Vellore Grade IV in Tuberculous Meningitis
Vellore grade IV is the most severe clinical grade in the Vellore grading system for tuberculous meningitis with hydrocephalus, characterized by profound neurological deterioration with decerebrate or decorticate posturing and is associated with extremely poor outcomes and high mortality rates. 1
Understanding the Vellore Grading System
The Vellore grading system is specifically used for clinical assessment of patients with tuberculous meningitis (TBM) and hydrocephalus. It consists of four grades:
- Grade I: Best clinical grade - patient alert and oriented with minimal neurological deficits
- Grade II: Moderate impairment
- Grade III: Severe impairment
- Grade IV: Worst grade - profound neurological deterioration with decerebrate/decorticate posturing
Clinical Significance of Vellore Grade IV
Patients with Vellore grade IV TBM with hydrocephalus have:
- Extremely poor prognosis
- High mortality rates (reported as high as 60%) 2
- Limited benefit from surgical interventions 1
- Questionable utility of neurosurgical procedures 1
Management Considerations for Grade IV Patients
The management of Vellore grade IV patients is challenging:
- Surgical intervention: The utility of ventriculoperitoneal (VP) shunt placement or endoscopic third ventriculostomy (ETV) in grade IV patients is debatable due to poor outcomes 1
- Mortality risk: Surgery for grade IV patients is associated with high mortality (up to 60%) 2
- Good outcome rates: Only about 20% of grade IV patients achieve good outcomes even with intervention 2
Treatment Approach
Despite poor prognosis, treatment should still be initiated:
Antitubercular therapy: Immediate initiation of the standard regimen as recommended by the American College of Physicians and Infectious Diseases Society of America 3
- Initial phase (2 months): Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol
- Continuation phase (7-10 months): Isoniazid and Rifampicin
Adjunctive corticosteroids: Strongly recommended for all TBM patients 3
- Dexamethasone (12 mg/day) or Prednisolone (60 mg/day), tapered over 6-8 weeks
Management of hydrocephalus:
- Medical management with dehydrating agents and steroids may be attempted first
- Surgical intervention has questionable benefit in grade IV but may be considered on a case-by-case basis
Prognostic Factors
Several factors contribute to poor outcomes in grade IV patients:
- Seizures (significantly increased hazard ratio for poor outcomes) 4
- Low Glasgow Coma Scale scores 4
- High cerebrospinal fluid cell count 4
- Delayed initiation of treatment 5
Important Caveats
- The decision for surgical intervention in grade IV patients should be carefully weighed against the high risk of mortality
- Early diagnosis and treatment of TBM before progression to grade IV is crucial for improving outcomes
- Even with optimal management, grade IV patients have significantly worse outcomes compared to those with less severe grades
- Hydrocephalus occurs in up to 85% of children with TBM and is generally more severe in children than adults 1
The Vellore grading system has been validated by multiple studies and serves as an important prognostic tool in the management of TBM with hydrocephalus, with grade IV representing the most severe form with the poorest prognosis.