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Managementofhydrocephalusinpatientswith
tuberculousmeningitis
Rajshekhar,Vedantam.NeurologyIndia 57.4 (JulAug2009):36874.

Abstract
Hydrocephalusisoneofthecommonestcomplicationsoftuberculousmeningitis(TBM)occurringinupto
85%ofchildrenwiththedisease.Itismoresevereinchildrenthaninadults.Itcouldbeeitherofthe
communicatingtypeortheobstructivetypewiththeformerbeingmorefrequentlyseen.TheVelloregrading
systemforclinicalgradingofpatientswithTBMandhydrocephaluswithgradeIbeingthebestgradeand
gradeIVbeingtheworstgradehasbeenvalidatedbyseveralauthors.Themanagementofhydrocephalus
canincludemedicaltherapywithdehydratingagentsandsteroidsforpatientsingoodgradesandthosewith
communicatinghydrocephalus.However,surgeryisrequiredforpatientswithobstructivehydrocephalusand
thoseinpoorgrades.Surgerycaninvolveeitheraventriculoperitonealshuntorendoscopicthird
ventriculostomy(ETV).ComplicationsofshuntsurgeryinpatientswithTBMandhydrocephalusarehighwith
frequentshuntobstructionsandshuntinfectionsrequiringrepeatedrevisions.ETVhasvariablesuccessin
thesepatientsandisgenerallynotadvisableinpatientsintheacutestagesofthedisease.Mortalityonlong
termfollowuphasbeenreportedtovaryfrom10.5%to57.1%inthosewithalteredsensoriumpriorto
surgeryand0to12.5%inpatientswithnormalsensorium.SurgeryforpatientsinVelloregradeIVis
usuallyassociatedwithapooroutcomeandhighmortalityandtherefore,itsutilityinthesepatientsis
debatable

FullText
Introduction
Tuberculousmeningitis(TBM)isstillaverycommonprobleminchildrenandadultsinIndia.Althoughthere
hasbeenareductioninthenumberofpatientswithTBM,itisestimatedthatinIndiathemortalitydueto
TBMisapproximately1.5/100,000population.[1]Hydrocephalusisoneofthemostcommoncomplications
ofTBM.Itisalmostalwayspresentinpatientswhohavehadthediseaseforfourtosixweeks.[2]Itismore
frequentandsevereinchildrenthaninadultsandalsooccursatanearlierstageinthediseaseprocess.[2]
ThemanagementofhydrocephalusinpatientswithTBMisdiscussedbasedontheavailableliteratureandan
algorithmissuggestedattheendofthisreview.
Pathophysiologyofhydrocephalus
HydrocephalusinpatientswithTBMcouldbeeitherofthecommunicatingortheobstructivetype,theformer
beingmorecommon.[3]Inbothinstances,themaincauseistheinflammatoryexudateoccupyingthe
subarachnoidspacesortheventricularpathways.Intheearlierstagesofthedisease,thethickgelatinous

exudatesblockthesubarachnoidspacesinthebaseofthebrain(notablytheinterpeduncularandambient
cisterns)leadingtocommunicatinghydrocephalus.[4]Theexudatesleadtoadensescarringofthe
subarachnoidspacesinthelaterstagesofthediseaseagainleadingtocommunicatingtypeof
hydrocephalus.Acommunicatinghydrocephaluscanalsoresultfromtheexudatesblockingthearachnoid
granulationswhichpreventtheabsorptionofcerebrospinalfluid(CSF).Theinflammationofthechoroid
plexusandependymaalsoleadstoanoverproductionofCSFintheacutephaseoftheillness.Thisalso
contributestothehydrocephalusandraisedintracranialpressure.Theobstructivetypeofhydrocephalus
developswhenthefourthventricularoutletsareblockedbytheexudatesorleptomeningealscartissueor
whenthereisobstructionoftheaqueducteitherduetoastrangulationofthebrainstembyexudatesorby
asubependymaltuberculoma.CommunicatingtypeofhydrocephalusismorecommoninTBMthanthe
obstructivetype.Schoemanetal.[3]foundthatthehydrocephaluswasofthecommunicatingtypein82%
oftheirpatientswithTBM.
Incidenceofhydrocephalus
InitialstudiesusingairencephalographyinpatientswithTBMfoundhydrocephalusin62%ofthepatients.
[5]Schoemanetal.[3]foundcomputertomography(CT)evidenceofhydrocephalusin83%of193children
withTBM.InaCTstudy,onlythreeof60childrenandadultswithTBMwerefoundtohavenormal
ventricles,givinganincidenceof95%.[6]Significantly,87%ofchildreninthisstudyhadsevere
hydrocephalus.Comparedtoanincidenceof71%inchildren,only12%ofadultswithTBMhad
hydrocephalus.Thus,itisevidentthathydrocephalusismorecommoninchildrenwithTBMcomparedto
adults.Hydrocephalusisalsomorecommoninthelaterstagesofthedisease.
Clinicalpresentation
Theclinicalfeaturesthatsuggestthepresenceofhydrocephalusarenonspecific.InanypatientwithTBM
withalteredsensorium,hydrocephalusshouldbesuspectedirrespectiveofthepresenceorabsenceof
papilledema.Hydrocephalusisalsolikelytobepresentinpatientswhoarealertandwhocomplainof
increasingheadachewithorwithoutvomitingandblurringofvision.
Gradingofpatients
Gradingofpatientswithanydiseaseisusefultoprognosticateoutcome.Althoughawidelyusedgrading
systemexistsforTBM,namelytheMRCgradingsystem[Table1],aspecificgradingsystemdidnotexistfor
patientswithTBMandhydrocephalus.Weproposedagradingsystem(Velloregradingsystem)basedonthe
presenceorabsenceofneurologicaldeficitsandlevelofsensorium[Table2].[7]Thisgradingsystemis
usefultogradethepatientsinretrospectivestudiesbutithassomedegreeofsubjectivityinassessing
sensorium.Therefore,thegradingsystemwasmodifiedtoincludetheGlasgowComaScale.[8]Thelatter
gradingsystemisreproducibleacrossdifferentlevelsofclinicalexpertiseandacrossdifferentdisciplinesof
healthcareworkersandis,therefore,amorereliablesystem.Mostimportantly,boththegradingsystems
havebeenshowntocorrelatewithoutcomeandarehencevaluableinprognosticatingintheindividual
patients.
Imaging
AcontrastCTscanistheimagingofchoiceinsickpatients,especiallychildren,asitcanbeperformed
withoutanesthesiaorsedationandcanbedoneinashorttimecomparedtoamagneticresonanceimaging
(MRI)scanwhichmightrequireapatienttostilllieforlongerperiods.Adequateinformationregarding
ventricularsize,subependymalseepage,presenceofinfarctsandtuberculomas,andpresenceofbasal
exudatescanbeobtainedfromacontrastenhancedCTscan.AlthoughaCTscanmightindicatewhetherthe
hydrocephalusisobstructiveorcommunicatinginnature,thisdifferentiationisnotalwayspossible.CTis

thereforenotusefulindeterminingthelevelofCSFblockinTBM.Airencephalographyremainsthemost
reliablewayofdeterminingthelevelofCSFobstruction.[9]Forexample,inthecaseswheretheCTscan
showsdilatationofthelateralandthirdventricleswithoutadilatedfourthventricle,itcansafelybe
presumedthatthehydrocephalusisduetoobstructiontotheCSFpathwaysintheregionoftheaqueduct.
Butifalltheventriclesaredilated,thenitisdifficulttodeterminewhetherthehydrocephalusisdueto
obstructionofthefourthventricularoutletsorduetoanobstructiontotheCSFpathwaysinthebasal
subarachnoidspaces,unlessthefourthventricleisseentobeincommunicationwiththecisternamagna.To
makethedifferentiationbetweenthetwotypesofhydrocephalus,adynamicstudysuchas
pneumoencephalogramorCTventriculogramisneeded.However,performingeitheroftheseinvestigations
exposesthepatienttoaninvasiveprocedurewithattendantrisks.
Medicalmanagement
Medicalmanagementmightbeofferedasthefirstlineoftherapytopatientswithcommunicating
hydrocephalus.[10]Thiscomprisessteroids,dehydratingagentssuchasmannitol,diureticssuchas
frusemide,andacetazolamidetoreduceCSFproduction.Taperingdosesofdexamethasone(12to
16mg/day)canbegivenforfourtosixweeks.Mannitolcanonlybeusedforacutedecompensationandis
notrecommendedformorethan72hoursduetotheoccurrenceofreboundintracranialhypertension.
Acetazolamide(100mg/kg)andfrusemide(1mg/kg)canbegivenforlongerperiodsofuptoamonth.
MedicalmanagementisgenerallysuccessfulinseveralpatientswithTBMwhoexhibitfeaturesofraised
intracranialpressure.Alongwiththeagentsmentionedabove,theantituberculoustherapy(ATT)also
probablyhelpsinreducingtheinflammatoryresponseleadingtoopeningoftheCSFpathways.Theaddition
ofacetazolamideandfurosemidewassignificantlymoreeffectiveinachievingnormalintracranialpressure
(ICP)thanantituberculousdrugsalone.[3]InastudyfromSouthAfricabyLamprectetal.,[10]217
childrenwithMRCstageIIandIIITBMandhydrocephaluswereinitiallymanagedmedicallyiftheyhad
communicatinghydrocephalus(asdeterminedbypneumoencephalographyorairencephalograms).This
strategyallowedtheauthorstoavoidshuntsurgeryinover70%ofthepatients.Evenintheother30%who
underwentshuntsurgery,41.5%(27patients)hadobstructivehydrocephalus.Soitappearsprudentto
suggestmedicalmanagementespeciallyinpatientswithbettersensorium(VelloregradeII)orifthey
definitelyhavecommunicatinghydrocephalus.However,thepatientsshouldbemonitoredcarefullyforany
worseningofsensoriumorlackofimprovementwithmedicalmanagement.Inthissituationashuntmight
havetobedonepromptly.
IntrathecalhyaluronidasehasbeentriedinsteadofshuntsurgeryinsomepatientswithTBMand
hydrocephalusandshowntohavesomebenefitintheformofimprovementinsensorium.Butitdidnotoffer
anyadvantageovershuntinsertionandthistherapyispresentlynotcommonlypractised.[3],[11]
Surgicalmanagement
EarlyattemptsatsurgicalmanagementofhydrocephalusinpatientswithTBMincludedrepeatedtappingof
theventriclesthroughburrholes,suboccipitaldecompression,lateralandthirdventriculostomy(open)and
ventriculosubarachnoidshunts.[12]Theavailabilityofreliableshuntsystemsintheearly1960s
dramaticallychangedthemanagementofhydrocephalus.
Indicationsforsurgery
PatientsingradesIandIIshouldundergosurgeryattheearliest.Ithasbeenshownthatoutcomesare
betterwithearlysurgeryespeciallyinpatientsinthebettergrades.TheSouthAfricangrouphassuggested
thatearlysurgerybereservedforthosewithobstructivehydrocephalusandmedicaltherapybetriedfor
thosewithcommunicatinghydrocephalus.[10]However,oneoftherisksofsuchastrategyisthatsome
patientsundergoingmedicaltherapymightdeterioraterapidlyandhaveapooroutcomeifshuntsurgeryis

delayed.Medicaltherapyalsoimpliescontinuousmonitoringofthepatientinthehospitalforprolonged
periodswhichmightnotbecosteffective.
NotallpatientswhoundergoshuntsurgeryforTBMwithhydrocephalusshowasignificantimprovementin
theirsensoriumorsymptoms.Itis,therefore,evidentthatthecauseofthealteredsensoriumandother
symptomsinthesepatientsarenotalwaysorcompletelyattributabletothehydrocephalus.Theencephalitis
thatiscausedbytheinflammatoryprocessesenvelopingthecerebralhemispheres,theischemiacausedby
thearteritisespeciallyofthesmallperforatorsatthebaseofthebrainprobablycontributeinequalifnot
morethanequalmeasuretothealteredsensorium.AconsiderableproportionofpatientswithTBM
especiallythoseinthepoorergradeshavebeenshowntohaveinfarctsofthebasalganglia,thalamusand
brainstem.ItisthesamegroupofpatientswhowillalsoexhibithydrocephalusontheCTscans.Thus,in
gradeIIIandIVpatients,itbecomesdifficulttodeterminethecauseofthealterationofsensorium.
Shuntsurgery
Ventriculoatrial(VA)shuntsweretheinitialchoiceforshuntprocedures.Thefearofdisseminatingthe
tuberculousdiseasethroughsuchshuntsystemwasdispelledbyreportsbyBhagwatiandothers,[13],[14],
[15],[16]whodescribedthesuccessfuluseofVAshuntsinpatientswithTBM.However,othershave
reportedoccasionalcasesofdisseminationofthediseasefollowingaVAshunt.[17]Therewasashiftto
ventriculoperitoneal(VP)shuntintheearly1980sandsincethenVPshunthasremainedtheshunt
procedureofchoiceforpatientswithTBMandhydrocephalus.Although,thereisatheoreticalriskof
developingtuberculousperitonitisfollowingaVPshunt,tothebestofourknowledgesuchanoccurrencehas
notbeenreported.Thetechniqueforshuntsurgerydoesnotdifferfromthatusedforhydrocephalusfrom
anyothercause.
Endoscopicthirdventriculostomy
Sincethepopularizationofendoscopicthirdventriculostomy(ETV)inthemid1990s,therehasbeenan
interestinavoidingshuntsinpatientswithhydrocephaluswiththehopethatifaforeignbodyinsertioncould
beavoided,theaccompanyingcomplicationsofashunt(infection,blockage,extrusion,abdominal
pseudocysts,skinerosionovershuntcomponents)couldalsobeavoided.Initially,Figajietal.[18]andwe
describedtheuseofETVinTBMrelatedhydrocephalusintwopatientseach.[19]Sincethen,therehave
beenseveralreportsontheuseofETVinthesepatientswithvaryingdegreesofsuccess.
Singhetal.[20]reportedasuccessrateofETVin77%of35patientswithTBMandhydrocephalus.Also,
60%hadearlyand17%haddelayedrecovery.Thesuccessrateswerenotrelatedtothetypeof
hydrocephalus(obstructiveorcommunicating).However,thepresenceofathinandtransparentfloorofthe
thirdventricleseemedtobeassociatedwithahighersuccessrateof87%.Hussainetal.[21]determined
that68%ofthepatientswithTBMandhydrocephalusbenefitedfromvariousendoscopicprocedures
includingETV.Inamorerecentstudybythesamegrouptheyfoundthat19of26(73%)patientswithTBM
andhydrocephalusrespondedtoETV.[22]Theyfoundthatpatientswithlongerdurationofsymptomsand
ATTweremorelikelytobenefitfromtheETV.Incontrast,Figajietal.[23]reportedasuccessfuloutcome
followingattemptedETVinonlysevenof17(41%)patientswithTBMandhydrocephalus.Infivepatients,
theETVwasperformedbutfailed,whereasinanotherfivetheprocedurehadtobeabandoneddueto
abnormalanatomy.TheyconcludedthatalthoughETVwastechnicallypossibleinpatientswithTBM,onlya
surgeonexperiencedinendoscopicproceduresshouldperformthesurgeryastheprocedureismore
demandingthaninothersituations.
InpatientswithTBM,thefloorofthethirdventricleisfrequentlythickandthesubarachnoidspaceisalso
likelytobeobliteratedbyexudatesmakingitdifficulttorecogniseanatomicallandmarks.Inthissituationit
mightbeprudenttoabandontheprocedurethanriskinjurytothebasilararteryanditsbranches.Wehave

attemptedETVinpatientswithTBMearlyinthecourseofdiseaseandfoundthatthefloorofthethird
ventriclebesidesbeingthickiscoatedwithsmalltuberclesandgranulationtissuethatbleedwhentouched
withevenabluntprobe.Asbleedingofevenminorintensitycanobscurethefieldduringendoscopic
procedures,webelievethatETVmightbebetteravoidedforacutehydrocephalusinpatientswithTBMand
bereservedforeitherinthosewhohavebeentreatedwithATTforatleastfourweeksorinwhomthe
diseaseisburntoutandthehydrocephalushasdevelopedlate.Chughetal.[22]foundthattheoutcome
wasbetterinthosewhoreceivedATTforfourweekspriortoETVthaninthoseoperatedearlier.Itcouldalso
beconsideredinpatientswhohaveshuntfailure,asitmightbeabetteroptionthanshuntrevisioninthese
patients.
Complicationsofsurgery
Shuntsurgery
IthasbeenreportedthatcomplicationsofshuntsurgeryarehigherinpatientswithTBMthaninpatients
withotherconditions.Thereasonsforthisarethepoorgeneralconditionofthesepatientsandalsothe
presenceofhigherproteinandcellularcontentintheCSFleadingtomorefrequentshuntobstruction.
Agarwaletal.[24]reportedshuntrelatedcomplicationsin11(30%)childrenandthreeof37childrenhad
toundergomultipleshuntrevisions.Paluretal.[7]reportedthat26of114(22.8%)patientshadto
undergooneormoreshuntrevisions,onepatientrequiringmorethanthreerevisions.SilandChatterjee
[25]reportedashuntinfectionrateof15.6%andrevisionrateof43.8%intheirseriesof37childrenwho
underwentshuntsurgeryforTBMwithhydrocephalus.Multiplerevisionsweredonein18.7%ofpatients.
Shuntinfectionanderosionofskinovertheshuntcomponentsaretheothermajorcomplicationsofshunt
surgeryinpoorgradepatientswithTBMandhydrocephalus.
Endoscopicthirdventriculostomy
FailureoftheETVwithCSFleakandbleedingduringthesurgeryarethemostcommonlyreported
complicationsofETV.Husainetal.[21]hadcomplicationsinthreeof28patientsundergoingETVforTBM
relatedhydrocephalus.Inamorerecentseries,thesameauthorshavereportedETVfailuresinsevenof26
patients.[22]Theydidnotreportanyothercomplicationsinthisseriesofpatients.Riskofinjurytothe
basilararteryanditsbranchesistheoreticallyhigherinpatientswithTBMduetothethickenedandopaque
thirdventricularfloor.
Outcome
AlltheearlyreportsofshuntsurgeryforhydrocephalusassociatedwithTBMreportpooroutcomeina
proportionofpatients.Bhagwati[13]reportedmortalityin3of7patientsundergoingshuntsurgery.Only4
of9patientstreatedwiththeUpdhyayaVAshuntimprovedfollowingsurgery.[15]Theother5patientsdied
atvaryingperiodsoftimeafterthesurgery.Paluretal.[9]reportedthatofthe114patientsfollowedupfor
anaverageof45.6monthsfollowingshuntsurgeryforTBMandhydrocephalus,48(42.1%)died.63(55%)
hadagoodoutcomeormoderatedisability.Agarwaletal.[21]reportedthat29of37children(78%)hada
goodoutcomeormoderatedisabilityat3monthsfollowupfollowingshuntsurgeryforTBMand
hydrocephalus.InvariousseriesofshuntsurgeryforTBMwithhydrocephalusreportedupto1991,the
mortalityrateforthosewithalteredsensoriumhasrangedfrom10.5%to57.1%andforthosewithnormal
sensoriumhasrangedfrom0to12.5%.[7],[14],[26],[27]Themortalityratesmightbehigherifthefollow
updurationislongerasthosewithseveredisabilitymightgoontodie.Thisisborneoutbythefactthatin
ourinitialretrospectivestudy,14ofthe48(29.1%)patientswhodied,didsomorethanoneyearafterthe
surgery.[7]Therefore,whileconsideringoutcomepatientsdischargedwithseveredisabilityshouldbe
categorizedwiththosewhohavedied.

Prognosticfactors
Inourseriesofpatients,114patientswhowerefollowedupfor6monthsto13years(mean45.6months)
followingshuntsurgeryforTBMwithhydrocephalus,westudiedvariousprognosticfactorstopredict
outcomefollowingshuntsurgery.[7]Age(09,10+years),durationofalteredsensorium(15days),CSF
cellcount(50/ml),CSFproteinlevel(50mg%),shuntrevisions(0,1+)andbilateralshunts(0,1),didnot
haveanysignficanteffectonthelongtermoutcome.Onlytheadmissiongrade[Table2]washighly
significant(P=0.0001)inpredictingtheoutcome.Thepresenceofinfarctsinthebasalgangliaandinternal
capsulearealsolikelytoindicateapooroutcomefollowingshunting.
Itisclearfromseveralsubsequentstudiesthatthegradeatpresentationisthebestandmostconsistent
predictorofoutcomefollowingshuntsurgeryinpatientswithTBM.Agarwaletal.[24]studied37children
withTBMandhydrocephaluswhohadundergoneshuntsurgery.TheyusedtheVelloregradingsystem
proposedbyus[Table2]andfoundthatallpatientsingradeIVwereleftwithseveredisabilityordied.They
recommendedshuntplacementinallchildrenofgradeIIandIIIasthispolicyhasyieldedthebestresults.
ForgradeIVchildrenexternalventriculardrainage,followedbyshuntingifimprovementoccursremainsthe
mostcosteffectiveprocedure.
SinghandKumar[28]reportedtheoutcomeofVPshuntin140childrenwhounderwentshuntsurgeryfor
TBMandhydrocephalus.TheyfoundagoodcorrelationbetweentheVelloregradeatshuntsurgerywiththe
outcome.AllthemortalitiesoccurredinpatientsingradeIV(43/87).
Inafollowupprospectivestudy,[8]wevalidatedtheutilityofourgradingsystem.Weusedanalgorithm
proposedinourinitialarticlein1991andevaluated32consecutivepatientswithTBMandhydrocephalusin
gradesIIIorIV.Weusedexternalventriculardrainage(EVD)toselectpatientsforVPshunt.Allbutoneof
thepatientsingradeIVdidnotimprovewithEVDandsuccumbedtothedisease.
ThegradingsystemproposedbyusandmodifiedtoincludetheGCS[Table3]isavalidsystemtopredict
outcomefollowingshuntsurgeryinpatientswithTBMandhydrocephalusashasbeenverifiedbyseveral
studies.[Table4]showstheoutcomeinpatientswhounderwentshuntsurgerycategorizedusingour
gradingsystem.
SilandChatterjee[25]notedthatallpatientswhofaredpoorlyfollowingshuntsurgery,intheirseriesof37
childrenwithTBMandhydrocephalus,hadevidenceofinfarctsintheirCTscans.Itisalsolikelythatthese
patientswereinthepoorerVelloregradesbeforeshunting.Statedotherwise,thoseinpoorergradesare
likelytohaveinfarctsandtherefore,infarctsonCTscanmightnotbeanindependentpredictorofoutcome.
Kemalogluetal.[29]notedthatpatientswithTBMwithmildandmoderatehydrocephaluswhounderwent
earlyshuntsurgery(twodaysafterdiagnosis)hadbetteroutcomescomparedtothosewhohaddelayed
surgery(threeweeksafterdiagnosis).Thiseffectwasnotseeninpatientswithseverehydrocephalus.While
thissuggeststhatearlysurgeryshouldbeofferedtopatientswithmildandmoderatehydrocephaluswithout
delayingitwhilewaitingtodeterminetheeffectofmedicaltherapy,itisunclearwhethershuntsurgery
couldhavebeenavoidedinsomeofthesepatients.
TBMinHIVpositivepatientsanddrugresistanttuberculous
Inacomparativestudyof30patientswithTBMandhydrocephalus,15beingHIVpositive,itwasfoundthat
mortalityrateandpooroutcomesatonemonthfollowingshuntsurgeryandATT,wereconsiderablyhigher
inHIVpositivepatientscomparedtothosewhowereHIVnegative.[30]TheHIVpositivegrouphada
mortalityrateof66.7%andpooroutcomein64.7%comparedwithmortalityrateof26.7%andpoor
outcomein30.8%intheHIVnegativegroup.NopatientintheHIVpositivegroupexperiencedagood

recovery.Nopatient(eitherHIVpositiveorHIVnegative)whopresentedinTBMGrade4survived,whereas
noHIVpositivepatientwhopresentedinTBMGrade3survived.Asignificantrelationshipwasnoted
betweenCD4countsandpatientoutcomes(P,0.031).ItwassuggestedthatHIVpositivepatientswithTBM
shouldundergoatrialofventricularorlumbarCSFdrainage,andonlythosewhoshowanimprovement
followingEVDshouldundergoshuntsurgery.
TheoutcomeofTBMwithhydrocephalusisfinallydependentontheresponseofthediseasetoATT.Itis
understandablethatinpatientswithdrugresistantTBeithermultidrugresistantTB(MDRTB)or
extensivelydrugresistantTB(XDRTB),theoutcomeislikelytobepoor.Therearehowever,nostudies
whichhavereportedontheoutcomefollowingsurgeryfordrugresistantTBM.
Suggestedmanagementalgorithm
ThemainaimofthesuggestedalgorithmistoimprovetheoutcomeofpatientswithTBMandhydrocephalus
andalsotoavoidshuntsurgeryinthosewhoareunlikelytobenefitfromthesurgery[Figure1].Thegrading
ofthepatientisimportantindecidingonfurthercourseofaction.Althoughmedicalmanagementcouldbe
triedforafewdaysoraweekinpatientsingradesIandII,thepatientshouldbemonitoredcloselyduring
thisperiodtodetectanyworseningorlackofimprovementandashuntshouldbepromptlyofferedincase
offailureofmedicalmanagement.Prolongingmedicaltherapyinpatientsingoodgradescouldbeharmful
andmayleadtoirreversiblebraindamage.
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Neurosurgery200047:6449.
AuthorAffiliation
VedantamRajshekhar:DepartmentofNeurologicalSciences,ChristianMedicalCollege,Vellore
CopyrightMedknowPublications&MediaPvt.Ltd.OctDec2009

Details
Subject

Medicaltreatment
Mortality
Patients
Tuberculosis
Medicalimaging
Meningitis

MeSH

DiagnosticImagingmethods,Humans,
Hydrocephaluscomplications,
Hydrocephalusepidemiology,TreatmentOutcome,
Tuberculosis,Meningealcomplications,
Tuberculosis,Meningealepidemiology,
Hydrocephalusdiagnosis(major),
Hydrocephalussurgery(major),
Tuberculosis,Meningealdiagnosis(major),
Tuberculosis,Meningealsurgery(major)

Title

Managementofhydrocephalusinpatientswithtuberculous
meningitis

Author

Rajshekhar,Vedantam

Publicationtitle

NeurologyIndia

Volume

57

Issue

Pages

36874

Numberofpages

Publicationyear

2009

Publicationdate

JulAug2009

Year

2009

Publisher

MedknowPublications&MediaPvt.Ltd.

Placeofpublication

Mumbai

Countryofpublication

India

Publicationsubject

MedicalSciencesPsychiatryAndNeurology

ISSN

00283886

Sourcetype

ScholarlyJournals

Languageofpublication

English

Documenttype

JournalArticle

DOI

http://dx.doi.org/10.4103/00283886.55572

Accessionnumber

19770534

ProQuestdocumentID

236931248

DocumentURL

http://search.proquest.com/docview/236931248?
accountid=139409

Copyright

CopyrightMedknowPublications&MediaPvt.Ltd.OctDec
2009

Lastupdated

20140322

Database

2databases Viewlist

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