Short-term and long-term outcomes in patients with cryptococcal meningitis after ventriculoperitoneal shunt placement

Abstract

ObjectiveThe purpose of this study was to assess the short-term and long-term outcomes of ventriculoperitoneal shunt (VPS) placement in patients with cryptococcal meningitis (CM).MethodsWe performed a retrospective analysis of all patients with CM admitted to the Peking Union Medical College Hospital from September 1990 to January 2021. We collected related clinical features to analyze the short- and long-term outcomes of VPS at 1 month and 1 year at least the following therapy, respectively. Overall survival (OS) was compared with all patients and a subgroup of critically ill cases by the Kaplan–Meier method with the log-rank test. Univariable and multivariable analyses were also performed using the Cox proportional hazard model to identify statistically significant prognostic factors.ResultsWe enrolled 98 patients, fifteen of whom underwent VPS. Those who received VPS had a lower cerebrospinal fluid (CSF) Cryptococcus burden (1:1 vs. 1:16; p = 0.046), lower opening pressures (173.3 mmH2 O vs. 224 mmH2O; p = 0.009) at lumbar punctures, and a lower incidence of critical cases (6.7 vs. 31.3%; p = 0.049). According to our long-term follow-up, no significant difference was shown in the Barthel Index (BI) between the two groups. Two patients in the VPS group suffered postoperative complications and had to go through another revision surgery. According to survival analysis, overall survival (OS) between the VPS and non-VPS groups was not significantly different. However, the Kaplan–Meier plots showed that critical patients with VPS had better survival in OS (p < 0.009). Multivariable analyses for critical patients showed VPS was an independent prognostic factor.ConclusionA VPS could reduce the intracranial pressure (ICP), decrease the counts of Cryptococcus neoformans by a faster rate and reduce the number of critical cases. The VPS used in critical patients with CM has a significant impact on survival, but it showed no improvement in the long-term Barthel Index (BI) vs. the conservative treatment and could lead to postoperative complications.

Subacute Hydrocephalus Revealing a Cryptococcus Infection in a Seven-Year-Old Child

“…The timing of the surgery according to Tang is dependent on the patient’s symptoms, as the presence of acute signs and symptoms of hydrocephalus are factors predictive of a better outcome after shunt placement [ 6 , 12 ]. On the other hand, some authors suggest prophylactic shunt placement to avoid irreversible neurological complications [ 8 , 11 ]. In our case, the patient presented with symptoms of high ICP as well as visual impairment and papilledema.…”

“…Some complications associated with VP shunting include infection (fungal infection or other secondary infections), shunt obstruction, and excessive shunting [ 7 ]. However, the benefits may outweigh the risks when compared with the poor neurological prognosis and possible death associated with untreated ICH and hydrocephalus in CM of the immunocompromised [ 11 , 13 ]. Data on long-term outcomes after VP shunting are not easily found since most studies are retrospective and life expectancy in these patients is short, not allowing for a proper follow-up [ 11 , 13 ].…”

“…However, the benefits may outweigh the risks when compared with the poor neurological prognosis and possible death associated with untreated ICH and hydrocephalus in CM of the immunocompromised [ 11 , 13 ]. Data on long-term outcomes after VP shunting are not easily found since most studies are retrospective and life expectancy in these patients is short, not allowing for a proper follow-up [ 11 , 13 ]. The study carried out by Wen et al on 72 patients was the first to obtain results of long-term follow-up, showing an improved overall survival rate even in critically ill patients undergoing VP shunting compared with the group of patients who did not [ 11 ].…”

“…Data on long-term outcomes after VP shunting are not easily found since most studies are retrospective and life expectancy in these patients is short, not allowing for a proper follow-up [ 11 , 13 ]. The study carried out by Wen et al on 72 patients was the first to obtain results of long-term follow-up, showing an improved overall survival rate even in critically ill patients undergoing VP shunting compared with the group of patients who did not [ 11 ]. Wen et al concluded that VP shunting should be applied to avoid death for patients with CM with uncontrollable ICH and rapid development of clinical symptoms, which aligns with our course of treatment [ 11 ].…”

Complex Decisions in HIV-Related Cryptococcosis: Addressing Second Episodes of Cryptococcal Meningitis

“…This should continue until the pressure returns to normal for two consecutive LPs, and symptoms of increased ICP have resolved [ 37 •]. In patients who have consistently elevated ICP, lumbar drains and ventriculoperitoneal shunts are options where available [ 54 – 57 ]. These interventions can decrease both the severity of the illness and the number of deaths.…”