Shunt surgery in poor grade patients with tuberculous meningitis and hydrocephalus: effects of response to external ventricular drainage and other variables on long term outcome

摘要

Thirty two poor grade patients (grade 3, 20 patients and grade4, 12 patients) with tuberculous meningitis and hydrocephalus wereprospectively studied to evaluate the response to external ventriculardrainage in predicting outcome after shunt surgery. All grade 3 patients underwent a shunt procedure irrespective of their response toexternal ventricular drainage, and an attempt was made to correlate theimmediate response to external ventricular drainage to their long termoutcome. Patients in grade 4 underwent shunt surgery only if there wasclinical improvement by at least one grade after external ventriculardrainage. Follow up (mean 23.1 months) was available for 30 patients(93%). Of the 20 patients in grade 3, seven underwent shunt surgerydirectly, 13 after an external ventricular drainage. In the group whichunderwent drainage, the immediate clinical response was improvement insix, no change in six, and death in one. Long term improvement or deathoccurred almost equally in all the subgroups. The immediate response to external ventricular drainage was not predictive of the long term outcome in grade 3 patients. All 12 patients in grade 4 underwent anexternal ventricular drainage and only one improved. The rest continuedto deteriorate and succumbed to the disease. Grade at admission was thesingle most important predictor of good outcome (p=0.002) and severityof hydrocephalus had an adverse impact on outcome (p= 0.04). The restof the variables studied (age, duration of illness, duration of alteredsensorium, CSF cell count, and CSF protein concentrations) had noeffect on long term outcome. All patients in grade 3 should be giventhe benefit of shunt surgery without a trial of external ventriculardrainage. However, patients in grade 4 should undergo an externalventricular drainage in view of the high mortality in this group.