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Three Decades of Vellore Grading for Tuberculous Meningitis with Hydrocephalus: A Reappraisal

Background: This review documents the evolution of the Vellore grading system for tuberculous meningitis and hydrocephalus (TBMH), its evaluation by different authors, and analyzes the need for further modification in light of the published literature. Methods: Published literature was searched in PubMed and Google Scholar using the search terms, “tuberculous meningitis hydrocephalus” and “Vellore grading.” The retrieved articles were reviewed by the author and the appropriate ones were chosen for inclusion in the study. Results: Vellore grade (1–4, with 1 being the best grade and 4 being the worst grade) was found to be the sole statistically significant factor associated with outcome following VP shunt or ETV in several studies. Additionally, Vellore grades also correlate with the likelihood of success following ETV. However, the use of response to external ventricular drainage (EVD) in managing Vellore grade 4 patients has remained contentious as a small but significant proportion of patients have a good outcome following shunt, irrespective of their response to the EVD. The latter findings suggest that grade 4 patients might not constitute a homogenous group. It is proposed that grade 4 be subdivided into grades 4a and 4b, which might help in prognostication and in surgical management of the hydrocephalus in patients with TBMH. Conclusions: Vellore grading has proved its utility as a prognostic tool and can aid surgical decision-making. However, management of patients in grade 4 might be better rationalized with its division into grades 4a and 4b.