Intraventricular Nicardipine for Reversible Vasospasm Related to Cryptococcal Meningovasculitis

Abstract

Introduction Basilar meningovasculitis causing diffuse vasospasm is an under recognized complication of CNS cryptococcal infection. We report the first case of intraventricular (IVT) nicardipine used to alleviate reversible vasospasm associated with fungal meningitis. Methods Case report Results A 28-year-old immunocompetent male diagnosed with Cryptococcal meningitis treated with one month of amphotericin B, flucytosine, and serial lumbar punctures, presented with lethargy and persistent dysmetria and dysarthria. CSF examination showed clearance of the Cryptococcus fungus but ICP remained high; therefore, an external lumbar drain was placed. After an initial two-day improvement, the patient became lethargic and had alternating episodes of hemiplegia, which progressed to a comatose state and bilateral extensor posturing. Continuous EEG showed diffuse slowing and no seizure activity. An extraventricular drain (EVD) was placed for ICP monitoring, however, pressures remained consistently ≤ 20 mmHg. Repeat MRI showed scattered bilateral cerebral ischemia and leptomeningeal enhancement. Diffuse vascular spasm was suspected on computed tomography angiography (CTA). This finding prompted an unsuccessful attempt at angiographic spasmolysis of the bilateral ICAs using intra-arterial verapamil. Initial TCD showed severe right (186 cm/s) and left (220 cm/s) middle cerebral artery (MCA) vasospasm. High-dose methylprednisolone and IVT nicardipine 4mg/2mL every 8 hours were initiated. One hour following IVT nicardipine administration, the MCA velocities improved on the right (110 cm/s) and left (104cm/s). Over the next several days, the patient was extubated, communicative, and tolerating a regular diet. A total of 12 doses of nicardipine were administered. A follow up CTA showed no signs of vasospasm. The patient was discharged to a rehabilitation facility on oral antifungals and nimodipine. Conclusions The treatment of elevated ICP associated with Cryptococcal meningitis consists of serial LPs, IV steroids, and CSF diversion. However, no literature exists on the association of cerebral vasospasm in Cryptococcal meningovasculitis or its treatment with intraventricular nicardipine.