Delayed Cerebral Injury in Adults With Bacterial Meningitis: A Novel Complication of Adjunctive Steroids?*

Gallegos, Cinthia; Tobolowsky, Farrell; Nigo, Masayuki; Hasbun, Rodrigo

doi:10.1097/ccm.0000000000003220

Cited by 27 publications

(20 citation statements)

References 12 publications

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“…Unexpectedly and contrary to published data 30,31 we did not identify dexamethasone administration to be independently associated with increased cerebral blood ow velocity in multivariate analysis. Prior to the wide spread use of adjunctive steroids in bacterial meningitis 32,33 cerebral vascular alterations were devastating but common complications mediated by cerebral vasculitis, septic emboli, intraarterial thrombosis or disseminated intravascular coagulation 31,[34][35][36] .…”

Section: Discussioncontrasting

confidence: 99%

“…As a reliable parameter for the general immune response to various stimuli, NLR does not represent an in ammatory marker within a speci c entity. Therefore, it remains unclear whether increased NLR-levels on admission re ect the state of bacterial infections or if high NLR values represent an independent surrogate to predict intracranial vascular alterations 30 . Future studies should investigate whether elevated NLR-levels in CABM-patients help to identify patients suitable for immune modulating treatments.…”

Section: Discussionmentioning

confidence: 99%

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Neutrophil-to-Lymphocyte Ratio is Associated With Increased Cerebral Blood Flow Velocity in Acute Bacterial Meningitis

Giede-Jeppe

Atay

Koehn

et al. 2020

Preprint

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ObjectiveIn community-acquired bacterial meningitis(CABM) intracranial vascular alterations are devastating complications which are triggered by neuroinflammation and result in worse clinical outcome. The neutrophil-to-lymphocyte ratio(NLR) represents a reliable parameter of the inflammatory response. So far, in CABM-patients the association between NLR and elevated cerebral blood flow velocity(CBFv) remains unclear.MethodsThis study included all (CABM)-patients admitted to a German tertiary center between 2006-2016. Patient demographics, in-hospital measures and neuroradiological data were retrieved from institutional databases. CBFv was assessed by transcranial Doppler sonography transcranial doppler(TCD). Patients’, radiological and laboratory characteristics were compared between patients with/without elevated CBFv. Multivariate-analysis investigated parameters independently associated with elevated CBFv. Receiver operating characteristic(ROC-)curve analysis was undertaken to identify the best cut-off for NLR to discriminate between increased CBFv.Results108 patients with CABM were identified. 27.8%(30/108) showed elevated CBFv. These patients had a worse clinical status on admission(Glasgow Coma Scale:12[9-14vs.14[11-15]; p=0.005) and required more often intensive care (30/30[100%]vs.63/78[80.8%];p=0.01).The causative pathogen was S. pneumoniae in 70%. These patients developed more often cerebrovascular complications with delayed cerebral ischemia(DCI) within hospital stay(p=0.031). A significantly higher admission-NLR was observed in patients with elevated CBFv(median[IQR]:elevated CBFv:24.0[20.4-30.2]vs. normal CBFv:13.5[8.4-19.5];p<0.001). After adjusting for significant parameters in univariate testing, NLR on admission was significantly associated with increased CBFv(Odds ratio[95%CI]:1.042[1.003-1.084];p=0.036). ROC-analysis identified a NLR of 20.9 as best cut-off value to discriminate between elevated CBFv(area under the curve=0.713, p<0.0001,Youden's Index=0.441;elevated CBFv:NLR>20.9 19/34[55.9%]vs.NLR<20.9 11/74[14.9%];p<0.001).ConclusionsIntracranial vascular complications are common among CABM-patients and are a risk factor for unfavorable outcome at discharge. NLR is independently associated with elevated CBFv.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Neutrophil-to-Lymphocyte Ratio is Associated With Increased Cerebral Blood Flow Velocity in Acute Bacterial Meningitis

Giede-Jeppe

Atay

Koehn

et al. 2020

Preprint

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“…15,26 Recently, delayed cerebral infarctions (DCI) have been reported in up to 4% of adults with bacterial meningitis that have been associated with the use of adjunctive dexamethasone. 77 The cause of DCI in bacterial meningitis is currently unknown. Fluid and electrolyte resuscitation must be administered to attain appropriate blood pressure and cerebral perfusion.…”

Section: Supportive Carementioning

confidence: 99%

<p>Management of Acute Bacterial Meningitis in Children</p>

Alamarat¹,

Hasbun²

2020

IDR

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Acute community-acquired bacterial meningitis (ABM) in children continues to have high rates of neurological morbidity and mortality despite the overall declining rates of infection attributed to the use of vaccines and intrapartum Group B Streptococcus prophylaxis. Prompt diagnosis and early antibiotic therapy are crucial and should not be delayed to obtain cranial imaging. Differentiating bacterial from viral meningitis continues to be a clinical dilemma especially in patients with previous antibiotic exposure. Clinical models and inflammatory biomarkers can aid clinicians in their diagnostic approach. Multiplex polymerase chain reaction and metagenomic next-generation sequencing are promising tools that can help in early and accurate diagnosis. This review will present the epidemiology of ABM in children, indications of cranial imaging, role of different models and serum biomarkers in diagnosing ABM, and management including the use of adjunctive therapies and methods of prevention.

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“…In between 1% and 4% of cases of ABM, patients will have good clinical recoveries initially, but after the first week will develop acute changes in their level of consciousness or develop new focal neurological signs [17,22,23]. These abrupt changes are commonly due to delayed CI (DCI).…”

Section: Delayed CImentioning

confidence: 99%

Acute bacterial meningitis and stroke

Siegel

2019

Neurol Neurochir Pol.

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Introduction. Acute bacterial meningitis remains a common disease, especially in developing countries. Although advances over the last century have improved mortality and morbidity, the neurological adverse effects remain high. Specifically, acute ischaemic stroke is a serious comorbidity that represents both disease severity and poor prognosis. This review presents the clinical connection between meningitis and stroke, and discusses the neuroinflammatory components that have direct ties between these diseases. State of the art. Ischaemic stroke is the direct result of the inflammatory response produced to eradicate infectious pathogens. Bacterial virulence factors and pathogen-associated molecular patterns cause direct damage to the blood-brain barrier and trigger leukocytes to react to the infection. Cytokines are released that cause further destruction of the blood-brain barrier, lead to neuronal death, and recruit the prothrombotic effects of the coagulation cascade through the complement system. Unfortunately, this inflammatory response causes vasculopathy and hypercoagulation of the cerebral blood vessels, leading to cerebral ischaemia. Clinical implications. Pharmacological attempts to mitigate this inflammatory response have produced both positive and negative results. On the one hand, corticosteroids have been shown to improve mortality if given early in patients with bacterial meningitis, particularly pneumococcal meningitis. On the other hand, corticosteroids have been linked to delayed cerebral infarction and other adverse effects. Future directions. New targets for specific inflammatory markers have shown success in rodent models, but have not yet been proven beneficial in humans. Genetic markers are on the horizon, and may serve as individualised targets for diagnosis and therapy.

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Delayed Cerebral Injury in Adults With Bacterial Meningitis: A Novel Complication of Adjunctive Steroids?*

Abstract: Delayed cerebral injury occurred in 4.1% of adults with bacterial meningitis, and it was associated with the use of adjunctive steroids. Future studies should explore the etiology and prevention of this devastating complication.

Cited by 27 publications

References 12 publications

Neutrophil-to-Lymphocyte Ratio is Associated With Increased Cerebral Blood Flow Velocity in Acute Bacterial Meningitis

Neutrophil-to-Lymphocyte Ratio is Associated With Increased Cerebral Blood Flow Velocity in Acute Bacterial Meningitis

<p>Management of Acute Bacterial Meningitis in Children</p>

Acute bacterial meningitis and stroke

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