EXPERT ANALYSIS AT ANA 2014
BALTIMORE (FRONTLINE MEDICAL NEWS) – Patients with seemingly desperate illnesses of the central nervous system can make a dramatic recovery if they receive appropriate, early antimicrobials and have enough time to respond.
When these illnesses strike, “Without timely, appropriate antimicrobials, we are in trouble,” Dr. Claude Hemphill said at the annual meeting of the American Neurological Association. “All is usually lost. But patients can look very sick and still make a good recovery if we treat early. However, good neurocritical care is crucial.”
As an example, he cited the case of a 28-year-old nurse who had symptoms of an upper respiratory infection, including fever and headache. Her mother found her unresponsive and with left arm flexure. She required suctioning, which revealed pus in her throat. She did open her eyes to loud voices, but couldn’t follow commands. She had severe right-sided hemiparesis.
Imaging showed a severe empyema with brain inflammation and cerebral venous sinus thrombosis. Further testing revealed an Staphylococcus aureus brain infection.
“This was an emergency neurosurgical situation and she went emergently to the operating room,” where she had a decompressive craniectomy and postoperative angiography, said Dr. Hemphill, the Kenneth Rainin Chair in Neurocritical Care at the University of California, San Francisco. She was started on antibiotics and had several days of tissue plasminogen activator infusion into the superior sagittal sinus. But she remained in a coma.”
Intracranial pressure (ICP) monitoring and brain oxygen monitoring were not favorable. By hospital day 29, “You could see swelling everywhere. The middle cerebral artery was pushed up, and there was brain herniation through the craniectomy. At this time, we were weaning her off barbiturates and strongly urged to give up. But we didn’t. We finished her treatment and sent her to a rehab facility.”
Ten weeks later, Dr. Hemphill got a call from the young woman, requesting a note to return to work as soon as her craniectomy skull flap healed. “I wrote the note and chalked it up to a good lesson for both me and my team.”
In addition to discovering the root cause of the primary injury (in this case, infective illness), a key to the nurse’s good recovery was the limiting of secondary brain injury, he said. ICP monitoring was crucial during treatment and the long waiting period, Dr. Hemphill said. But ICP monitoring for these patients is often viewed as an unusual tactic.
“If you ask the neurosurgeon for an ICP, you might get a funny look,” he warned. “In the U.S. at least, not doing so is merely an accepted practice pattern – it’s not anything based on the pathophysiology of the disease.”
Even if the situation looks grim, Dr. Hemphill advised optimizing treatment to give patients with encephalitis a fighting chance. Antimicrobials may be helpful even if no infective agent can be identified. Corticosteroids, especially dexamethasone, appear beneficial if given concomitantly. “The reason we shouldn’t defer dexamethasone is that the blood-brain barrier may be less permeable after antibiotics,” Dr. Hemphill noted.
Glycerol, anti-inflammatory drugs, and paracetamol have not been proven helpful.
Because nonconvulsive status epilepticus isn’t uncommon, he also recommended continuous EEG monitoring, although prophylactic anticonvulsants are not usually indicated.
Dr. Hemphill had no financial disclosures.
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