intra-operative ventriculo-stomography could help in confirming the adequacy of endoscopic procedure, thereby facilitating the need for shunt. Intraoperative observations of the patent aqueduct and prepontine cistern scarring are predictors of the risk of ETV failure. Such patients may be considered for shunt surgery. Magnetic resonance ventriculography and cine phase contrast magnetic resonance imaging are effective in assessing subarachnoid space and stoma patency after ETV. Proper case selection, post-operative care including monitoring of ICP and need for external ventricular drain, repeated lumbar puncture and CSF drainage, Ommaya reservoir in selected patients could help to increase success rate and reduce complications. Most of the complications develop in an early post-operative, but fatal complications can develop late which indicate an importance of long term follow up.

Effects of the implantation of Ommaya reservoir in children with tuberculous meningitis hydrocephalus: a preliminary study

OBJECTIVE

The role of Ommaya reservoir implantation in children with tuberculous meningitis hydrocephalus (TBMH) has been seldomly reported. Therefore, we performed this study to determine the role of the Ommaya reservoir in the treatment of children with TBMH.

METHODS

We retrospectively analyzed the effects of Ommaya reservoir implantation in 12 children with TBMH. Intracapsular puncture of the reservoir was performed for draining the cerebrospinal fluid and the TBM was treated by intraventricular injection of isoniazid.

RESULTS

The ideal treatment outcome was observed in nine (75 %) of the 12 children; two (16.7 %) children developed serious disabilities and one of them (8.3 %) eventually died. The treatment method was effective for all six (100 %) children with Palur grade II TBM but showed no effect in three (50 %) children with grade III and IV TBM. The number of leukocytes in the cerebrospinal fluid decreased to 20 × 10(6)/L (75 %) within 2 weeks after implantation of the reservoirs. Finally, the Ommaya reservoirs in eight children were removed but were retained in four children. Four children had to undergo ventriculoperitoneal shunt.

CONCLUSION

Ommaya reservoir implantation has been shown to be effective in treating children with TBMH. This method may be largely suitable for children with early grade II TBM or partly in children with grade III TBM who have mild or moderate hydrocephalus that can alleviate after short-term treatment. Thus, a good proportion of children who undergo Ommaya reservoir implantation can avoid ventriculoperitoneal shunt surgery.

Endoscopic observations of blocked ventriculoperitoneal (VP) shunt: a step toward better understanding of shunt obstruction and its removal

OBJECTIVES

Most of our understanding of ventriculoperitoneal (VP) shunt blockage (ventricular end) is based on in vitro studies of blocked VP shunts. Not much information is available regarding the in vivo changes that occur in the tube and in the surrounding ventricle. The primary aim of our study was to observe and analyse these changes, directly, through the endoscope, in patients with blocked shunts undergoing an endoscopic third ventriculostomy (ETV). Based on these findings, we have also suggested criteria for safe removal of the VP shunt tube following ETV.

MATERIAL AND METHODS

ETV was performed with standard technique in patients with blocked VP shunt. The ventricular end of the shunt tube was inspected through the endoscope, for changes in ventricle linings as well as in the shunt tube. These changes were correlated with the age of the patient, etiology of HC, type or make of the shunt tube, duration of shunt placement to ETV and the CSF findings.

RESULTS

Fifty-three patients of blocked VP shunt underwent ETV from July 2006 to April 2010. Thirty patients had Chhabra (CH) V P Shunt (Surgiwear, India) and 23 had ceredrain (CD) shunt (Hindustan Latex, India). The age of the patients ranged from 2 months to 60 years (mean--13.33 years.). Various causes of hydrocephalus (HC) included congenital hydrocephalus (aqueductal stenosis) in 18 patients, post-meningitis hydrocephalus (PMH) in 32 cases, neuro-cysticercosis (NCC) in 2 patients and intraventricular haemorrhagic (IVH) in 1 patient. Clinical and radiological improvement occurred in 33 (62.21%), and 24 (45%) patients, respectively. Freedom from shunt was attained in 20 (38%) patients. The changes around the shunt tube were seen in 41 (77%). Hyperaemia and neovascularised ependyma was seen in 20 (37%) and 15 (28%) patients. Encasement of the tube was seen in 41%. Ependymal growth and neovascularised shunt tubes were noticed in 15% each. Choroid plexus blocking the tube was seen in only four cases (7%). VP shunt was revised in 14 patients (26.4%). Patient with infective etiology had more changes (p < 0.005). Age, CSF findings and make of shunt tube had no relation with endoscopic observations (p< 0.02).

CONCLUSIONS

ETV has a role in shunt failures. It can offer patient a chance of shunt free life. Endoscopic observation of shunt tube and ventricle can unfold several interesting in vivo findings pertaining to shunt obstruction. Shunt should only be removed if there are no adhesions and neovascularisation.

Preoperative third ventricular bowing as a predictor of endoscopic third ventriculostomy success

OBJECT

Patients with hydrocephalus often present with both intraventricular obstructive and communicating components, and determination of the predominant component is difficult. Other investigators have observed that third ventricular floor deformation, or "bowing" of the third ventricular floor, is a good indicator of intraventricular obstructive hydrocephalus, resulting in higher success rates with endoscopic third ventriculostomy (ETV). However, additional third ventricular bowing assessment and statistical evidence demonstrating a difference in ETV outcome with third ventricular bowing is needed. The authors hypothesized that patients with preoperative bowing of the third ventricle would exhibit greater long-term success rates after ETV and that lack of bowing would result in increased failure rates after ETV.

METHODS

The authors determined success and failure for 59 ETVs performed in 56 patients, and recorded patient age, time to failure, and preoperative third ventricular anatomy, as well as history of infection, intraventricular hemorrhage, and previous shunt. Third ventricular anatomy was assessed on MR imaging for bowing, which was classified as any of the following: depression of the third ventricular floor, enlargement of the supraoptic recess, anterior curvature of the lamina terminalis, dilation of the proximal aqueduct to a greater extent than the distal aqueduct, and blunting or posterior bowing of the suprapineal recess. Univariate and multivariate analyses of ETV failure and the time to failure were performed using logistic regression and the Cox proportional hazards model, respectively.

RESULTS

After adjusting for patient age and history of infection, there was a significant association between lack of anterior third ventricular preoperative bowing (either lamina terminalis, supraoptic recess, or third ventricular floor) and ETV failure (adjusted HR 2.79, 95% CI 1.08-7.20). Of the patients with bowing, 70.5% experienced success with ETV, as did 33.3% of the patients without bowing. Among the individual structures, absence of bowing in the anterior aspect of the third ventricular floor was significantly associated with censored time to ETV failure (multivariate HR 2.59, 95% CI 1.01-6.66; final model including age and history of infection).

CONCLUSIONS

The presence of preoperative third ventricular bowing is predictive of ETV success, with nearly a 3-fold likelihood of success compared with patients treated with ETV in the absence of such bowing. Although bowing is predictive, 33% of patients without bowing were also treated successfully with ETV.

Management of post-tubercular hydrocephalus

PURPOSE

Tubercular meningitis can lead to hydrocephalus which is a challenging condition to treat in this setting. There is no consensus on treatment protocols for this condition. We have reviewed the literature and formulated treatment guidelines based on available literature and our own experience.

OBSERVATIONS

The main available options for management of tubercular hydrocephalus are conservative medical therapy, ventriculoperitoneal shunt and endoscopic third ventriculostomy (ETV). There is no universal consensus regarding the treatment protocol. However, decision regarding the best treatment should be based on the clinical condition of the patient, presence or absence of meningitis, duration of the disease, communicating or non- communicating hydrocephalus, socioeconomic condition of the patient, surgeons expertise, availability of resources for endoscopy. We have given a treatment algorithm for treatment of these patients which can help in protocol-based management of such cases.

CONCLUSION

Tubercular basal meningitis is a medical problem with limited role of neurosurgery except when patient develops hydrocephalus. Management of hydrocephalus in this condition is challenging and fraught with a myriad of complications. Ventriculoperitoneal shunt is an ideal option of vast majority of patients. However, in case of availability of endoscopic facility and expertise, ETV can be an option in selected group of patients. Our algorithm for management can help a clinician to objectively assess the patient and decide on a protocol-based management.

Use of endoscopic third ventriculostomy in hydrocephalus of tubercular origin

PURPOSE

The purpose of this paper was to study the feasibility of endoscopic third ventriculostomy (ETV) as a treatment modality in patients with hydrocephalus of tubercular origin.

MATERIALS AND METHODS

Literature on ETV in hydrocephalus of tubercular origin has been reviewed, and we have gathered experiences of neurosurgeons from various institutions in our country practicing ETV.

RESULTS

Hydrocephalus, a common complication of tubercular meningitis, may be of communicating type or of obstructive variety. The communicating type is treated by medical therapy in 70-92% cases, whereas the obstructive type requires surgical intervention. The outcome of surgery depends upon gradation of disease. Shunting however has been a nightmare for neurosurgeons treating such patients (Smyth et al., Pediatr Neurosurg 39: 258-263, 2003). The shunts tend to get blocked with debris. Having found ETV as a successful modality of treatment in obstructive hydrocephalus of other etiology, neurosurgeons have attempted it in hydrocephalus of tubercular origin. Though various authors have had a success rate of 65-68%, failure has been quite high in acute cases due to thickening of the floor of third ventricle and distorted anatomy. The success rate is higher in chronic and burnt out cases.

CONCLUSION

Tubercular meningitic hydrocephalus is difficult to treat endoscopically as compared with other forms of meningitic hydrocephalus and requires adequate expertise and experience, especially in acute cases. Therefore, one would be justified in avoiding the use of ETV in acute cases and wait till patient presents with a failed shunt. Use of ETV in subacute and chronic cases seems to be justified as the first line of treatment.

The neurosurgical and acute care management of tuberculous meningitis: evidence and current practice

Tuberculous meningitis (TBM) is the most lethal form of tuberculosis; mortality is high and survivors are often left neurologically disabled. Several factors contribute to this poor outcome, including cerebrovascular involvement with ensuing brain ischemia, hydrocephalus and raised intracranial pressure, direct parenchymal injury, hyponatremia, and seizures. However, there is little standardisation of management with respect to these aspects of care across different centers, largely because the evidence base for much of the supportive treatment of patients with TBM is poor, leading to substantial differences in management protocols. This review emphasizes some of the uncertainties and controversies pertinent to the surgical treatment of hydrocephalus in TBM and the medical supportive management of the patient during the acute phase of the illness, with the aims of raising awareness and stimulating debate. The focus is on the management of hyponatremia, cerebral hemodynamics and intracranial pressure, medical and surgical treatment for hydrocephalus, and the intensive care management of patients in the acute severe stage of the illness. Very little data are available to address these issues with good evidence and so institutional preferences are common; this is perhaps most notable for the management of hydrocephalus, and so in this the review highlights our personal practice. The brain needs protection while the source of the illness is addressed. Without attention to these aspects of management there will always be a limit to the effectiveness of antimicrobial therapy in TBM, so there is a strong imperative for the controversies to be resolved and the limitations of our current care to be addressed. Existing protocols should be rigorously examined and novel strategies to protect the brain should be explored. To this end, a prospective, multi-disciplinary and multi-centered approach may yield answers to the questions raised in this review.

HIV-associated tuberculous meningitis--diagnostic and therapeutic challenges

HIV-associated tuberculous meningitis (TBM) poses significant diagnostic and therapeutic challenges and carries a dismal prognosis. In this review, we present the clinical features and management of HIV-associated TBM, and compare this to disease in HIV-uninfected individuals. Although the clinical presentation, laboratory findings and radiological features of TBM are similar in HIV-infected and HIV-uninfected patients, some important differences exist. HIV-infected patients present more frequently with extra-meningeal tuberculosis and systemic features of HIV infection. In HIV-associated TBM, clinical course and outcome are influenced by profound immunosuppression at presentation, emphasising the need for earlier diagnosis of HIV infection and initiation of antiretroviral treatment.

Tumor irrigation fluid enhances diagnostic efficacy in endoscopic biopsies of intracranial space-occupying lesions

PURPOSE

Intraventricular neuroendoscopic CNS biopsiesare small, fragmented, and tissue is frequently inadequate for diagnosis. We have attempted to increase cellular yield using tumor irrigation fluid (TIF) and a cyto-histological approach for diagnosis of intracranial tumors, cysts, and infections.

METHODS

A retrospective group of 147 cases, where only endoscopic biopsies were obtained, was compared with a prospective group of 31 cases where along with the endoscopic biopsies, tumor irrigation fluid (TIF) was collected. Tumor cyst fluid was obtained from cystic tumors (n=6). Small tumor fragments in the TIF were utilized to make squash smears (n=31). Clotted fragments were processed for sections in (n=3). Centrifuged deposit smears were prepared from tumor irrigation fluid and tumor cyst fluid.

RESULTS

Conclusive pathological diagnosis in endoscopic biopsies could be arrived at in 77.4% (24/31) prospective cases and 80.3% (118/147) in retrospective cases. Collection of TIF with a cyto-histological diagnostic approach gave a significantly higher rate of conclusive pathological diagnosis in 93.5% (29/31) cases in the prospective group.

CONCLUSIONS

Additional tissue from TIF preserves the original biopsy, provides more material for diagnosis and gives a better morphological picture in smears. Hence diagnosis of endoscopic CNS biopsies can be rendered in more cases and with greater degree of confidence.

Complex hydrocephalus (combination of communicating and obstructive type): an important cause of failed endoscopic third ventriculostomy

Background

Hydrocephalus can be classified as purely obstructive, purely communicating or due to combinations of pathologies (obstruction in addition to defective absorption). Endoscopic third ventriculostomy (ETV) as an alternative to shunt procedures is an established treatment for obstructive hydrocephalus. However, patients who have combination of pathologies (complex hydrocephalus) could result in failure of ETV in spite of a patent stoma. The aim of this study was to prospectively evaluate the incidence of complex hydrocephalus in patients with obstructive hydrocephalus who failed an endoscopic third ventriculostomy.

Findings

Seventy one patients of obstructive hydrocephalus who underwent ETV in our institution were included in this study. Aetiology of hydrocephalus included congenital aqueductal stenosis in 42 and tubercular meningitis (TBM) in 29 patients. Failure of ETV was seen in 15 (21%) patients. These 15 patients included 6 (14.3%) from the congenital group and 9 (31.0%) patients from the TBM group. Iohexol CT ventriculography confirmed a patent stoma (suggesting a complex hydrocephalus) in 10 (66.7%) out of the 15 failed ETV cases. The incidence of complex hydrocephalus was more common in TBM group (8/29 patients, 27.60%) compared to congenital group (2/42 patients, 4.8%). The complex hydrocephalus patients with a patent ETV stoma were successfully managed by a lumbar peritoneal (LP) shunt.

Conclusion

Ten out of the 71 patients (14%) with obstructive hydrocephalus who underwent an ETV had a complex hydrocephalus, which was the major (66.7%) cause for failure of ETV. Improving methods to detect the exact type of hydrocephalus pre-operatively could increase success rate of ETV and avoid an unnecessary operative procedure (ETV).

Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy

OBJECT

Endoscopic third ventriculostomy (ETV) is increasingly being used as an alternative treatment for post-tuberculous meningitis (TBM) hydrocephalus. The aim of this study was to affirm the role of ETV in patients with TBM hydrocephalus and also to study the usefulness of cine phase-contrast MR imaging (cine MR imaging) for functional assessment of the ETV stoma. An additional goal was to identify factors that influence the outcome of ETV, so as to define patients with TBM hydrocephalus in whom ETV is warranted.

METHODS

Twenty-six patients with TBM hydrocephalus treated with ETV were evaluated clinically and with cine MR imaging postoperatively. The duration of follow-up ranged from 1 to 15 months. The authors evaluated flow void changes in the floor of the third ventricle and analyzed parameters from the preoperative data, which they then used as a basis for comparison between endoscopically successful and endoscopically unsuccessful cases.

RESULTS

The overall success rate of ETV in TBM hydrocephalus was 73.1% in this case series. Cine MR imaging showed a sensitivity of 94.73% and specificity of 71.42% for the functional assessment of third ventriculostomy in these patients, with the efficacy being maintained during follow-up. The outcome of ETV showed a statistically significant correlation with the stage of illness and presence of intraoperative cisternal exudates. Although duration of symptoms and duration of preoperative antituberculous therapy (ATT) appeared to influence the outcome, their correlation with outcome was not statistically significant.

CONCLUSIONS

Endoscopic third ventriculostomy should be considered as the first surgical option for CSF diversion (that is, before shunt surgery) in patients with TBM hydrocephalus. Cine MR imaging is a highly effective noninvasive tool for the postoperative functional assessment of stomata. Patients who presented with a history of longer duration and those who were administered preoperative ATT for a longer period had a better outcome of endoscopic treatment. Outcome was poorer in patients who presented with higher stages of illness and in those in whom cisternal exudates were observed intraoperatively.

[Treatment of extrapulmonary tuberculosis and complicated forms of pulmonary tuberculosis]

Tuberculosis is one of the most important health problems worldwide. In developed countries there is an increased number of cases due to different reasons. The most likely determinant cause is from immigrants coming from high endemic areas. This phenomenon is a direct cause of the increase in extrapulmonary and complicated pulmonary forms of tuberculosis. There are only a few controlled clinical trials evaluating therapies for extrapulmonary tuberculosis. Consequently, documented evidence is scarce, particularly in paediatrics. The majority of therapeutic recommendations are based on series of cases or expert opinions, with a lack of uniformity provided by the different consensus of the main scientific societies. The main objective of this fourth consensus by the Tuberculosis Study Group of the Spanish Society of Paediatric Infectious Diseases (Sociedad Española de Infectología Pediátrica, SEIP) is to perform a thorough revision of the data obtained from scientific literature, in order to establish recommendations for the treatment of extrapulmonary tuberculosis and complicated forms of pulmonary tuberculosis, adapted to the characteristics and drugs available in Spain.

Central nervous system tuberculosis: pathogenesis and clinical aspects

Tuberculosis of the central nervous system (CNS) is a highly devastating form of tuberculosis, which, even in the setting of appropriate antitubercular therapy, leads to unacceptable levels of morbidity and mortality. Despite the development of promising molecular diagnostic techniques, diagnosis of CNS tuberculosis relies largely on microbiological methods that are insensitive, and as such, CNS tuberculosis remains a formidable diagnostic challenge. Insights into the basic neuropathogenesis of Mycobacterium tuberculosis and the development of an appropriate animal model are desperately needed. The optimal regimen and length of treatment are largely unknown, and with the rising incidence of multidrug-resistant strains of M. tuberculosis, the development of well-tolerated and effective antibiotics remains a continued need. While the most widely used vaccine in the world largely targets this manifestation of tuberculosis, the BCG vaccine has not fulfilled the promise of eliminating CNS tuberculosis. We put forth this review to highlight the current understanding of the neuropathogenesis of M. tuberculosis, to discuss certain epidemiological, clinical, diagnostic, and therapeutic aspects of CNS tuberculosis, and also to underscore the many unmet needs in this important field.

Concurrent syringomyelia and intradural extramedullary tuberculoma as late complications of tuberculous meningitis

Tuberculous meningitis (TBM) is a common presentation of extrapulmonary tuberculosis. TBM is associated with many complications. However, concurrent syringomyelia and intradural extramedullary tuberculoma occurring in a patient treated for TBM is rare. Only one such case has been reported earlier. A 27-year-old woman presented with paraparesis of 2 months duration. She had been treated for TBM 8 months earlier. She was found to have an extensive syringomyelia from C2 to the conus medullaris and an intradural extramedullary tuberculoma at the lower thoracic levels. At surgery, a thick, granulomatous lesion was found in the intradural extramedullary plane. Following excision of the granulomatous lesion, a syringostomy was done. The patient was treated with antituberculous drugs and steroids. Six months after treatment, there was no significant change in her neurological status. Concurrent syringomyelia and intradural extramedullary tuberculoma should be entertained in the differential diagnosis when a patient presents with myelopathy following TBM. The pathogenesis of syringomyelia in this condition is discussed.

Factors affecting the outcome of neuroendoscopy in patients with tuberculous meningitis hydrocephalus: a preliminary study

BACKGROUND

In recent years, ETV has been found to be effective in patients with TBMH; however, its precise selection criteria are yet to be established. We carried out this study to identify the factors affecting the outcome of ETV in TBMH.

METHODS

Fourteen patients with TBMH (11 male patients and 3 female patients; mean age, 15.7 years; range, 9 months to 40 years) formed the study group. Various preoperative (clinical grade, ventricular morphology, basal exudates, and CNS tuberculoma) and perioperative (ependymal tubercles, third ventricular floor anatomy, exudates, and adhesions) factors were studied with regard to the result of ETV. Endoscopic third ventriculostomy could be performed on 13 patients; however, an unidentifiable third ventricular floor anatomy precluded ETV in the remaining patient. Endoscopic third ventriculostomy was assigned as "failed" if the patient needed shunt, required EVD, or died in the postoperative period. The average follow-up period for the patients was 5 months.

RESULTS

Endoscopic third ventriculostomy was successful in 9 of the 14 (64.2%) patients subjected to neuroendoscopy. Statistical analysis did not show any significant association of ventricular morphology (P = .109), basal enhancement on CT (P = .169), CNS tuberculoma (P = .169), and clinical grade (P = .057) with the result of ETV, probably because of the small number of cases. However, patients with severe hyponatremia, extra-CNS tuberculosis, an unidentifiable third ventricular floor anatomy, and adhesions in the prepontine cistern had a failed ETV. Patients with tuberculoma in the brain had a successful ETV.

CONCLUSIONS

Endoscopic third ventriculostomy is likely to fail in the presence of advanced clinical grade, extra-CNS tuberculosis, dense adhesions in prepontine cisterns, and an unidentifiable third ventricular floor anatomy. Tuberculoma in the brain in cases of TBMH may be associated with a successful ETV.

Endoscopic third ventriculostomy in prepontine-suprasellar tuberculoma with tuberculous meningitis hydrocephalus: a case report

We present a case of prepontine-suprasellar tuberculoma involving the premamillary region of the third ventricular floor, a site suitable to perform an endoscopic third ventriculostomy (ETV) stoma, managed endoscopically, and discuss our findings. A 5-year-old male child was admitted in an unconscious state with a history of gradually progressive symptoms of raised intracranial pressure and low-grade fever for the last 3 months. Head computed tomography showed thick enhancing basal exudates, a prepontine-suprasellar ring-enhancing lesion with consequent obstructive hydrocephalus. The child was subjected to urgent endoscopy which revealed multiple ependymal tubercles along with prepontine-suprasellar tuberculoma involving the premamillary region of the third ventricular floor. The tuberculoma was decompressed using a 5-french catheter, and ETV was performed. Postoperatively, the child improved clinicoradiologically on antitubercular chemotherapy and needed no further cerebrospinal fluid diversion surgery; he is under regular follow-up. We conclude that ETV may be attempted even in the presence of thick basal exudates and/or prepontine-suprasellar tuberculoma.

Endoscopy for tuberculous hydrocephalus

INTRODUCTION

The role of endoscopy in hydrocephalus due to infectious aetiology is unclear. Tuberculous hydrocephalus is a useful model to study because it presents particular challenges and the pathophysiology of the cerebrospinal fluid disturbance is well known.

MATERIALS AND METHODS

We present the results of 24 endoscopic operations in tuberculous meningitis.

RESULT

Endoscopic third ventriculostomy (ETV) was attempted in 17 patients: seven were successful, five failed, and five were not completed due to abnormal anatomy. There were five fenestration procedures, three of which were successful. Endoscopic biopsy of two tuberculomas failed to yield a bacteriological result. These operations were more difficult to perform than for hydrocephalus due to other aetiologies.

CONCLUSION

Although ETV is technically possible in this situation, it is imperative that the patients are adequately selected for the procedure to ensure optimal treatment and that the surgeon has experience with difficult cases.