Decompressive craniectomy in herpes simplex encephalitis: a case report

Abstract

Herpes Simplex Encephalitis is the commonest form of sporadic encephalitis. Availability of effective antiviral therapy viz Acyclovir has significantly reduced the mortality of Herpes Simplex Encephalitis. Elevated intracranial pressure resulting in herniation syndromes continues to be an important cause of mortality. Antiviral therapy and medical measures for managing raised intracranial pressure including osmotic diuretics, careful usage of steroids and controlled hyperventilation continue to be the cornerstones in management of these patients. Authors present a 38-year-old male patient with Cerebrospinal fluid Meningo-encephalitic panel positivity for herpes simplex virus 1 and bilateral temporal lobe lesions with secondary decline due to impending herniation syndrome despite osmotic diuretics and steroids with patient survival and complete recovery following decompressive hemicraniectomy.

Surgical Management in Herpes Simplex Encephalitis: Illustrative Case Report and Systematic Review of the Literature

“…Decompressive craniectomy with or without concurrent temporal lobectomy was frequently reported in HSVE cases (72% [46/64]) in the setting of clinical deterioration and radiological evidence of elevated ICP. 8,16-19,21,22,24,25,28,30,33,38,40-43,46-54,56-59,61,62,64-67 However, temporal or frontal lobectomy without craniectomy was also sometimes reported (28% [18/64]) for surgical decompression in HSVE cases. 20,23,24,26,27,29,32-36,39,44,48,53,63 Although elevated ICP in HSVE often results from diffuse cerebral edema, numerous patients (19% [12/64]) developed frank hemorrhage that required surgical evacuation because of significant mass effect and neurological deterioration.…”

“…Two additional patients with obstructive hydrocephalus associated with HSVE had good functional outcomes 31,60 after surgical drainage. Notably, favorable long-term outcomes were observed after surgical decompression that occurred after both relatively short (≤10 days) 17,21,28,30,34,36,37,39,50,[52][53][54]57,58,67 and more protracted 8,16,27,29,33,[41][42][43][44]48,51,53,61 periods of HSVE symptoms. However, in-hospital mortality (20% [12/61]) and moderate to severe long-term functional disability (23% [14/61]) were also prevalent.…”

“…Decompressive craniectomy with or without concurrent temporal lobectomy was frequently reported in HSVE cases (72% [46/64]) in the setting of clinical deterioration and radiological evidence of elevated ICP. 8,[16][17][18][19]21,22,24,25,28,30,33,38,[40][41][42][43][46][47][48][49][50][51][52][53][54][56][57][58][59]61,62,[64][65][66][67] However, temporal or frontal lobectomy without craniectomy was also sometimes reported (28% [18/64]) for surgical decompression in HSVE cases. 20,23,24,26,27,29,[32][33][34][35][36]…”