Background
Increased intracranial pressure (ICP) frequently complicates cryptococcal meningitis. Therapeutic lumbar punctures (LPs) have acute survival benefits in the first week, and we sought to understand the longer-term survival impact of therapeutic LPs.
Methods
We prospectively enrolled HIV-seropositive adults with cryptococcal meningitis from 2013 to 2017 in Uganda. CSF opening pressure was measured at diagnosis. Therapeutic LPs were scheduled on days 3, 7, 10, 14, and performed additionally as clinically indicated. We assessed the association between clinical characteristics, CSF parameters, and 14- and 30-day mortality by baseline ICP. We also assessed 30-day mortality by number of follow-up therapeutic LPs performed within 7 days.
Results
Our analysis included 533 participants. Participants with baseline ICP > 350 mmH2O were more likely to have Glasgow Coma Scale score (GCS) <15 (p < .001), seizures (p < 0.01), and higher quantitative cryptococcal cultures (p < .001), while participants with ICP <200 mmH2O were more likely to have baseline sterile CSF cultures (p < .001) and CSF WBC >=5 cells/mcL (p = 0.02). 30-day mortality was higher in participants with baseline ICP >350 mmH2O and ICP <200 mmH2O as compared with baseline ICP 200-350 mmH2O (Hazard Ratio 1.55; 95%CI, 1.10–2.19; p = 0.02). Among survivors at least 7-days, the 30-day relative mortality was 50% higher among participants who didn’t receive any additional therapeutic LPs compared to those with >=1 additional follow up LP (33% vs 22%; p = 0.04), irrespective of baseline ICP.
Conclusion
Management of increased ICP remains crucial in improving clinical outcomes in cryptococcal meningitis. Guidelines should consider an approach to therapeutic LPs that isn’t dictated by baseline ICP.