Srikantha Umesh, Morab Jagadeesh V, Sastry Savitr, Abraham Rojin, Balasubramaniam Anandh, Somanna Sampath, Devi Indira, Bangalore Chandramouli A, Pandey Paritosh
Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India.
J Neurosurg Pediatr. 2009 Aug;4(2):176-83. doi: 10.3171/2009.3.PEDS08308.
Hydrocephalus is the most common complication of tubercular meningitis (TBM). Relieving hydrocephalus by ventriculoperitoneal (VP) shunt placement has been considered beneficial in patients in Palur Grade II or III. The role of VP shunt placement in those of Grade IV is controversial and the general tendency is to avoid its use. Some authors have suggested that patients in Grade IV should receive a shunt only if their condition improves with a trial placement of an external ventricular drain (EVD). In the present study, the authors assessed the outcome of VP shunt placement in patients in Grade IV TBM with hydrocephalus to examine the factors predicting outcome and to determine whether a trial with an EVD is absolutely necessary prior to shunt placement.
Ninety-five consecutive cases of TBM with hydrocephalus in which the patients underwent VP shunt placement were retrospectively analyzed, and direct VP shunts were placed whenever possible. An EVD was placed first only in the presence of deranged blood parameters. Outcomes were assessed both in the short and long term.
The mean patient age was 17.5 years (range 1-55 years). Fifty-two patients underwent direct VP shunt placement, and the remaining 43 received EVDs first. Overall, 33 and 45% of patients had favorable short- and long-term outcomes, respectively. Age older than 3 years and duration of altered sensorium < or = 3 days were predictive of a favorable short-term outcome. Glasgow Coma Scale score at presentation was predictive of long-term outcome. Of the patients who did not improve with placement of an EVD prior to VP shunt insertion, 24 and 18% had favorable short- and long-term outcomes, respectively; this was not significantly different from the outcome in the patients who underwent direct VP shunt placement.
Direct VP shunt placement is an effective option in patients with Grade IV TBM with hydrocephalus. Age and duration of altered sensorium are predictive of short-term outcome, while Glasgow Coma Scale score at presentation predicts long-term outcome. Ventriculoperitoneal shunts should be considered even in patients who do not improve with an EVD.
脑积水是结核性脑膜炎（TBM）最常见的并发症。对于帕卢二级或三级患者，通过脑室腹腔（VP）分流术缓解脑积水被认为是有益的。VP分流术在四级患者中的作用存在争议，一般倾向于避免使用。一些作者建议，四级患者只有在试行外置脑室引流（EVD）后病情改善时才应接受分流术。在本研究中，作者评估了四级TBM合并脑积水患者VP分流术的结果，以检查预测结果的因素，并确定在进行分流术之前是否绝对需要试行EVD。
回顾性分析95例连续的TBM合并脑积水且接受VP分流术的患者，尽可能直接进行VP分流。仅在血液参数紊乱时才首先放置EVD。对短期和长期结果均进行了评估。
患者平均年龄为17.5岁（范围1 - 55岁）。52例患者直接进行了VP分流，其余43例首先接受了EVD。总体而言，分别有33%和45%的患者获得了良好的短期和长期结果。年龄大于3岁且意识改变持续时间≤3天可预测短期良好结果。就诊时的格拉斯哥昏迷量表评分可预测长期结果。在VP分流术前放置EVD后病情未改善的患者中，分别有24%和18%获得了良好的短期和长期结果；这与直接进行VP分流的患者的结果无显著差异。
直接VP分流术是四级TBM合并脑积水患者的有效选择。年龄和意识改变持续时间可预测短期结果，而就诊时的格拉斯哥昏迷量表评分可预测长期结果。即使是EVD治疗无效的患者也应考虑行VP分流术。
