Role of Surgical Procedures (VP Shunt and ETV) in Tuberculous Meningitis with Hydrocephalus (TBMH): A Systematic Review

OBJECTIVE: Hydrocephalus is one of the most common complications of tuberculous meningitis. Various cerebrospinal fluid diversion procedures, endoscopic third ventriculostomy (ETV) and shunt surgery, are performed for the management of the hydrocephalus associated with tuberculous bacterial meningitis (TBM). There is decreased clarity on the type of procedure to be done. So, this study aims at generating knowledge to understand the conditions in which either of the two procedures, ETV and shunt surgery, is a better option and to develop good practice guidelines for the treatment of tubercular meningitis hydrocephalus (TBMH). MATERIALS AND METHODS: A systematic search of literature was performed by using PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) for articles published from January 2001 to April 2020. A total of 15 studies were included irrespective of their design and having diagnosis with TBMH treated with ventriculoperitoneal shunt surgery (VPS) or ETV. Then, a systemic review was done regarding outcomes, complications, and recommendations made in different studies. RESULTS: The total number of patients diagnosed with TBMH was 603; among them, 348 patients had VPS and 255 patients had ETV. In the VPS group, the patient’s good outcome varied from 25% to 68% and complication rate ranged from 10% to 43.8%. The average percentage of good outcome in the VPS group was 51.8%. In the ETV group, the patient’s good outcome varied from 41% to 77% and complication rate ranged from 10% to 23.5%. The average percentage of good outcome in the ETV group was 68%. There was a significant difference in the average percentage of good outcome in the ETV versus the VPS shunt group (P-value was 0.008). CONCLUSION: There was a significant difference in the average percentage of good outcome after ETV than VPS, and complication rate was also slightly lower after ETV than VPS during the chronic phase of illness. So during the acute phase of illness VPS placement is preferred whereas in the chronic burnout phase ETV is preferred because poor anatomy leads to more complications with ETV during the acute phase of the disease.