Childs Nerv Syst (2014) 30:851–857 DOI 10.1007/s00381-014-2371-1
ORIGINAL PAPER
A randomized study of ventriculoperitoneal shunt versus endoscopic third ventriculostomy for the management of tubercular meningitis with hydrocephalus Pawan Goyal & Chhitij Srivastava & Bal Krishna Ojha & Sunil K Singh & Anil Chandra & R. K. Garg & Swati Srivastava
Received: 26 October 2013 / Accepted: 16 January 2014 / Published online: 4 February 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract 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 Duration of illness ≤2 months >2 months CSF proteins ≤1 g/dl >1 g/dl CSF cell count ≤50 cells/mm3 >50 cells/mm3 History of ATT No Yes Modified Vellore grade 1 2 3 4 Focal deficit No Yes Cranial nerve deficit No Yes Duration of altered sensorium 8–14 days >14 days
eventually died. Three patients had bulge at the ETV site. Shunt-related complications occurred in four (17 %) patients and consisted of an obstruction at the lower end of the shunt in three (13 %) cases, leading to revision, and one (4 %) patient had an infection at the shunt chamber site, leading to skin excoriation and meningitis.
Discussion To the best of our knowledge, there have been no randomized trial done previously to compare the outcome of ETV and shunt in TBMH. Radiological analysis Based on reduction of periventricular lucency, decrease in the size of ventricles, and reappearance of CSF in
ETV (n=24) OR (95 % CI)
Shunt (n=24) OR (95 % CI)
Total (n=48) OR (95 % CI)
0.50 (0.10–2.60)
1.09 (0.21–5.76)
0.70 (0.22–2.19)
0.56 (0.11–2.90)
1.29 (0.23–7.05)
0.88 (0.27–2.82)
0.93 (0.16–5.54)
1.40 (0.28–7.02)
1.04 (0.33–3.30)
0.56 (0.11–2.90)
1.03 (0.21–5.15)
0.72 (0.23–2.25)
0.60 (0.11–3.34)
0.60 (0.11–3.40)
0.60 (0.18–2.03)
1.70 (0.97–2.51) 2.67 (1.10–4.27) 3.40 (2.32–7.69)
1.60 (0.45–2.14) 2.24 (0.97–3.85) 2.76 (2.04–5.72)
2.15 (1.13–3.24) 3.68 (2.21–5.33) 6.41 (2.79–9.57)
1.75 (0.31–9.75)
0.67 (0.13–3.45)
1.04 (0.33–3.30)
2.22 (0.33–14.80)
0.67 (0.13–3.45)
1.05 (0.32–3.45)
3.57 (0.41–5.14) 4.43 (1.59–7.95)
0.60 (0.09–2.99) 1.00 (0.13–4.57)
1.26 (0.33–4.84) 1.62 (0.37–7.20)
subarachnoid space (Fig. 4), it was observed that patients in the shunt group showed 89 % recovery in the features of TBMH over a period of 6 months, while in ETV group, the recovery was 74.8 %. In the study done by Yadav et al., in patients operated for ETV, radiological recovery was only 52 % within 3 weeks [21]. Singh et al. had seen radiological recovery in 55.6 % of his patients over a period of 12 weeks [18]. This suggests that decrease in the size of ventricle occurs slowly after ETV and may not correlate well with the clinical outcome. Failure to improve after ETV does not always mean that ETV is malfunctioning. It could be related to the associated features of TBM such as infarcts as seen in this study (six cases had infarcts on CT, out of which four failed to recover after ETV). Yadav et al. also had similar opinion [21]. A multiple regression analysis done by Kalita et al. suggested infarction on CT scan to be one of the most important predictor of the outcome of TBM at 6-month follow up [8].
Childs Nerv Syst (2014) 30:851–857
855
Fig. 4 a Case of TBM hydrocephalus showing dilated ventricles, periventricular lucencies, and effaced sulci. b CT scan of the same patient 1 month after ETV. Periventricular lucencies have disappeared and sulci are well visualized. Note that ventriculomegaly is still persisting
Outcome Prediction of outcome of TBM is difficult because of its protracted course, diversity of underlying pathological mechanisms, variation of host immunity, and virulence of mycobacterium tuberculosis [13]. Modified Vellore grading is the best and most consistent predictor of outcome following surgery in patients with TBM hydrocephalus. Table 3 shows that the clinical outcome is consistently poor in grade IV in all studies. Overall success rate in ETV group in our study was 41.7 %, which is less compared to some of the previous studies (Table 4). This may be due to the fact that 88 % of patients in our study belonged to grades 3 and 4 as compared to 54 % in the study done by Husain et al. [5] and only 19 % in the study done by Yadav et al. [21]. We had a 100 % success rate in grade 1 similar to Yadav et al., while in grade 4, it was 33.3 % in our study and 50 % in the study done by Yadav et al. Singh et al. [18] and Chugh et al. [2] graded their patients on the basis of MRC grade. They too found that the results were poorer in poor grades as compared to better grades. Age, CSF cells, and proteins did not have any impact on the outcome of CSF diversion procedures. Other studies .[12, 14]. related to shunt have not seen any correlation of the above variables with the outcome. We did not find any correlation of the outcome with the duration of illness in the shunt group.
Also, earlier studies in the shunt group .[12, 19] .did not find any correlation of the outcome with the duration of illness. In ETV group, we had better results in patients with longer duration of illness (>2 months). There was 50 % success rate in patients with the longer duration of illness as compared to 35.7 % in patients with the shorter duration (7 days) were found to have lower success rate in the ETV group, but not in shunt group. But statistical significance of such correlation could not be established on binary logistic regression analysis. Mathew et al. [12] and Palur et al. [14] did not also find any correlation of success with the duration of altered sensorium. Complications In ETV group, CSF leak was noted in seven cases, while two patients developed meningitis, out of which one patient eventually died. Husain et al. [5] had complications in 3 of 28 patients undergoing ETV, while Yadav et al. [21] reported leak in 6 out of 50 patients. The shunt infection rate in our study (4 %) was much less compared to the other recent studies (e.g., Lamprecht et al., 13.8 % [10]; Agarwal et al., 14 % [1]). Shunt malfunction rate in our study (13 %) leading to revision is similar to other studies like Lamprecht et al., 14 % [10] and Agarwal et al., 16 % [1]). Shunt versus ETV in TBMH It was found that patients in the shunt group show improvement in the modified Vellore grading at a faster rate as compared to ETV group. At 6 months, the difference in improvement in the shunt group (63.6 %) as compared to ETV (56.1 %) was 7.5 %, which is of no statistical significance. Patients undergoing shunt show more radiological recovery and that too at a faster
rate as compared to ETV group. Patients undergoing ETV have an arrested hydrocephalus type of picture. This may be due to the fact that after ETV, patients CSF dynamics get into an equilibrium in which enlarged ventricles are not due to raised intracranial pressure. Most of the ETV failures occurred in less than 3 months of surgery (8 out of 10). This suggests that the risk of ETV failure is higher in the early phase of treatment. Therefore, if the patient survives the early high-risk period, they could experience long-term treatment survival advantage.
Conclusion VP shunting has better immediate outcome in hydrocephalus as compared to ETV. In the initial period, patients undergoing ETV should be watched closely for ETV failure, as in early phase, ETV failure and complications are more common in this group as compared to patients undergoing VP shunt. Over a period of 6 months, clinical as well as radiological recovery in ETV catches up with that of shunt. As most of the ETV failure occurs in the initial 3 months of surgery and it is a proven fact that shunt has life-long risk of malfunction and infection, so there could be some rationale of attempting ETV in TBM hydrocephalus because a successful ETV might confer long-term benefits over shunt. As the chances of ETV failure increases in active tuberculosis, so it is better to attempt ETV in the later phase after starting antitubercular treatment. ETV is more physiological than shunt surgery; hence, longterm outcome of hydrocephalus may tilt in favor of ETV, performed after adequate chemotherapy with antitubercular drugs and steroids. Although the number of cases in the present study is limited, it certainly offers a comparison of two alternating ways of treating hydrocephalus in TBM. It is certainly worth trying ETV before subjecting the patient to shunt. More randomized studies and longer follow up monitoring are required to critically evaluate the efficacy of ETV in comparison to shunt, its predictive factors in outcome, and timing of surgery in TBMH. Limitations of study Forty-eight cases taken in this study are very limited. More number of cases are required for a good comparative study. Six-month follow up is another limiting factor. Follow up of longer duration may tilt the result in favor of endoscopic third ventriculostomy.
Childs Nerv Syst (2014) 30:851–857 Acknowledgement This study was funded by intramural research cell grant, King George’s Medical University, Lucknow, India.
References 1. Agrawal D, Gupta A, Mehta VS (2005) Role of shunt surgery in pediatric tubercular meningitis with hydrocephalus. Indian Pediatr 42:245–50 2. Chugh A, Husain M, Gupta RK, Ojha BK, Chandra A, Rastogi M (2009) Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy. J Neurosurg Pediatr 3:371–7 3. Eghwrudjakpor PO, Allison AB (2010) Evolution of surgical interventions for hydrocephalus: patient preferences and the need for proper information. Internet J Med Update 5:55–62 4. Figaji AA, Fieggen AG, Peter JC (2007) Endoscopy for tuberculous hydrocephalus. Childs Nerv Syst 23:79–84 5. Husain M, Jha DK, Rastogi M, Husain N, Gupta RK (2005) Role of neuroendoscopy in the management of patients with tuberculous meningitis hydrocephalus. Neurosurg Rev 28:278–83 6. Husain M, Jha D, Vatsal DK, Thaman D, Gupta A, Husain N et al (2003) Neuro-endoscopic surgery—experience and outcome analysis of 102 consecutive procedures in a busy neurosurgical centre of India. Acta Neurochir 145:369–76 7. Jonathan A, Rajshekhar V (2005) Endoscopic third ventriculostomy for chronic hydrocephalus after tuberculous meningitis. Surg Neurol 63:32–5 8. Kalita J, Misra UK (1999) Outcome of tuberculous meningitis at 6 and 12 months: a multiple regression analysis. Int J Tuberc Lung Dis 3:261–5 9. Kemaloglu S, Ozkan U, Bukte Y, Ceviz A, Ozates M (2002) Timing of shunt surgery in childhood tuberculous meningitis with hydrocephalus. Pediatr Neurosurg 37:194–8
857 10. Lamprecht D, Schoeman J, Donald P, Hartzenberg H (2001) Ventriculoperitoneal shunting in childhood tuberculous meningitis. Br J Neurosurg 15:119–25 11. Marais S, Thwaites G, Schoeman JF, Torok ME, Misra UK, Prasad K et al (2010) Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis 10:803–12 12. Mathew JM, Rajshekhar V, Chandy MJ (1998) Shunt surgery for poor grade patients with tuberculous meningitis and hydrocephalus: effect of response to external ventricular drainage and other factors on long-term outcome. J Neurol Neurosurg Psychiatry 65:115–8 13. Misra UK, Kalita J, Roy AK, Mandal SK, Srivastava M (2000) Role of clinical, radiological and neurophysiological changes in predicting the outcome of tuberculous meningitis: a multivariable analysis. J Neurol Neurosurg Psychiatry 68:300–3 14. Palur R, Rajshekhar V, Chandy MJ, Joseph T, Abraham J (1991) Shunt surgery for hydrocephalous in tubercular meningitis: a longterm follow-up study. J Neurosurg 74:64–9 15. Rajshekhar V (2009) Management of hydrocephalus in patients with tuberculous meningitis. Neurol India 57:368–74 16. Sil K, Chatterjee S (2008) Shunting in tuberculous meningitis: a neurosurgeon’s nightmare. Childs Nerv Syst 24:1029–32 17. Singh D, Kumar S (1996) Ventriculoperitoneal shunt in post tubercular hydrocephalus. Ind Pediatr 33:854–5 18. Singh D, Sachdev V, Singh AK, Sinha S (2005) Endoscopic third ventriculostomy in post-tuberculous meningitic hydrocephalus: a preliminary report. Minim Invasive Neurosurg 48:47–52 1 9 . S r i k a n t h a U , M o r a b J V, S a s t r y S , A b r a h a m R , Balasubramaniam A, Somanna S et al (2009) Outcome of ventriculoperitoneal shunt placement in grade IV tubercular meningitis with hydrocephalus: a retrospective analysis in 95 patients. J Neurosurg Pediatr 4:176–83 20. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–4 21. Yadav YR, Parihar V, Agrawal M, Bhatele PR (2011) Endoscopic third ventriculostomy in tubercular meningitis with hydrocephalus. Neurol India 59:855–60
ORIGINAL PAPER
A randomized study of ventriculoperitoneal shunt versus endoscopic third ventriculostomy for the management of tubercular meningitis with hydrocephalus Pawan Goyal & Chhitij Srivastava & Bal Krishna Ojha & Sunil K Singh & Anil Chandra & R. K. Garg & Swati Srivastava
Received: 26 October 2013 / Accepted: 16 January 2014 / Published online: 4 February 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract 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 Duration of illness ≤2 months >2 months CSF proteins ≤1 g/dl >1 g/dl CSF cell count ≤50 cells/mm3 >50 cells/mm3 History of ATT No Yes Modified Vellore grade 1 2 3 4 Focal deficit No Yes Cranial nerve deficit No Yes Duration of altered sensorium 8–14 days >14 days
eventually died. Three patients had bulge at the ETV site. Shunt-related complications occurred in four (17 %) patients and consisted of an obstruction at the lower end of the shunt in three (13 %) cases, leading to revision, and one (4 %) patient had an infection at the shunt chamber site, leading to skin excoriation and meningitis.
Discussion To the best of our knowledge, there have been no randomized trial done previously to compare the outcome of ETV and shunt in TBMH. Radiological analysis Based on reduction of periventricular lucency, decrease in the size of ventricles, and reappearance of CSF in
ETV (n=24) OR (95 % CI)
Shunt (n=24) OR (95 % CI)
Total (n=48) OR (95 % CI)
0.50 (0.10–2.60)
1.09 (0.21–5.76)
0.70 (0.22–2.19)
0.56 (0.11–2.90)
1.29 (0.23–7.05)
0.88 (0.27–2.82)
0.93 (0.16–5.54)
1.40 (0.28–7.02)
1.04 (0.33–3.30)
0.56 (0.11–2.90)
1.03 (0.21–5.15)
0.72 (0.23–2.25)
0.60 (0.11–3.34)
0.60 (0.11–3.40)
0.60 (0.18–2.03)
1.70 (0.97–2.51) 2.67 (1.10–4.27) 3.40 (2.32–7.69)
1.60 (0.45–2.14) 2.24 (0.97–3.85) 2.76 (2.04–5.72)
2.15 (1.13–3.24) 3.68 (2.21–5.33) 6.41 (2.79–9.57)
1.75 (0.31–9.75)
0.67 (0.13–3.45)
1.04 (0.33–3.30)
2.22 (0.33–14.80)
0.67 (0.13–3.45)
1.05 (0.32–3.45)
3.57 (0.41–5.14) 4.43 (1.59–7.95)
0.60 (0.09–2.99) 1.00 (0.13–4.57)
1.26 (0.33–4.84) 1.62 (0.37–7.20)
subarachnoid space (Fig. 4), it was observed that patients in the shunt group showed 89 % recovery in the features of TBMH over a period of 6 months, while in ETV group, the recovery was 74.8 %. In the study done by Yadav et al., in patients operated for ETV, radiological recovery was only 52 % within 3 weeks [21]. Singh et al. had seen radiological recovery in 55.6 % of his patients over a period of 12 weeks [18]. This suggests that decrease in the size of ventricle occurs slowly after ETV and may not correlate well with the clinical outcome. Failure to improve after ETV does not always mean that ETV is malfunctioning. It could be related to the associated features of TBM such as infarcts as seen in this study (six cases had infarcts on CT, out of which four failed to recover after ETV). Yadav et al. also had similar opinion [21]. A multiple regression analysis done by Kalita et al. suggested infarction on CT scan to be one of the most important predictor of the outcome of TBM at 6-month follow up [8].
Childs Nerv Syst (2014) 30:851–857
855
Fig. 4 a Case of TBM hydrocephalus showing dilated ventricles, periventricular lucencies, and effaced sulci. b CT scan of the same patient 1 month after ETV. Periventricular lucencies have disappeared and sulci are well visualized. Note that ventriculomegaly is still persisting
Outcome Prediction of outcome of TBM is difficult because of its protracted course, diversity of underlying pathological mechanisms, variation of host immunity, and virulence of mycobacterium tuberculosis [13]. Modified Vellore grading is the best and most consistent predictor of outcome following surgery in patients with TBM hydrocephalus. Table 3 shows that the clinical outcome is consistently poor in grade IV in all studies. Overall success rate in ETV group in our study was 41.7 %, which is less compared to some of the previous studies (Table 4). This may be due to the fact that 88 % of patients in our study belonged to grades 3 and 4 as compared to 54 % in the study done by Husain et al. [5] and only 19 % in the study done by Yadav et al. [21]. We had a 100 % success rate in grade 1 similar to Yadav et al., while in grade 4, it was 33.3 % in our study and 50 % in the study done by Yadav et al. Singh et al. [18] and Chugh et al. [2] graded their patients on the basis of MRC grade. They too found that the results were poorer in poor grades as compared to better grades. Age, CSF cells, and proteins did not have any impact on the outcome of CSF diversion procedures. Other studies .[12, 14]. related to shunt have not seen any correlation of the above variables with the outcome. We did not find any correlation of the outcome with the duration of illness in the shunt group.
Also, earlier studies in the shunt group .[12, 19] .did not find any correlation of the outcome with the duration of illness. In ETV group, we had better results in patients with longer duration of illness (>2 months). There was 50 % success rate in patients with the longer duration of illness as compared to 35.7 % in patients with the shorter duration (7 days) were found to have lower success rate in the ETV group, but not in shunt group. But statistical significance of such correlation could not be established on binary logistic regression analysis. Mathew et al. [12] and Palur et al. [14] did not also find any correlation of success with the duration of altered sensorium. Complications In ETV group, CSF leak was noted in seven cases, while two patients developed meningitis, out of which one patient eventually died. Husain et al. [5] had complications in 3 of 28 patients undergoing ETV, while Yadav et al. [21] reported leak in 6 out of 50 patients. The shunt infection rate in our study (4 %) was much less compared to the other recent studies (e.g., Lamprecht et al., 13.8 % [10]; Agarwal et al., 14 % [1]). Shunt malfunction rate in our study (13 %) leading to revision is similar to other studies like Lamprecht et al., 14 % [10] and Agarwal et al., 16 % [1]). Shunt versus ETV in TBMH It was found that patients in the shunt group show improvement in the modified Vellore grading at a faster rate as compared to ETV group. At 6 months, the difference in improvement in the shunt group (63.6 %) as compared to ETV (56.1 %) was 7.5 %, which is of no statistical significance. Patients undergoing shunt show more radiological recovery and that too at a faster
rate as compared to ETV group. Patients undergoing ETV have an arrested hydrocephalus type of picture. This may be due to the fact that after ETV, patients CSF dynamics get into an equilibrium in which enlarged ventricles are not due to raised intracranial pressure. Most of the ETV failures occurred in less than 3 months of surgery (8 out of 10). This suggests that the risk of ETV failure is higher in the early phase of treatment. Therefore, if the patient survives the early high-risk period, they could experience long-term treatment survival advantage.
Conclusion VP shunting has better immediate outcome in hydrocephalus as compared to ETV. In the initial period, patients undergoing ETV should be watched closely for ETV failure, as in early phase, ETV failure and complications are more common in this group as compared to patients undergoing VP shunt. Over a period of 6 months, clinical as well as radiological recovery in ETV catches up with that of shunt. As most of the ETV failure occurs in the initial 3 months of surgery and it is a proven fact that shunt has life-long risk of malfunction and infection, so there could be some rationale of attempting ETV in TBM hydrocephalus because a successful ETV might confer long-term benefits over shunt. As the chances of ETV failure increases in active tuberculosis, so it is better to attempt ETV in the later phase after starting antitubercular treatment. ETV is more physiological than shunt surgery; hence, longterm outcome of hydrocephalus may tilt in favor of ETV, performed after adequate chemotherapy with antitubercular drugs and steroids. Although the number of cases in the present study is limited, it certainly offers a comparison of two alternating ways of treating hydrocephalus in TBM. It is certainly worth trying ETV before subjecting the patient to shunt. More randomized studies and longer follow up monitoring are required to critically evaluate the efficacy of ETV in comparison to shunt, its predictive factors in outcome, and timing of surgery in TBMH. Limitations of study Forty-eight cases taken in this study are very limited. More number of cases are required for a good comparative study. Six-month follow up is another limiting factor. Follow up of longer duration may tilt the result in favor of endoscopic third ventriculostomy.
Childs Nerv Syst (2014) 30:851–857 Acknowledgement This study was funded by intramural research cell grant, King George’s Medical University, Lucknow, India.
References 1. Agrawal D, Gupta A, Mehta VS (2005) Role of shunt surgery in pediatric tubercular meningitis with hydrocephalus. Indian Pediatr 42:245–50 2. Chugh A, Husain M, Gupta RK, Ojha BK, Chandra A, Rastogi M (2009) Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy. J Neurosurg Pediatr 3:371–7 3. Eghwrudjakpor PO, Allison AB (2010) Evolution of surgical interventions for hydrocephalus: patient preferences and the need for proper information. Internet J Med Update 5:55–62 4. Figaji AA, Fieggen AG, Peter JC (2007) Endoscopy for tuberculous hydrocephalus. Childs Nerv Syst 23:79–84 5. Husain M, Jha DK, Rastogi M, Husain N, Gupta RK (2005) Role of neuroendoscopy in the management of patients with tuberculous meningitis hydrocephalus. Neurosurg Rev 28:278–83 6. Husain M, Jha D, Vatsal DK, Thaman D, Gupta A, Husain N et al (2003) Neuro-endoscopic surgery—experience and outcome analysis of 102 consecutive procedures in a busy neurosurgical centre of India. Acta Neurochir 145:369–76 7. Jonathan A, Rajshekhar V (2005) Endoscopic third ventriculostomy for chronic hydrocephalus after tuberculous meningitis. Surg Neurol 63:32–5 8. Kalita J, Misra UK (1999) Outcome of tuberculous meningitis at 6 and 12 months: a multiple regression analysis. Int J Tuberc Lung Dis 3:261–5 9. Kemaloglu S, Ozkan U, Bukte Y, Ceviz A, Ozates M (2002) Timing of shunt surgery in childhood tuberculous meningitis with hydrocephalus. Pediatr Neurosurg 37:194–8
857 10. Lamprecht D, Schoeman J, Donald P, Hartzenberg H (2001) Ventriculoperitoneal shunting in childhood tuberculous meningitis. Br J Neurosurg 15:119–25 11. Marais S, Thwaites G, Schoeman JF, Torok ME, Misra UK, Prasad K et al (2010) Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis 10:803–12 12. Mathew JM, Rajshekhar V, Chandy MJ (1998) Shunt surgery for poor grade patients with tuberculous meningitis and hydrocephalus: effect of response to external ventricular drainage and other factors on long-term outcome. J Neurol Neurosurg Psychiatry 65:115–8 13. Misra UK, Kalita J, Roy AK, Mandal SK, Srivastava M (2000) Role of clinical, radiological and neurophysiological changes in predicting the outcome of tuberculous meningitis: a multivariable analysis. J Neurol Neurosurg Psychiatry 68:300–3 14. Palur R, Rajshekhar V, Chandy MJ, Joseph T, Abraham J (1991) Shunt surgery for hydrocephalous in tubercular meningitis: a longterm follow-up study. J Neurosurg 74:64–9 15. Rajshekhar V (2009) Management of hydrocephalus in patients with tuberculous meningitis. Neurol India 57:368–74 16. Sil K, Chatterjee S (2008) Shunting in tuberculous meningitis: a neurosurgeon’s nightmare. Childs Nerv Syst 24:1029–32 17. Singh D, Kumar S (1996) Ventriculoperitoneal shunt in post tubercular hydrocephalus. Ind Pediatr 33:854–5 18. Singh D, Sachdev V, Singh AK, Sinha S (2005) Endoscopic third ventriculostomy in post-tuberculous meningitic hydrocephalus: a preliminary report. Minim Invasive Neurosurg 48:47–52 1 9 . S r i k a n t h a U , M o r a b J V, S a s t r y S , A b r a h a m R , Balasubramaniam A, Somanna S et al (2009) Outcome of ventriculoperitoneal shunt placement in grade IV tubercular meningitis with hydrocephalus: a retrospective analysis in 95 patients. J Neurosurg Pediatr 4:176–83 20. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–4 21. Yadav YR, Parihar V, Agrawal M, Bhatele PR (2011) Endoscopic third ventriculostomy in tubercular meningitis with hydrocephalus. Neurol India 59:855–60
