Treatment of vasospasm in bacterial meningitis with hemodynamic augmentation

Abstract

Learning Objectives: Cerebrovascular complications occur in 15-20% of patients with acute bacterial meningitis infections and are associated with a poor prognosis. Arterial narrowing is the most common finding, most likely resulting from inflammation associated with meningitis. Currently, there is a paucity of data on the treatment of severe vasospasm associated with meningitis. We report neurologic recovery from hemodynamic management in a patient with meningitis associated vasospasm. Methods: A 43 year old female was admitted to a medical intensive care unit with fever, right ear pain with drainage, and seizures. Brain imaging revealed bilateral otomastoiditis, right temporal cerebritis, and right transverse sinus thrombosis requiring anticoagulation. Vancomycin, metronidazole, and ceftriaxone were initiated for meningitis followed by mastoidectomy. Prior to surgery, a head and neck computer tomography angiography revealed diffuse decreased caliber of the intracranial vessels, concerning for vasospasm. Transcranial Doppler ultrasound confirmed cerebral artery vasospasm. Neurology consultants recommended conservative hemodynamic augmentation given risk for bleeding with venous sinus thrombosis with a goal systolic blood pressure (SBP) of 120-140 mmHg and mean arterial pressure (MAP) no greater than 100. Phenylephrine was initiated, although nicardipine was later required to maintain target SBP goal. After initiation of SBP augmentation within 12 hours, the patient's Glasgow Coma Scale (GCS) score improved from 5 to 10. Within several weeks, the patient was discharged with significant neurological recovery only limited by global aphasia which recovered at follow-up. Results: Hemodynamic augmentation therapy is an important treatment strategy for vasospasm in patients with subarachnoid hemorrhage (SAH) with the goal of improving cerebral perfusion to overcome the increased vascular resistance in the cerebral arteries. This case demonstrates meningitis associated vasospasm can also be mitigated by augmentation of SBP in an effort to increase cerebral perfusion and minimize neurologic injury. Hemodynamic augmentation may have a role in the treatment of cerebrovascular complications of bacterial meningitis such as vasospasm. Neurologic improvement occurred after initiation of hemodynamic augmentation in this patient with severe vasospasm induced by inflammation from meningitis.