The value of transcranial Doppler imaging in children with tuberculous meningitis.

PURPOSE: Transcranial Doppler imaging (TCDI) is potentially a valuable investigational tool in children with tuberculous meningitis (TBM), a condition often complicated by pathology relevant to Doppler imaging such as raised intracranial pressure (ICP) and cerebral vasculopathies. METHODS: Serial TCDI was performed on 20 TBM children with the aim of investigating cerebrovascular haemodynamics and the relationship between pulsatility index (PI) and ICP. RESULTS: We observed a poor correlation between ICP and PI in children with communicating hydrocephalus (p = 0.72). No decline in PI was noted following 7 days of medical therapy for communicating hydrocephalus (p = 0.78) despite a concomitant decline in ICP. Conversely, a decline in PI was noted in all four children with non-communicating hydrocephalus who underwent cerebrospinal fluid diversion. High blood flow velocities (BFV) in all the basal cerebral arteries were observed in 14 children (70 %). The high BFV persisted for 7 days suggesting stenosis due to vasculitis rather than functional vasospasm. Complete middle cerebral artery (MCA) occlusion, subnormal mean MCA velocities (<40 cm/s) and PIs (<0.4) correlated with radiologically proven large cerebral infarcts. CONCLUSIONS: TCDI-derived PI is not a reliable indicator of raised ICP in children with tuberculous hydrocephalus. This may be attributed to individual variation of tuberculous vascular disease, possibly compromising cerebral vascular compliance and resistance. Basal artery stenosis secondary to vasculitis is observed during the acute stage of TBM in the majority of children.

Short intensified treatment in children with drug-susceptible tuberculous meningitis.

BACKGROUND: The World Health Organization recommends 12-month treatment (2RHZE/10RH) for children with tuberculous meningitis (TBM). Studies evaluating length of antituberculous treatment for TBM report similar completion and relapse rates comparing 6-month treatment with 12-month treatment. METHODS: A prospective evaluation to determine whether short-course intensified treatment (6 RHZEth for HIV-infected and 9RHZEth for HIV-infected) is sufficient and safe in children with drug-susceptible TBM. RESULTS: Of 184 children with TBM, median age 58 months and 90 (49%) male, 98 children (53%) presented at stage II TBM, 64 (35%) at stage III TBM and only 22 (12%) at stage I TBM. Ninety (49%) children were treated at home after the first month of therapy; all others received their full treatment in hospital. The HIV prevalence was 14% (22/155 children tested). Anti-TB drug-induced hepatotoxicity occurred in 5% (8 of 143 children tested), all tested negative for viral hepatitis; in all 8 cases, the original regimen was restarted without recurrence. After treatment completion, 147 (80%) children had a good outcome, 7 (3.8%) died. There was no difference in outcome between HIV-infected and HIV-uninfected children who completed treatment (P = 0.986) nor between TBM-hydrocephalic children who were medically treated or shunted (P = 0.166). CONCLUSION: Short intensified treatment is safe and effective in both HIV-infected and HIV-uninfected children with drug-susceptible TBM.

The role of aspirin in childhood tuberculous meningitis.

Arterial stroke is the main cause of poor outcome in childhood tuberculous meningitis. Aspirin has an antithrombotic action at low dose and anti-ischemic and anti-inflammatory properties, which are dose-related. The aim of the study was to explore the possible benefits of aspirin in children with tuberculous meningitis. A total of 146 consecutive children with a diagnosis of probable tuberculous meningitis were studied. Patients were randomized into 3 groups: (1) placebo group, (2) low-dose aspirin group, and (3) high-dose aspirin group. Twenty-nine additional patients who received aspirin before admission were excluded from the randomized study, but continued on low-dose aspirin. Aspirin, irrespective of dose, did not show any significant benefit regarding morbidity (hemiparesis and developmental outcome) and mortality. Aspirin was well tolerated, but 1 death was probably related to aspirin. The fact that the outcome of the high-dose aspirin group compared favorably with the other treatment groups despite younger age and more severe neurological involvement at baseline needs further investigation.