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REVIEW ARTICLE
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Role of surgical procedures (VP shunt and ETV) in tuberculous meningitis with hydrocephalus (TBMH): A systematic review


 Department of Neurology, Government Medical College, Kota, Rajasthan, India

Date of Submission02-Aug-2020
Date of Decision27-Oct-2020
Date of Acceptance11-Feb-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Seeta Ram Yadav,
Department of Neurology, Government Medical College, Kota 324001, Rajasthan.
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpn.JPN_286_20

 

   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.


Keywords: Endoscopic third ventriculostomy, tuberculous meningitis with hydrocephalus, ventriculoperitoneal shunt



How to cite this URL:
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 [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=327904





   Introduction Top


Tuberculous meningitis carries a high rate of mortality and morbidity. Hydrocephalus is one of the most common complications of TBM, occurring in up to 85% of children with the disease, and it still remains a major cause of childhood morbidity and mortality in India.[1] It is almost always present in patients who have had the disease for four to six weeks. It is more frequent and severe in children than in adults and also occurs at an earlier stage in the disease process.[2]

Hydrocephalus in patients with TBM could be of either the communicating or the obstructive type, with the former being more common.[3] An obstructive type of hydrocephalus may develop in TBM due to either blockage of fourth ventricle by thick exudates or leptomeningeal scarring.[1] Communicating hydrocephalus may result from an overproduction of cerebrospinal fluid or secondary to reduced absorption of cerebrospinal fluid. Communicating hydrocephalus is seen more commonly in patients with TBM.[1] Schoeman et al. found that the hydrocephalus was of the communicating type in 82% of their patients with TBM.[3]

The management of TBMH includes medical management as well as surgical management. Medical management includes the use of anti-tuberculosis therapy in a combination of steroids, and various dehydrating agents such as acetazolamide, furosemide, and mannitol. Neurosurgical procedures are being used in TBM since 1951. Surgical management of hydrocephalus in patients with TBM included lateral and third ventriculostomy and ventriculo-subarachnoid shunts repeated tapping of the ventricles through burr holes, suboccipital decompression etc.[4] After 1980, shunt surgery and then ETV became popular.

The grade of the patient at admission usually determines the management strategy. There are various grading systems for patients with TBMH. One of the commonly used systems is the Vellore grading system [Table 1] proposed by Palur et al.[5]
Table 1: Vellore grading of TBMH

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Aims and objectives

To study the comparative outcomes and complications of surgical procedures in TBMH with the aim of endorsing good practice guidelines for the treatment of TBMH.


   Materials and Methods Top


A systematic search of literature was performed by using PubMed and CENTRAL for articles published from January 2001 to April 2020. A total of 15 studies [Table 2] on TBMH treated with VPS or ETV, irrespective of their design, were included in this review (flow chart). Most of the studies included pediatric age group patients. A total of 603 patients with TBMH who had undergone VPS surgery or ETV were evaluated. All literature was studied regarding outcomes, complications, and recommendations. A good outcome was defined both clinically and radiologically: clinically as a resolution of signs and symptoms of increased intracranial pressure and radiologically as a reduction in dilatation of the ventricular system and resolution of periventricular ooze. End point of outcome was defined as the resolution of symptoms and signs after VPS and ETV. The success rate of VPS is defined as the resolution of sustained symptoms and working shunt. Statistical analysis of data was made by using the chi-square test to determine P-value (<0.05) to find out significant differences in outcomes after VPS or ETV.
Table 2: Studies including VP shunt or ETV in patients with TBMH

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   Result Top


In the ventriculoperitoneal shunt group, good outcome rate varied from 25% to 68% in different studies [Table 3]. Good outcome rate was maximum (68%) in a study performed by Kankane et al. whereas it was minimum (25%) in a study performed by Sil and Chatterjee et al.[6],[7],[8],[9],[10],[11],[12],[13] The average percentage of good outcome was 51.8%. It was calculated by the addition of good outcome rate and then by dividing it by the number of VPS studies included in the review.
Table 3: Comparative studies of good outcome after ETV and VPS in patients with TBMH

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In the ETV group, good outcome rate varied from 41% to 77% in different studies and it reached up to 87% in a study performed by Singh et al. when ETV was conducted in patients with a thin and transparent third ventricular wall.[10],[12],[14],[15],[16],[17],[18],[19],[20] The average percentage of good outcome after ETV was 68%.

There was a significant difference in the average percentage of good outcome after ETV and VPS (p-value was .008), which is statistically confirmed by applying the chi-square test.

The complication rate in the VPS group varied from 10% to 43.8% in different studies: It was minimum (10%) in a study performed by Kankane et al. and maximum (43.8%) in a study done by Sil and Chatterjee et al.[6],[7],[9],[11],[12],[13],[19]

In the ETV group, the complication rate varied from 10% to 23.5% in different studies. It was minimum (10%) in a study done by Husain et al. whereas it was maximum (23.5%) in a study performed by Savardekar et al.[14],[17],[19],[20]


   Discussion Top


Data pertaining to 603 patients were analyzed from all qualified studies for a systematic review. All patients had TBM associated with hydrocephalus, which was treated with either VPS or ETV. Overall, 348 patients underwent VPS whereas 255 patients underwent ETV. For prognostic purposes, various studies divided patients according to different systems of grading for hydrocephalus. In most studies, success rate or good outcome was determined either clinically or radiologically. It was clinically determined by the resolution of signs or symptoms of increased intracranial pressure after VP shunt or ETV. It was radiologically determined by a reduction in the dilatation of the ventricular system and the resolution of periventricular ooze.

In the ventriculoperitoneal shunt group, success rate varied from 25% to 68% in different studies. Success rate was maximum (68%) in a study performed by Kankane et al. whereas it was minimum (25%) in a study performed by Sil and Chatterjee et al.[6],[7],[8],[9],[10],[11],[12],[13]

In patients with Grade III TBMH after VPS placement, the studies conducted by Savardekar et al. and Kankane et al. showed comparable good outcomes in 71.4% and 77.5%, respectively.[11],[19] However, Agrawal et al., reported good outcome only in 40% patients.[7] Kankane et al. found severe disability in 22.5% patients. As expected, poor outcome in patients with Grade IV TBMH after VP shunt placement varied from 10% to 100% in different studies.[7],[8],[11]

The complication rate in the VPS group rate varied from 10% to 43.8% in different studies: It was minimum (10%) in a study performed by Kankane et al. and maximum (43.8%) in a study done by Sil and Chatterjee et al.[6],[7],[9],[11],[12],[13],[19] Most of the complications were related to shunt surgery, such as shunt infection, shunt obstruction, which led to shunt failure and frequent shunt revision. It has been reported that the complications of shunt surgery are higher in patients with TBM than in patients with other conditions. The reasons for these complications were the poor general condition of patients and also the presence of higher protein and cellular content in the CSF, leading to more frequent shunt obstruction.

Agarwal et al. reported shunt-related complications in 11 (30%) children, and three of 37 children (8.10%) had to undergo multiple shunt revisions.[7] Kankane et al. found shunt-related complications in 10% cases, among whom 4% had infection and 6% had shunt blockade.[11] Savardekar et al. observed VP shunt-related complications in 23.5% patients.[19] In a study of 26 shunt surgeries, Aranha et al. found 38.4% failure rate and all these required shunt revisions.[12] Sil and Chatterjee et al. found shunt infection in 15.6% cases and shunt blockade in 43.8% cases.[13]

In the ETV group, success rate varied from 41% to 77% in different studies and it reached up to 87% in a study performed by Singh et al. when ETV was done in patients with a thin and transparent third ventricular wall.[10],[12],[14],[15],[16],[17],[18],[19],[20]

In the ETV group, complication rate varied from 10% to 23.5% in different studies. It was minimum (10%) in a study done by Husain et al. whereas it was maximum (23.5%) in a study performed by Savardekar et al. In the ETV group, the most common reported complications were CSF leak, bleeding during the surgery, and stoma block. Failure to improve after ETV can be due to the blocked stoma, complex hydrocephalus, or vascular compromise. The ETV is technically difficult in post-infective hydrocephalus, especially in the acute phase of the disease due to the presence of inflammation, thick and opaque floor of the third ventricle. This is possibly due to an increased risk of hemorrhage and neurovascular injury, especially in the acute phase.[14],[17],[19] Endoscopic third ventriculostomy over VPS avoids the insertion of a foreign body in the form of a shunt; it leads to the prevention of complications such as shunt infection, blockage, and abdominal pseudo-cyst formation.


   Conclusions Top


In this systematic review, there was significant difference in the average percentage of good outcome after ETV than VPS. The outcome was poor in TBM with Grade IV compared with Grade III after VPS. Complication rate was slightly lower in ETV than VPS during the chronic phase of illness. So during the acute phase VP shunt surgery is preferred whereas during the chronic burnout phase ETV is preferred because poor anatomy leads to more complications with ETV during the acute phase of the disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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