Development of a prediction rule for diagnosing postoperative meningitis: a cross-sectional study.

OBJECTIVE Diagnosing nosocomial meningitis (NM) in neurosurgical patients is difficult. The standard CSF test is not optimal and when it is obtained, CSF cultures are negative in as many as 70% of cases. The goal of this study was to develop a diagnostic prediction rule for postoperative meningitis using a combination of clinical, laboratory, and CSF variables, as well as risk factors (RFs) for CNS infection. METHODS A cross-sectional study was performed in 4 intensive care units in Medellín, Colombia. Patients with a history of neurosurgical procedures were selected at the onset of febrile symptoms and/or after an increase in acute-phase reactants. Their CSF was studied for suspicion of infection and a bivariate analysis was performed between the dependent variable (confirmed/probable NM) and the identified independent variables. Those variables with a p value ≤ 0.2 were fitted in a multiple logistic regression analysis with the same dependent variable. After determining the best model according to its discrimination and calibration, the ß coefficient for each selected dichotomized variable obtained from the logistic regression model was used to construct the score for the prediction rule. RESULTS Among 320 patients recruited for the study, 154 had confirmed or probable NM. Using bivariate analysis, 15 variables had statistical associations with the outcome: aneurysmal subarachnoid hemorrhage (aSAH), traumatic brain injury, CSF leak, positioning of external ventricular drains (EVDs), daily CSF draining via EVDs, intraventricular hemorrhage, neurological deterioration, age ≥ 50 years, surgical duration ≥ 220 minutes, blood loss during surgery ≥ 200 ml, C-reactive protein (CRP) ≥ 6 mg/dl, CSF/serum glucose ratio ≤ 0.4 mmol/L, CSF lactate ≥ 4 mmol/L, CSF leukocytes ≥ 250 cells, and CSF polymorphonuclear (PMN) neutrophils ≥ 50%. The multivariate analysis fitted a final model with 6 variables for the prediction rule (aSAH diagnosis: 1 point; CRP ≥ 6 mg/dl: 1 point; CSF/serum glucose ratio ≤ 0.4 mmol/L: 1 point; CSF leak: 1.5 points; CSF PMN neutrophils ≥ 50%: 1.5 points; and CSF lactate ≥ 4 mmol/L: 4 points) with good calibration (Hosmer-Lemeshow goodness of fit = 0.71) and discrimination (area under the receiver operating characteristic curve = 0.94). CONCLUSIONS The prediction rule for diagnosing NM improves the diagnostic accuracy in neurosurgical patients with suspicion of infection. A score ≥ 6 points suggests a high probability of neuroinfection, for which antibiotic treatment should be considered. An independent validation of the rule in a different group of patients is warranted.

Síndrome de Moyamoya y complicaciones neurológicas en un paciente con enfermedad de células falciforme / Moyamoya syndrome and neurological complications in a patient with sickle cell disease

La enfermedad de células falciformes, aunque infrecuente, es una patología con una alta comorbilidad; el ataque cerebrovascular (ACV) y las malformaciones vasculares por deformidad endotelial, son complicaciones mayores y catastróficas en las pacientes con alteraciones falciformes, es por esto que el adecuado seguimiento de estos pacientes permite prevenir la alta tasa de complicaciones que esta enfermedad conlleva. Se presenta el caso de una mujer de raza negra de 24 años con enfermedad de células falciformes, con infartos cerebrales en la adolescencia y quien durante su gestación se complica con hemorragia intraventricular secundaria a múltiples malformaciones vasculares tipo Moyamoya, desarrollando un estado epiléptico convulsivo y deterioro neurológico irreversible.

Sickle cell disease, although infrequent, is a disease with high comorbidity, stroke and vascular malformations by endothelial deformity are major and catastrophic complications in patients with sickle cell disease, which is why proper monitoring of these patients can prevent the high rate of complications that this disease leads. The situation of a 24 years old african-american woman with sickle cell disease and several strokes during adolescence is exposed. The patient had a complicated pregnancy due to secondary intraventricular hemorrhage and multiple vascular malformations type Moyamoya. She developed a convulsive status epilepticus and an irreversible neurological impairment.