Endoscopic Challenges and Applications in Tuberculous Meningitis

Endoscopy for hydrocephalus caused by infectious diseases presents clear challenges to the surgeon. Hydrocephalus caused by tuberculous meningitis is a good model to explore many of the issues that should be considered in the management of these patients. Tuberculous hydrocephalus may be communicating or noncommunicating management options include medical treatment (for communicating hydrocephalus), ventriculoperitoneal shunting, and endoscopic third ventriculostomy. No guidelines exist currently, and therefore management protocols are specific to each center. Because brain ischemia attributable to vasculitis is common in these patients, optimal treatment of intracranial pressure (ICP) is even more important than usual, and this has implications for the management decisions. Effective treatment of these patients should lead to normalization of ICP and resolution of the hydrocephalus, rather than merely avoiding extreme elevations of ICP. However, this also must be weighed against the surgical and long-term complications associated with the procedures used. There are specific endoscopic challenges that occur as the result of abnormal anatomy and the fact that hydrocephalus presents during the acute phase of the disease, rather than being postinfectious. In this article we examine the arguments for various therapeutic approaches and discuss the gathering experience in the literature about endoscopy in tuberculous meningitis in the context of overall management options.