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Utility of lumbar and external ventricular drainage in the management of meningitis: a systematic review
Journal article   Open access   Peer reviewed

Utility of lumbar and external ventricular drainage in the management of meningitis: a systematic review

Mitchell D Kilgore, Christopher Carr, Morgan Kuchar, Marissa Tucci, Mansour Mathkour, Tyler Scullen, Hussam Abou-Al-Shaar, R Shane Tubbs and Aaron S Dumont
Neurosurgical focus, v 59(5), E4
01 Nov 2025
DOI: https://doi.org/10.3171/2025.8.FOCUS25673
PMID: 41175399
Featured in Collection :   UN Sustainable Development Goals @ Drexel
url
https://doi.org/10.3171/2025.8.FOCUS25673View
Published, Version of Record (VoR) Open

Abstract

Cerebrospinal Fluid Shunts - methods Disease Management Drainage - methods Humans Hydrocephalus - surgery Meningitis - surgery
Meningitis involves high mortality and morbidity, particularly when associated with elevated intracranial pressure (ICP). Lumbar and external ventricular drainage (LD/EVD) have been used as adjuncts to standard antimicrobial therapy in severe meningitis; however, there is no established standard of care for incorporating these into existing treatment paradigms. This study aimed to synthesize the existing literature and provide treatment recommendations regarding CSF diversion in meningitis, emphasizing the use of divertive treatment even in the absence of hydrocephalus. The PubMed database was systematically reviewed according to the PRISMA guidelines and included all studies describing LD and/or EVD in meningitis. Forty-one studies on the use of LD and/or EVD in meningitis were identified, involving 715 total patients. Twenty-five (61%) of 41 studies used LD, and 24 (59%) used EVD. Study designs included a nonrandomized controlled trial (n = 1), a cohort study (n = 1), case-control studies (n = 3), case series (n = 3), and individual case reports (n = 33). There were 16 reports of fungal meningitis (39%), 11 (27%) bacterial, and 6 (15%) tuberculous. Nine reports (22%) described comorbid HIV infection. Of the 6 studies including a control group, 4 (67%) reported favorable results associated with CSF diversion. Seven (16%) of 45 patients described in case reports or case series died despite CSF diversion (5 with EVD, 2 with LD), and 17 (38%) required permanent shunt placement (9 ventriculoperitoneal shunts, 8 lumboperitoneal shunts). The studies reviewed in this paper suggested CSF diversion may lead to more favorable outcomes in certain cases, particularly fungal, bacterial, and tuberculous meningitis compared to conservative treatment alone, even in the absence of radiological evidence of hydrocephalus. These more favorable outcomes may be related to improved infectious source clearance or opportunity for intrathecal drug delivery in addition to sustained ICP reduction. The authors recommend that, while it may be appropriate to initially offer a less invasive approach to CSF diversion in the form of a lumbar drain, they believe it is appropriate to escalate care to more aggressive treatment via an external ventricular drain in patients who do not respond to LD, and as initial treatment in higher risk patients with a need for continuous ICP monitoring or signs of hydrocephalus. Nevertheless, studies were heterogeneous and prone to selection bias, underscoring the need for future well-designed interventional studies in homogeneous patient populations.

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Collaboration types
Domestic collaboration
International collaboration
Web of Science research areas
Clinical Neurology
Surgery
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