Recovery From Surgery for Tuberculosis of the Central Nervous System in Children

Postoperative Orders 

• ICU vs. standard care unit: Most patients in poor stages, as mentioned earlier, might need ICU care for fluid management and ICP monitoring.
• IVF and rate: At presentation and in the postoperative period, many of the patients have compromised volume status. The first step is to assess the volume status and replace the volume with normal saline and simultaneously investigate for hyponatremia.
• Ventilator support: Ventilator support may be needed, especially for patients with associated pulmonary TB.
• Diet: A high-protein diet is usually recommended.
• Physical therapy and orthotics: Neurorehabilitation is needed in the postoperative period. Mobility equipment includes wheelchairs, walkers, crutches, and canes.

Hydrocephalus

• Monitored postoperative setting: The child is kept in a monitored setting to avoid overdrainage or shunt failure. Malnutrition and higher protein content and cellularity in the CSF have been proposed to be predisposing factors to shunt malfunction.

Tuberculomas/tuberculous abscess

• Monitored postoperative setting: Close follow-up is required to monitor for clinical deterioration secondary to the expansion of any intracerebral tuberculoma following the start of anti-TB therapy or from paradoxical reactions to the drugs (27, 28). Concomitant steroid therapy probably has a preventive role against these focal lesions. However, with continued treatment, eventual resolution of these tuberculomas occurs.
• Immune reconstitution disease in HIV patients: The management of CNS TB is complicated in HIV- infected patients by the potential for drug interactions, drug toxicity, and paradoxical reactions or immune reconstitution disease (7, 52). Immune reconstitution disease is usually manifested by fever and an apparent clinical worsening of disease. It has been widely reported in association with CNS TB. Risk factors include a low CD4 count (usually less than 50 cells/µl), initiation of antiretroviral therapy shortly after initiation of anti-TB therapy (typically within 2 months), a rapid fall in viral load, and a rise in CD4 cell count. In the context of CNS TB immune reconstitution disease can be life-threatening, with expansion of intracerebral tuberculomas or enlargement of spinal lesions (17, 26, 53).

Postoperative Morbidity

• Standard after craniotomy: Special attention must be paid to fluid/electrolyte balance and nutritional status to improve wound healing. Anti–TB therapy should be continued and steroids administered when indicated.