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Tuberculous meningitis and hydrocephalus

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DOI: 10.1016/j.jinf.2013.03.002 · Source: PubMed

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Journal of Infection (2013) 66, 330e337

www.elsevierhealth.com/journals/jinf

Hydrocephalus in tuberculous meningitis:

Incidence, its predictive factors and impact on the
prognosis
Tushar Raut a, Ravindra Kumar Garg a,*, Amita Jain b, Rajesh Verma a,
Maneesh Kumar Singh a, Hardeep Singh Malhotra a, Neera Kohli c,
Anit Parihar c

a
Department of Neurology, King George Medical University, Uttar Pradesh, Lucknow 226003, India
b
Department of Microbiology, King George Medical University, Uttar Pradesh, Lucknow 226003, India
c
Department of Radiodiagnosis, King George Medical University, Uttar Pradesh, Lucknow 226003, India

Accepted 26 December 2012

Available online 2 January 2013

KEYWORDS Summary Background: Hydrocephalus is one of the most common complications of tubercu-
Tuberculosis; lous meningitis. The present study evaluated the incidence, predictive factors and impact of
Meningeal tuberculosis; hydrocephalus on overall prognosis of tuberculous meningitis.
Tuberculoma; Material and methods: In a prospective cohort study, all patients fulfilling the inclusion crite-
Cerebrospinal fluid; ria of tuberculous meningitis underwent clinical and cerebrospinal fluid evaluation, together
Stroke; with magnetic resonance imaging of the brain. Patients were treated with antituberculosis
Ventriculo-peritoneal drugs and dexamethasone. Follow up neuroimaging was done after 6 months. Hydrocephalus
shunt was assessed using Evan’s index.
Results: Of 80 patients with tuberculous meningitis, 52(65%) had hydrocephalus at presenta-
tion. During follow up, 8 new patients developed hydrocephalus. Factors associated with hy-
drocephalus included advanced stage of disease, severe disability, duration of illness > 2
months, diplopia, seizures, visual impairment, papilledema, cranial nerve palsy, hemiparesis,
CSF total cell count > 100/cu.mm, CSF protein > 2.5 g/l. Neuroimaging factors that were sig-
nificantly associated with hydrocephalus included basal exudates, tuberculoma and infarcts.
Multivariate analysis revealed visual impairment, cranial nerve palsy and the presence of basal
exudates as significant predictors of hydrocephalus. In 13 patients, with early tuberculous
meningitis, there was complete resolution of hydrocephalus. Hydrocephalus was significantly
associated with mortality and poor outcome.

* Corresponding author. Tel.: þ91 9335901790; fax: þ91 522 2258852.

E-mail address: garg50@yahoo.com (R.K. Garg).

0163-4453/$36 ª 2012 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jinf.2012.12.009
 Author's personal copy
Hydrocephalus in tuberculous meningitis
Conclusion: Hydrocephalus occurs in approximately two-third of patients with tuberculous
meningitis and has an unfavorable impact on the prognosis. Hydrocephalus in early stages of
tuberculous meningitis may resolve completely.
ª 2012 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
Introduction
Tuberculous meningitis is a frequent form of central nervous
system tuberculosis that carries a high mortality and disabil-
ity. Tuberculous meningitis is pathologically characterized by
presence of thick basilar exudates. In the basal region of the
brain, exudates are predominantly present around the circle
of Willis, often extending to the ambient, Sylvian and pontine
cisterns, and around the optic chiasma.
Hydrocephalus is one of the most common complications
of tuberculous meningitis and it has been shown to
adversely affect the outcome.1e3 Two types (communicat-
ing and obstructive) of hydrocephalus are seen in patients
with tuberculous meningitis. The obstructive type of hydro-
cephalus develops when the fourth ventricular outlets are
blocked by the basal exudates and leptomeningeal inflam-
mation, or when there is an obstruction in the aqueduct.4
Communicating hydrocephalus develops when either there
is overproduction of cerebrospinal fluid (CSF) or there is de-
fective absorption of CSF in the subarachnoid space. Com-
municating hydrocephalus is much more frequent. Mild to
moderate hydrocephalus responds well to medical treat-
ment but surgery is required when there are manifestations
of raised intracranial pressure. Ventriculo-peritoneal shunt
is preferred surgical treatment. Other surgical options for
the management of hydrocephalus include endoscopic third
ventriculostomy, external ventricular drainage and Om-
maya reservoir implantation.5e7
Computed tomography (CT) and magnetic resonance
(MR) imaging are commonly used neuroimaging methods
to diagnose hydrocephalus in tuberculous meningitis. MRI is
more sensitive in detecting early changes of hydrocephalus,
infarcts, granuloma and exudates. In hydrocephalus, MRI is
more valuable as it demonstrates the ventricular volume
and flow of CSF through the aqueduct of Sylvius and
foramen of Monroe.1e3,8,9
In this prospective cohort study, we assessed the in-
cidence of hydrocephalus at presentation and during the
course of the illness. We evaluated the predictive factors of
hydrocephalus in patients with tuberculous meningitis. We
also evaluated the impact of hydrocephalus on the prog-
nosis of the disease.
Material and methods
This study was a prospective cohort study, conducted from
October 2010 to august 2012, in the Department of
Neurology, King George’s Medical University, Lucknow,
Uttar Pradesh, India. Our university is a large tertiary
care medical Center which caters to more than 100 million
people. Our university is situated in a region which is a high
endemic zone for tuberculosis. Prior ethical approval was
obtained from the Institutional Ethics Committee. Before
331
enrollment, a written informed consent was taken, either
from the patients or their legal guardians.
Clinical entry criteria
Patients with a history suggestive of subacute or chronic
meningitis were clinically assessed. Symptoms and signs,
those were suggestive of meningitis, included one or more
of the following: headache, vomiting, fever, neck stiffness,
convulsions, focal neurological deficits or altered senso-
rium. All patients were categorized into definite, probable,
or possible tuberculous meningitis groups. The definite
cases of tuberculous meningitis either had presence of
acid-fast bacilli in CSF, mycobacteria cultured from CSF or
CSF was positive for mycobacterial nucleic acid amplifica-
tion test. The probable cases fulfilled the clinical entry
criteria plus a total diagnostic score of 10 or more points
(when cerebral imaging is not available) or 12 or more
points (when cerebral imaging was available) plus exclusion
of alternative diagnoses. The possible cases included
clinical entry criteria plus a total diagnostic score of 6e9
points (when cerebral imaging is not available) or 6e11
points (when cerebral imaging is available) plus exclusion of
alternative diagnoses.10
Disease severity
Patients were classified according to the British Medical
Research Council (BMRC) staging system. Patients with
stage I disease had a Glasgow Coma Scale score of 15
with no focal neurologic signs; patients with stage II had
signs of meningeal irritation with slight or no alteration of
sensorium and minor neurological deficit (like cranial nerve
palsies) or no deficit (Glasgow coma scale score 11e14);
and patients with stage III had severe alteration of
sensorium, convulsions, focal neurological deficit and in-
voluntary movements (Glasgow coma scale score <10).11
Evaluation
All enrolled patients were subjected to a detailed clinical
evaluation. The work up included complete blood count,
peripheral blood smear examination, erythrocyte sedimen-
tation rate (ESR), blood sugar, blood urea nitrogen and
serum creatinine, liver function tests, serum electrolytes,
chest X-ray and enzyme-linked immunosorbent assay for
human immunodeficiency virus (HIV). CSF biochemical and
microscopic examination, including India-ink preparation,
were performed. CSF Sediments were stained and cultured
(LowensteineJensen media) by standard methods. CSF
specimens were also tested for mycobacterial polymerase
chain reaction (PCR). All patients were also subjected to MR
imaging of the brain using Signa Excite 1.5 Tesla instrument
(General Electric Medical Systems, Milwaukee, WI, USA).
 Author's personal copy
332
The scans were reviewed by an experienced neuroradiolo-
gist, who was unaware of treatment and patient outcome.
Definition of hydrocephalus
Hydrocephalus was defined as ventriculomegaly with Evan’s
ratio (maximal width of frontal horns/maximal width of
inner skull) more than >0.30; and/or size of one or both
temporal horns greater than 2 mm. Other imaging changes,
like presence of sulcal effacement, periventricular ooze
(transependymal flux of CSF into the periventricular paren-
chyma, particularly at the tips of the frontal, occipital and
temporal horns), type of hydrocephalus (communicative or
obstructive), meningeal enhancement, exudates, tuber-
culomas and infarcts, were also recorded. Communicating
hydrocephalus was defined as hydrocephalus with a dilated
fourth ventricle. There was no evidence of an obstruction
of the intraventricular CSF pathways, including the fourth
ventricular outflow and the cerebral aqueduct. Size of
fourth ventricle remained unchanged in obstructive hydro-
cephalus.4,12 (Fig. 1) Mild, moderate, and severe hydro-
cephalus were categorized if Evan’s ratios were <0.34,
0.35e0.40, and >0.40 respectively.13
Definition of other neuroimaging findings
On gadolinium-enhanced MRI, meningeal inflammation was
defined as the enhancement of pia-arachnoid, which extends
into the subarachnoid spaces of the sulci, basal cisterns and
enhancement along the inner table of the skull and in the
dural folds of the falx and tentorium. The exudates were
defined as a thick area of enhancement in the regions of basal
cisterns and Sylvian fissure. Tuberculoma was defined as
discrete or coalescing lesions which were showing homoge-
neous nodular contrast enhancement or showing a ring
enhancement. Infarct was defined as an area of abnormal
signal intensity in a vascular distribution without any
evidence of mass effect. Infarcts were hyperintense to
Figure 1 (A) Axial T2 FLAIR sequence shows calculation of Evans’s ratio (in this case more than 30%). Periventricular T2 FLAIR
hyperintensity indicates periventricular CSF ooze suggestive of active hydrocephalus (marked by arrows). (B) Axial T2 FLAIR
sequence shows measurement of temporal horn width.
T. Raut et al.
gray matter on both spin density and T2-weighted images.
These lesions were hypointense on T1-weighted images.
Treatment
All included patients were treated with an antituberculosis
regimen as recommended by World Health Organization for
the treatment of central nervous system tuberculosis.
Patients received 2 months of daily oral isoniazid (5 mg/
kg of body weight; maximum, 300 mg), rifampicin (10 mg/
kg; maximum, 600 mg), pyrazinamide (25 mg/kg; maxi-
mum, 2 g/day) and intramuscular streptomycin (20 mg/kg;
maximum 1 gm/day), followed by 7 months administration
of isoniazid and rifampicin.14 Patients also received dexa-
methasone for eight weeks. Corticosteroid regimen con-
sisted of intravenous dexamethasone for 4 weeks
(0.4 mg/kg body weight per day and then tapered off de-
creasing 0.1 mg/kg every week) and then oral treatment
for 4 weeks, starting at a total of 4 mg per day and decreas-
ing by 1 mg each week. Antiepileptic drugs were used in the
patients who had seizures. Pyridoxine was given orally
20e40 mg/day to all the patients. In patients with clinical
evidence of elevated intracranial pressure, 20% mannitol
and acetazolamide were used. Mannitol was used in dosage
schedule of 0.25e1.0 g/kg body weight every 6 hourly for
2e7 days. Neurosurgical opinion sought in patients with un-
satisfactory response to medical treatment.
Follow up and outcome assessment
Disability assessment was done using modified Barthel index
(MBI), which is a 20 point scoring system. Assessment of
disability included degree of dependence for bowel and
bladder, grooming, toilet use, transfer, mobility, dressing,
feeding, use of stairs and bathing. For each activity, a score
of 0 indicated a complete dependence, and a score of 2 or 3
indicated that the patient was able to perform activities
independently. A score of <12 indicated poor functional
 Author's personal copy
Hydrocephalus in tuberculous meningitis
status and a score of >12 indicated good functional status.
Assessment of disability as per MBI was done at baseline and
at the end of 1st, 3rd and 6th month of follow up. MBI >12,
at the end of 6 months, was considered as good outcome.
Follow up MR study was done after 6 months.
Statistical analysis
The statistical analysis was performed using the Statistical
Package for Social Sciences, version 16 for windows (SPSS,
Chicago IL, USA) and Microsoft Excel. Both univariate and
multivariate analysis were done to evaluate the predictors
for hydrocephalus. Univariate analysis was performed by
Chi-square test for non-parametric data and student’s “t”
test for independent variables for parametric data. Rela-
tive risks with95% confidence interval were ascertained. For
multivariate analysis, binary logistic regression was per-
formed to see the impact of individual predictors of
hydrocephalus. KaplaneMeier analysis was performed to
estimate the event free survival for the outcome with or
without baseline hydrocephalus using the Log Rank test.
Statistical significance was defined at p value of <0.05. Sta-
tistical analysis was two-tailed.
Results
Baseline characteristics
We enrolled 96 patients of tuberculous meningitis. Sixteen
patients were excluded. Reasons for exclusion of 16
patients have been given in Fig. 2. Finally, 80 patients
were evaluated and followed up. Mean age of our cohort
was 30.1 (range 14e68) years. Mean duration of illness
was 97.7  21.2 days. Majority (36; 45%) of the patients,
Figure 2 Flow diagram of the study.
333
at the time of inclusion, were in stage- II. In our study,
there were 36 (45%) bacteriologically confirmed cases.
Four patients were lost to follow up and their last observa-
tions were carried forward up to 6 months. None of the pa-
tient was HIV positive. In none of the patients drug
resistance to antituberculosis drug was demonstrated.
Other base-line characteristics have been shown in Table 1.
Incidence of hydrocephalus
At inclusion, hydrocephalus was demonstrated in 52 (65%)
patients of tuberculous meningitis. Twenty patients (38.5%)
had mild hydrocephalus. Remaining, 32 (61.5%) patients had
moderate or severe hydrocephalus (Evan’s ratio equal or
more than 0.34). Periventricular ooze was present in 20
(38.5%) patients. Five patients had asymmetric dilatation of
lateral ventricles. Sulcal effacement was seen in 32 patients
(61.5%). Among patients with hydrocephalus, acute infarcts
were noted in 22 patients (42.4%), basal exudates in 38
(73.1%) and tuberculoma in 27 patients (51.9%). Among 32
patients with moderate to severe hydrocephalus, 25 (48%)
had a communicating type of hydrocephalus. And 7 (13.4%)
patients had possible obstructive type of hydrocephalus.
Predictors of hydrocephalus
On univariate analysis, clinical factors associated with
hydrocephalus were advanced stage tuberculous meningitis
(p Z 0.0012), baseline MBI12 (p Z 0.002), duration of ill-
ness >2 months (p Z 0.002), diplopia (p Z 0.001), seizures
(p Z 0.002), visual impairment (p Z 0.001), papilledema
(p Z 0.001, cranial nerve palsy (p Z 0.001) and hemipare-
sis (p Z 0.001). Pulmonary tuberculosis (p Z 0.001), CSF
total cell count >100/cu.mm (p Z 0.009), CSF protein
 Author's personal copy

334 T. Raut et al.

Table 1 Baseline characteristics in patients of tuberculous meningitis with and without hydrocephalus (n Z 80).
Characteristics Total N Z 80 Baseline No baseline Level of
hydrocephalus N Z 52 hydrocephalus N Z 28 significance
n % n % n % P
Age > 25 years 46 57.5 30 57.7 16 57.1 0.850
Male 43 53.8 29 55.8 14 50.0 0.573
Female 37 46.3 23 44.2 14 50.0
Duration of illness 43 53.8 35 67.3 08 28.6 0.002
> 2 months
Pulmonary tuberculosis 18 22.5 14 26.9 04 14.3 0.653
MRC stage I 25 31.3 11 21.2 14 50.0 0.001
MRC stage II 34 42.5 21 40.4 13 46.4
MRC stage III 21 26.3 20 38.5 01 03.6
Fever 76 95.9 51 98.1 25 89.3 0.192
Headache 73 91.3 48 92.3 25 89.3 0.079
Vomiting 59 73.8 41 78.9 18 64.3 0.088
Seizures 30 37.5 26 50.0 04 14.3 0.006
Altered sensorium 31 38.8 23 44.3 08 28.6 0.117
Meningeal signs 71 88.8 48 92.3 23 82.1 0.170
Diplopia 51 63.8 41 78.9 10 35.7 0.001
Cranial nerve 62 77.5 49 94.2 13 46.4 0.000
involvement
Papilledema 50 62.5 41 78.9 09 32.1 0.001
Optic atrophy 10 12.5 08 15.4 02 07.2 0.001
Normal vision 44 55.0 21 40.4 23 82.1
Low vision 36 45.0 31 59.6 05 17.9 0.002
CSF AFB stain 21 26.3 18 34.6 03 10.7 0.06
CSF AFB culture 28 35.0 21 40.4 7 25.0 0.258
CSF TB PCR 36 45.0 28 53.8 8 28.6 0.076
Definite TBM 36 45.0 28 53.8 8 28.6
Probable TBM 25 31.3 15 28.9 10 35.7
Possible TBM 19 23.8 11 21.2 8 28.6 0.445
Meningeal enhancement 74 92.5 50 96.2 24 85.7 0.091
Basal exudates 42 52.5 38 73.1 04 14.3 0.000
Tuberculoma 31 38.8 27 51.9 04 14.3 0.001
Infarct 26 32.5 22 42.3 04 14.3 0.011
Good outcome (MBI > 12) 57 71.3 31 59.6 26 92.9
Poor outcome MBI (<12) 23 28.8 21 40.4 02 07.2 0.002
AFB Z acid-fast bacilli; MRC Z Medical Research Council; CSF Z cerebrospinal fluid; PCR Z polymerase chain reaction;
TB Z tuberculosis; TBM Z tuberculous meningitis; MBI Z modified barthel index.

>2.5 g/l (p Z 0.05) were also associated with hydrocepha-
lus. Among the neuroimaging features, presence of basal
exudates (p Z 0.001), tuberculomas (p Z 0.001) and in-
farcts (p Z 0.011), were associated with occurrence of hy-
drocephalus. On binary logistic regression analysis, factors
that were significantly associated with presence of hydro-
cephalus included vision impairment (p Z 0.005), cranial
nerve involvement (p Z 0.012) and presence of basal exu-
dates (p Z 0.001). These three predictors had a very high
sensitivity, specificity (>80%) and a high positive predictive
value (90.2%) with a fair accuracy (86.3%), for prediction of
hydrocephalus.
Follow up
During the course of study, 10 patients died (median survival
50 days, range 25e110 days). All 10 patients, who died, had
hydrocephalus. Of 52 patients with hydrocephalus, 6 were
subjected to surgery (4 later died and 2 had partial
improvement). Among patients with baseline hydrocepha-
lus, 31 (59.6%) had a good outcome (MBI > 12). Twenty-one
patients had improved completely after six months. Eleven
cases (21.2%) had a poor outcome (MBI  12); clinical
condition of 5 patients had worsened. In 28 patients without
baseline hydrocephalus, 26 (92.8%) had a good outcome
(MBI > 12); among these patients 21 (75%) had improved
completely. Only 2 patients of later group had a poor
outcome, both experienced deterioration during follow up.
Follow up neuroimaging was done in 54 (32 with
hydrocephalus and 22 without hydrocephalus, at inclusion)
patients. Among patients with baseline hydrocephalus, 13
patients had complete resolution and 12 patients had
partial resolution. In 3 patients hydrocephalus persisted
while in another 4 patients, ventricles size further in-
creased. Of the 22 patients without baseline
 Author's personal copy

Hydrocephalus in tuberculous meningitis 335

hydrocephalus, 8 patients developed new hydrocephalus.

Of these 8 patients, only 2 had clinical deterioration. Most
of the factors, that were significantly associated with
complete resolution of hydrocephalus, indicated presence
of a less severe form of tuberculous meningitis. (Table 2).

Prognosis of tuberculous meningitis after 6 months

In our study, poor prognostic factors of tuberculous men-

ingitis were seizures (p Z 0.006), visual impairment
(p Z 0.001), hemiparesis (p Z 0.001) and paraparesis
(p Z 0.001). Baseline MBI  12 (p Z 0.008) and advanced
stage (Stage III) (p Z 0.001) were also associated with
poor outcome. Among the neuroimaging parameters, pres-
ence of hydrocephalus (p Z 0.002) and basal exudates
(p Z 0.001) were associated with poor outcome. On multi-
variate analysis, none of these factors were significantly as-
sociated with poor outcome.

Prognosis among patients with baseline
hydrocephalus
Factors associated with poor outcome (death or disability),
among patients with baseline hydrocephalus, were pres-
ence of hemiparesis (p Z 0.029), stage III tuberculous men-
ingitis (p Z 0.002), pulmonary tuberculosis (p Z 0.006) and
poor baseline MBI  12 (p Z 0.03). KaplaneMeier cumula-
tive survival curve analysis showed that the patients with
baseline hydrocephalus had significantly higher incidence
of death and severe disability comparable to those without
hydrocephalus (p Z 0.006). (Fig. 3).
Discussion
In our study, hydrocephalus was present in majority (65%)
of the patients. During follow up, hydrocephalus developed
in 8 new cases. Various studies, in the past, have reported
Figure 3 KaplaneMeier survival curves in patients of tuber-
culous meningitis with or without hydrocephalus at observed
at the time of inclusion in the study.
the incidence of hydrocephalus ranging from 17 to 95%.15e19
Earlier, air encephalography was used for the diagnosis of
hydrocephalus. In an air encephalography based study, hy-
drocephalus was observed in 62% of the pediatric patients
of tuberculous meningitis.20
Hydrocephalus can develop early in the course of the
disease or can develop paradoxically, following antituber-
culosis treatment.21,22 The predictive factors of hydroceph-
alus, in patients with tuberculous meningitis, have scantly
been evaluated. In a study, long duration of illness, ad-
vanced stage of disease, focal neurological deficit, and
presence of infarcts were significantly associated with hy-
drocephalus.21 In our study as well, hydrocephalus was
more frequent in patients with advanced disease, severe
disability and a long-duration of illness. Presence of

Table 2 Baseline characteristics predicting complete resolution of baseline hydrocephalus after 6 months (Univariate analy-
sis) (n Z 32).
Characteristic Total Complete resolution (n Z 13) Partial or no resolution (n Z 19) P value
n n % n %
Duration of illness < 2 months 13 7 53.5 06 31.6 0.281
MRC stage I & II 19 11 84.6 08 42.1 0.028
Seizures 13 05 38.5 08 42.1 0.873
Initial GCS 15/15 18 11 84.6 07 36.8 0.012
Normal vision 21 11 84.6 10 52.6 0.136
Hemiparesis 08 01 07.7 07 36.8 0.146
Baseline MBI > 12 19 12 92.3 07 36.8 0.003
CSF TLC < 100/cu.mm 17 11 84.6 06 31.6 0.005
CSF protein < 2.5 g% 17 11 84.6 06 31.6 0.005
Mild hydrocephalus 16 12 92.3 04 21.1 0.001
Basal exudates 12 03 23.1 09 47.4 0.307
Infarct 12 03 23.1 09 47.4 0.307
Tuberculoma 09 02 15.4 07 36.8 0.355
CSF Z cerebrospinal fluid; GCS- Z Glasgow coma scale; TLC Z total leucocyte count; MRC Z Medical Research Council.
Values in bold are statistically significant.
 Author's personal copy
336
hydrocephalus is, in fact, an indication of severe disease.
Most of the complications of tuberculous meningitis, includ-
ing hydrocephalus, develop because of thick copious exu-
dates, which are dominantly present in the
interpeduncular, suprasellar, and Sylvian cisterns. Opto-
chiasmatic arachnoiditis is a devastating form of tubercu-
lous meningitis and often associated with profound vision
loss and hydrocephalus.2,21 Hydrocephalus is often associ-
ated with raised intracranial pressure and several other
complications of tuberculous meningitis. Increased intra-
cranial pressure, if remains untreated, results in alteration
in consciousness. In addition to this, elevated intracranial
pressure can lead to stretching of already compromised
vessels (like the pericallosal arteries) and may produce in-
farcts.23 Optic nerve may be compressed by enlarged di-
lated third ventricle resulting in vision loss and optic
atrophy. Thus, clinical parameters like vision impairment
and cranial nerve palsy can act as important clinical indica-
tors for the presence of hydrocephalus, even before neuro-
imaging is obtained.
In earlier studies, hydrocephalus had been found a de-
terminant of poor outcome and mortality.1,17,21,24 In our
study, as well, hydrocephalus unfavorably affected overall
prognosis in patients with tuberculous meningitis. Hydro-
cephalus resolution was more frequent in patients with
milder form of disease. Corticosteroids have shown to re-
duce the number of deaths and increase the survival in adult
patients, however, role of dexamethasone, in the treatment
of hydrocephalus, is uncertain.25 Thwaites and co-workers
could not observe any significant reduction in the proportion
of patients with meningeal enhancement or hydrocephalus
at days 60 or 270 of dexamethasone treatment compared
with placebo.12 Possibly, this is the reason which explains
limited long-term benefit of corticosteroids.26 Mannitol is
frequently used in tuberculous meningitis, but its exact
role needs to be established by well-designed trials. It
may have a beneficial effect on lowering the intracranial
pressure, but not on survival or disability.7,27
In our study, 6 patients were subjected to CSF diversion
procedures. Shunt surgery is, generally, indicated in pa-
tients with obstructive hydrocephalus. Shunt surgery is also
considered in patients with either an advanced disease or
a deteriorating clinical condition. Currently, two types of
surgeries are performed; ventriculo-peritoneal shunt or
endoscopic third ventriculostomy. Endoscopic third ventri-
culostomy creates a communication between third ventri-
cle and subarachnoid space bypassing cerebral aqueduct. It
is now considered as a safe and effective treatment option
for hydrocephalus.7 Unfortunately, not all patients, who
undergo shunt surgery, show a significant improvement. In
some centers shunt surgery is performed when the clinical
condition of the patient improves following temporary ex-
ternal ventricular drainage.4 Studies have shown that tu-
berculous meningitis with hydrocephalus requiring CSF
diversion carries significant short-term mortality.4 The pa-
tients, who had cerebral infarcts, had an even worse out-
come. Mortality in the group with infarcts was 100%,
compared to 42% in the group without infarcts.28
We used the Evan’s ratio to diagnose hydrocephalus
because of its simplicity and its ability to identify ventri-
culomegaly.29 Recently, Evan’s ratio has been criticized as
its value can vary, depending on the level of the brain
T. Raut et al.
scan image at which the frontal horns and maximal inner
skull diameters are measured.30 However, Evan’s ratio is
still frequently used method to diagnose hydrocephalus.31
The distinction between two types of hydrocephalus (com-
municating and obstructive type) is often not clear cut. For
example, if all the ventricles are enlarged, then it is diffi-
cult to establish whether the hydrocephalus is due to ob-
struction of the fourth ventricular outlets or due to
an obstruction to the CSF pathways in the basal subarach-
noid spaces. In patients with tuberculous meningitis com-
municating hydrocephalus is much more common than
obstructive hydrocephalus.4
In conclusion, hydrocephalus is a common complication
of tuberculous meningitis.
If a patient had neurological deficits, seizures or is in bad
clinical conditions, cranial imaging should be performed to
check for hydrocephalus. Majority of patients having mild
hydrocephalus had a good outcome and complete resolu-
tion with medical management. CSF diversion procedures
may not bring desired results in rapidly deteriorating
patients.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.jinf.2012.12.009.
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