Clinical determinants distinguishing communicating and non-communicating hydrocephalus in childhood tuberculous meningitis at presentation

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Stellenbosch : Stellenbosch University
ENGLISH ABSTRACT: Introduction: Hydrocephalus occurs in up to 80% of children with tuberculous meningitis (TBM), of which the majority (70-80%) is of a communicating nature. Communicating hydrocephalus develops when cerebrospinal fluid (CSF) obstruction occurs at the level of the tentorium, whilst non-communicating hydrocephalus emanates from basal exudates that obstruct the outflow foramina of the fourth ventricle. Identifying the type of hydrocephalus is of critical importance since communicating hydrocephalus can be medically treated with diuretics whilst non-communicating hydrocephalus requires surgical CSF diversion. Conventional neuroimaging does not allow differentiation of the type of hydrocephalus. In resource-limited settings, air-encephalography is the only investigative modality that allows differentiation. Objective: We aimed to investigate whether there are clinical features at baseline that allow differentiation between communicating and non-communicating hydrocephalus in children with TBM. Design: A retrospective hospital-based cross-sectional study spanning 30 years (1985-2015). Results: Out of 441 children with tuberculous hydrocephalus, 122 (27.7%) and 319 (72.3%) had non-communicating and communicating hydrocephalus respectively. Children with noncommunicating hydrocephalus exhibited longer duration of symptoms (p=0.03) and were more inclined to develop hyponatremia (p=0.10). No children with TBM and HIV co-infection had non-communicating hydrocephalus. No differences were identified in relation to the age of onset, stage of TBM disease, Glasgow Coma Scale (GCS), cranial neuropathies, hemiplegia; signs and symptoms of raised intracranial pressure and/or brainstem dysfunction. Conclusion: No clinical useful determinants were identified in children with tuberculous hydrocephalus that reliably allow differentiation between communicating and noncommunicating hydrocephalus. This finding is explained by the fact that common TBM related complications such as brainstem ischaemia and raised intracranial pressure (ICP) share similar clinical signs, thereby mimicking of each other’s clinical determinants. The absence of non-communicating hydrocephalus in children with TBM and HIV co-infection likely reflects their defective host-inflammatory response. Air-encephalography remains the gold standard of determining the level of CSF block in resource-limited settings.
AFRIKAANSE OPSOMMING: Geen opsomming beskikbaar.
Thesis (MMed)--Stellenbosch University, 2022.