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

Grände, Per-Olof LU ; Myhre, Erling LU ; Nordström, Carl-Henrik LU and Schliamser, Silvia LU (2002) In Acta Anaesthesiologica Scandinavica 46(3). p.264-270
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 (beta1-antagonist,alpha2-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... (More)
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 (beta1-antagonist,alpha2-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 (<10 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 lumbar dural puncture shortly before development of the brain stem symptoms. These symptoms gradually regressed after initiation of therapy, and in one patient reversal of brain stem herniation was documented by MRI. CONCLUSIONS: Severe bacterial meningitis can be associated with increased ICP, which can be reduced using the Lund Concept. The high survival rate, the low frequency of sequelae and the reversal of signs of imminent brain stem herniation in these high-risk patients indicated beneficial effects of the intervention. The study confirms earlier observations that lumbar dural puncture is potentially hazardous in patients with intracranial hypertension, because it may trigger brain stem herniation. A normal CT brain scan does not rule out intracranial hypertension. (Less)
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keywords
Brain Stem, Adult, Adolescence, Child, Preschool, Encephalocele : prevention & control, Human, Intracranial Hypertension : diagnosis, Intracranial Hypertension : etiology, Intracranial Pressure, Intracranial Hypertension : therapy, Meningitis, Bacterial : complications, Bacterial : diagnosis, Pneumococcal : complications, Pneumococcal : diagnosis, Middle Age, Monitoring, Physiologic, Spinal Puncture : adverse effects, Encephalocele : etiology
in
Acta Anaesthesiologica Scandinavica
volume
46
issue
3
pages
264 - 270
publisher
Wiley-Blackwell Publishing Ltd
external identifiers
  • wos:000174808200007
  • scopus:0036202638
ISSN
0001-5172
DOI
10.1034/j.1399-6576.2002.460307.x
language
English
LU publication?
yes
id
512e29e5-a336-493e-8bba-24dcc68f1557 (old id 107468)
alternative location
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11939916&ordinalpos=23&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
date added to LUP
2016-04-01 12:08:10
date last changed
2020-02-12 03:55:09
@article{512e29e5-a336-493e-8bba-24dcc68f1557,
  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 (beta1-antagonist,alpha2-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 (&lt;10 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 lumbar dural puncture shortly before development of the brain stem symptoms. These symptoms gradually regressed after initiation of therapy, and in one patient reversal of brain stem herniation was documented by MRI. CONCLUSIONS: Severe bacterial meningitis can be associated with increased ICP, which can be reduced using the Lund Concept. The high survival rate, the low frequency of sequelae and the reversal of signs of imminent brain stem herniation in these high-risk patients indicated beneficial effects of the intervention. The study confirms earlier observations that lumbar dural puncture is potentially hazardous in patients with intracranial hypertension, because it may trigger brain stem herniation. A normal CT brain scan does not rule out intracranial hypertension.},
  author       = {Grände, Per-Olof and Myhre, Erling and Nordström, Carl-Henrik and Schliamser, Silvia},
  issn         = {0001-5172},
  language     = {eng},
  number       = {3},
  pages        = {264--270},
  publisher    = {Wiley-Blackwell Publishing Ltd},
  series       = {Acta Anaesthesiologica Scandinavica},
  title        = {Treatment of intracranial hypertension and aspects on lumbar dural puncture in severe bacterial meningitis.},
  url          = {https://lup.lub.lu.se/search/ws/files/2796543/623593.pdf},
  doi          = {10.1034/j.1399-6576.2002.460307.x},
  volume       = {46},
  year         = {2002},
}