Ventricular and lumbar cerebrospinal fluid analysis in 77 HIV-negative patients with Cryptococcal meningitis who received a ventriculoperitoneal shunt

Patients

A complete of 100 patients with CM have been admitted to the Department of Neurosurgery of Lingnan Hospital, Branch of the Third Affiliated Hospital of Sun Yat-sen University, from January 2016 to August 2020. Only 77 patients with CM have been retrospectively analyzed. The inclusion criterion was the particular prognosis of CM. Exclusion standards included the next: (1) Patients with out VPS placement; (2) Patients who had received a shunt previous to admission to our hospital; (3) Patients who had VPS placement by different groups of neurosurgeons and patients with out lumbar CSF check inside 48 h earlier than VPS (Fig. 1).

Diagnosis of CM

A particular prognosis of CM required at the least one of many following standards^17,24: (1) Positive India ink staining of CSF with centrifuged sediment for Cryptococcus; (2) Positive tradition of Cryptococcus from CSF; (3) Compatible histopathology (5- to 10-μm encapsulated yeast noticed in mind tissue); (4) Probable CM was thought-about in patients with scientific signs of meningitis and a optimistic check of Cryptococcal antigen, and/or optimistic CSF findings by metagenomic next-generation sequencing. All CM patients in this research had a particular prognosis of CM. Tuberculosis was dominated out by T-SPOT, acid-fast bacilli (AFB) smear, and ELISA.

Treatments

Antifungal remedy earlier than VPS placement was totally different based mostly on the attending doctor’s desire and the affected person’s tolerance of the drug. Therapeutic choices are restricted to amphotericin B, flucytosine, fluconazole, and voriconazole in our hospital. A comparatively unified antifungal routine of flucytosine plus fluconazole was used after VPS apart from 5 patients (Table 1). Corticosteroids have been administered to patients with immune reconstitution inflammatory syndrome. Patients with elevated CSF strain have been handled with intravenous mannitol and underwent a repeated lumbar puncture earlier than VPS placement. A VPS was thought-about when patients suffered from neurological deterioration brought on by intractable elevated intracranial strain and/or progressive ventricular enlargement. No patients in this research received EVD, as this feature has not been often thought-about at our division since 2016 as a result of excessive frequency of secondary an infection. Lumbar puncture was used to dynamically monitor CSF adjustments after VPS placement.

VPS placement

The tip of the ventricular catheter was positioned through a frontal strategy into the foramen of Monro or the third ventricle by way of the anterior horn of the ipsilateral lateral ventricle, based mostly on a prior definition of correct ventricular catheter placement²⁵. The non-dominant hemisphere aspect was the popular aspect of placement. Accurate placement, which is essential to make sure all of the drainage holes are in the ventricle, is important for patients with CM with out ventriculomegaly. Two forms of adjustable shunt gadgets have been used, the proGAV2.0 valve (Miethke) and the Strata II valve (Medtronic). Usually, the preliminary valve strain was set to 200 mm H₂O, or gear 2.5, respectively. The valve strain was adjusted in line with affected person’s scientific response. The valve strain could be adjusted down when a affected person exhibited persistent neurological dysfunction, progressive ventricular enlargement, and a excessive opening strain on lumbar puncture. The valve strain could be adjusted up when a affected person displays orthostatic headache and a low opening strain on lumbar puncture. Prophylactic anti-epileptic medication have been often administered peri-operatively. Shunt issues have been recorded inside six months after VPS. Three patients who had a shunt obstruction have been efficiently revised. Two patients have been adjusted the depth of the tube insertion; one affected person was revised by the alternative of a new shunt tube.

Acquisition and detection of CSF parameters

We recorded the CSF testing outcomes, which met the next necessities: Lumbar CSF samples have been obtained by lumbar puncture inside 48 h earlier than VPS placement, and 1–3 days (stage 1), 5–7 days (stage 2), 14 ± 2 days (stage 3), 30 ± 5 days (stage 4), 60 ± 7 days (stage 5), 90 ± 7 days (stage 6), and 180 ± 14 days (stage 7) after VPS placement. Ventricular CSF was obtained throughout shunt insertion immediately from the lateral ventricle (Fig. 1). CSF analysis included white blood cell (WBC) rely and crimson blood cells (RBCs) rely, complete protein focus, CSF/blood glucose ratio, chloride ion stage, and Cryptococcal rely. When seen blood contamination occurred, one leukocyte was subtracted per 1000–1500 crimson blood cells to estimate the true CSF WBC rely²⁶. Cryptococcal rely was decided by counting the variety of Cryptococcus per milliliter of CSF through India ink staining.

Definition of ventriculomegaly

Ventriculomegaly was recognized on the idea of dilation of the temporal horn of the lateral ventricle and/or an Evans’ index of > 0.3, as decided by CT and/or MRI. Evans’ index refers back to the ratio of the ventricular width of the bilateral frontal horn to the utmost biparietal diameter²².

Six-month neurological end result

All patients in the research exhibited neurological signs earlier than VPS placement, reminiscent of headache, visible adjustments, listening to impairments, disturbance of consciousness, muscle weak spot, seizures, cognitive impairment and urinary incontinence. Neurological outcomes, which have been evaluated at six months after VPS placement, have been divided into 4 ranges: cured, higher, worse, and dying.

Statistical analysis

All statistical analysis was carried out utilizing SPSS model 22 software program (SPPS Inc., Chicago, IL, USA). All numerical variables of CSF parameters have been introduced as median and vary or interquartile vary as they have been non-normally distributed knowledge. Categorical variables have been expressed as counts and percentages. A Wilcoxon signed-rank check was used to check lumbar and ventricular CSF parameters and analyze lumbar CSF change after shunting surgical procedure. The Mann–Whitney U check have been used to research CSF parameters in patients with and with out ventriculomegaly, and patients with and with out surgical issues. Chi-squared check or Fisher’s precise check was used for comparisons of binary categorical variables, as applicable. Statistical significance was set at a worth of p < 0.05.

Ethics approval and consent to take part

The Clinical (*77*) Ethical Committee of the Third Affiliated Hospital of Sun Yat-sen University permitted the research (02-167-01) and waived the requirement of written knowledgeable consent. No experiments have been performed with human members (or their tissue). All data was stored nameless. The research complies with the Declaration of Helsinki.