Ventriculoperitoneal shunt in cryptococcal meningitis with hydrocephalus

Fourteen patients with cryptococcal meningitis were reviewed. All patients had a ventriculoperitoneal shunt for hydrocephalus. Early recognitions and prompt relief of hydrocephalus were useful for eight patients who showed rapid deterioration of consciousness or signs of cerebral herniation. There was no surgical response in four patients who had had weeks of confusion or mental change. It seems, therefore, that the duration of disturbance of consciousness or change of mentality before shunting is critical in determination of the outcome of the treatment. Ventricular shunting was effective in relieving papilledema in five patients. However, the surgery did not prevent the development of papilledema to optic atrophy and subsequent blindness in two patients. Hence, in addition to hydrocephalus with increased intracranial pressure, conditions such as direct invasion of the optic pathways by Cryptococcus neoformans or optochiasmatic arachnoiditis may be responsible for the visual failure. Ventricular shunting was also helpful in restoring paraparesis in one patient. Of the cerebrospinal fluid determinations, low protein concentration was a favorable indicator for surgery. Of the seven patients who received the surgical procedure before the start of antifungal therapy, four showed a significant improvement despite active infection of the central nervous system. None of the seven patients deteriorated because of the surgical operation. Thus, active stage of cryptococcal meningitis does not contraindicate the necessity of shunting, and premedication with antifungal drugs is unnecessary. Also, no shunt-related morbidity and mortality was seen in this study.