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Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure (ICP), hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. The importance of emergent administration of appropriate antimicrobial therapy cannot be overstated, but critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available to manage central nervous system (CNS) infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes. It is our opinion that ICP measurement should be strongly considered in selected patients with CNS infections, particularly those who are comatose. Treatments for intracranial hypertension, specifically in the setting of CNS infection, are described in this paper. For bacterial meningitis, intravenous dexamethasone should be administered, beginning concomitantly with the initial dose of antibiotics, at least until Streptococcus pneumoniae can be excluded as a pathogen. Clinicians should maintain a high index of suspicion for nonconvulsive seizures. Deterioration in neurologic status should also prompt early use of CT or magnetic resonance angiography and venography to exclude cerebrovascular complications.
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PMID:Neurocritical care of patients with central nervous system infections. 1857 24

Bacterial meningitis is still a serious disease with a high risk of mortality and sequels. The progress in antibiotic treatment has not improved the prognosis. Thus, optimizing the initial care and the treatment of the most severe cases should improve the outcome. No study has compared the outcome according to the level of care at the admission site. There is evidence that the most severe cases should be managed by critical care units. It seems reasonable to recommend initial admission of common cases to units able to provide intensive care. Most people now agree that fluid restriction has not demonstrated its efficiency, furthermore it might have deleterious effects. However, a fluid overload should be avoided. Maintaining cerebral perfusion is a key issue in the treatment of bacterial meningitis and requires monitoring both arterial blood pressure and intracranial pressure. Intracranial pressure monitoring is probably useful to optimize the treatment of the most severe cases. The aggressive treatments of cerebral edema have not been evaluated but seem, in some limited series, able to improve some life threatening situations. The benefit of systematic glycerol administration needs confirmation. Seizures should be treated with the usual medications. However, drugs with potentially deleterious effects on hemodynamics should be avoided. There is no sufficient evidence to support the administration of a systematic prophylactic treatment. Fever should be treated when above 39.5 degrees C/40 degrees C and in the case of intracranial hypertension. There is no clinical study to explore the modifications of fever on bacterial growth or on inflammation as observed in some experimental studies.
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PMID:[Adjunctive therapies (excluding corticosteroids). Site of initial management]. 1941 Apr 4

Early clinical data must lead to suspect bacterial meningitis if fever, the most frequent sign, is present and if it is associated with more or less constant neurological and meningeal signs (consciousness impairment, headache, neck stiffness, focal neurological deficit, seizure, etc.). A skin rash is frequent in case of meningococcal meningitis whereas cranial nerve palsy is more in favor of tuberculous or Listeria meningitis. Presence of otitis, sinusitis, pneumonia, or a recent head trauma strongly suggests a pneumococcal involvement. Tuberculous meningitis is generally characterized by a slow evolution of meningeal signs together with aspecific signs. The main prognostic factors are consciousness impairment, circulatory instability, focal neurological signs, and advanced age. Morbidity and mortality are increased in case of pneumococcal compared to meningococcal meningitis. Cranial tomodensitometry gives further information about intracranial complications of meningitis. In some cases, particularly if focal neurological or intracranial hypertension signs are present, it must be performed before a lumbar puncture. The risk factors of meningitis must be investigated and treated if possible according to the bacterium. The management of patient after hospital discharge depends on evolution after treatment. The presence of neurological sequels imposes a specialized ambulatory follow-up. Neuropsychological sequels (cognitive dysfunction, memory impairment) can also persist for years even in absence of other neurological disorders.
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PMID:[Managing adult patients with acute community-acquired meningitis presumed of bacterial origin]. 1947 96

Retinal hemorrhages in children occasionally accompany bacterial meningitis, usually due to hemophilus or meningococcal organisms. The hemorrhages may be intraretinal, usually in the posterior pole of the eye and few in number, or, more uncommonly, subhyaloid or vitreous. Pathogenesis may include vasculitis, disseminated intravascular coagulation, or intracranial hypertension. We report 2 cases of bilateral severe retinal hemorrhages in fatal Streptococcus pneumoniae meningitis.
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PMID:Severe retinal hemorrhages in infants with aggressive, fatal Streptococcus pneumoniae meningitis. 2022 31

In the acute setting, the primary objective is to decide whether the headache is primary, secondary but benign (for example a headache associated with a cold), or secondary to a potentially life-threatening cause (subarachnoid hemorrhage (SAH), bacterial meningitis, intracranial hypertension). The cornerstone of headache diagnosis is the interview with the patient, followed by a thorough physical examination. These two first clinical steps determine the need for investigation, immediate with inpatient care or on an outpatient basis, and the treatment to recommend, acutely and for future attacks in the case of primary headache. The indication for referral to a neurologist for long-term follow-up is assessed. Headaches can be separated into four groups: (1) recent onset and thunderclap; (2) recent onset with progressive installation: (3) well known to the patient and episodic (attacks with headache-free periods, as in episodic migraine or cluster headache); and (4) chronic daily headaches (more than 3 months, more than 15 days of headache per month). Headaches with a recent onset and judged unusual or worrisome by the patient (even one with frequent headaches) must raise the suspicion of a secondary cause and need to be investigated. Headaches that continue for months or years are more often primary, but secondary causes need to be ruled out in certain cases.
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PMID:Acute headache in the emergency department. 2081 19

Bacterial meningitis remains a life-threatening disease mainly due to intracranial hypertension. However, decompressive craniectomy (DC) and the use of cerebral microdialysis (MD) and brain tissue oxygen pressure measurement (pTiO(2) ) are poorly described in this disease. We report a case of a 56-year-old woman admitted for severe bacterial meningitis complicating mastoiditis. Despite maximal medical treatment, intracranial pressure increased above 30 mmHg, with a decline in pTiO(2) and MD results indicating cerebral ischaemia. A bilateral DC was performed. Neurological outcome was favourable, and on discharge, the patient was able to live independently. This is the first report of DC in meningitis guided by cerebral MD and pTiO(2) . Invasive multimodal neuromonitoring should be used in severe meningitis and DC could be considered in the case of refractory intracranial hypertension.
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PMID:Decompressive craniectomy guided by cerebral microdialysis and brain tissue oxygenation in a patient with meningitis. 2105 42

We present a 10-year-old boy with a greater than 5-year history of cerebrospinal fluid rhinorrhea. He experienced nine episodes of bacterial meningitis and underwent four surgical repairs, including two endoscopic repairs via the lateral nasal cavity, a craniotomy repair via forehead epidural, and endoscopic repair in combination with a ventriculoperitoneal shunt. The first three surgeries failed, but the fourth was successful, with no recurrence during 2.5 years of follow-up. We suggest that ventriculoperitoneal shunts be considered for refractory recurrent cerebrospinal fluid rhinorrhea, particularly in patients after multiple failures of conventional surgical repair, to reduce intracranial hypertension caused by long-term chronic cerebrospinal fluid compensatory production.
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PMID:Ventriculoperitoneal shunt strategy for cerebrospinal fluid rhinorrhea repair: a case report and review of the literature. 2304 21

Streptococcus pneumoniae is a common cause of bacterial meningitis, frequently resulting in severe neurological impairment. A seven-month-old child presenting with Streptococcus pneumoniae meningoencephalitis developed right basal ganglia and hypothalamic infarctions. Daily episodes of agitation, hypertension, tachycardia, diaphoresis, hyperthermia, and decerebrate posturing were observed. The diagnosis of paroxysmal autonomic instability with dystonia was established. The patient responded to clonidine, baclofen, and benzodiazepines. Although this entity has been reported in association with traumatic brain injury, and as a sequel to some nervous system infections, this is the first case, to our knowledge, associated with pneumococcal meningoencephalitis.
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PMID:Paroxysmal autonomic instability with dystonia after pneumococcal meningoencephalitis. 2309 76

There are a number of hereditary and non-hereditary central nervous system (CNS) disorders, which directly or indirectly affect the heart (brain-heart disorders). The most well-known of these CNS-disorders are epilepsy, stroke, subarachanoid bleeding, bacterial meningitis, and head injury. In addition, a number of hereditary and non-hereditary neurodegenerative disorders may impair cardiac functions. Affection of the heart may manifest as arrhythmias, cardiomyopathy, or autonomic dysfunction. Rarer cardiac complications of CNS disorders include heart failure, systolic or diastolic dysfunction, myocardial infarction, arterial hypertension, or pulmonary hypertension. Cardiomyopathy induced by hereditary CNS disease mainly include stress-induced myocardial dysfunction, known as Takotsubo syndrome (TTS). CNS disease triggering TTS includes epilepsy, ischemic stroke, subarachnoid bleeding, or PRES syndrome. Arrhythmias induced by hereditary CNS disease include supraventricular or ventricular arrhythmias leading to palpitations, dizziness, vertigo, fainting, syncope, (near) sudden cardiac death, or sudden unexplained death in epilepsy (SUDEP). Appropriate management of cardiac involvement in CNS-disorders is essential to improve outcome of affected patients.
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PMID:CNS-disease affecting the heart: brain-heart disorders. 2503 54

In the setting of increased intracranial pressure (ICP), various rhythm disturbances have been associated, ranging from tachyarrhythmias to bradyarrhythmias with atrioventricular dissociation. Although most of these observations have been in patients with traumatic brain injuries, it is known that children with acute bacterial meningitis may also have severe intracranial hypertension. We present the case of a previously healthy 2-year-old boy diagnosed with listeria meningitis. Along with clinical signs suggestive of increased ICP and brainstem involvement, our patient had persistent bradyarrhythmia with hemodynamic compromise that was refractory to epinephrine and successfully managed with isoproterenol.
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PMID:Listeria meningitis-associated bradyarrhythmia treated with isoproterenol. 2506 9


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