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Editorial

Tuberculous meningitis and hydrocephalus

Atul Goel
Department of Neurosurgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400012, India.

Although there are a large number of publications available ness, focal neurological deficits, decerebrate spasms and death
in the literature recommending the benefits of a shunt proce- are a result of arteritis and infarcts in the brainstem,
dure in tuberculous meningitis, the subject deserves a more hypothalamus, basal ganglia and the hemisphere.
comprehensive analysis. Hydrocephalus frequently accompa- The primary symptoms in tuberculous meningitis are fever,
nies tuberculous meningitis. Mild to severe hydrocephalus is headache, vomiting, blindness, focal convulsions, worsening
almost always identified on computer based imaging in cases consciousness, decerebrate spasms and respiratory embar-
with tuberculous meningitis and occurs early in the patho- rassment. All these symptoms are related to the convexity
logical events. Despite this fact, all cases of tuberculous men- and basal meningeal infection and cannot be attributed di-
ingitis associated with hydrocephalus are not suitable for a rectly to raised intracranial pressure or hydrocephalus. Mark-
shunt operation. edly bulging fontanelle and enlarging head size is seldom
The exact pathogenesis of hydrocephalus in tuberculous observed in tuberculous meningitis. The intraventricular
meningitis is unclear. The hydrocephalus is probably a result pressure in cases of hydrocephalus with tuberculous menin-
of basal adhesive meningeal reaction wherein the flow of the gitis is generally low or only marginally raised. The treat-
CSF is obliterated in its course from the point of exit from ment strategy for tuberculous meningitis and hydrocepha-
the fourth ventricle to the site of its absorption in the arach- lus should be aggressive anti-tuberculous drugs and wher-
noid villi. Obliteration of the arachnoid villi themselves and ever necessary institution of steroids. Ventricular CSF di-
various other speculations have been proposed as to the cause versionary surgery may not be necessary in most cases and
of the hydrocephalus in tuberculous meningitis. Like in tu- can be avoided. Shunt surgery on the basis of radiological
berculosis elsewhere in the body, in tuberculous infection of imaging diagnosis and for the sake of helping the situation
the brain, basal arachnoiditis and arteritis suggests presence of hydrocephalus in presence of other florid evidence of tu-
of an aggressive disease and the presence of tuberculomas berculous meningitis, more often than not, is of no benefit.
suggests an aggressive body response and a relatively favorable Monitoring of intraventricular pressure can be helpful in situ-
outcome. ations where there is doubt about the need of a shunt opera-
Basal arachnoiditis can be mild to very extensive in tuber- tion. Due to an immunocompromised state of patients with
culous meningitis. The tuberculous exudates result in gum- tuberculous meningitis, chances of shunt tube related infec-
ming up of the subarachnoid spaces. Visual deficit is in gen- tion are more predominant.
eral a result of affection of the optic nerve and its membranes. In adolescents and adults with tuberculous meningitis and
Optic atrophy and visual deficits, occur relatively early in the hydrocephalus, the signs of increased intracranial pressure
clinical course and suggests the severity of the disease. Hemi- and drowsiness are more predominant. Such patients are usu-
spheric convexity arachnoiditis result in cortical irritation and ally benefited by a shunt. In some cases, when the disease
can cause focal convulsions. Apart from adhesive basal arach- process is dying down, hydrocephalus can develop and result
noiditis the other important pathological event that occurs is in symptoms of headache, drowsiness and impairment of level
basal arteritis. Small or large vessel arteritis is the principle of sensorium. Such situations also can occasionally be helped
crippling factor in the neurological squeal of tuberculous men- by a shunt surgery. Before a shunt is done it maybe a good
ingitis. Worsening sensorium from drowsiness to unconscious- idea to assess the intraventricular pressure.

Atul Goel
Department of Neurosurgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400012, India. E-mail: atulgoel62@hotmail.com

Neurology India June 2004 Vol 52 Issue 2 155

CMYK 155