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Endoscopic third ventriculostomy for chronic hydrocephalus after tuberculous meningitis
Surgical Neurology 63 (2005) 32 – 35 www.surgicalneurology-online.com
Technique
Endoscopic third ventriculostomy for chronic hydrocephalus after tuberculous meningitis Ashish Jonathan, MBBS, Vedantam Rajshekhar, MCh* Department of Neurological Sciences, Christian Medical College and Hospital, Vellore 632004, Tamil Nadu, India Received 2 June 2003; accepted 8 March 2004
Abstract
Background: Cerebrospinal fluid diversion procedures are indicated in patients with hydrocephalus after tuberculous meningitis (TBM). We present 2 patients with hydrocephalus after TBM who were successfully treated with endoscopic third ventriculostomy (ETV). Methods: Two patients had been diagnosed with hydrocephalus after TBM and had undergone ventriculoperitoneal shunt surgery for the same. They presented with multiple episodes of shunt dysfunction. Endoscopic third ventriculostomy was performed (twice for one patient), and the patients were evaluated clinically and radiologically after the procedure. Results: On long-term clinical follow-up (3 and 2 years, respectively), both patients were asymptomatic after the ETV. The first patient was radiologically evaluated 7 months after the procedure and the second patient 2 years after the procedure. The first patient showed a decrease in ventricular size. The second patient did not show any significant change in the ventricular size. Conclusion: Endoscopic third ventriculostomy can be considered as a safe and long-lasting solution for hydrocephalus after chronic TBM. D 2005 Elsevier Inc. All rights reserved.
Keywords:
Endoscopic third ventriculostomy; Hydrocephalus; Tuberculous meningitis
1. Introduction Hydrocephalus is one of the most common complications of tuberculous meningitis (TBM). Tandon et al [10] state that hydrocephalus is present in nearly all patients who have had the disease for more than 4 to 6 weeks. Hydrocephalus in TBM can be communicating, obstructive, or a combination of both. In the acute stages, basal exudates, and in the chronic stages, adhesive leptomeningitis cause a subarachnoid block that impedes the passage of cerebrospinal fluid (CSF) through the arachnoid granulations into the venous sinuses. Obstructive hydrocephalus can also occur in patients with TBM because of obstruction of the aqueduct or the foramina of Lushka or Magendie. Several patients with TBM may have a combination of obstructive and communicating hydrocephalus. In a study
* Corresponding author. Tel.: +91 416 2222102; fax: +91 416 2232035, +91 416 2232103. E-mail address: [email protected] (V. Rajshekhar). 0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2004.03.011
by Lampretch et al [4] of 217 patients with TBM hydrocephalus, 38 had noncommunicating hydrocephalus and were shunted. Of the remaining 179 patients with communicating hydrocephalus, 27 patients had failure of medical therapy and required shunting. The traditional treatment of hydrocephalus after TBM is CSF diversion [5,7]. The most common form of CSF diversion is shunt. Ventriculoatrial and ventriculopleural shunts have been largely replaced by the ventriculoperitoneal (VP) shunt. Shunt systems can be plagued by various complications, of which infection and dysfunction are the most common. Endoscopic third ventriculostomy (ETV) is an alternative form of CSF diversion [2,8], which has been shown to be successful in the management of obstructive hydrocephalus. However, its utility in the treatment of patients with hydrocephalus after TBM has not been conclusively proven. We report 2 patients with bburnt-out Q TBM and hydrocephalus in whom ETV successfully relieved hydrocephalus resulting from shunt dysfunction.
A. Jonathan, V. Rajshekhar / Surgical Neurology 63 (2005) 32–35
2. Case reports 2.1. Case 1 A 23-year-old woman, with a known case of post-TBM hydrocephalus and 4 episodes of shunt dysfunction, presented with recurrent headaches and vomiting for 4 days after the last shunt surgery. She also had noticed impairment of upward gaze and bilateral drooping of the eyelids for the past 20 days. On examination, there was bilateral papilledema. The pupils were equal and sluggishly reactive to light. There was loss of upward gaze and convergence. There were no other cranial nerve deficits. Computed tomography (CT) scans showed dilatation of the lateral and third ventricles. 2.1.1. Course of illness She underwent ETV. She was asymptomatic for a week, then she again developed features of raised intracranial pressure. A magnetic resonance imaging phase-contrast study done to assess the patency of the ventriculostomy showed no flow across the ventriculostomy defect. Because she already had multiple episodes of shunt dysfunction, a repeat ETV was performed. The previous ventriculostomy site was found to have closed off. After the ETV revision, she has been asymptomatic. On follow-up, 3 years later, she was asymptomatic for raised pressure and had a decrease in ventricular volume as compared with the preoperative scan (Fig. 1). The ventricular volumes were as follows: pre-ETV, 218 mL; post-ETV, 166 mL; on 7 months follow-up after ETV, 76 mL. 2.2. Case 2 A 54-year-old man had been treated for TBM and had undergone a right VP shunt in 1991, which was revised once in 1992 and twice in 1999. He presented in 2000 with a history of recurrent episodes of vomiting for 2 days.
33
On examination, he had bilateral papilledema. There was mild upgaze paresis. Computed tomography scan showed the shunt tip to be in the right temporal horn, and there was moderate dilatation of the lateral and third ventricles. 2.2.1. Course of illness He presented with clinical features of shunt dysfunction. Computed tomography scan showed malposition of the ventricular end of the previously placed shunt tube. He underwent an ETV. On evaluation 2 years after the surgery, he was asymptomatic. Assessment of the ventricular volume (lateral and third ventricles) on the preoperative CT and the 2-year follow-up CT scan showed no significant change in the volume of the ventricles (40 and 39 mL). 3. Discussion Cerebrospinal fluid diversion, in addition to pharmacotherapy for the primary disease, is the accepted form of treatment of hydrocephalus after TBM. However, the longterm outcome is dependent on the preoperative Glasgow coma score or grade of the patient [5,7]. Response to external ventricular drainage may be used as a predictor of outcome after shunt surgery [5]. Lampretch et al [4] studied 217 patients with stages II and III TBM (British Medical Research Council Classification of TBM) and hydrocephalus. They determined the type of hydrocephalus (communicating or obstructive) using pneumoencephalograms. Ventriculoperitoneal shunts were performed in acute cases if the hydrocephalus was noncommunicating or after failed medical therapy if the hydrocephalus was of the communicating type. After this protocol, only 65 of 217 patients eventually required VP shunt. Of these, 38 patients had noncommunicating hydrocephalus, all of which were shunted. The 179 patients with communicating hydroceph-
Fig. 1. Preoperative (A) and postoperative (B) images in case 1. The postoperative CT scan shows a significant decrease in ventricular size. Note the shunt tubes in the lateral ventricle in the preoperative CT scan (A).
34
A. Jonathan, V. Rajshekhar / Surgical Neurology 63 (2005) 32–35
alus were treated with acetazolamide and furosemide in addition to antituberculosis drugs. These patients were referred for VP shunting if their CSF pressure did not decrease or if their clinical condition deteriorated and CT scan showed progressive hydrocephalus. Of the 179 patients with communicating hydrocephalus, 27 required shunting. Good outcome or moderate disability was seen in 55.4%, and 12.3% died. In this study, shunt patients had a complication rate of 32.3% over a follow-up period of 6 months. Of these, the most common cause of shunt dysfunction was shunt obstruction without infection in 9 patients and shunt obstruction with infection in 9 patients. Other complications seen were overshunting in 2 patients and wound disruption in 1 patient. In 2 studies on the management of hydrocephalus after TBM performed in our department, we found that patients in the worst grade had a high mortality and high rate of shunt-related complications [5,7]. Therefore, an effective alternative to shunt surgery could be beneficial in some of these patients. Endoscopic third ventriculostomy is an accepted method for the treatment of obstructive hydrocephalus. It has also been shown to be an effective alternative to shunt revision in patients affected by obstructive hydrocephalus presenting with shunt malfunction or infection [1-3,8]. The role of ETV in communicating hydrocephalus is not clear. There are reports of successful outcome with ETV in some patients with communicating hydrocephalus such as those with normal pressure hydrocephalus [6]. In view of these observations, hydrocephalus after TBM, which may be obstructive, communicating, or a combination of both, should be amenable to treatment with ETV provided the TBM has been treated. Siomin et al [9] evaluated the safety, efficacy, and indications for ETV in 101 patients who had hydrocephalus with a history of subarachnoid hemorrhage or intraventricular hemorrhage and/or CSF infection. They reported on 42 patients who had history of CSF infection. The overall success rate of ETV in these 42 patients was 64.3%. The severity, number, location, or type of infection did not appear to affect the outcome of the procedure. The concerns in a patient with a postmeningitic state pertain to the patency of the subarachnoid space in the basal cisterns and to the absorption capacity of the arachnoid villi. The arachnoiditis could seal off parts of the basal cisterns, and exudates could block the arachnoid villi, thus, preventing reabsorption of the CSF diverted into the subarachnoid space from the ventricles after the ETV. The second concern is that in these patients, there is a possibility of arachnoidal inflammatory process closing off the ventriculostomy stoma even in patients with burnt-out disease. This seems to have happened in case 1 in whom the ETV has to be repeated, but after the second ETV, the patient has remained asymptomatic for more than 3 years. Although ETV is a good alternative to shunt revision, potential complications of ETV should also be borne in mind [4]. In addition to the complications associated with ETV
when it is done as a primary procedure, ETV in patients who have malfunctioning or infected shunts presents special problems. The floor of the third ventricle after meningitis may be thick and opaque, making it difficult to perforate and to visualize the vessels in the interpeduncular cistern. In addition, the floor of the third ventricle and the underlying arachnoid cyst or villi could be vascularized and can bleed during the perforation. Therefore, an experienced operator should perform ETV in these patients, and the procedure may have to be terminated in some patients if difficulties arise because of the above-mentioned factors. 4. Conclusion Endoscopic third ventriculostomy can be considered as an ideal, safe, and long-lasting solution for hydrocephalus after chronic TBM. This is especially so if the patient has one or multiple episodes of shunt dysfunction. References [1] Cinalli G, Salazar C, Mallucci C, Yada JZ, Zerah M, Sainte-Rose C. The role of endoscopic third ventriculostomy in the management of shunt malfunction. Neurosurgery 1998;43:1323 - 9. [2] Hopf NJ, Grunert P, Fries G, Resch KDM, Perneczky A. Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures. Neurosurgery 1999;44:795 - 806. [3] Jones RF, Stening WA, Kwok BC, Sands TM. Third ventriculostomy for shunt infections in children. Neurosurgery 1993;32:855 - 9. [4] Lampretch D, Schoeman J, Donald P, Hartzenberg H. Ventriculoperitoneal shunting in children in childhood tuberculous meningitis. Br J Neurosurg 2001;15:119 - 25. [5] Mathew JM, Rajshekhar V, Chandy MJ. Shunt surgery in poor grade patients with tuberculous meningitis and hydrocephalus: effects of response to external ventricular drainage and other variables on longterm outcome. J Neurol Neurosurg Psychiatry 1998;65:115 - 8. [6] Mitchel P, Mathew R. Third ventriculostomy in normal pressure hydrocephalus. Br J Neurosurg 1999;13:382 - 5. [7] 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 - 9. [8] Sainte-Rose C, Hooven MD, Hirsh JF. A new approach in the treatment of hydrocephalus. J Neurosurg 1987;66:213 - 26. [9] Siomin V, Cinalli G, Grotenhuis A, Golash A, Oi S, Kothbauer K, Weiner H, Roth J, Beni-Adani L, Pierre-Kahn A, Takahashi Y, Mallucci C, Abbott R, Wisoff J, Constantini S. Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage. J Neurosurg 2002;97:519 - 24. [10] Tandon PN, Bhatia R, Bhargava S. Tuberculous meningitis. In: Vinken PJ, Bruyn GW, Kalwans HL, editors. Microbial disease. Handbook of clinical neurology, vol. 52. Amsterdam7 Elsevier; 1998. p. 195 - 226.
Commentary Endoscopic third ventriculostomy is a good alternative to VP shunting in some patients with hydrocephalus. Although ETV is an old procedure and has acquired new relevance in selected pathologies underlying hydrocephalus, it is most effective in noncommunicating hydrocephalus, particularly
A. Jonathan, V. Rajshekhar / Surgical Neurology 63 (2005) 32–35
in tumors of the posterior fossa. However, additional indications are of major importance because the surgical procedure is relatively safe and it brings the possibility of endogenously mediated restoration of CSF circulation without using foreign artifacts. This feature makes ETV a good alternative to VP shunting, considering that the longterm evolution of most shunting devices, including the more sophisticated and expensive, has many complications. The results of Jonathan and Rajshekhar show good results of ETV in patients with hydrocephalus secondary to a severe infectious disorder of the meninges. The long-term improvement achieved in these 2 patients is unexpected because the main origin of hydrocephalus in most cases of meningeal tuberculosis is disturbance of CSF absorption due to residual fibrosis at the subarachnoid tissue, which theoretically would not be solved by an alternative route of CSF circulation. However, the result is welcome, but the number of cases must be increased to find the optimal indications of ETV in cases of hydrocephalus secondary to infectious disorders of the meninges, such as bacterial meningitis and neurocysticercosis. Julio Sotelo, MD Instituto Nacional de Neurologia y Neurocirurgia Mexico City 14269, Mexico In this article, the authors reported 2 cases of TBM complicated with hydrocephalus and increased intracranial pressure. The first case was a 23-year-old woman initially treated with traditional shunt procedure, but consequently followed by 4 episodes of shunt dysfunction with recurrent
35
headaches and vomiting. The second case was a 54-year-old man who has undergone VP shunt for his hydrocephalus. He had multiple shunt dysfunctions 10 years after the procedure. The patient in case 1 finally underwent ETV and was asymptomatic for 1 week only. She then underwent repeat ETV and remained asymptomatic for 3 years. The patient in case 2 was asymptomatic for 2 years after ETV; however, the ventricle volume remained the same. Most cases of TBM are associated with basal meningitis, which might result in either communicating or obstructive hydrocephalus. According to the authors’ statement, ETV is an accepted method for the treatment of obstructive hydrocephalus, but the role of ETV in communicating hydrocephalus is not clear. Endoscopic third ventriculostomy can be considered as an alternative procedure to relieve hydrocephalus when the division of CSF is not successful after multiple shunt dysfunctions. Endoscopic third ventriculostomy is a good procedure to relieve hydrocephalus when the third ventricle is enlarged and its floor is thin and transparent, allowing visualization of the vessels in the interpeduncular cistern. If the floor of the third ventricle is thick and opaque because of previous meningitis or other causes, ETV should not be considered because it is potentially very risky. A few cases of TBM had complications of hydrocephalus with multiple septa within the enlarged ventricle. In this situation, ETV may not adequately and effectively relieve the hydrocephalus. Ming-Chien Kao, MD, DMSc Department of Neurosurgery National Taiwan University Hospital Taipei, Taiwan
Postmodernism entices us with the siren call of liberation and creativity, but it may be an invitation to intellectual and moral suicide. –Gertrude Himmelfarb (b. 1922), U.S. historian (On Looking Into the Abyss, ch. 7, 1994)
Technique
Endoscopic third ventriculostomy for chronic hydrocephalus after tuberculous meningitis Ashish Jonathan, MBBS, Vedantam Rajshekhar, MCh* Department of Neurological Sciences, Christian Medical College and Hospital, Vellore 632004, Tamil Nadu, India Received 2 June 2003; accepted 8 March 2004
Abstract
Background: Cerebrospinal fluid diversion procedures are indicated in patients with hydrocephalus after tuberculous meningitis (TBM). We present 2 patients with hydrocephalus after TBM who were successfully treated with endoscopic third ventriculostomy (ETV). Methods: Two patients had been diagnosed with hydrocephalus after TBM and had undergone ventriculoperitoneal shunt surgery for the same. They presented with multiple episodes of shunt dysfunction. Endoscopic third ventriculostomy was performed (twice for one patient), and the patients were evaluated clinically and radiologically after the procedure. Results: On long-term clinical follow-up (3 and 2 years, respectively), both patients were asymptomatic after the ETV. The first patient was radiologically evaluated 7 months after the procedure and the second patient 2 years after the procedure. The first patient showed a decrease in ventricular size. The second patient did not show any significant change in the ventricular size. Conclusion: Endoscopic third ventriculostomy can be considered as a safe and long-lasting solution for hydrocephalus after chronic TBM. D 2005 Elsevier Inc. All rights reserved.
Keywords:
Endoscopic third ventriculostomy; Hydrocephalus; Tuberculous meningitis
1. Introduction Hydrocephalus is one of the most common complications of tuberculous meningitis (TBM). Tandon et al [10] state that hydrocephalus is present in nearly all patients who have had the disease for more than 4 to 6 weeks. Hydrocephalus in TBM can be communicating, obstructive, or a combination of both. In the acute stages, basal exudates, and in the chronic stages, adhesive leptomeningitis cause a subarachnoid block that impedes the passage of cerebrospinal fluid (CSF) through the arachnoid granulations into the venous sinuses. Obstructive hydrocephalus can also occur in patients with TBM because of obstruction of the aqueduct or the foramina of Lushka or Magendie. Several patients with TBM may have a combination of obstructive and communicating hydrocephalus. In a study
* Corresponding author. Tel.: +91 416 2222102; fax: +91 416 2232035, +91 416 2232103. E-mail address: [email protected] (V. Rajshekhar). 0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2004.03.011
by Lampretch et al [4] of 217 patients with TBM hydrocephalus, 38 had noncommunicating hydrocephalus and were shunted. Of the remaining 179 patients with communicating hydrocephalus, 27 patients had failure of medical therapy and required shunting. The traditional treatment of hydrocephalus after TBM is CSF diversion [5,7]. The most common form of CSF diversion is shunt. Ventriculoatrial and ventriculopleural shunts have been largely replaced by the ventriculoperitoneal (VP) shunt. Shunt systems can be plagued by various complications, of which infection and dysfunction are the most common. Endoscopic third ventriculostomy (ETV) is an alternative form of CSF diversion [2,8], which has been shown to be successful in the management of obstructive hydrocephalus. However, its utility in the treatment of patients with hydrocephalus after TBM has not been conclusively proven. We report 2 patients with bburnt-out Q TBM and hydrocephalus in whom ETV successfully relieved hydrocephalus resulting from shunt dysfunction.
A. Jonathan, V. Rajshekhar / Surgical Neurology 63 (2005) 32–35
2. Case reports 2.1. Case 1 A 23-year-old woman, with a known case of post-TBM hydrocephalus and 4 episodes of shunt dysfunction, presented with recurrent headaches and vomiting for 4 days after the last shunt surgery. She also had noticed impairment of upward gaze and bilateral drooping of the eyelids for the past 20 days. On examination, there was bilateral papilledema. The pupils were equal and sluggishly reactive to light. There was loss of upward gaze and convergence. There were no other cranial nerve deficits. Computed tomography (CT) scans showed dilatation of the lateral and third ventricles. 2.1.1. Course of illness She underwent ETV. She was asymptomatic for a week, then she again developed features of raised intracranial pressure. A magnetic resonance imaging phase-contrast study done to assess the patency of the ventriculostomy showed no flow across the ventriculostomy defect. Because she already had multiple episodes of shunt dysfunction, a repeat ETV was performed. The previous ventriculostomy site was found to have closed off. After the ETV revision, she has been asymptomatic. On follow-up, 3 years later, she was asymptomatic for raised pressure and had a decrease in ventricular volume as compared with the preoperative scan (Fig. 1). The ventricular volumes were as follows: pre-ETV, 218 mL; post-ETV, 166 mL; on 7 months follow-up after ETV, 76 mL. 2.2. Case 2 A 54-year-old man had been treated for TBM and had undergone a right VP shunt in 1991, which was revised once in 1992 and twice in 1999. He presented in 2000 with a history of recurrent episodes of vomiting for 2 days.
33
On examination, he had bilateral papilledema. There was mild upgaze paresis. Computed tomography scan showed the shunt tip to be in the right temporal horn, and there was moderate dilatation of the lateral and third ventricles. 2.2.1. Course of illness He presented with clinical features of shunt dysfunction. Computed tomography scan showed malposition of the ventricular end of the previously placed shunt tube. He underwent an ETV. On evaluation 2 years after the surgery, he was asymptomatic. Assessment of the ventricular volume (lateral and third ventricles) on the preoperative CT and the 2-year follow-up CT scan showed no significant change in the volume of the ventricles (40 and 39 mL). 3. Discussion Cerebrospinal fluid diversion, in addition to pharmacotherapy for the primary disease, is the accepted form of treatment of hydrocephalus after TBM. However, the longterm outcome is dependent on the preoperative Glasgow coma score or grade of the patient [5,7]. Response to external ventricular drainage may be used as a predictor of outcome after shunt surgery [5]. Lampretch et al [4] studied 217 patients with stages II and III TBM (British Medical Research Council Classification of TBM) and hydrocephalus. They determined the type of hydrocephalus (communicating or obstructive) using pneumoencephalograms. Ventriculoperitoneal shunts were performed in acute cases if the hydrocephalus was noncommunicating or after failed medical therapy if the hydrocephalus was of the communicating type. After this protocol, only 65 of 217 patients eventually required VP shunt. Of these, 38 patients had noncommunicating hydrocephalus, all of which were shunted. The 179 patients with communicating hydroceph-
Fig. 1. Preoperative (A) and postoperative (B) images in case 1. The postoperative CT scan shows a significant decrease in ventricular size. Note the shunt tubes in the lateral ventricle in the preoperative CT scan (A).
34
A. Jonathan, V. Rajshekhar / Surgical Neurology 63 (2005) 32–35
alus were treated with acetazolamide and furosemide in addition to antituberculosis drugs. These patients were referred for VP shunting if their CSF pressure did not decrease or if their clinical condition deteriorated and CT scan showed progressive hydrocephalus. Of the 179 patients with communicating hydrocephalus, 27 required shunting. Good outcome or moderate disability was seen in 55.4%, and 12.3% died. In this study, shunt patients had a complication rate of 32.3% over a follow-up period of 6 months. Of these, the most common cause of shunt dysfunction was shunt obstruction without infection in 9 patients and shunt obstruction with infection in 9 patients. Other complications seen were overshunting in 2 patients and wound disruption in 1 patient. In 2 studies on the management of hydrocephalus after TBM performed in our department, we found that patients in the worst grade had a high mortality and high rate of shunt-related complications [5,7]. Therefore, an effective alternative to shunt surgery could be beneficial in some of these patients. Endoscopic third ventriculostomy is an accepted method for the treatment of obstructive hydrocephalus. It has also been shown to be an effective alternative to shunt revision in patients affected by obstructive hydrocephalus presenting with shunt malfunction or infection [1-3,8]. The role of ETV in communicating hydrocephalus is not clear. There are reports of successful outcome with ETV in some patients with communicating hydrocephalus such as those with normal pressure hydrocephalus [6]. In view of these observations, hydrocephalus after TBM, which may be obstructive, communicating, or a combination of both, should be amenable to treatment with ETV provided the TBM has been treated. Siomin et al [9] evaluated the safety, efficacy, and indications for ETV in 101 patients who had hydrocephalus with a history of subarachnoid hemorrhage or intraventricular hemorrhage and/or CSF infection. They reported on 42 patients who had history of CSF infection. The overall success rate of ETV in these 42 patients was 64.3%. The severity, number, location, or type of infection did not appear to affect the outcome of the procedure. The concerns in a patient with a postmeningitic state pertain to the patency of the subarachnoid space in the basal cisterns and to the absorption capacity of the arachnoid villi. The arachnoiditis could seal off parts of the basal cisterns, and exudates could block the arachnoid villi, thus, preventing reabsorption of the CSF diverted into the subarachnoid space from the ventricles after the ETV. The second concern is that in these patients, there is a possibility of arachnoidal inflammatory process closing off the ventriculostomy stoma even in patients with burnt-out disease. This seems to have happened in case 1 in whom the ETV has to be repeated, but after the second ETV, the patient has remained asymptomatic for more than 3 years. Although ETV is a good alternative to shunt revision, potential complications of ETV should also be borne in mind [4]. In addition to the complications associated with ETV
when it is done as a primary procedure, ETV in patients who have malfunctioning or infected shunts presents special problems. The floor of the third ventricle after meningitis may be thick and opaque, making it difficult to perforate and to visualize the vessels in the interpeduncular cistern. In addition, the floor of the third ventricle and the underlying arachnoid cyst or villi could be vascularized and can bleed during the perforation. Therefore, an experienced operator should perform ETV in these patients, and the procedure may have to be terminated in some patients if difficulties arise because of the above-mentioned factors. 4. Conclusion Endoscopic third ventriculostomy can be considered as an ideal, safe, and long-lasting solution for hydrocephalus after chronic TBM. This is especially so if the patient has one or multiple episodes of shunt dysfunction. References [1] Cinalli G, Salazar C, Mallucci C, Yada JZ, Zerah M, Sainte-Rose C. The role of endoscopic third ventriculostomy in the management of shunt malfunction. Neurosurgery 1998;43:1323 - 9. [2] Hopf NJ, Grunert P, Fries G, Resch KDM, Perneczky A. Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures. Neurosurgery 1999;44:795 - 806. [3] Jones RF, Stening WA, Kwok BC, Sands TM. Third ventriculostomy for shunt infections in children. Neurosurgery 1993;32:855 - 9. [4] Lampretch D, Schoeman J, Donald P, Hartzenberg H. Ventriculoperitoneal shunting in children in childhood tuberculous meningitis. Br J Neurosurg 2001;15:119 - 25. [5] Mathew JM, Rajshekhar V, Chandy MJ. Shunt surgery in poor grade patients with tuberculous meningitis and hydrocephalus: effects of response to external ventricular drainage and other variables on longterm outcome. J Neurol Neurosurg Psychiatry 1998;65:115 - 8. [6] Mitchel P, Mathew R. Third ventriculostomy in normal pressure hydrocephalus. Br J Neurosurg 1999;13:382 - 5. [7] 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 - 9. [8] Sainte-Rose C, Hooven MD, Hirsh JF. A new approach in the treatment of hydrocephalus. J Neurosurg 1987;66:213 - 26. [9] Siomin V, Cinalli G, Grotenhuis A, Golash A, Oi S, Kothbauer K, Weiner H, Roth J, Beni-Adani L, Pierre-Kahn A, Takahashi Y, Mallucci C, Abbott R, Wisoff J, Constantini S. Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage. J Neurosurg 2002;97:519 - 24. [10] Tandon PN, Bhatia R, Bhargava S. Tuberculous meningitis. In: Vinken PJ, Bruyn GW, Kalwans HL, editors. Microbial disease. Handbook of clinical neurology, vol. 52. Amsterdam7 Elsevier; 1998. p. 195 - 226.
Commentary Endoscopic third ventriculostomy is a good alternative to VP shunting in some patients with hydrocephalus. Although ETV is an old procedure and has acquired new relevance in selected pathologies underlying hydrocephalus, it is most effective in noncommunicating hydrocephalus, particularly
A. Jonathan, V. Rajshekhar / Surgical Neurology 63 (2005) 32–35
in tumors of the posterior fossa. However, additional indications are of major importance because the surgical procedure is relatively safe and it brings the possibility of endogenously mediated restoration of CSF circulation without using foreign artifacts. This feature makes ETV a good alternative to VP shunting, considering that the longterm evolution of most shunting devices, including the more sophisticated and expensive, has many complications. The results of Jonathan and Rajshekhar show good results of ETV in patients with hydrocephalus secondary to a severe infectious disorder of the meninges. The long-term improvement achieved in these 2 patients is unexpected because the main origin of hydrocephalus in most cases of meningeal tuberculosis is disturbance of CSF absorption due to residual fibrosis at the subarachnoid tissue, which theoretically would not be solved by an alternative route of CSF circulation. However, the result is welcome, but the number of cases must be increased to find the optimal indications of ETV in cases of hydrocephalus secondary to infectious disorders of the meninges, such as bacterial meningitis and neurocysticercosis. Julio Sotelo, MD Instituto Nacional de Neurologia y Neurocirurgia Mexico City 14269, Mexico In this article, the authors reported 2 cases of TBM complicated with hydrocephalus and increased intracranial pressure. The first case was a 23-year-old woman initially treated with traditional shunt procedure, but consequently followed by 4 episodes of shunt dysfunction with recurrent
35
headaches and vomiting. The second case was a 54-year-old man who has undergone VP shunt for his hydrocephalus. He had multiple shunt dysfunctions 10 years after the procedure. The patient in case 1 finally underwent ETV and was asymptomatic for 1 week only. She then underwent repeat ETV and remained asymptomatic for 3 years. The patient in case 2 was asymptomatic for 2 years after ETV; however, the ventricle volume remained the same. Most cases of TBM are associated with basal meningitis, which might result in either communicating or obstructive hydrocephalus. According to the authors’ statement, ETV is an accepted method for the treatment of obstructive hydrocephalus, but the role of ETV in communicating hydrocephalus is not clear. Endoscopic third ventriculostomy can be considered as an alternative procedure to relieve hydrocephalus when the division of CSF is not successful after multiple shunt dysfunctions. Endoscopic third ventriculostomy is a good procedure to relieve hydrocephalus when the third ventricle is enlarged and its floor is thin and transparent, allowing visualization of the vessels in the interpeduncular cistern. If the floor of the third ventricle is thick and opaque because of previous meningitis or other causes, ETV should not be considered because it is potentially very risky. A few cases of TBM had complications of hydrocephalus with multiple septa within the enlarged ventricle. In this situation, ETV may not adequately and effectively relieve the hydrocephalus. Ming-Chien Kao, MD, DMSc Department of Neurosurgery National Taiwan University Hospital Taipei, Taiwan
Postmodernism entices us with the siren call of liberation and creativity, but it may be an invitation to intellectual and moral suicide. –Gertrude Himmelfarb (b. 1922), U.S. historian (On Looking Into the Abyss, ch. 7, 1994)