Factors influencing shunt malfunction in patients with tuberculous meningitis

Abstract

Background

Hydrocephalus secondary to tuberculous meningitis (TBM) is a challenging condition to treat. Though ventriculo-peritoneal (VP) shunt is an accepted modality of treatment for hydrocephalus in TBM, there is a high rate of complications associated with the same.

Objective

The study was planned to evaluate various factors associated with shunt malfunction in patients undergoing VP shunt surgery for hydrocephalus due to TBM.

Materials and Methods

A retrospective review of all the patients undergoing VP shunt and shunt revision for TBM between 2004 and 2008 was performed. 449 VP shunt surgeries were performed in 432 patients for hydrocephalus due to TBM. Among these 70 shunt revisions were performed in 53 patients.

Results

Shunt malfunction rate in our series was 16.2%. High cerebrospinal fluid (CSF) protein concentration (>200 mg/dL) was associated with 5 times increased incidence of shunt malfunction. Patients with hyponatremia (Na+ <130 mEq/dL) prior to surgery had a 3 times increased incidence of shunt malfunction (P < 0.05). Other factors such as duration of symptoms, presence of neurological deficits, Evan’s index, third ventricular diameter, thickness of exudates, presence of infarcts, anemia, CSF cellularity and CSF glucose concentration were not associated with increased incidence of shunt malfunction. Analysis showed that shunt viability was longest in patients with normal serum sodium levels and CSF protein concentration less than 200 mg/dL and shortest in patients with low serum sodium and CSF protein concentration more than 200 mg/dL.

Conclusions

Patients with pre-operative hyponatremia and high CSF protein concentration have a higher incidence of shunt malfunction and need to be followed-up closely.

Key words

Hydrocephalus - hyponatremia - shunt malfunction - tuberculous meningitis - ventriculo-peritoneal shunt

• References

• 1 Kalita J, Misra UK, Ranjan P. Predictors of long-term neurological sequelae of tuberculous meningitis: A multivariate analysis. Eur J Neurol 2007; 14: 33-37
• 2 Kemaloglu S, Ozkan U, Bukte Y, Ceviz A, Ozates M. Timing of shunt surgery in childhood tuberculous meningitis with hydrocephalus. Pediatr Neurosurg 2002; 37: 194-198
• 3 Rajshekhar V. Management of hydrocephalus in patients with tuberculous meningitis. Neurol India 2009; 57: 368-374
• 4 Agrawal D, Gupta A, Mehta VS. Role of shunt surgery in pediatric tubercular meningitis with hydrocephalus. Indian Pediatr 2005; 42: 245-250
• 5 Sil K, Chatterjee S. Shunting in tuberculous meningitis: A neurosurgeon’s nightmare. Childs Nerv Syst 2008; 24: 1029-1032
• 6 Brydon HL, Hayward R, Harkness W, Bayston R. Physical properties of cerebrospinal fluid of relevance to shunt function. 1: The effect of protein upon CSF viscosity. Br J Neurosurg 1995; 9: 639-644
• 7 Brydon HL, Hayward R, Harkness W, Bayston R. Physical properties of cerebrospinal fluid of relevance to shunt function. 2: The effect of protein upon CSF surface tension and contact angle. Br J Neurosurg 1995; 9: 645-651
• 8 Srikantha U, Morab JV, Sastry S, Abraham R, Balasubramaniam A, Somanna S. et al Outcome of ventriculoperitoneal shunt placement in Grade IV tubercular meningitis with hydrocephalus: A retrospective analysis in 95 patients. Clinical article. J Neurosurg Pediatr 2009; 4: 176-183
• 9 Palur R, Rajshekhar V, Chandy MJ, Joseph T, Abraham J. Shunt surgery for hydrocephalus in tuberculous meningitis: A long-term follow-up study. J Neurosurg 1991; 74: 64-69
• 10 Lamprecht D, Schoeman J, Donald P, Hartzenberg H. Ventriculoperitoneal shunting in childhood tuberculous meningitis. Br J Neurosurg 2001; 15: 119-125
• 11 Jain G, Mukerji G, Dixit A, Manshani N, Yadav YR. The impact of nutritional status on the outcome of Indian patients undergoing neurosurgical shunt surgery. Br J Nutr 2007; 98: 944-949
• 12 Roos KL. Mycobacterium tuberculosis meningitis and other etiologies of the aseptic meningitis syndrome. Semin Neurol 2000; 20: 329-335
• 13 Guindi S, Mansour MM, Girgis NI, Miner WF. Serum and cerebrospinal fluid proteins in tuberculous meningitis. Eur Neurol 1980; 19: 247-251
• 14 Mansour MM, Guindi S, Girgis NI. Levels of individual serum and cerebrospinal fluid proteins in purulent and tuberculous meningitis. Eur Neurol 1981; 20: 40-45
• 15 Kilincoglu BF, Dalkilic T, Dincbal MN, Aydin Y. Shunting in hydrocephalus due to tuberculous meningitis. Cases presenting with high cerebrospinal fluid proteins in pediatric age. J Neurosurg Sci 2009; 53: 49-53
• 16 Singh BS, Patwari AK, Deb M. Serum sodium and osmolal changes in tuberculous meningitis. Indian Pediatr 1994; 31: 1345-1350
• 17 Rapoport S, West CD, Brodsky WA. Salt losing conditions; the renal defect in tuberculous meningitis. J Lab Clin Med 1951; 37: 550-561
• 18 Yee AH, Burns JD, Wijdicks EF. Cerebral salt wasting: Pathophysiology, diagnosis, and treatment. Neurosurg Clin N Am 2010; 21: 339-352
• 19 Narotam PK, Kemp M, Buck R, Gouws E, van Dellen JR, Bhoola KD. Hyponatremic natriuretic syndrome in tuberculous meningitis: The probable role of atrial natriuretic peptide. Neurosurgery 1994; 34: 982-988
• 20 Ohta M, Ito S. Hyponatremia and inflammation. Rinsho Byori 1999; 47: 408-416
• 21 Brydon HL, Bayston R, Hayward R, Harkness W. The effect of protein and blood cells on the flow-pressure characteristics of shunts. Neurosurgery 1996; 38: 498-504
• 22 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: 371-377
• 23 Jonathan A, Rajshekhar V. Endoscopic third ventriculostomy for chronic hydrocephalus after tuberculous meningitis. Surg Neurol 2005; 63: 32-34
• 24 Jha DK, Mishra V, Choudhary A, Khatri P, Tiwari R, Sural A. et al Factors affecting the outcome of neuroendoscopy in patients with tuberculous meningitis hydrocephalus: A preliminary study. Surg Neurol 2007; 68: 35-41