Surgical treatment of intracranial hypertension in encephalic cryptococcosis

Abstract

The incidence of cryptococcosis has risen sharply together with the growing number of patients with Acquired Immunodeficiency Syndrome (AIDS). Cryptococcal meningitis is nowadays the most common intracranial non-viral infection in such cases. One of its most serious complications is intracranial hypertension (ICH), a situation that can lead either to early death, or disabling sequelae. The authors analyse a series of 10 cases of encephalic cryptococcosis with ICH, and describe the clinical course, diagnosis, medical and surgical treatment, and evolution. The physiopathology of ICH in these patients is discussed, proposing placement of a ventriculo-peritoneal shunt as the primary and emergency treatment, even when ventricular enlargement might be absent. Although the present series is certainly small, from the preceding discussion and according to an extensive bibliographical review, our conclusion is that patients with encephalic cryptococcosis and uncontrollable ICH should receive surgical treatment, consisting of an emergency diversion of the CSF, because serial lumbar punctures are not enough to improve the clinical course, that if left to its natural evolution would lead to a fatal outcome in a short time. In spite of the fact that CSF shunts were carried out on immunocompromised patients, no superinfections occurred.

Evaluation of ventriculoperitoneal shunt in the treatment of intracranial hypertension in the patients with cryptococcal meningitis: A report of 12 cases

“…Once the patients have VPS conditions, VPS should be performed because VPS therapeutic effects are certain. It was reported that 21 patients recovered after VPS (100%) [4][5][6][7], which is consistent with our results (91.6%) (11 patients all recovered except one patient who wanted to discharge).…”

“…So far, only 21 patients with CM have received VPS [4][5][6][7], demonstrating that surgeons do not exactly know the therapeutic effects and indication of VPS for CM. In the past, we also had the same confusion.…”

“…Although dehydration drugs and repeated lumbar puncture are used in CM treatment [3], intracranial hypertension still cannot be controlled in some patients with CM. In fact, since the 1980s, ventriculoperitoneal shunt (VPS) has been used to reduce intracranial hypertension in CM; but it is reported that only 21 patients with CM have received VPS until February 2014 [4][5][6][7]. This may be that dilation of the cerebral ventricles is not common in the patients with CM combined with intracranial hypertension, and surgeons do not know how the therapeutic effects of VPS are and what complications VPS can cause in the treatment of intracranial hypertension in CM patients without dilation of the cerebral ventricles.…”

Shunting in cryptococcal meningitis

“…In the cryptococcal meningitis series by Calvo et al, 5 there was a 40% rate of ventriculitis in patients with external ventricular drains. Lumbar and ventricular drains are generally placed at the bedside and do not achieve the same standards of antisepsis required by intraoperative placement of shunts.…”

Microlymphatic Biology

“…It is well known that the formation of cerebro-spinal fluid takes place in the choriod plexuses in ventricles, and in man its total volume is about 140 ml with total daily production about 500 ml or 0.25% of total volume per minute [341] . The arachnoid projections begin to develop at or around the time of birth and occur in abundance only in the adult [342,345,346] . The functional importance of brain fluid drainage is apparent whereas the mechanisms responsible for it still remain unclear.…”