Ventriculitis

If the doctor diagnoses "ventriculitis", then this means that a complication has developed that threatens not only the health, but also the patient's life. Pathology is an inflammatory reaction that affects the walls of the cerebral ventricles: this is a serious intracranial infectious disease that develops in patients suffering from various disorders of the central nervous system - in particular, traumatic brain injury, intracranial surgery, infectious and inflammatory diseases can act as the primary problem. The mortality rate from complications is very high. [1]

Epidemiology

If we consider the statistical information about ventriculitis, then we can see that most authors mention the incidence of cases of the disease, either depending on their cause, or as complications of other pathologies of the nervous system. There are no separate statistics for ventriculitis. 

As the American Center for Pathology Control and Prevention informs, in general, infectious lesions of the central nervous system are in eleventh place among all hospital infections, with a frequency of 0.8% (more than 5.5 thousand patients annually). 

To date, the most investigated pathogenetic type of the disease is ventriculitis, which was formed as a result of the ventricular drainage procedure. In such cases, ventriculitis developed in 0-45% of patients. If we consider the incidence of complications by the duration of the drainage, then the indicator is 11-12 patients per thousand drainage days. At the same time, over the years, the number of cases is gradually decreasing, which may be associated with the improvement of methods of medical manipulations and diagnostics, as well as with the optimization of the quality of processing of surgical instruments. 

Some experts have drawn a parallel in the occurrence of ventriculitis and meningoencephalitis due to neurosurgical operations. The prevalence of such pathologies, according to various information, is 1-23%: such a wide percentage range is associated with different diagnostic criteria used that are used in research. In many studies, only those cases were taken into account in which the crops of cerebrospinal fluid revealed the growth of certain pathogenic microorganisms. [2]

The incidence of ventricular catheter-associated ventriculitis (or care-related ventriculitis) ranges from 0 to 45%, depending on insertion and treatment technique (usually less than 10%). [3], [4]

Causes ventriculitis

Ventriculitis is an infectious disease. In newborns, infection occurs in utero. In older patients, the causes are most often as follows:

• Open craniocerebral traumatic injuries, fractures of the base or cranial vault, other injuries in which there is a violation in the brain tissues located in the periventricular zone, as well as the formation of cerebrospinal fistulas through which the infection penetrates inside. An inflammatory reaction develops when pathogenic flora enters the ventricular space.
• Penetrating cranial injuries - in particular, gunshot wounds, penetration of various foreign objects, which entails an infection in the brain tissue.
• A cerebral abscess located near the ventricular system. With a spontaneous opening of the focus, its internal purulent contents go into the ventricle, or into the periventricular space. As a result, ventriculitis develops.
• Inflammation of the brain, encephalitis can also spread to the ventricles - in particular, infectious pathogens enter the ventricular cavity.
• Purulent inflammation of the meninges. The spinal membranes are closely adjacent to the subarachnoid space, which is filled with cerebrospinal fluid and is part of the general cerebrospinal fluid system. The pathogenic flora enters the spinal tract, diverges through the ventricles, causing an inflammatory process like ventriculomeningitis.
• Neurosurgical operations. In case of aseptic disturbances during the operation in the area of the ventricles of the brain, it is possible for an infectious agent to penetrate into the ventricular space. This is possible with insufficient sterilization of surgical instruments, such as a puncture needle, drains, etc.

A number of increased likelihood of developing ventriculitis include cases of wounds and other cranial injuries, surgical manipulations on the brain, and intrauterine infection of the fetus (septic processes). [5]

Risk factors

The risk group for ventriculitis is made up of patients with the following features:

• oncological pathologies, chronic hematological disorders;
• drug addiction, chronic alcohol dependence;
• frequent head injuries;
• endocrine disorders;
• immunodeficiency states of different nature (genetic diseases, HIV infection, asplenia, etc.);
• advanced age (over 70 years). [6]

Additional risk factors for the appearance of ventriculitis are:

• late appeal to a doctor (later than on the third day after the development of the pathological process);
• improperly provided first aid at the pre-medical stage, or lack of necessary assistance;
• cerebral arterial atherosclerosis with signs of discirculatory encephalopathy against the background of hypertension.

If the patient belongs to one of the risk groups, or has any of the risk factors, then this obviously indicates a high probability of a severe or complicated course of the pathology, which may require urgent and competent use of therapeutic and rehabilitation measures. [7]

Significant factors in the development of ventriculitis are:

• the presence of blood in the ventricles or subarachnoid space;
• the presence of other systemic infections;
• leakage of cerebrospinal fluid, in particular in patients with penetrating cranial trauma;
• prolonged drainage of the cerebral ventricles and the introduction of fluids into them for washing.

Many experts point to the involvement in the occurrence of ventriculitis by frequent sampling of cerebrospinal fluid by catheterization for research. According to some information, if the catheterization lasts more than one week, then this significantly increases the likelihood of developing an infectious process. However, the issue of the duration of drainage and the need for preventive replacement of the catheter is still controversial. To reduce the risk of developing ventriculitis, some authors suggest tunneling the catheter to remove it from the milling hole to the area of exit from the skin. It is recommended to make an indent less than 50 mm from the milling hole, or withdraws the catheter in the chest or upper segment of the anterior abdominal wall. [8]

Pathogenesis

The options for the ingestion of an infectious agent into the cerebral ventricles are different. So, the development of ventriculitis can start as a result of the direct delivery of pathogens from the external environment. This happens with open craniocerebral injuries, during neurosurgical surgery - for example, the risk zone includes such interventions as the installation of a ventricular drainage for patients with hemorrhages in the cranium, an acute form of hydrocephalus, spinal valve bypass, and other open access operations. Contact divergence of the infection during the opening of the cerebral abscess into the ventricular system, hematogenous spread during the circulation of bacteria in the bloodstream, cerebrospinal penetration during the reverse flow of cerebrospinal fluid in patients with primary and secondary meningitis or meningoencephalitis is also possible. 

Presumably, the reverse flow of cerebrospinal fluid occurs during the transformation of the pulse movement of the cerebrospinal fluid through a deterioration in the elasticity of the intracranial subarachnoid spaces, which is caused by inflammatory changes or hemorrhage. [9]

The specified mechanism of development of ventriculitis determines the frequent association of the disease with the inflammatory process in the meninges. [10]

As a result of opening a cerebral abscess into the ventricular system, ventriculitis also occurs. But often there is another, "mirror" option: with a complicated course of ventriculitis, an encephalitis focus develops in the adjacent tissues with the formation of a cerebral abscess. 

Symptoms ventriculitis

If ventriculitis develops against the background of penetrating traumatic or wound injuries, then the patient feels a strong and sudden general deterioration in well-being. The body temperature rises, and the indicators exceed 38 ° C. A similar picture is observed with spontaneous opening of a cerebral abscess. If patients are conscious, then most often they voice complaints of severe pain in the head and growing agitation. There is a significant increase in heart rate (more than 120-130 beats per minute), blanching or redness of the skin (which is especially noticeable on the face), shortness of breath, vomiting, after which it does not become easier. The meningeal syndrome is clearly marked.

Strengthening of motor activity (psychomotor agitation) is replaced by tonic-clonic or clonic convulsions. During the attacks, progressive impairment of consciousness is noted. The patient becomes lethargic, lethargic, sleepy: the stupor stage begins with a gradual fall into a coma. The patient's body is depleted, which may be accompanied by a slight decrease in temperature indicators to the level of subfibrality, as well as a decrease in the intensity of meningeal manifestations.

If ventriculitis develops in a newborn baby as a result of intrauterine infection, then a serous inflammatory process takes place, not accompanied by any clinical signs. Pathology is determined during ultrasound diagnostics. With the development of pathology, as a septic complication, pathognomonic symptoms are absent, however, the baby's condition is significantly aggravated. [11]

The initial clinical picture during the development of ventriculitis quickly makes itself felt, as it develops literally "before our eyes." Characterized by severe diffuse headache, bouts of vomiting against the background of the absence of nausea and relief. The general state of health is rapidly deteriorating. Severe conditions are accompanied by frequent changes in periods of excitement and apathy, convulsive seizures, the appearance of hallucinations and impaired consciousness, the development of stupor and coma.

The following are considered pathognomonic signs of ventriculitis:

• hyperesthesia (hypersensitivity);
• muscle tonic symptoms;
• pain syndrome.

Increased sensitivity during the development of ventriculitis is an increase in sound, light, tactile sensitivity. A pronounced muscular-tonic sign is the stiffness of the occipital muscles (increased tone), which can be determined by passive tilt of the head with an attempt to bring the patient's chin to the chest. The state of muscle hypertonicity can also be determined by the peculiar posture of the patient, who lies on his side, arching his back and throwing his head backward, bending and tucking his legs towards the stomach.

Pain syndrome covers the head, eyes, is noted at the points of exit of the trigeminal nerve, in the occipital region and cheekbones. [12]

Ventriculitis in newborns

Diagnosis and treatment of congenital anomalies of the central nervous system with the development of ventriculitis is a very important issue in medicine, since in recent years this pathology has become increasingly common. Purulent ventriculitis is a particularly severe intracranial complication caused by the ingress of microflora into the cerebral ventricles. There is no characteristic CT-picture in pathology. It can be detected when an abscess breaks out into the ventricles, during the formation of a cerebrospinal fistula, which communicates with the ventricles, or it can be based on clinical and cerebrospinal fluid manifestations. [13]

The development of purulent meningoencephalitis and ventriculitis is possible with progressive internal occlusive hydrocephalus. Complication can manifest as a result of the ascent of infection with a combination of congenital CNS defect with an infected spinal hernia, or with isolated hydrocephalus with generalization of meningoencephalitis.

The characteristic clinical signs of hydrocephalus and ventriculitis are a rapid increase in head circumference, spastic tetraparesis, bright membranous manifestations, and prolonged persistent hyperthermia. When coexisting with cerebrospinal hernias, symptoms are complemented by lower paraparesis, dysfunction of the pelvic organs with the presence of a tense hernial sac.

The course of the inflammatory process is usually severe, against the background of gross neurological failure. Taking into account the complexity of treatment, the degree of mortality, the severity of disability, an important point should be the improvement of preventive preventive measures during pregnancy planning. It is important to carry out qualified prenatal diagnostics and, if necessary, step-by-step treatment during the first months of a baby's life until complications and decompensated conditions appear. It is recommended to do this only in a specialized neurosurgical clinic or department.

Neurosonography is considered the most informative screening technique for the morphological determination of brain lesions in children during the neonatal period. Neurosonography has the greatest diagnostic value in terms of detecting congenital anomalies of the central nervous system, internal hydrocephalus, periventricular hemorrhage and leukomalacia at the stage of cyst formation. [14]

Forms

The first information about the existence of ventriculitis was obtained almost a hundred years ago. They were published by S. Nelson, an American specialist in pathology. A little earlier, suggestions were made about the belonging of granular ependymatitis to chronic lesions of cerebral ependyma: the pathology, according to doctors, could develop as a complication of tuberculosis, syphilis, chronic alcohol intoxication, echinococcosis, senile dementia and other chronic pathologies of the central nervous system. The works of Dr. Kaufman turned out to be important, who believed that traumatic and alcoholic injuries, acute infectious processes became the primary factors in the development of the disease.

Nelson's descriptions of the disease include an analysis of the chronic form of hydrocephalus. In particular, the doctor pointed out the difficulties in determining the etiology of granular ependymatitis, since the pathology can be both inflammatory and non-inflammatory in nature. [15]

Subsequently, other terms were used in medicine to characterize the disease - in particular, they mention ependymatitis, ependymitis, intraventricular abscess, ventricular empyema, and even the so-called "piocephalus". After the assumption of the development of an inflammatory process inside the vessels, Dr. A. Zinchenko (about fifty years ago) introduced the term chorioependymatitis into medical use. In addition, the types of the disease were identified:

• nonspecific ventriculitis (allergic, infectious, viral, sinusogenic, tonsilogenic, rheumatic, otogenic, post-traumatic and intoxication pathology);
• specific ventriculitis (tuberculous, syphilis, parasitic pathology).

The course of the disease was divided into acute, subacute and chronic stages.

According to the quality of cerebrospinal dynamics, the following types of pathology began to be distinguished:

• occlusive ventriculitis against the background of obliteration of the pathways of the cerebrospinal fluid;
• non-occlusive ventriculitis in the phase of hypersecretion or hyposecretion (fibrosclerotic variant with hypotension).

In the future, the name ependymatitis was hardly mentioned in medical circles. The term "ventriculitis", which can develop in the following forms, has become much more widespread:

• the primary form, due to the direct entry of infection into the ventricular structures - for example, during penetrating trauma and wounds, surgical operations;
• a secondary form that occurs when pathogenic microorganisms enter from a focus already in the body - for example, with meningoencephalitis, cerebral abscess.

Complications and consequences

With the development of the inflammatory process in the ventricular system - ventriculitis - pus enters the cerebrospinal fluid. As a result, the cerebrospinal fluid becomes more viscous, its circulation is disrupted. The condition is aggravated if the liquor ducts are clogged with accumulations of purulent masses. Intracranial pressure increases, brain structures are compressed, cerebral edema develops.

When the inflammatory process spreads to the region of the fourth ventricle, the cavity of the latter expands, and the developing hydrocephalus leads to compression of the adjacent brain stem. Vital centers localized in the medulla oblongata and the area of the bridge are affected. Increased pressure leads to respiratory and cardiovascular disorders, which significantly increases the risk of death of the patient. [16]

The most severe consequence of ventriculitis is considered a fatal outcome. In other cases, disability and dementia are possible.

Recovered patients may experience residual effects such as asthenia, emotional instability, chronic headache, intracranial hypertension.

Prerequisites for successful treatment of patients with ventriculitis:

• timely and comprehensive diagnostic measures with adequate and competent therapy;
• individual and integrated approach;
• complete reorganization of the primary infectious focus. [17]

Diagnostics ventriculitis

The main diagnostic criterion for ventriculitis is considered to be a positive indicator of infection in the cerebrospinal fluid, or the presence of at least two characteristic symptoms of the disease:

• a febrile condition with a temperature exceeding 38 ° C, pain in the head, meningeal signs, or symptoms of the affected cranial nerves;
• changes in the composition of cerebrospinal fluid (pleocytosis, increased protein or decreased glucose);
• the presence of microorganisms during microscopic examination of Gram-stained cerebrospinal fluid;
• isolation of microorganisms from the blood;
• a positive diagnostic laboratory sample of cerebrospinal fluid, blood or urinary fluid without culture detection (latex agglutination);
• diagnostic antibody titer (IgM or fourfold increase in IgG titer in paired sera).

The clinic and neurology of ventriculitis, as well as the results of laboratory tests, are of decisive diagnostic importance. In the course of computed tomography, a slight increase in the density of the cerebrospinal fluid can be determined, which is due to the presence of pus and detritus, as well as a periventricular decrease in density as a result of edema of the inflammatory altered ependyma from the subependymal layer. [18]

In many cases, the diagnosis of ventriculitis is confirmed by the detection of paraventricular localization of the zones of cerebral destruction, which have a message with the ventricular cavity, in combination with other symptoms. [19]

The optimal method for neuroimaging ventriculitis is magnetic resonance imaging of the brain using the DWI, FLAIR and T1-WE modes with contrast. Most often, it is possible to detect intraventricular detritus and pus, with predominant localization in the region of the occipital horns or triangles of the lateral ventricles, sometimes in the fourth ventricle during MRI diagnostics of a patient in a horizontal position. An additional MRI sign of ventriculitis is the presence of an enhanced contour of the ventricular lining (typical for 60% of cases). There are also signs of choroidal plexitis, including an indistinct blur signal from the boundaries of the enlarged choroidal plexus.

In early childhood, neurosonography is used as the main diagnostic method: the picture of ventriculitis is similar in features to that of computed or magnetic resonance imaging:

• increased echogenicity of the cerebrospinal fluid and the identification of other echogenic inclusions due to the presence of pus and detritus;
• increased echogenicity and thickening of the ventricular walls (in particular, due to fibrin layers);
• increased echogenicity of the choroidal plexus, with blur and deformation of the outlines. [20]

Tests include a study of blood and cerebrospinal fluid:

• the glucose content in the cerebrospinal fluid is less than 40% of the plasma glucose content (less than 2.2 mmol per liter);
• increased protein content in the cerebrospinal fluid;
• microbiological CSF culture is positive, or the pathogen is detected in a smear of cerebrospinal fluid (with Gram stain);
• there is cerebrospinal fluid cytosis with a neutrophil level of 50% or more of the total;
• in the blood, leukocytosis with a stab shift is noted;
• the plasma level of C-reactive protein increases. [21]

The etiology of the disease is established by cultural isolation of the pathogen during bacteriological inoculation of cerebrospinal fluid and blood. It is imperative to take into account the duration and atypical growth of the culture. Serological tests (RSK, RNGA, RA) suggest the study of paired sera with a two-week interval. [22]

Instrumental diagnostics consists of computed or magnetic resonance imaging, neurosonography, lumbar puncture. Encephalography is used to assess the functional state of the brain and the degree of damage to the nervous tissue. Electroneuromyography demonstrates the severity of damage to the conducting nerve pathways if the patient has paresis or paralysis.

Differential diagnosis

If an intraventricular hyperintense signal is detected on MRI, differential diagnosis of ventriculitis with intraventricular hemorrhage is performed. Clinical practice shows that in relatively rare cases, a pathological hyperintense signal is detected:

• in 85% of cases with FLAIR mode;
• at 60% in T1-VI mode with contrast;
• in 55% of cases - in the DWI mode. [23]

It must be borne in mind that areas of periventricular hyperintensity of the bordering type are also noted in patients with hydrocephalus, without infectious complications, which is associated with transependymal migration of cerebrospinal fluid and the formation of periventricular edema. [24]

Treatment ventriculitis

The most important measure in the therapy of ventriculitis is antibiotic therapy. In order for such treatment to be as effective as possible, a set of medicines is selected for the initial therapeutic stage, taking into account the alleged cause of the disease and microbiological parameters. The doctor determines the most appropriate dosage and frequency of antibiotic administration. [25]

Rational prescription of drugs involves determining the etiological factor of the disease and clarifying the sensitivity of the isolated culture of the microorganism to antibiotics. Bacteriological techniques help to identify the pathogen after 2-3 days from the moment the material was removed. The result of the sensitivity of microorganisms to antibacterial drugs can be assessed after another 24-36 hours. [26]

Antibiotic treatment for patients with ventriculitis should be started as early as possible, without spending time waiting for the results of instrumental diagnostics and examination of cerebrospinal fluid, immediately after taking blood for sterility. Doses of antibiotics are set as maximum permissible doses. [27]

Empirical treatment of ventriculitis necessarily involves the use of Vancomycin in combination with Cefepime or Ceftriaxone. If the patient's age exceeds 50 years, or if the disease was preceded by an immunodeficiency state, Amikacin is prescribed as an auxiliary drug. [28]

An alternative regimen suitable for patients with severe allergic reactions to β-lactam antibiotics involves the use of Moxifloxacin or Ciprofloxacin in combination with Vancomycin. Patients over 50 years of age or suffering from immunodeficiency conditions additionally receive Trimethoprim / Sulfomethoxazole. [29]

About 15 minutes before the first injection of the antibacterial drug, an injection of Dexamethasone should be given, based on a dosage of 0.15 mg per kilogram of body weight. If, during microscopy of the cerebrospinal fluid, gram-positive diplococci were found, or a positive latex agglutination reaction to pneumococci in the blood or cerebrospinal fluid was found, then the administration of Dexamethasone is continued every 6 hours for 2-4 days, at the same dosage. In other situations, Dexamethasone should not be used. [30]

Ventriculitis may require additional intraventricular antibacterial agents. Thus, Vancomycin, Colistin and aminoglycosides are considered safe and effective drugs for this purpose. Polymyxin B is recognized as the best option. The dosage is established empirically, taking into account the achievement of the required therapeutic drug content in the cerebrospinal fluid. [31]

Perhaps epidural administration of such drugs:

• Vancomycin 5-20 mg per day;
• Gentamicin 1-8 mg per day;
• Tobramycin 5-20 mg per day;
• Amikacin 5-50 mg per day;
• Polymyxin B 5 mg per day;
• Colistin 10 mg per day;
• Quinupristin or Dalfopristin 2-5 mg per day;
• Teicoplanin 5-40 mg per day.

Any β-lactam antibiotics - in particular, penicillin, cephalosporin drugs and carbapenems - are not suitable for subarachnoid administration, since they increase seizure activity.

The combination of intravenous and intraventricular antibiotics is always preferred and effective. [32]

As soon as the results of the study of cerebrospinal fluid and the resistance of the microbial flora to antibiotic therapy are ready, the doctor corrects the antibacterial treatment, choosing a drug to which the special sensitivity of microorganisms is noted. [33]

The effect of antibiotic therapy is assessed according to clinical and laboratory indicators:

• weakening and disappearance of clinical symptoms;
• elimination of intoxication;
• stabilization of laboratory diagnostic indicators;
• "Purity" of repeated crops of cerebrospinal fluid.

In addition to antibiotic therapy, patients with ventriculitis often undergo drainage of the cerebral ventricles to eliminate acute hydrocephalus, which occurs as a result of occlusion of the spinal canal with particles of pus and detritus. It is important to carefully follow the rules of asepsis and antiseptics during the procedure, to regularly carry out dressings, to process the drainage areas, to ensure the cleanliness of the connectors and containers for the cerebrospinal fluid. [34]

The duration of treatment for patients is determined depending on the type of pathogen:

• at least two weeks with pneumococci;
• one week for group B streptococci;
• three weeks with enterobacteriaceae.

In the course of treatment, an assessment of clinical and laboratory efficiency is performed.

If antibiotic therapy is ineffective, two weeks after the start of treatment, it is recommended to perform an endoscopic operation to revise the ventricles, using an elastic endoscope and flushing the system with Ringer's solution or other similar drugs. Endoscopy can be repeated: the procedure is repeated in the absence of positive dynamics within three weeks after the previous intervention. [35]

Throughout the entire period of a person's stay in the hospital, doctors monitor vital signs, maintain them at an optimal level with the help of constant and careful infusion of saline solutions. The quality of diuresis is also controlled. To prevent depletion, parenteral nutrition is provided, hygienic care is carried out.

Additional symptomatic therapy for ventriculitis includes:

• correction of the hypoxic state (artificial ventilation of the lungs);
• anti-shock measures (corticosteroids, Heparin, Fraxeparin, Gordox, Contrikal);
• careful detoxification treatment (Infukol, Heisteril, fresh frozen plasma, albumin);
• dehydration and decongestant treatment (Mannitol, 40% Sorbitol solution, Lasix);
• improvement of metabolic and neurovegetative protection of brain structures (Nootropil, Cavinton, Trental, Actovegin);
• compensation of energy costs (Moriamin, Polyamine, Lipofundin, etc.).

For pain relief use analgesics (including narcotic), non-steroidal anti-inflammatory drugs.

Prevention

Modern neurosurgery involves the use of ventricular catheters, richly treated with antibacterial agents (by the method of impregnation), which reduces the risk of infection during drainage. As practice shows, the use of such catheters, along with careful adherence to other preventive measures, helps to reduce the risk of infection to almost 0%. [36],  [37], [38]

It is possible to prevent the development of ventriculitis. To do this, it is necessary to treat otorhinolaryngological and dental pathologies in time, avoid injuries and not contact infected people, strengthen immunity, and prevent intoxication and stress. [39], [40]

Forecast

According to information published by experts, the mortality rate in patients with post-drainage ventriculitis ranges from 30 to 40%. In patients of different ages who underwent neurosurgical operations with complications such as meningitis or ventriculitis, poor clinical prognosis was observed in almost 80% of cases, of which:

• death of the patient was noted in more than 9% of cases;
• in more than 14% of cases, a persistent vegetative state developed;
• almost 36% of patients experienced severe pathological changes;
• in almost 20% of cases, moderate pathological changes were observed.

More than 20% of patients recovered well, 60% of children showed positive dynamics. The most unfavorable prognosis for the most part related to people over 46 years of age, showing a focal neurological picture, or demonstrating a level of consciousness less than 14 points according to the Glasgow Coma Scale. Cases in which there was a need for mechanical ventilation - artificial ventilation of the lungs - had a poor prognosis.

In general, in patients with ventriculitis of various origins (including post-drainage and other developmental options), the mortality rate is about 5%. An extremely unfavorable prognosis is noted if ventriculitis has arisen as a result of the penetration of multi-resistant microflora. For example, when baumannii is damaged by Acinetobacters, the mortality rate even with systemic administration of Colistin is more than 70%. The number of deaths in such a situation can be significantly reduced by supplementing systemic treatment with intraventricular use of Colistin.

The above indicators reflect the prognostic data provided by foreign authors. In the countries of the post-Soviet space, such information is insufficient due to the lack of serious research on this issue. There is only a general statistical rate of death in patients with ventriculitis, which ranges from 35 to 50% or more.

It can be concluded that ventriculitis is a problem that requires comprehensive study. This is necessary both to prevent the development of pathology and to successfully treat it.