Intracerebral haemorrhage in bacterial meningitis.

OBJECTIVE: To determine the incidence, clinical course, radiological patterns, and clinical outcome of intracerebral haemorrhage (ICH) complicating community-acquired bacterial meningitis. METHODS: The clinical characteristics and outcome of patients with ICH complicating bacterial meningitis were studied in a prospectively nationwide cohort in the Netherlands performed from 2006 to 2018. RESULTS: ICH was identified in 44 of 2306 episodes of bacterial meningitis (1.9%). Nine of these patients (20%) were diagnosed with ICH on admission and 35 (80%) during clinical course after a median of 5 days (1-9). ICH occurred in 4 patients with endocarditis (9%), 9 patients on anticoagulation (vitamin K antagonists and heparin; 20%), and 10 patients with cerebral infarctions (23%). In 31 patients (70%) ICH was a lobar haematoma. ICH in bacterial meningitis was associated with high rates of death (24 of 44 [55%] vs. 346 of 2200 [16%]; P < 0.001) and unfavourable outcome compared to non-ICH patients (39 of 44 [89%] vs. 798 of 2200 [36%]; P < 0.001). Neurological sequelae on discharge occurred frequently in ICH survivors compared to non-ICH patients (15 of 20 [75%] vs. 203 of 1669 [12%]; P < 0.001). CONCLUSIONS: ICH is a rare but severe complication in patients with bacterial meningitis occurring in those with endocarditis, cerebral infarction, and anticoagulant use. ICH complicating bacterial meningitis is associated with high rates of death and morbidity.

Subarachnoid Hemorrhage in Bacterial Meningitis Patients.

INTRODUCTION: Subarachnoid hemorrhage (SAH) has been described as an uncommon complication of community-acquired bacterial meningitis. However, the incidence, clinical course, and outcome are unclear. METHODS: We assessed the clinical characteristics, incidence, and clinical outcome of patients with SAH complicating bacterial meningitis in a prospective nationwide cohort study from 2006 to 2018 in the Netherlands. Patients were identified through the Netherlands Reference Laboratory for Bacterial Meningitis, which receives around 90% of CSF isolates of all Dutch patients with bacterial meningitis, or after direct report by the treating physician. RESULTS: SAH was diagnosed in 22 of 2,306 episodes (0.9%), of which 7 (32%) were diagnosed upon admission and 15 (68%) during admission. All patients showed clinical deterioration before SAH was diagnosed: altered mental status in 18 of 22 patients (82%), focal neurological symptoms in 2 (9%) and, new-onset fever with severe tachycardia in 1 (5%). Acute onset of headache was not reported in any of the patients. Distribution of blood was diffuse in the subarachnoid space in 7 patients (32%), multifocal in 8 patients (36%), and focal in 7 patients (32%) of 22 patients. In 6 patients (27%), CT angiography, MR angiography, or digital subtraction angiography was performed, showing a mycotic aneurysm in 1 patient (5%) and vasculitis in 1 patient (5%). Presence of SAH in bacterial meningitis patients was associated with a poor prognosis assessed at discharge: 12 of 22 patients with SAH died (54%) compared to 361 of 2,257 (16%, p < 0.001) without SAH, and 19 of 22 had an unfavorable outcome (86%) compared to 831 of 2,257 (37%, p < 0.001). CONCLUSION: SAH is an uncommon complication in bacterial meningitis and is associated with high case fatality and morbidity.

Cerebral venous thrombosis in pneumococcal meningitis: An autopsy study.

AIMS: Cerebral venous thrombosis (CVT) is a rare but severe complication of bacterial meningitis. The histopathological features of CVT in meningitis patients have not been described. MATERIALS AND METHODS: We studied histopathology findings of brain autopsy material from 2 patients with bacterial meningitis complicated by CVT and compared findings with those in 3 CVT patients without meningitis and 1 patient with bacterial meningitis without CVT. The histological slides were re-evaluated and assessed for the presence of thrombosis, cerebral venous sinus mural inflammation and bleeding, inflammation at the thrombosis attachment point, endothelial abnormalities, and the presence of bacteria. RESULTS: The 2 patients who died of bacterial meningitis complicated by CVT showed multifocal deep intramural inflammation in the cerebral venous sinus, whereas this was absent in patients with only bacterial meningitis or CVT. Bacteria were identified within the intramural inflammation and thrombus. CONCLUSION: We observed bacterial invasion causing multifocal deep intramural inflammation and venous wall disintegration as CVT in pneumococcal meningitis.

Bacterial meningitis complicated by cerebral venous thrombosis.

INTRODUCTION: Community-acquired bacterial meningitis may be complicated by cerebral venous thrombosis (CVT), but this has not systematically been studied. METHODS: We evaluated clinical characteristics and outcome of CVT in adults with community-acquired bacterial meningitis in a prospective nationwide cohort study of bacterial meningitis (2006-2018) in the Netherlands. RESULTS: CVT occurred in 26 of 2220 episodes with bacterial meningitis (1%). The diagnosis of CVT was made on the day of presentation in 15 patients (58%) and during hospital stay in 11 patients after a median of 6 days (IQR 2-7). Sinusitis or otitis was present in 16 of 24 patients (67%). Patients with CVT presented more often in a coma than those without CVT (53 vs. 18%; P = 0.001) and the clinical course was more often complicated by focal neurologic deficits (58 vs. 22%; P < 0.001). Twelve patients of 26 (46%) had parenchymal lesions on neuroimaging, of whom two (8%) were specific for CVT. The transverse sinus was most frequently thrombosed (18 of 26; 69%). Streptococcus pneumoniae was the most common causative pathogen, occurring in 17 of 26 patients (65%). Eleven patients (44%) received anticoagulant therapy with heparin and none of them developed intracerebral hemorrhage during admission. Unfavorable outcome, as defined as a score on the Glasgow Outcome Scale <5, occurred in 14 of 26 patients (54%) and 4 patients (15%) died. DISCUSSION AND CONCLUSION: CVT is a rare complication of bacterial meningitis and mainly occurs in patients with coma, ear, nose and throat infections, and focal neurologic deficits.

[Headache: consider cavernous sinus thrombophlebitis]. / Hoofdpijn: denk aan sinus-cavernosustromboflebitis.

A 38-year-old woman presented with a 1-week history of progressive headache and acute onset of left-sided hemiparesis. Neurological examination showed bradyphrenia and intermittent left hemiparesis. Brain neuroimaging revealed cavernous sinus thrombosis, subdural empyema, pathological vessel-wall enhancement of the right middle cerebral artery and ischaemia in the right striatum. Cavernous sinus thrombophlebitis with secondary vasculitis and ischaemic stroke was diagnosed. Bacteraemia due to Streptococcus intermedius from a jaw infection was found and she received antibiotic treatment. At six-month follow-up, her symptoms had improved remarkably. Clinical signs such as progressive headache, which does not respond to analgesics, subtle cranial nerve palsy and increased infectious parameters should alert the clinician to conduct appropriate neuroimaging studies. Early initiation of effective antibiotic treatment in these cases is essential and can change the course of the illness and improve prognosis.