Case Report Pediatr Neurosurg 2007;43:42–46 DOI: 10.1159/000097525
Received: September 26, 2005 Accepted after revision: February 9, 2006
Endoscopic Third Ventriculostomy in PrepontineSuprasellar Tuberculoma with Tuberculous Meningitis Hydrocephalus: A Case Report Deepak Jha a Prakash Khatri a Ajay Choudhary a Rajeev Sethi b Sushil Kumar a Departments of a Neurosurgery and b Radiology, St. Stephens Hospital, Tishazari, Delhi, India
Key Words Endoscopic third ventriculostomy Hydrocephalus Tuberculous meningitis
Abstract We present a case of prepontine-suprasellar tuberculoma involving the premamillary region of the third ventricular floor, a site suitable to perform an endoscopic third ventriculostomy (ETV) stoma, managed endoscopically, and discuss our findings. A 5-year-old male child was admitted in an unconscious state with a history of gradually progressive symptoms of raised intracranial pressure and low-grade fever for the last 3 months. Head computed tomography showed thick enhancing basal exudates, a prepontine-suprasellar ring-enhancing lesion with consequent obstructive hydrocephalus. The child was subjected to urgent endoscopy which revealed multiple ependymal tubercles along with prepontine-suprasellar tuberculoma involving the premamillary region of the third ventricular floor. The tuberculoma was decompressed using a 5-french catheter, and ETV was performed. Postoperatively, the child improved clinicoradiologically on antitubercular chemotherapy and needed no further cerebrospinal fluid diversion surgery; he is under regular follow-up. We conclude that ETV may be attempted even in the presence of thick basal exudates and/or prepontine-suprasellar tuberculoma. Copyright © 2007 S. Karger AG, Basel
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Introduction
Tuberculous meningitis hydrocephalus (TBMH) is a known complication of tuberculous meningitis. Various modalities of treatment are available, including conservative treatment with dehydrants, external shunt and external ventricular drain with or without external shunt. Recently, endoscopic third ventriculostomy (ETV) has been found effective in TBMH, and an increasing number of neuroendoscopists are offering ETV to such patients [1–7]. To date, factors affecting the outcome of ETV in TBMH are not identified. In our earlier study, we included 1 case each of suprasellar/third ventricular tuberculoma and tubercular abscess over the third ventricular roof; however, premamillary regions were not involved in either of these patients [5]. There is no report on endoscopic treatment of prepontine-suprasellar tuberculoma involving the premamillary region. Here, we present a case with thick basal exudates, considered as exclusion criteria in our earlier report, and discuss our findings. Case Report A 5-year-old male child presented with a low-grade fever, progressive headache and vomiting for the last 3 months. Acute exacerbations of symptoms were noted by the parents 3 days before admission to our hospital and he was admitted in an unconscious
Dr. Deepak Jha St. Stephens Hospital Tishazari, Delhi 110054 (India) Tel. +91 98119 66623, Fax +91 11239 32412 E-Mail
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Fig. 1. Preoperative head CTs showing
thick basal exudates, a ring-enhancing lesion in the prepontine-suprasellar region with dilated lateral and third ventricles with periventricular leukomalacia.
Fig. 2. a Endoscopic view showing the perforated third ventricular floor with caseous material (arrow head) anterior to the mamillary bodies (block arrows). Tubercles are visible over the ependymal surface of the third ventricle (thin arrows). Minimal ooze is seen from the third ventricular floor perforation. b Partially decompressed tuberculoma showing residual cheesy caseous material on the anterior left side of the dorsum sellae (arrow head). The angiographic catheter tip (thin arrow) is visible over the mamillary bodies (block arrows).
state with tonic extensor spasms. His Glasgow coma score was E1V1M2, the pupils were 4 mm bilaterally and sluggishly reacting to light. Urgent head computed tomography (CT) was done, which showed enhancing thick basal exudates, a prepontine-suprasellar ring-enhancing lesion suggestive of tuberculoma with dilated lateral and third ventricles with periventricular lucency (fig. 1a, b). Urgent cerebrospinal fluid (CSF) diversion surgery in the form of endoscopic decompression of the tuberculoma with ETV or external shunt was planned. The patient was placed in a supine position with his head turned to the left side supported by a sand bag below the right shoulder. Gaab Universal Endoscope System (Karl Storz, Tuttlingen, Germany) was used. Basic endoscopic technique was followed, as mentioned in our earlier reports [2, 5]. A right precoronal 10-mm burr hole was made, the dura opened in a cruciate fashion, and the working sheath was inserted into the lateral ventricle by free hand technique. A 4-mm 0° rigid telescope (Karl Storz) was used for the rest of the surgery. Tubercles were seen all over the ependymal surface of the lateral and third ven-
tricles; however, they were most abundantly spread over the wall of the third ventricle. Mamillary bodies and infundibular recess were identified. The premamillary area was seen bulging, which was perforated bluntly with the help of a 5-french cut length angiographic catheter tip (fig. 2a) [8]. The opening was dilated using a 3-french Fogarty balloon. Partial decompression of the thick cheesy content of the tuberculoma made the dorsum sellae visible (fig. 2b). Continuous irrigation by Ringer’s solution was used throughout the procedure. Further decompression of the tuberculoma was done along the posterior surface of the dorsum sellae, avoiding the pontine side of the created cavity to safeguard injury to the basilar artery which could not be identified. After partial decompression of the tuberculoma, the tip of the Fogarty catheter was advanced into the prepontine space over the dorsum sellae, the inferior membranous wall of the cavity was perforated bluntly under endoscopic vision, and the stoma was balloon dilated. There was minimal ooze from the margin of the third ventricular floor opening which was easily controlled by irrigation.
ETV in Prepontine-Suprasellar Tuberculoma
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Fig. 3. Follow-up MRIs of the brain at 5 months after surgery. a T1 (left) and T2
(right) weighted axial images show a decrease in ventricular size, minimal periventricular leukomalacia and tuberculoma in the right posterior thalamus. b Contrast-enhanced T1-weighted sagittal image showing residual tuberculoma in the mesencephalic cistern confluent with the dorsum sellae. c Axial T2-weighted (right) and contrast-enhanced T1-weighted (left) images at the base of the third ventricle showing multiple tuberculoma in the basal and perimesencephalic cisterns confluent with the dorsum sellae. No definite flow void is seen in the region of the ETV stoma and aqueduct. d Sagittal midline cine phase contrast gradient images (48/10.8/20 TR/ TE/flip angle) represent a point in midsystole (right) and middiastole (left). Pulsatile CSF flow is seen within the prepontine cistern. No rapid flow is seen through the ETV stoma, the aqueduct or in the third and fourth ventricles.
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Jha /Khatri /Choudhary /Sethi /Kumar
Table 1. Comparison of the patient and lesion characteristics, treatment and outcome of similar cases in the literature
Report
Age years
Sex Radiological finding
Endoscopic intervention
ExS
Husain et al. [5], 2005
40
F
suprasellar/third ventricular tuberculoma
ETV, subtotal resection of tuberculoma
no
Husain et al. [5], 2005
25
M
abscess over third ventricular roof
ETV, drainage of abscess
yes
5
M
prepontine/suprasellar tuberculoma
decompression of tuberculoma, ETV
no
Current report
ExS = Need for external shunt.
Postoperatively, CSF was drained once a day by lumbar puncture using a 22-gauge spinal needle for 5 consecutive days. The amount of CSF was 12 ml on the 1st postoperative day and gradually decreased to about 5 ml on the 5th postoperative day. The patient gradually improved over a period of 2 weeks. Ventricular CSF showed findings consistent with TBMH. Postoperatively, the patient was kept on 4-drug antitubercular therapy (ATT). Corticosteroid (dexamethasone, 0.5 mg/kg body weight), started at admission, was gradually tapered off over a period of 4 weeks. Five-month follow-up MRI showed diminution in ventricular size, a decrease in basal exudates and multiple tuberculoma, mainly in the basal cisterns confluent with the dorsum sellae (fig. 3a–c). CSF flow studies by phase contrast and T2-weighted axial sequences at the base of the third ventricle for flow void were inconclusive due to the presence of residual tuberculoma in the region of the ETV stoma (fig. 3c, d). The patient was asymptomatic at 5 months after surgery and is under regular follow-up.
Discussion
TBMH is a common condition, especially in developing countries. In the last 3 years, there are few reports showing the effectiveness of ETV in TBMH [1–6]. Factors affecting the outcome in such cases are still not identified. In our earlier report, thick basal exudates shown by head CT were considered as exclusion criteria [5]; however, successful ETV in this patient raises doubts about our earlier assumption. In our earlier report, we included 1 case each of TBMH with suprasellar/third ventricular tuberculoma and tubercular abscess spread over the third ventricular roof. In these cases, partial decompression of the tuberculoma and drainage of the abscess were performed, respectively (table 1); however, neither of these associated lesions were ETV in Prepontine-Suprasellar Tuberculoma
causing technical difficulty in making the ETV stoma, as premamillary regions were not involved [5]. The site of the third ventricular floor perforation is chosen after identifying the mamillary bodies, the infundibular recess and the dorsum sellae. We prefer to make the stoma above the premamillary region closer towards the dorsum sellae (just posterior to it), which we feel is the most important landmark for ETV. In the reported case, the dorsum sellae could be identified only after initial decompression of the tuberculoma. Further decompression along the posterior surface of the dorsum sellae and perforation of its inferior membrane were done under endoscopic vision. ETV in distorted third ventricular floor anatomy due to a lesion in the suprasellar-prepontine cistern may cause basilar artery injury, which was avoided by early identification of the dorsum sellae and carrying out further decompression along the posterior surface of it. Perforation of the thick and adherent third ventricular floor in patients with TBMH is not feasible or safe, and external shunt remains the option in these patients [1, 5, 6]. ETV is usually done with the patient in supine position, with the head in neutral position, which is not suitable for external shunt surgery, as the passage of the shunt tube through the subcutaneous space of the neck will not be possible. We positioned, painted and draped the patient as we use to do for external shunt surgery. Orientation of the image at the monitor was adjusted by rotating the camera head. This position may be helpful in patients with TBMH, as external shunt surgery can be done in the same session through the same burr hole. TBMH is a dynamic pathological process and keeps on improving with ATT and timely use of steroids [9–11]. Restoration of the CSF flow and decompression of the tuberculoma/abscess improve intracranial hemodynamPediatr Neurosurg 2007;43:42–46
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ics and allow better drug delivery [10, 11]. Tubercular exudates gradually disappear over a period of time with ATT. Removing CSF in patients with pathological intracranial pressure, mainly in the first few days, may improve the outcome [9–13]. Visudhiphan and Chiemchanya [7] have used acetazolamide and repeated lumbar puncture as a treatment modality for TBMH in children. In addition, lumbar puncture after ETV also helps to keep the ETV stoma patent and removes exudative debris [2, 5]. We used lumbar puncture to drain the CSF in the early postoperative period. Residual tuberculoma in the region of the ETV stoma may be the reason for inconclusive CSF flow studies done by axial T2 images at the base of the third ventricle and phase contrast sequences. However, no flow through the aqueduct or in the fourth ventricle and absence of clini-
coradiological signs of hydrocephalus indirectly support that ETV is functioning. There is no report of CSF flow studies performed in patients with TBMH after ETV or a case similar to ours, and further research is needed to understand the pattern of CSF flow in these patients. External shunts show poor results in TBMH and are associated with life-long complications; however, ETV, if successful, cures the hydrocephalus [14–16]. We feel that it is even more logical to attempt ETV in children as they have a greater life expectancy and may thus face most of the complications of an external shunt. We conclude that ETV may be effective in patients with thick basal exudates and with prepontine-suprasellar tuberculoma. It avoids complications of external shunt and ensures a better response to ATT.
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