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Thirty two poor grade patients (grade 3, 20 patients and grade 4, 12 patients) with tuberculous meningitis and hydrocephalus were prospectively studied to evaluate the response to external ventricular drainage in predicting outcome after shunt surgery. All grade 3 patients underwent a shunt procedure irrespective of their response to external ventricular drainage, and an attempt was made to correlate the immediate response to external ventricular drainage to their long term outcome. Patients in grade 4 underwent shunt surgery only if there was clinical improvement by at least one grade after external ventricular drainage. Follow up (mean 23.1 months) was available for 30 patients (93%). Of the 20 patients in grade 3, seven underwent shunt surgery directly, 13 after an external ventricular drainage. In the group which underwent drainage, the immediate clinical response was improvement in six, no change in six, and death in one. Long term improvement or death occurred almost equally in all the subgroups. The immediate response to external ventricular drainage was not predictive of the long term outcome in grade 3 patients. All 12 patients in grade 4 underwent an external ventricular drainage and only one improved. The rest continued to deteriorate and succumbed to the disease. Grade at admission was the single most important predictor of good outcome (p=0.002) and severity of hydrocephalus had an adverse impact on outcome (p= 0.04). The rest of the variables studied (age, duration of illness, duration of altered sensorium, CSF cell count, and CSF protein concentrations) had no effect on long term outcome. All patients in grade 3 should be given the benefit of shunt surgery without a trial of external ventricular drainage. However, patients in grade 4 should undergo an external ventricular drainage in view of the high mortality in this group.

Thirty consecutive Indian patients with focal or generalised seizures and single, small (less than 10 mm), enhancing lesions on CT scans (SSECTL) were studied. Five patients (Group A) were treated with anticonvulsants alone and did not have a biopsy. In ten patients (Group B) a CT guided stereotaxic biopsy of the lesion was carried out and in the remainder (15-Group C) and excision biopsy of the lesion was carried out following CT guided stereotaxic localisation. In all patients in Group B the lesion were reported as "chronic nonspecific inflammation". In seven of 15 patients in Group C the lesions showed a cysticercus with a granuloma and in a further five the pathology was that of a "parasitic granuloma" but the parasite could not be identified. Biopsy did not reveal a tuberculoma or neoplasm in any of the patients. The lesions studied are the same as "disappearing" CT lesions reported in Indian patients, as in 12 of 15 patients in Groups A and B, who could be followed up for more than three months, the lesions had spontaneously disappeared or left calcific residues. It is concluded that in Indian epileptic patients with SSECTL cysticercosis is the commonest aetiology. A treatment protocol for these patients is suggested on the basis of the findings.

A study of the clinical, radiological, and pathological correlations in 43 patients with solitary cysticercus granuloma and epilepsy focused on factors that might help in predicting the presence of the parasite in the granuloma and those that might influence the formation of oedema around the granuloma. The duration of symptoms (< six months and > or = six months) and CT morphology of the granuloma (ring and disc, type A; nodular lesion, type B) were studied as factors that could possibly predict the presence of the parasite in the granuloma. The influence of sex of the patient and the presence of a neutrophilic response in the granuloma on the intensity of oedema around the lesion as seen on CT was also studied. The pathological features were studied in the excised granulomas. The intact or degenerated form of the cysticercus was evident in 22 of 43 specimens. Neither the duration of seizures (P = 0.17) nor the type of lesion on CT (P = 0.16) was predictive of the presence of the parasite in the granuloma. The sex of the patient (P = 0.51) and the neutrophilic response in the specimen (P = 0.73) did not correlate with the degree of oedema on CT indicating that neither of these host factors was a major determinant of oedema production. The findings point to the varied and unpredictable natural history of solitary cysticercus granulomas and the complex nature of host-parasite interactions in individual patients. The inability to predict the presence of the parasite in the granuloma on the basis of the clinical or radiological features precludes a selection of patients with such lesions for cysticidal drug treatment.