Elsevier

World Neurosurgery

Volume 111, March 2018, Pages e178-e182
World Neurosurgery

Original Article
Correlation of Lactate Concentration in Peripheral Plasma and Cerebrospinal Fluid with Glasgow Outcome Scale for Patients with Tuberculous Meningitis Complicated by Acute Hydrocephalus Treated with Fluid Diversions

https://doi.org/10.1016/j.wneu.2017.12.007Get rights and content

Background

Tuberculous meningitis (TBM) is an endemic infectious disease in developing countries, and it can become a serious illness in children. Treatment of TBM is more difficult and prone to failure than treatment of pulmonary tuberculosis. TBM causes hydrocephalus, cerebral edema, increased intracranial pressure, global ischemia, and neurologic deficits, which disturb cellular metabolism and increase lactate levels. A reliable, widely available clinical indicator of TBM severity is needed. Successful treatment of TBM is assessed using the Glasgow Outcome Scale (GOS).

Methods

This prospective cohort study included 34 patients with TBM and acute hydrocephalus who had undergone fluid diversions and were admitted to Dr. Hasan Sadikin Hospital in Bandung from 2014 to 2015. A portable machine for blood glucose measurement was used to measure lactate concentrations. Statistical significance was defined as P ≤ 0.05.

Results

Average levels of plasma and cerebrospinal fluid (CSF) lactate were 1.99 ± 0.70 mmol/L and 3.04 ± 1.05 mmol/L, respectively. A significantly higher level of lactate was observed in CSF compared with plasma. Preoperative plasma lactate was negatively correlated to GOS (r = −0.539; P = 0.013), and CSF lactate was negatively correlated to GOS (r = −0.412; P = 0.027). Average lactate levels in CSF (central) were higher than plasma (peripheral) levels. GOS scale of patients decreased with increased plasma and CSF lactate levels.

Conclusions

Examination of plasma and CSF lactate levels should be included in routine examinations to determine extent of cellular damage and GOS score in patients with TBM and acute hydrocephalus who have undergone fluid diversions.

Introduction

Tuberculous meningitis (TBM) is a bacterial infection of Mycobacterium tuberculosis that affects the meningeal layers. TBM was first identified by Whytt at Edinburgh University in 1768 after analyzing 10 cases of hydrocephalus caused by M. tuberculosis infection.1 The incidence of tuberculosis (TB) cases in Indonesia has declined with improved health care, but it still ranks very high, tied with China as the second-most TB-infected population, after India. Approximately 528,000 new cases of M. tuberculosis infection were diagnosed in the 232 million people in Indonesia in 2007, which equals 244 new cases per 100,000 people. The number of fatalities in 2007 was 91,400, or 39 cases per 100,000 people.2, 3

Three processes of M. tuberculosis infection create neurologic deficits: formation of adhesions, vasculitis, and encephalitis or myelitis. Adhesions are formed from exudates in the basal portion of the meninges, which become solidified. Exudates are formed after inoculation by a bacilli-rich focus that erupts into the subarachnoid space. The formation of adhesions inhibits cerebrospinal fluid (CSF) flow and absorption, which causes hydrocephalus. M. tuberculosis attaches to the blood-brain barrier, which incites microvascular inflammation, and vasculitis results when M. tuberculosis attacks the endothelial lining of brain vasculature. This reaction causes ischemia, infarcts, and stroke syndromes, creating irreversible neurologic deficits.4

A marker of clinical severity in these patients is needed. This marker should be widespread and easily measured. Lactate levels in CSF were investigated for this role because an increase in lactate level is a more significant predictor than other conventional markers, such as CSF glucose, ratio between CSF and plasma glucose, CSF protein, and leukocyte count.5 Examination of lactate levels when performing CSF diversion is important to determine the severity of brain parenchyma damage caused by vasculitis, edema, and global ischemia resulting from the primary disease and hydrocephalus, which is a complication that causes anaerobic metabolism in glial cells. Comparison of plasma and CSF lactate levels is important to analyze their correlation to the clinical Glasgow Outcome Scale (GOS) score to determine success of treatment of acute hydrocephalus in patients with TBM.

Section snippets

Materials and Methods

This study was a prospective cohort study of patients with TBM with acute hydrocephalus who underwent fluid diversions. We performed analytic correlations of levels of preoperative plasma lactate, CSF lactate, and GOS score after surgery to determine the effect of acute hydrocephalus in TBM on brain cell metabolism. Nova StatStrip Hospital Glucose Monitoring System (Nova Biomedical, Waltham, Massachusetts, USA) were used to measure lactate concentrations. The target population was patients with

Results

The largest group of patients in our sample were adults >18 years old (64.7%), followed by preschool children 3–5 years old (20.6%). There was a male predilection in the incidence of acute hydrocephalus in patients with TBM (58.8%) with a male-to-female ratio of 1:0.7. Other measured variables included time to CSF diversion, which was mostly 12 to <24 hours (38.2%) and 24 to <48 hours (26.5%). Another variable was Glasgow Coma Scale (GCS) score on presentation: 47.06% of patients arrived

Discussion

The age of our patients closely matched national data on TB epidemiology, with children (3–5 years old; 20.6%) mostly affected in a highly prevalent population and adults (>18 years old; 64.7%) mostly affected in populations with low TB prevalence. Age plays a major role in the pathophysiology of TBM.1, 4 TBM cases in children in developing countries, such as Indonesia, are exacerbated by poor nutrition, squalor, poverty, lack of health awareness, and poor health care infrastructure. Adult

Conclusions

Intraoperative CSF lactate when performing CSF diversion was higher than preoperative plasma lactate levels in patients with TBM and acute hydrocephalus, and these levels reached 1.5 times plasma lactate levels. An increase in preoperative plasma lactate levels in patients with TBM correlated with poorer outcome, as assessed using the GOS; this correlation also applied for increased CSF lactate levels.

References (24)

  • Z. Zhang et al.

    Lactate clearance as a useful biomarker for the prediction of all-cause mortality in critically ill patients: a systematic review study protocol

    BMJ Open

    (2014)
  • Cited by (6)

    Conflict of interest statement: This study was supported by Grants-in-Aid from the Ministry of Research, Technology and Higher Education of the Republic of Indonesia No. 30/E/KPT/2017 (PUPT) to A.F. and from the Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia (ALG 1-1-6) to H.M.N.

    View full text