Decompressive craniectomy in herpes simplex encephalitis

Abstract

Intracranial hypertension is a common cause of morbidity in herpes simplex encephalitis (HSE). HSE is the most common form of acute viral encephalitis. Hereby we report a case of HSE in which decompressive craniectomy was performed to treat refractory intracranial hypertension. A 32-year-old male presented with headache, vomiting, fever, and focal seizures involving the right upper limb. Cerebrospinal fluid-meningoencephalitic profile was positive for herpes simplex. Magnetic resonance image of the brain showed swollen and edematous right temporal lobe with increased signal in gray matter and subcortical white matter with loss of gray, white differentiation in T2-weighted sequences. Decompressive craniectomy was performed in view of refractory intracranial hypertension. Decompressive surgery for HSE with refractory hypertension can positively affect patient survival, with good outcomes in terms of cognitive functions.

Surgical Management in Herpes Simplex Encephalitis: Illustrative Case Report and Systematic Review of the Literature

“…Decompressive craniectomy with or without concurrent temporal lobectomy was frequently reported in HSVE cases (72% [46/64]) in the setting of clinical deterioration and radiological evidence of elevated ICP. 8,16-19,21,22,24,25,28,30,33,38,40-43,46-54,56-59,61,62,64-67 However, temporal or frontal lobectomy without craniectomy was also sometimes reported (28% [18/64]) for surgical decompression in HSVE cases. 20,23,24,26,27,29,32-36,39,44,48,53,63 Although elevated ICP in HSVE often results from diffuse cerebral edema, numerous patients (19% [12/64]) developed frank hemorrhage that required surgical evacuation because of significant mass effect and neurological deterioration.…”

“…Decompressive craniectomy with or without concurrent temporal lobectomy was frequently reported in HSVE cases (72% [46/64]) in the setting of clinical deterioration and radiological evidence of elevated ICP. 8,[16][17][18][19]21,22,24,25,28,30,33,38,[40][41][42][43][46][47][48][49][50][51][52][53][54][56][57][58][59]61,62,[64][65][66][67] However, temporal or frontal lobectomy without craniectomy was also sometimes reported (28% [18/64]) for surgical decompression in HSVE cases. 20,23,24,26,27,29,[32][33][34][35][36]…”

“…Two additional patients with obstructive hydrocephalus associated with HSVE had good functional outcomes 31,60 after surgical drainage. Notably, favorable long-term outcomes were observed after surgical decompression that occurred after both relatively short (≤10 days) 17,21,28,30,34,36,37,39,50,[52][53][54]57,58,67 and more protracted 8,16,27,29,33,[41][42][43][44]48,51,53,61 periods of HSVE symptoms. However, in-hospital mortality (20% [12/61]) and moderate to severe long-term functional disability (23% [14/61]) were also prevalent.…”

“…29,44,63 Notably, nearly all surgical patients with HSVE-associated seizures reported in the literature displayed additional evidence of severely elevated ICP before undergoing surgery. 8,[16][17][18][19][20]23,25,27,29,32,36,37,[41][42][43][44][45][46]50,52,58,64,65 Only one report in this review described ATL specifically to control medically refractory status epilepticus in a patient with acute HSVE. 12,55 This patient underwent a right ATL approximately 3 weeks after the onset of illness and ultimately achieved resolution of seizures with minimal functional impairment.…”