Neuro-Intensive Treatment Targeting Intracranial Hypertension Improves Outcome in Severe Bacterial Meningitis: An Intervention-Control Study

Abstract

ObjectiveTo evaluate the efficacy of early intracranial pressure (ICP)-targeted treatment, compared to standard intensive care, in adults with community acquired acute bacterial meningitis (ABM) and severely impaired consciousness.DesignA prospectively designed intervention-control comparison study of adult cases from September 2004 to January 2012.PatientsIncluded patients were confirmed ABM-cases, aged 16–75 years, with severely impaired mental status on admission. Fifty-two patients, given ICP-targeted treatment at the neuro-intensive care unit, and 53 control cases, treated with conventional intensive care, were included. All the patients received intensive care with mechanical ventilation, sedation, antibiotics and corticosteroids according to current guidelines. Additional ICP-treatment in the intervention group included cerebrospinal fluid drainage using external ventricular catheters (n = 48), osmotherapy (n = 21), hyperventilation (n = 13), external cooling (n = 9), gram-doses of methylprednisolone (n = 3) and deep barbiturate sedation (n = 2) aiming at ICP <20 mmHg and a cerebral perfusion pressure of >50 mmHg.MeasurementsThe primary endpoint was mortality at two months and secondary endpoint was Glasgow outcome score and hearing ability at follow-up at 2–6 months.OutcomesThe mortality was significantly lower in the intervention group compared to controls, 5/52 (10%) versus 16/53 (30%; relative risk reduction 68%; p<0.05). Furthermore, only 17 patients (32%) in the control group fully recovered compared to 28 (54%) in the intervention group (relative risk reduction 40%; p<0.05).ConclusionsEarly neuro-intensive care using ICP-targeted therapy, mainly cerebrospinal fluid drainage, reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission.

The use of mannitol in HIV-infected patients with symptomatic cryptococcal meningitis

“…At first, Mannitol is used to manage elevated ICP in various conditions such as bacterial meningitis, tuberculosis meningitis, and brain injury (11,(19)(20)(21). In China, mannitol administration is still one of the recommended choices for the management of HIV-associated CM based on expert opinions (22).…”

“…Patients with neurological symptoms (such as headache, seizures and confusion) associated with elevated ICP are routinely treated with mannitol, a hyperosmotic drug used for controlling elevated ICP caused by many other reasons (11)(12)(13). Here, we retrospectively analyzed the clinical and laboratory data of the patients with HIV-associated CM at our hospital to evaluate the prognosis of the patients and the adverse effects that may be related to mannitol administration.…”

Acute Bacterial Meningitis: Focused Update on Pathophysiology and Treatment Among Adults in "African Meningitis Belt" of North-Western Nigeria

“…In patients with communicating hydrocephalus who are awake and can be monitored clinically, invasive measures such as repetitive lumbar punctures or placement of an external lumbar drain can be considered but might not be necessary. [33,34] …”

Cerebrospinal Fluid in Clinical Neurology

“…Accompanying meningovasculitis leading to stroke, diffuse brain oedema and hydrocephalus, pyocephalus, empyema and brain abscess, sinus or intracranial venous thrombosis are the most frequent intracranial complications and need to be monitored, actively looked for and managed within a neurocritical care unit (Edberg et al 2011 ;Glimåker et al 2014 ). Very recently, it has been shown that in case of impaired consciousness, the placement of an intracranial pressure monitoring probe and external ventricular drainage may reduce mortality from 30 to 10 % (Glimåker et al 2014 ).…”

“…Very recently, it has been shown that in case of impaired consciousness, the placement of an intracranial pressure monitoring probe and external ventricular drainage may reduce mortality from 30 to 10 % (Glimåker et al 2014 ). Therefore, every patient with acute bacterial meningitis and impaired consciousness needs to be monitored for intracranial pressure in a specialised neurocritical care unit.…”