Treatment of intracranial hypertension and aspects on lumbar dural puncture in severe bacterial meningitis

Abstract

Background: Brain stem herniation due to raised intracranial pressure (ICP) is a common cause of mortality in severe bacterial meningitis, but continuous measurements of ICP and the effects of ICP-reducing therapy in these patients have, to our knowledge, not been described. Methods: During a four-year period, an ICP-monitoring device was implanted in patients admitted to our hospital with severe bacterial meningitis and suspected intracranial hypertension. ICP above 20 mmHg was treated using the Lund Concept, which includes antihypertensive therapy (b 1 -antagonist,a 2 -agonist), normalization of the plasma colloid osmotic pressure and the blood volume, and antistress therapy. Results: ICP above 20 mmHg was found in all 12 patients studied. It was effectively reduced in all but two patients, who died. Both patients had a low cerebral perfusion pressure (Ͻ10 mmHg), dilated pupils at start of therapy and were beyond recovery. Radiological signs of brain swelling were present in only five patients. Seven patients recovered fully, while mild audiological impairment was observed in two and minor neurological sequelae in one patient. Eight patients showed signs suggesting imminent brain stem herniation before start of ICP-reducing treatment, seven of whom had been subjected to diagnostic lum-

Mechanisms behind postspinal headache and brain stem compression following lumbar dural puncture – a physiological approach

“…Venous stasis in the narrow subtentorial region may also aggravate the oedema. All these mechanisms taken together may explain the observations that signs of brain stem compression and even death may develop very quickly after LP (11). The significant transtentorial brain swelling showed in Fig 5b also must have developed quickly as the patient was fully communicable just a few hours before the MR investigation.…”

“…An important reason why no consensus has been reached regarding the use of LP in patients with suspected raised ICP is that no reliable scientific studies on potential adverse effects with LP have been made. As a matter of precaution, some authors recommend that LP should be avoided in patients with clear signs of raised ICP, such as progressive loss of consciousness, agitation and motor anxiety, increasing blood pressure, pupil abnormalities and other focal neurological signs (8,9,11). LP is, however, frequently used in clinical practice also in risk patients (13).…”

“…An outcome study from our hospital of severe meningitis showed that in most patients developing brain stem symptoms, these appeared shortly after LP (11). It has been argued that the suspected temporal relation between signs of brain stem compression and LP may be a coincidence, as LP often is performed at a critical time point, and often shortly after start of antibiotic treatment with subsequent release of toxic substances (12).…”

Infecciones comunitarias que requieren ingreso en UCI

“…La afectación cerebral (meningoencefalitis) causa frecuentemente deterioro progresivo del nivel de conciencia, así como crisis epilépticas; sin embargo, la profilaxis anticomicial no está indicada, aunque sí el tratamiento enérgico de las crisis. El edema vasogénico, que conlleva hipertensión intracraneal (HTIC) grave (signos clínicos, radiológicos o sonográficos), afecta al nivel de conciencia, debiendo valorarse la monitorización invasiva de la presión intracraneal y su tratamiento si procede 26,27 . La hidrocefalia, aunque infrecuente, puede provocar deterioro.…”

Severe traumatic brain injury management and clinical outcome using the Lund concept

“…Two of the patients died, resulting in a mortality rate of 20% (Grände et al, 2002). The remaining 10 patients recovered to a GOS of 4-5.…”