Clinical relevance of hydrocephalus in bacterial meningitis in adults

Neuroimaging of the Most Common Meningitis and Encephalitis of Adults: A Narrative Review

Meningitis is the infection of the meninges, which are connective tissue membranes covering the brain, and it most commonly affects the leptomeninges. Clinically, meningitis may present with fever, neck stiffness, altered mental status, headache, vomiting, and neurological deficits. Encephalitis is an infection of the brain, which usually presents with fever, altered mental status, neurological deficits, and seizure. Meningitis and encephalitis are serious conditions which could also coexist, with high morbidity and mortality, thus requiring prompt diagnosis and treatment. Imaging plays an important role in the clinical management of these conditions, especially Magnetic Resonance Imaging. It is indicated to exclude mimics and evaluate the presence of complications. The aim of this review is to depict imaging findings of the most common meningitis and encephalitis.

Acute Hydrocephalus Associated with Streptococcus anginosus Meningitis

Introduction

Meningitis-related acute hydrocephalus is rare, challenging to diagnose, and has a high mortality rate.

Case description

Here we describe the case of a 76-year-old patient diagnosed with bacterial meningitis who developed acute hydrocephalus and subsequently died.

Discussion

Although meningitis-related acute hydrocephalus is usually non-occlusive, occlusive hydrocephalus may also occur. Moreover, worsening hydrocephalus despite cerebrospinal fluid drainage should prompt a diagnosis of obstructive hydrocephalus. In such conditions, potential management strategies include ventriculoperitoneal shunt and endoscopic third ventriculostomy.

Conclusion

In patients with meningitis-related hydrocephalus, worsening despite appropriate antibiotic administration, treatment may be complicated by ventriculitis and obstructive hydrocephalus, which can be fatal. If intracranial pressure is not medically controlled, bilateral decompression craniectomy should be considered as a potential management strategy.

LEARNING POINTS

The extreme rarity of obstructive hydrocephalus caused by bacterial meningitis can lead to delayed diagnosis and treatment.Ventriculoperitoneal shunt and endoscopic third ventriculostomy are the indicated management strategies for early diagnosis of obstructive hydrocephalus.Bilateral decompression craniectomy may be an option in such cases.

Persistent Severe Cerebral Edema with Neutrophil Infiltration Following Listeria Meningitis

A 51-year-old man was admitted to the hospital with a diagnosis of Listeria monocytogenes meningitis. Diffuse cerebral edema appeared after improvement of meningitis with appropriate treatment and worsened for two months. Due to brain herniation, brain tissue leaked through the incision made during the drain insertion in a hydrocephalus surgery. We found pathological evidence of significant neutrophil infiltration with a few lymphocytes without bacterial detection in the degraded brain tissue. The present case indicates that fatal cerebral edema with significant neutrophil infiltration may develop even after appropriate treatment for L. monocytogenes meningitis.

A rare case of posttraumatic meningitis presenting with acute hydrocephalus

Posttraumatic meningitis is a severe complication of traumatic brain injury (TBI) that dramatically increases its mortality. Skull-base fractures increase the risk of posttraumatic meningitis. Posttraumatic hydrocephalus was encountered in 0.7 %–29 % of the patients with severe head injury. Posttraumatic hydrocephalus should be differentiated from ventriculomegaly due to brain atrophy.

We present a clinical case of a 52-year-old patient after a mild TBI and a linear skull base fracture who developed acute hydrocephalus in the context of a posttraumatic meningitis within the first week after the injury. The occurrence of hydrocephalus in patients with posttraumatic meningitis is not well studied but could lead to rapid deterioration of the patient. It results from injury-induced disturbance of CSF flow either through obstruction or lack of CSF reabsorption. Factors increasing the risk of posttraumatic meningitis are - operative interventions, skull base fractures and CSF leakage. Patients with meningitis usually present with lower GCS score. The lower GCS is a harbinger of worse prognosis. Therefore, aggressive medical treatment is warranted.

With this case study we show that meningitis presenting with PTH can develop rapidly over 24 h within the first week post mild head injury with basilar skull fracture. A swift response in providing timely ventricular drainage, together with an appropriate antimicrobial coverage, can greatly reduce any lasting neurological deficits and produce a good clinical outcome.

First reported case of hydrocephalus in jointly diagnosed bacterial meningitis and a colloid cyst: how Ockham's razor became Hickam's dictum

We report the first case in the literature of acute hydrocephalus due to a simultaneous diagnosis of bacterial (not asceptic) meningitis and a colloid cyst. Diagnosing disease is the cornerstone skill of a medical practitioner. Both education and experience allow for sharpening of this skill throughout years of medical practice. Disease is fraught with nuances and inconsistencies which can render an accurate diagnosis a difficult task. Medical practitioners can be guilty of cognitive biases such as Ockham's razor. We present the case of a patient with an initial diagnosis of obstructive hydrocephalus secondary to a colloid cyst. However, pneumococcal meningitis blunted Ockham's razor in favour of Hickam's dictum.

Post-traumatic hydrocephalus - incidence, risk factors, treatment, and clinical outcome

OBJECTIVES

Post-traumatic hydrocephalus (PTH) is well-known after traumatic brain injury (TBI), but there is limited evidence regarding patient selection for ventriculo-peritoneal (VP)-shunt treatment. In this study, we investigated the incidence and risk factors for PTH and the indication for and outcome after shunt treatment.

MATERIALS AND METHODS

In this retrospective study, 836 TBI patients, treated at our neurointensive care (NIC) unit at Uppsala university hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiology, treatments, and outcome variables were evaluated.

RESULTS

Post-traumatic ventriculomegaly occurred in 46% of all patients at NIC discharge. Twenty-nine (3.5%) patients received a VP-shunt. Lower GCS M at admission, greater amount of subarachnoid hemorrhage, meningitis, decompressive craniectomy (DC), and ventriculomegaly at NIC discharge were risk factors for receiving a VP-shunt. Fourteen of the PTH patients showed impeded recovery or low-pressure hydrocephalus symptoms, of whom 13 experienced subjective clinical improvement after shunt treatment. Five PTH patients showed deterioration in consciousness, of whom four improved following shunt treatment. Five DC patients received a shunt due to subdural hygromas (n =2) or external brain herniation (n = 3), of whom two patients improved following treatment. Five patients were vegetative with concurrent ventriculomegaly and these patients did not have any positive shunt response. Altogether, 19 (66%) PTH patients improved after shunt surgery.

CONCLUSION

Post-traumatic ventriculomegaly was common, but few developed symptomatic PTH and received a VP-shunt. Patients with low-pressure hydrocephalus symptoms had the best shunt response, whereas patients with suspected vegetative state exhibited a minimal shunt response.

Neuroinfectious Disease Emergencies

Neuroinfectious diseases can affect immunocompetent and immunosuppressed individuals and cause a variety of emergencies including meningitis, encephalitis, and abscess. Neurologic infections are frequently complicated by secondary injuries that also present emergently such as cerebrovascular disease, acute obstructive hydrocephalus, and seizure. In most cases, timely recognition and early treatment of infection can improve the morbidity and mortality of infectious neurologic emergencies.

Decompressive Craniectomy in Traumatic Brain Injury-Craniectomy-Related and Cranioplasty-Related Complications in a Single Center

OBJECTIVE

Decompressive craniectomy (DC) relieves intracranial hypertension after severe traumatic brain injury (TBI), but it has been associated with poor clinical outcome in 2 recent randomized controlled trials. In this study, we investigated the incidence and explanatory variables for DC-related and cranioplasty (CP)-related complications after TBI.

METHODS

In this retrospective study, we identified 61 patients with TBI who were treated with DC in the neurointensive care unit, Uppsala University Hospital, Sweden, between 2008 and 2018. Demography, admission status, radiology, and clinical outcome were analyzed.

RESULTS

Eleven patients (18%) were reoperated because of postoperative hemorrhage after DC. Six (10%) developed postoperative infection during neurointensive care. Twenty-eight (46%) developed subdural hygromas and 10 (16%) received a permanent cerebrospinal fluid shunt. Sixteen patients (26%) died before CP. Median time to CP was 7 months (range, 2-19 months) and 32 (71%) were operated on with autologous bone and 13 (29%) with synthetic material primarily. In 9 patients with autologous bone (29%), the CP had to be replaced because of bone resorption/infection, whereas this did not occur after synthetic material (P = 0.04). However, all 4 postoperative hemorrhages after CP occurred when synthetic material was used (P = 0.005).

CONCLUSIONS

DC and CP surgery have a high risk for complications, leading to additional neurosurgery in about one third of cases. Synthetic CP materials may decrease the risk of reoperation, but special care with hemostasis is required because of increased risk of postoperative hemorrhage. Future trials need to address these topics to further improve the outcome for these patients.

A Clinical Study on the Use of Intraventricular Polymyxin B Supplemented by Continuous External Ventricular Drainage in the Treatment of Drug-Resistant Gram-Negative Bacilli Intracranial Infection

Purpose

To investigate the clinical effect of ventricular polymyxin B supplemented by continuous external ventricular drainage in the treatment of intracranial infection with multidrug-resistant (MDR) or extensively drug-resistant (XDR) Gram-negative (G-) bacilli following neurosurgery.

Patients and Methods

A retrospective analysis was performed on 28 patients who had G-bacilli intracranial infection following neurosurgery in our department between January 2017 and December 2019. The patients were treated with intraventricular polymyxin B supplemented by continuous external ventricular drainage. The clinical characteristics, treatment process, cerebrospinal-fluid-related indicators, results and prognosis were analysed.

Results

All of 28 patients developed an infection subsequent to neurosurgery, and cerebrospinal fluid (CSF) cultures demonstrated MDR/XDR G- bacilli, including Acinetobacter baumannii in 14 cases, Klebsiella pneumoniae in 9 cases, Pseudomonas aeruginosa in 3 cases, and Enterobacter cloacae in 2 cases. The ventricular drainage tube remained unobstructed in all patients during treatment, and intraventricular polymyxin B combined with intravenous antibiotics were administered each day. The duration of treatment with intraventricular polymyxin B was 14.96±4.28 days, and the time required to obtain a negative CSF culture was 8.23±4.02 days. The bacterial clearance rate from cerebrospinal fluid was 92.9% (26/28), and the clinical cure rate was 82.1% (23/28). Among them, 18 patients underwent ventriculoperitoneal shunt insertion for hydrocephalus 82.5 (59.5,114.75) days after the infection was cured, and the mortality rate was 17.6% (5/28). There was no significant change in patient blood creatinine levels before and after treatment. Cured patients were followed up for 4 months to 3 years, and no recurrences were observed.

Conclusion

Treatment of intracranial infection with MDR/XDR G- bacilli using early intraventricular polymyxin B supplemented by continuous external ventricular drainage treatment may be a safe and effective treatment strategy.

Acute communicating hydrocephalus caused by extravasation of digital subtraction angiography contrast medium: a case report and literature review

With the increasing use of endovascular technology in the treatment of various conditions, there has been an inevitable rise in cases with extravasation of contrast medium. We present a case in which extravasation of a large quantity of contrast medium resulted in acute communicating hydrocephalus. A 78-year-old woman came to the hospital because of abnormal right-sided limb movement, and was diagnosed with occlusion of the left internal carotid artery. The patient underwent timely intra-arterial mechanical thrombectomy. Postoperative computed tomography (CT) examination revealed a high-density shadow of the left basal ganglia and left frontal lobe. Twelve hours later, the patient fell into a coma. Repeat head CT indicated acute hydrocephalus with no evidence of obstruction. The patient underwent emergency external ventricular drainage, and the drainage fluid was observed to be clear. The patient regained consciousness after the procedure and the drainage tube was removed 4 days later. The patient had no recurrence of hydrocephalus. The mechanisms and treatment of this condition are discussed.

[Extra-ventricular drainage for the treatment of pneumococcal meningitis and hydrocephalus: a case report]

A 53-year-old man was referred to our hospital because of fever and disturbed consciousness with a left-sided toothache from 5 days ago. Neurological examinations revealed a low level of consciousness, nuchal rigidity, bilateral mydriasis, and positive Babinski sign. A lumbar puncture yielded clouded fluid with a WBC 22,698/μl (polynuclear cell 98%), 681 mg/dl of protein and 0 mg/dl of glucose. The antigen of Streptococcus pneumoniae in urine and cerebrospinal fluid (CSF) were positive. Streptococcus pneumoniae was isolated from CSF culture. Brain CT on admission showed a communicating hydrocephalus. Diagnosis of pneumococcal meningitis with hydrocephalus was made and we treated with ceftriaxone and dexamethasone. The lumbar drainage placed at L 3/4 level became occluded, thus, extra-ventricular drainage was performed. Intracranial pressure (ICP) was 20 cmH₂O upon insertion of the ICP sensor. At Day 2, the ICP decreased to 10 cmH₂O and never increased during his course of hospitalization. Repeat brain CT showed no hydrocephalus. He responded to antimicrobial therapy and became lucid and afebrile. At Day 4, the extra-ventricular drainage was removed because of bleeding from right choroid plexus on brain CT. We treated with antimicrobial therapy until Day 21. He was transferred to another hospital for rehabilitation with mild neurological sequelae at Day 31. The cases presenting with hydrocephalus in the acute phase of bacterial meningitis has a high mortality rate. The presence of hydrocephalus is a poor prognostic factor. Although the therapeutic value of extra-ventricular drainage for hydrocephalus has been unclear, his report represents a case for neurologists to consider performing extra-ventricular drainage for hydrocephalus.

Pneumococcal Meningitis Complicated by Cerebral Vasculitis, Abscess, Hydrocephalus, and Hearing Loss

Intracranial abscesses, postinfectious vasculitis, and hydrocephalus are rare complications of Streptococcus pneumoniae (S. pneumoniae) meningitis, and to our knowledge, there have been no case reports where all these 3 complications occurred in a single patient with Streptococcus pneumoniae meningitis. Here, we report a case of a 48-year-old male who developed postinfectious vasculitis, abscess, hydrocephalus, and hearing loss after S. pneumoniae meningitis. Clinicians ought to be aware of the possible adverse outcomes of S. pneumoniae meningitis and the limitations of current treatment options.

A prospective study of magnetic resonance imaging patterns of central nervous system infections in pediatric age group and young adults and their clinico-biochemical correlation

Background:

Infections of the central nervous system (CNS) are common and routinely encountered. Our aim was to evaluate the neuroimaging features of the various infections of the CNS so as to differentiate them from tumoral, vascular, and other entities that warrant a different line of therapy.

Aims:

Our aim was to analyze the biochemical and magnetic resonance imaging (MRI) features in CNS infections.

Settings and Design:

This was a longitudinal, prospective study over a period of 1½ years.

Subjects and Methods:

We studied cerebrospinal fluid (CSF) findings and MRI patterns in 27 patients of 0–20 years age group with clinical features of CNS infections. MRI was performed on MAGNETOM Avanto 18 Channel 1.5 Tesla MR machine by Siemens India Ltd. The MRI protocol consisted of diffusion-weighted and apparent diffusion coefficient imaging, turbo spin echo T2-weighted, spin echo T1-weighted, fluid-attenuated inversion recovery (FLAIR), and gradient-echo in axial, FLAIR in coronal, and T2-weighted in sagittal plane. Contrast-enhanced T1-weighted sequence and MR spectroscopy were done whenever indicated.

Results and Conclusions:

We found that most of the children belong to 1–10 years age group. Fungal infections were uncommon, mean CSF adenosine deaminase values specific for tuberculosis and mean CSF glucose-lowered in pyogenic. Hemorrhagic involvement of thalamus with/without basal ganglia and brainstem involvement may indicate Japanese encephalitis or dengue encephalitis. Diffusion restriction or hemorrhage in not expected in the brainstem afflicted lesions of rabies. Congenital cytomegalovirus can cause cortical malformations. T1 hyperintensities with diffusion restriction may represent viral encephalitis. Lesions of acute disseminated encephalomyelitis (ADEM) may mimic viral encephalitis. Leptomeningeal enhancement is predominant in pyogenic meningitis. Basilar meningitis in the presence of tuberculomas is highly sensitive and specific for tuberculosis.

Neurological sequelae of bacterial meningitis

OBJECTIVES

We reported on occurrence and impact of neurological sequelae after bacterial meningitis.

METHODS

We reviewed occurrence of neurological sequelae in children and adults after pneumococcal and meningococcal meningitis.

RESULTS

Most frequently reported sequelae are focal neurological deficits, hearing loss, cognitive impairment and epilepsy. Adults with pneumococcal meningitis have the highest risk of developing focal neurological deficits, which are most commonly caused by cerebral infarction, but can also be due to cerebritis, subdural empyema, cerebral abscess or intracerebral bleeding. Focal deficits may improve during clinical course and even after discharge, but a proportion of patients will have persisting focal neurological deficits that often interfere in patient's daily life. Hearing loss occurs in a high proportion of patients with pneumococcal meningitis and has been associated with co-existing otitis. Children and adults recovering from bacterial meningitis without apparent neurological deficits are at risk for long-term cognitive deficits. Early identification of neurological sequelae is important for children to prevent additional developmental delay, and for adults to achieve successful return in society after the disease.

CONCLUSIONS

Neurological sequelae occur in a substantial amount of patients following bacterial meningitis. Most frequently reported sequelae are focal neurological deficits, hearing loss, cognitive impairment and epilepsy.

Brain ventricular dimensions and relationship to outcome in adult patients with bacterial meningitis

Background

Experimental studies suggest that changes in brain ventricle size are key events in bacterial meningitis. This study investigated the relationship between ventricle size, clinical condition and risk of poor outcome in patients with bacterial meningitis.

Methods

Adult patients diagnosed with bacterial meningitis admitted to two departments of infectious diseases from 2003 through 2010 were identified. Clinical and biochemical data as well as cerebral computed tomographic images were collected. The size of the brain ventricles were presented as a Ventricle to Brain Ratio (VBR). Normal range of VBR was defined from an age matched control group. A multivariate analysis was performed to identify predictors of 30-day mortality.

Results

One hundred and seven patients were included. Eighty-one patients had a CT scan at the time of diagnosis. VBR was identified as an independent risk factor of 30-day mortality, Mortality Rate Ratio: 6.03 (95 % confidence interval: 1.61-22.64, p = 0.008) for highest versus lowest tertile. A VBR deviating more than 2 standard deviations from the normal range was associated with increased mortality.

Conclusions

Brain ventricles are commonly subject to marked changes in size as a consequence of meningitis. Increased brain ventricle size in the acute phase of bacterial meningitis was associated with increased mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1097-3) contains supplementary material, which is available to authorized users.

Bacterial infections of the central nervous system

Bacterial CNS infections comprise a wide spectrum of diseases, which may be acquired outside or inside the hospital, affect immunocompetent or immunocompromised patients, and be associated with trauma or procedures, as well as other exposures.

Hydrocephalus is a rare outcome in community-acquired bacterial meningitis in adults: a retrospective analysis

Background

Community-acquired bacterial meningitis (CABM) continues to have a high mortality rate and often results in severe sequelae among survivors. Lately, an increased effort has been focused on describing the neurological complications of meningitis including hydrocephalus. To aid in this field of research we set out to ascertain the risk and outcome of hydrocephalus in patients with community-acquired bacterial meningitis (CABM) in North Denmark Region.

Methods

We conducted a retrospective population-based cohort study of CABM cases above 14 years of age. Cases diagnosed during a 13-year period, 1998 through 2010, were identified in a laboratory register and data were acquired through patient records. Cases not confirmed by culture met other strict inclusion criteria. The diagnosis of hydrocephalus relied upon the radiologists’ reports on cranial imaging. Outcome was graded according to the Glasgow Outcome Scale at discharge from the primary admission. Long-term sequelae were based upon any subsequent hospital contacts until the end of 2011.

Results

Hydrocephalus was diagnosed in five of 165 episodes (3%) and all were classified as communicating. Only 120 patients had cranial imaging done and in this group the rate was 4.2%. In three cases hydrocephalus was present at admission, while two cases were diagnosed on days 44 and 99, respectively, due to altered mental status. The aetiology was either Eschericia coli (n = 2) or Streptococcus pneumoniae (n = 3). Case fatality was 60% among cases with hydrocephalus and 17% among other cases. Case fatality was similar irrespective of whether patients had a cranial CT or not.

Conclusions

Hydrocephalus was diagnosed in 3% of adolescent and adult cases with CABM and had a high case fatality rate in spite of specialised medical care and neurosurgical interventions. Our findings are comparable with a recent Dutch national prospective study.

Neurocritical care of patients with central nervous system infections

Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure (ICP), hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. The importance of emergent administration of appropriate antimicrobial therapy cannot be overstated, but critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available to manage central nervous system (CNS) infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes. It is our opinion that ICP measurement should be strongly considered in selected patients with CNS infections, particularly those who are comatose. Treatments for intracranial hypertension, specifically in the setting of CNS infection, are described in this paper. For bacterial meningitis, intravenous dexamethasone should be administered, beginning concomitantly with the initial dose of antibiotics, at least until Streptococcus pneumoniae can be excluded as a pathogen. Clinicians should maintain a high index of suspicion for nonconvulsive seizures. Deterioration in neurologic status should also prompt early use of CT or magnetic resonance angiography and venography to exclude cerebrovascular complications.

Difficulty diagnosing chronic cryptococcal meningitis in idiopathic CD4+ lymphocytopenia

A 64-year-old man with idiopathic CD4(+) lymphocytopenia developed cognitive impairment and gait ataxia with isolated obstructive hydrocephalus, which was fatal. Cerebrospinal fluid showed mild pleocytosis, but the etiology was not revealed by extensive analysis. At autopsy, inflammatory cells, CD8(+) lymphocytes and abundant macrophages but not CD4(+) lymphocytes were infiltrating the meninges at the base of the brain. Electron microscopy demonstrated that inflammation was caused by Cryptococcus neoformans, which was localized exclusively within macrophages, where it grew with budding. Our study suggests that, in idiopathic CD4(+) lymphocytopenia, macrophages can efficiently phagocytize but inefficiently digest C. neoformans, thus representing a vehicle of chronic intracellular infection.

Neurocritical care of patients with central nervous system infections

Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure, hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. Critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available in managing central nervous system infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes.

Community-acquired Pseudomonas meningitis causes acute obstructive hydrocephalus

INTRODUCTION

Pseudomonas aeruginosa (PS) infection is serious in children and can cause malignant external otitis, endophthalmitis, endocarditis, meningitis, pneumonia, and septicemia (Huang et al. Pediatr Infect Dis J 1). The treatment of Pseudomonas infection requires prompt medical evaluation and appropriate antibiotic treatment.

CASE REPORT

We report the case of a 6-month-old boy with an unusual presentation of acute obstructive hydrocephalus owing to Pseudomonas meningitis. Treatment with optimal antibiotic begun immediately after the pathogen was recognized and continued for 4 weeks. The patient received prompt surgical intervention for the complication of acute obstructive hydrocephalus.

CONCLUSION

The early stage of obstructive hydrocephalus caused by community-acquired Pseudomonas is rare and should be immediately detected.

In vivo study of experimental pneumococcal meningitis using magnetic resonance imaging

BACKGROUND

Magnetic Resonance Imaging (MRI) methods were evaluated as a tool for the study of experimental meningitis. The identification and characterisation of pathophysiological parameters that vary during the course of the disease could be used as markers for future studies of new treatment strategies.

METHODS

Rats infected intracisternally with S. pneumoniae (n = 29) or saline (n = 13) were randomized for imaging at 6, 12, 24, 30, 36, 42 or 48 hours after infection. T1W, T2W, quantitative diffusion, and post contrast T1W images were acquired at 4.7 T. Dynamic MRI (dMRI) was used to evaluate blood-brain-barrier (BBB) permeability and to obtain a measure of cerebral and muscle perfusion. Clinical- and motor scores, bacterial counts in CSF and blood, and WBC counts in CSF were measured.

RESULTS

MR images and dMRI revealed the development of a highly significant increase in BBB permeability (P < 0.002) and ventricle size (P < 0.0001) among infected rats. Clinical disease severity was closely related to ventricle expansion (P = 0.024). Changes in brain water distribution, assessed by ADC, and categorization of brain 'perfusion' by cortex DeltaSI(bolus) were subject to increased inter-rat variation as the disease progressed, but without overall differences compared to uninfected rats (P > 0.05). Areas of well-'perfused' muscle decreased with the progression of infection indicative of septicaemia (P = 0.05).

CONCLUSION

The evolution of bacterial meningitis was successfully followed in-vivo with MRI. Increasing BBB-breakdown and ventricle size was observed in rats with meningitis whereas changes in brain water distribution were heterogeneous. MRI will be a valuable technique for future studies aiming at evaluating or optimizing adjunctive treatments.

Mortality associated with central nervous system tuberculosis

BACKGROUND

Tuberculosis (TB) of the central nervous system (CNSTB) is associated with higher mortality rates than other forms of TB. Epidemiologic associations with and prognostic indicators of CNSTB have not been assessed in a large US population-based study.

METHODS

Between 1995 and 2004 and using a population-based active surveillance study, we compared patients with CNSTB to patients with TB affecting sites other than CNS (non-CNSTB) with respect to sociodemographic, clinical and Mycobacterium tuberculosis genotype variables. Risk factors associated with mortality at 180 days were compared between the 2 groups.

RESULTS

We enrolled 92 patients with CNSTB and 3570 with non-CNSTB. HIV co-infection was present in 31 (33.7%) of the CNSTB cases. In a Cox proportion hazard model, we found that CNSTB patients who died within 180 days were more likely to be older (HR 1.06, 95% CI 1.02-1.10), have a positive MTB culture from a CNS source (HR 5.11, 95% CI 1.06-24.62) and have hydrocephalus (HR 10.62, 95% CI 3.28-34.36) than patients who survived CNSTB. HIV co-infection association with mortality was not statistically significant (HR 1.74, 95% CI 0.35-8.62).

CONCLUSIONS

In our cohort, hydrocephalus was the most important predictor of mortality post-CNSTB diagnosis.

Postmeningitis headache: case report

We report a case of a 18-year-old female patient that developed a migraine-like headache following an acute meningococcal meningitis. She had no previous history of recurrent headaches. The pain was intense, pulsatile and throbbing, typically unilateral, without aura. Its frequency increased during the following weeks and a prophylactic treatment with amitriptyline and atenolol was initiated. There was remission of the attacks.

Drug Insight: adjunctive therapies in adults with bacterial meningitis

Despite the availability of effective antibiotics, mortality and morbidity rates associated with bacterial meningitis are high. Studies in animals have shown that bacterial lysis, induced by treatment with antibiotics, leads to inflammation in the subarachnoid space, which might contribute to an unfavorable outcome. The management of adults with bacterial meningitis can be complex, and common complications include meningoencephalitis, systemic compromise, stroke and raised intracranial pressure. Various adjunctive therapies have been described to improve outcome in such patients, including anti-inflammatory agents, anticoagulant therapies, and strategies to reduce intracranial pressure. Although a recent randomized trial provided evidence in favor of dexamethasone treatment, few randomized clinical studies are available for other adjunctive therapies in adults with bacterial meningitis. This review briefly summarizes the pathogenesis and pathophysiology of bacterial meningitis, and focuses on the evidence for and against use of the available adjunctive therapies in clinical practice.