**10. Treatment of hydrocephalus in TBM**

The most common classification system used in patients with TBM and hydrocephalus is Vellore grading system which was introduced for the first time in 1991 and later modified in 1998 [48, 49]. This system classifies TBM in four grades, grade I representing the patient with GCS 15 points, and grade IV representing the patient in a deep coma (**Table 1**).

There is no doubt that the treatment of TBM is represented by the prompt initiation of antituberculosis treatment (6). Regarding the treatment of hydrocephalus from TBM, we have two types of treatment: medical and surgical, the second being the most frequently used [7].

#### **10.1 Medical treatment**


Patients with communicating hydrocephalus are generally treated with medication. Studies have shown that the use of steroids reduces mortality in all patients with

#### **Table 1.**

*Modified Vellore grading for patients with tuberculosis meningitis and hydrocephalus [48, 49].*

TBM; moreover, they reduce the incidence of neurological sequelae. Corticosteroid treatment reduces inflammation and vasogenic edema, improving the signs of intracranial hypertension [6, 46, 47]. Acetazolamides and diuretics can also be used, because they reduce CSF production and improve interstitial edema. In more severe cases, mannitol can be administered, especially to delay the surgical treatment of hydrocephalus [6].

#### **10.2 Surgical treatment**

The surgical treatment of hydrocephalus is reserved for patients who are refractory to drug treatment, or for patients in whom drug treatment no longer has any effect on hydrocephalus. The principle of surgical treatment of hydrocephalus is to divert the CSF flow. The main surgical options include bedside external ventricular shunt, ventriculoperitoneal shunt or endoscopic third ventriculostomy [7, 48].

A meta-analysis that included 19 studies and 1038 patients reported a good outcome in 58.3% of patients [49]. As expected, the best outcome was reported in patients with grade-I TBM, and the worst outcome was reported in patients with grade-IV TBM. Also, a frequently encountered complication is a malfunctioning shunt, which may require revision of the shunt [50]. The patients most exposed to this complication are those with very high CSF protein levels. Other complications included shunt displacement, shunt erosion or development of peritoneal cysts [51].

Endoscopic third ventriculostomy is an effective alternative method to ventriculoperitoneal shunt, this surgical method being particularly indicated in communicating hydrocephalus, such as Sylvius aqueduct stenosis occurred in TBM [51].

#### **11. Evolution and complications**

Among **short-term complications**, communicating hydrocephalus represents approximately 80% of cases of TBM, more common than non-communicative. Other frequent complications are paralysis of the cranial nerves (3,6, and 7). The VI nerve is the most frequently involved, its damage leading to relatively sudden ophthalmoplegia and diplopia. Blindness can occur due to compression of the optic nerve during the development of hydrocephalus, through optochiasmatic arachnoiditis or through optic nerve granuloma. The involvement of small and large vessels, with the development of vasculitis obliterans, can cause ischemic and hemorrhagic complications, which occur especially in the territory of the internal carotid artery, the middle cerebral artery and small perforating vessels. Ischemic vascular accidents occur in approximately 30% of TBM cases and can manifest in a variety of ways [52, 53].

**Long-Term Complications** are represented by cognitive disability, seizures, cerebrovascular accidents manifested by hemiparesis and aphasia, myelitis manifested by paraparesis and hydrocephalus complicated with increased intracranial pressure.

Affecting the hypothalamus in TBM can determine diabetes insipidus, obesity, adipose-genital syndrome, precocious puberty and delay in height growth [52].

The **sequelae** of TBM are represented by motor deficits, cognitive deficits, blindness, deafness, epilepsy, behavioral disorders, the decrease in school performance in children [52–54].

#### *Hydrocephalus in Tuberculous Meningitis DOI: http://dx.doi.org/10.5772/intechopen.110251*

The appearance of hydrocephalus is clinically manifested by varying degrees of alteration of the state of consciousness in patients with tuberculous meningitis [5, 54]. Tuberculomas and brain abscesses can cause convulsions and motor deficits [54–56].

Hydrocephalus in infants with TBM can cause the following symptoms: vomiting, drowsiness, irritability, difficult feeding, convulsions, low muscle tone, "sunset" gaze, poor reactivity to external stimuli, lack of growth and development [49, 56].

The symptoms that make up the clinical picture of hydrocephalus in the case of a young child diagnosed with TBM are represented by headache, blurred vision or diplopia (double vision), increased cranial perimeter, drowsiness, loss of balance, poor coordination of movements, convulsions, decreased appetite and in certain situations, urinary incontinence (involuntary loss of urine) [49, 54, 56].

Behavioral and cognitive changes in children with hydrocephalus frequently include irritability, personality changes, delayed acquisition of age-specific skills (speech) or decreased school performance.

The treatment of hydrocephalus is etiological and involves performing a cerebral surgical intervention represented by


Drug treatment aims to reduce symptoms and involves the administration of diuretics and anticonvulsants to improve the patient's general condition. Medical therapy should be tried prior to any form of surgical intervention; manitol, furosemide, acetazolamide and dexamethasone should be used first. CSF pressure monitoring can be useful in cases where CSF (ventricular) drainage is considered in obstructive hydrocephalus, and the decision to perform the procedure must be based on the patient's level of consciousness and the degree of ventricular dilatation visualized on brain imaging (CT or MRI). If hydrocephalus is the cause of clinical deterioration, repeated lumbar punctures or external ventricular drainage has been recommended [49, 56, 57].
