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LETTER TO THE EDITOR
Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 233
 

Endoscopic third ventriculostomy in tuberculous meningitis needs more evidence


1 Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
2 Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Neurology, Vivekananda Institute of Medical Sciences, Kolkata, India
4 Department of Medicine, S.P. Medical College, Bikaner, Rajasthan, India

Date of Web Publication14-Aug-2012

Correspondence Address:
Usha K Misra
Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow- 226 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.99739

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How to cite this article:
Misra UK, Kalita J, Prabhakar S, Chakravarty A, Kochar D, Nair P P. Endoscopic third ventriculostomy in tuberculous meningitis needs more evidence. Ann Indian Acad Neurol 2012;15:233

How to cite this URL:
Misra UK, Kalita J, Prabhakar S, Chakravarty A, Kochar D, Nair P P. Endoscopic third ventriculostomy in tuberculous meningitis needs more evidence. Ann Indian Acad Neurol [serial online] 2012 [cited 2019 Jul 15];15:233. Available from: http://www.annalsofian.org/text.asp?2012/15/3/233/99739


Sir,

We thank the authors for their interest in "cerebral malaria and bacterial meningitis" by Misra et al. [1] The authors highlight the importance of endoscopic third ventriculostomy (ETV) in the management of tuberculous meningitis (TBM) associated hydrocephalus. They suggest that ventriculoperitoneal (VP) shunt is no longer the treatment of choice; instead ETV should be preferred for the management of hydrocephalus even in the early stage of TBM as it precludes many shunt related problems such as infection and block.

Endoscopic techniques are a welcome change and have simplified the management of several disorders including hydrocephalus. Very little data is available on the management of hydrocephalus in the patients with TBM using ETV; therefore, individual or institutional preferences are common. [2] Hydrocephalus in TBM has certain special features; the floor of third ventricle is often thick and the subarachnoid space is often obliterated by basal exudates which may obscure the anatomical landmarks especially the vertebrobasilar artery and its branches. Rajshekhar in his experience of ETV in the early stage of TBM reported that the floor of third ventricle was thick and covered by granulation tissue or tuberculoma which bleed even on touch with a blunt probe. Bleeding during ETV obscures the endoscopic view and renders the surgery difficult. [3] ETV therefore requires skilled and experienced surgeon who are available in only a few centers in our country.

The available experience on ETV in TBM related hydrocephalus is based on small series of 17-59 patients and the success rates have ranged between 41% and 81%. [4],[5],[6],[7] The difficulty in ETV was highlighted in a study from South Africa, in which success was achieved in 7 out of 17 patients, ETV failed in 5 and had to be abandoned in another 5 patients. [6] The results of ETV in TBM related hydrocephalus are better in the patients who have received anti tubercular treatment for at least 4 weeks, or if the hydrocephalus has developed late. [5],[8] When the exudates has organized and the floor of third ventricle is thin. I would respectfully disagree with the authors' statement that "A sincere attempt to establish CSF pathway by an endoscopic method should be done before placing a shunt" it seems prudent that ETV should be avoided in the early stage of TBM especially in untreated patients. ETV may have some role in the patients who have shunt failure or have received anti-tubercular treatment for at least 4 weeks.

New techniques should be rigorously evaluated and compared with the standard treatment before being recommended for general use or being included in the national guidelines. We hope that soon high quality data will be generated so that the proper place of ETV in the management of TBM associated hydrocephalus could be determined. In our opinion, the evidence at the moment is not sufficient to recommend ETV in the routine management of TBM related hydrocephalus especially in the early stage.

 
   References Top

1.Misra UK, Kalita J, Prabhakar S, Chakravarty A, Kochar D, Nair PP. Cerebral malaria and bacterial meningitis. Ann Indian Acad Neurol 2011;14: S35-9.  Back to cited text no. 1
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2.Figaji AA, Fieggen AG. Endoscopic challenges and applications in tuberculous meningitis. World Neurosurg 2012.  Back to cited text no. 2
    
3.Rajshekhar V. Management of hydrocephalus in patients with tuberculous meningitis. Neurol India 2009;57: 368-74.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Singh D, Sachdev V, Singh AK, Sinha S. Endoscopic third ventriculostomy in post-tubercular meningitic hydrocephalus: a preliminary report. Minim Invasive Neurosurg 2005;48: 47-52.  Back to cited text no. 4
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5.Husain M, Jha DK, Rastogi M, Husain N, Gupta RK. Role of neuroendoscopy in the management of patients with tuberculous meningitis hydrocephalus. Neurosurg Rev 2005;28: 278-83.  Back to cited text no. 5
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6.Figaji AA, Fieggen AG, Peter JC. Endoscopic third ventriculostomy in tuberculous meningitis. Childs Nerv Syst 2003;19: 217-25.  Back to cited text no. 6
[PUBMED]    
7.Yadav YR, Parihar V, Agrawal M, Bhatele PR. Endoscopic third ventriculostomy in tubercular meningitis with hydrocephalus. Neurol India 2011;59: 855-60.  Back to cited text no. 7
  Medknow Journal  
8.Chugh A, Husain M, Gupta RK, Ojha BK, Chandra A, Rastogi M. Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: Prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy. J Neurosurg Pediatr 2009;3: 371-7.  Back to cited text no. 8
[PUBMED]    



This article has been cited by
1 Tuberculous meningitis: more questions, still too few answers
Guy E Thwaites,Ronald van Toorn,Johan Schoeman
The Lancet Neurology. 2013; 12(10): 999
[Pubmed] | [DOI]



 

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