Hydrocephalus in Tuberculous Meningitis - Pearls and Nuances
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Published on: February 29, 2020
Vimal K Paliwal1, Ravindra K Garg2
1Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
Abstract:
Tuberculous meningitis (TBM) is associated with high mortality. A large proportion of patients with TBM, who survive, live with disabling neurological sequelae. Hydrocephalus is one of the common complications of TBM, seen in up to 80% of patients. Hydrocephalus may be a presenting feature or may develop paradoxically after the commencement of antituberculosis treatment. The Hallmark pathological feature of TBM is a thick gelatinous exudate, dominantly present at basal parts of the brain. Exudate encases and strangulates cranial nerve trunks like optic nerve, optic chiasma, and vessels of the circle of Willis. Basal exudate also blocks the cerebrospinal fluid (CSF) flow in the brain, resulting in ventriculomegaly. It is often difficult to differentiate between two common types (communicating and obstructive) of hydrocephalus on basis of routine neuroimaging. Progressive hydrocephalus, clinically manifests with a potentially life-threatening high intracranial pressure. Patients with deteriorating vision loss and deteriorating consciousness, often need a surgical CSF diversion procedure (ventriculoperitoneal shunt or endoscopic third ventriculostomy) to be performed. CSF diversion may be life-saving. However, the long-term benefits of CSF diversion are largely unknown.
Insights
Tuberculous meningitis (TBM) causes significant mortality and neurological issues. Hydrocephalus, a common TBM complication, may necessitate surgical cerebrospinal fluid diversion, though its long-term benefits require further study.
Area of Science:
- Neurology
- Infectious Diseases
- Neurosurgery
Background:
- Tuberculous meningitis (TBM) is a severe infection with high mortality and frequent neurological sequelae.
- Hydrocephalus affects up to 80% of TBM patients, presenting at diagnosis or developing during treatment.
- Pathologically, TBM involves basal exudates that obstruct cerebrospinal fluid (CSF) flow, causing ventriculomegaly.
Purpose of the Study:
- To review the pathophysiology and clinical implications of hydrocephalus in tuberculous meningitis.
- To discuss the diagnostic challenges in differentiating hydrocephalus types in TBM.
- To highlight the role and uncertainties surrounding surgical CSF diversion in TBM management.
Main Methods:
- Literature review focusing on the pathogenesis of hydrocephalus in TBM.
- Analysis of clinical presentations and neuroimaging findings.
- Discussion of surgical interventions for hydrocephalus in TBM.
Main Results:
- Basal exudates in TBM commonly lead to obstructive or communicating hydrocephalus.
- Differentiating hydrocephalus types on routine imaging can be challenging.
- Surgical CSF diversion (ventriculoperitoneal shunt, ETV) may be life-saving for progressive hydrocephalus.
Conclusions:
- Hydrocephalus is a critical complication of TBM, often requiring intervention.
- The long-term efficacy and outcomes of CSF diversion procedures in TBM patients remain largely undetermined.
- Further research is needed to optimize management strategies for TBM-associated hydrocephalus.
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