case discussionherniation after lp is not rare - may be gradual due to ongoing csf leakage...

Case discussionMeningitis

MasterclassIC Schiermonnikoog 2012

Case (1)

• 57-year-old male

• No previous medical history

• Presents to the ER with headache and altered mental status (6 hours duration)

• Temperature 39.4 0C

Case (2)

• RR 22/min, HR 123 bpm, BP 170/80 mmHg

• No obvious skin lesions

• Heart normal

• Inspiratory crackles LLL

• Neck stiffness, Kernig (-), Brudzinski (-), E3M6V4, no focal neurologic findings, no papilledema

Case (3)

• WBC 16.3

• CRP 211 mg/L

• Lactate 1.4 mmol/l

• Thrombocytes 199.000 mm3

• Other lab results essentially normal

• Blood cultures are taken

Clinical diagnosis

Meningitis

ICU fellow raises following questions:Is a LP essential for our therapy - what are the

risks and can we predict the risk with a CT-scan?

Lumbar puncture

• WBC 2530/mm3

• Protein 4.6 g/L

• CSF:blood glucose ratio 0.06

• Lactate 8.2 mmol/l

• Gram stain: gram-positive cocci

Lactate (2 - 4.5 mmol/l) and prediction of bacterial vs aseptic meningitis

AUC = 0.9840

Huy NT. Crit Care 2010;14:R240

Huy NT. Crit Care 2010;14:R240

Case (4)

• Definitive diagnosis of pneumococcal meningitis (both liquor and blood)

• Treatment is started with corticosteroids and ceftriaxone / amoxicillin

ICU fellow raises following questions:Are corticosteroids really beneficial - how do

they work and what if the causative organism is meningococcus? Are there alternative agents?

Pneumococcal meningitis

• 70% has an underlying disorder

✓ Otitis or sinusitis 43%

✓ Pneumonia 18%

✓ Immunocompromised 22%

Case (5)• 12 hours after admission level of

consciousness decreases - E2M4V2

???

Cerebral infarctions

• Occur in 25 - 30% (in total)

• Develop during clinical course in ≈ 50%

• Patients are usually older

• Especially associated with S. Pneumoniae

• Increased morbidity and mortality (45% mortality with definite cerebral infarction)

Cerebral infarctions

• No evidence of large vessel vasculitis

• Small vessel vasculitis does not colocate with areas of infarction

• No systemic intravascular coagulation

• Local cell swelling and coagulation?

Intracranial hemorrhage• 24 out of 860 episodes

of bacterial meningitis (2.8%)

• 8 upon presentation and 16 during clinical course

• S. Pneumoniae in 67%

• Mortality 63% (vs 15%)

• Anticoagulants at admission OR 5.84

Mook-Kanamori BB. PLOSOneE 2012;7:e45271

Other causes

%

Nonconvulsive status epilepticus is rare

Cerebral abscess

• 14/950 (1.5%) episodes (on admission 5 - during hospitalization 9 [med 16 D])

• Multiple abscesses in 8

• Mortality 3 (21%) and unfavourable outcome 10 (71)

• Three causes: (1) primary brain abscess with rupture (2) endocarditis with meningitis/abscess (3) meningitis/cerebritis

Jim KK. J Infect 2012;64:236-238

Case (6)

• A CT-scan is repeated

Edema of left temporal lobe - small left subdural collection - hypodensityanterior left frontal lobe - 5 mm midline shift

Case (7)

• ICU transfer

• Hemodynamic monitoring

• Mechanical ventilation

• Intracranial pressure monitor (right frontal lobe)

ICU fellow raises following questions:Is ICP monitoring useful in patients with meningitis?

Is there evidence for an optimal treatment?

Case (8)

• Initial ICP pressure 15 mmHg

• Over the next day ICP increases to 25 mmHg

Case (9)

• Increased sedation

• Hypertonic saline (Na+ 150 mmol/l)

• Minimal hyperventilation (PaCO2 5 kPa)

• Normothermia → hypothermia (33 - 350)

Case (10)

• Progressive increase ICP (35 - 40 mmHg)

• Cerebral perfusion pressure 65 mmHg

• Repeated consultation of neurosurgeon for left sided decompression craniectomy → refusal because of dismal prognosis

ICU fellow raises following question:What is the immediate and longterm outcome of

pneumococcal bacterial meningitis in adults?

Case (11)

• Progressive deterioration

• Patient dies 74 hours after admission

Questions

• Group 1 - Is a LP essential for our therapy - what are the risks and can we predict the risk with a CT-scan?

• Group 2 - Are corticosteroids really beneficial - how do they work and what if the causative organism is meningococcus? Are there alternative agents?

Questions

• Group 3 - Is ICP monitoring useful in patients with meningitis? Is there evidence for an optimal treatment?

• Group 4 - What is the immediate and longterm outcome of pneumococcal bacterial meningitis in adults?

Is a LP essential for our therapy - what are the risks and can we predict the risk with a CT-scan?

Joff AR. J Intensive Care Med 2007;22:194-207

• Incidence of brain herniation in acute bacterial meningitis ≈ 5% and accounts for ≈ 30% of deaths

• Raised ICP is common, occurs early in the course and is higher in non-survivors (edema, hyperemia and ↑CSF outflow resistance)

Early brain edema

Muralidharan R. Arch Neurol 2011;68:513-516

• In the setting of an intracranial mass, herniation after LP is not rare - may be gradual due to ongoing CSF leakage

• Multiple case series show a temporal association between LP and herniation in acute bacterial meningitis

Within 3 hrs after LP 38%

4 - 12 hrs after LP 41%

Before and > 12 hrs after LP 21%

• A CT-scan may indicate cerebral tissue shift in proximity to a compartment opening: lateral shift of midline structures, loss of suprachiasmatic and basilar cisterns, obliteration or shift of fourth ventricle, obliteration of superior cerebellar quadrigeminal plate cisterns with sparing of the ambient cisterns (RISK)

• Approximately 40% of patients have a normal CT-scan at time of herniation

CT-scan

Variables associated with abnormal CT

• Age > 60

• Immunocompromised state

• History of CNS disease

• Altered level of consciousness

• Focal neurologic deficits

Hasbun R. N Engl J Med 2001;345:1727-1733

• The following clinical signs may predict herniation after LP in ABM: deteriorating level of consciousness GCS ≤ 11, seizures, dilated pupil, fixed eye deviation, decerebrate posture, papilledema (often late sign), respiratory abnormalities → even with a normal CT-scan, a LP should not be performed

Outcome of herniation

• Mortality is ± 55% and 50% of survivors have a good outcome. Aggressive treatment with mannitol/hypertonic saline is warranted

Risks of avoiding a LP

• Definitive diagnosis - bacterial cause and antibiotic susceptibility but blood cultures positive in 50% (meningococci) or 80 - 90% (pneumococci)

• Although CSF cultures become rapidly negative after antibiotic treatment (MC 2h, PC 6h) biochemical changes are abnormal for 48 - 72 hours

Always consider DD of ABM

• Tuberculous meningitis

• Cerebral malaria

• Herpes simplex encephalitis

• Opportunistic infections

Ventricular puncture?

Protein

Leucocytes

Lactate

Gerber J. Neurology 1998;51:1710-1714

Ventricular-Lumbar gradient

Are corticosteroids really beneficial - how do they work and what if the causative organism is

meningococcus?

Dex

Dex

van de Beek D. Lancet Neurol 2010;9:254-263

Meningococcal meningitis

90% Dex 17% Dex

Heckenberg SGB. Neurology 2012;79:1563-1569

Anti-C5a treatment?

N = 439Woehrl B. J Clin Invest 2011;121:3943-3953

Woehrl B. J Clin Invest 2011;121:3943-3953

Is ICP monitoring useful in patients with meningitis?

Is there evidence for an optimal treatment?

N = 10N = 5

Lindvall P. Clin Infect Dis 2004;38:384-390

Treatment according to Lund concept

• Maintain normal colloid osmotic pressure (normal sodium and normal albumin)

• Reduce hydrostatic capillary pressure (CPP as low as 50 mmHg with metoprolol and clonidine)

• Normoventilation

• Epoprostonol to improve microcirculation and reduce capillary permeability

• If ICP > 20 than thiopental - CSF drainage - dihydroergotamine - decompression

Decompression

Baussart B. Acta Anaesthesiol Scand 2006;50:762-765

Meningitis - intraparenchymal hemorrhage

No residual neurologic deficits

Di Rienzo A. Acta Neurochir 2008;150:1057-1065

Di Rienzo A. Acta Neurochir 2008;150:1057-1065

No residual neurologic deficits

Meningitis - subdural fluid collection - left LV displacement

Bordes J. Acta Anaesthesiol Scand 2011;55:130-133

Edberg M. Acta Anaesthesiol Scand 2011;55:732-739

N = 32

What is the immediate and longterm outcome of pneumococcal bacterial meningitis in adults?

• N = 352

• In-hospital mortality 30%

• Focal abnormalities at discharge 30%✓ Cranial nerve 28%

✓ Cerebral 11%

✓ Aphasia 3%

✓ Hemiparesis 7%

✓ Hearing impairment 22%

Weisfelt M. Lancet Neurol 2006;5:123-129

Weisfelt M. Lancet Neurol 2006;5:123-129

Cognitive outcome

• N = 155 (79 after pneumococcal and 76 after meningococcal infection)

• Memory, attention/executive function, psychomotor function, intelligence, depression/QOL

Hoogman M. J Neurol Neurosurg Psychiatry 2007;78:1092-1096

Hoogman M. J Neurol Neurosurg Psychiatry 2007;78:1092-1096