Multimodal cerebral monitoring and decompressive surgery for the treatment of severe bacterial meningitis with increased intracranial pressure.

Bacterial meningitis is still associated with a high mortality, mainly because of cerebral herniation as a result of increased intracranial pressure. Published data stress the necessity of an early diagnosis and immediate start of antibiotic therapy. Nevertheless, there are only few reports in which therapeutic strategy was based on the monitoring and the reduction of intracranial pressure (ICP). We report one case of bacterial meningitis caused by Neisseria meningitidis with an initial ICP value of 60 mmHg, which was treated by large hemicraniectomy and ventriculostomy, leading to a favorable neurological long-term result. The surgical decision was accelerated by an accurate ICP evaluation based on cerebral monitoring [transcranial Doppler ultrasonography (TCD) and intracranial ICP-device]. In selected patients with bacterial meningitis and clinical and radiological evidence of elevated ICP, cerebral monitoring and aggressive reduction of ICP may be crucial to improve survival and neurological outcome. When maximal medical ICP treatment fails to reduce severe intracranial hypertension, decompressive craniectomy should be rapidly proposed.

Treatment of thromboembolic complications of fulminant meningococcal septic shock.

A patient report of fulminant meningococcal septic shock is described. The presentation, hospital course, and reconstructive efforts are outlined, and a brief review of meningococcal infection is included. Emphasis is placed on the algorithm used to determine treatment. A 19-year-old Hispanic male presented with all the hallmarks of Waterhouse-Friderichsen syndrome (WFS)-sudden onset, high fever, dyspnea with intermittent cyanosis, shock, disseminated intravascular coagulopathy, and the development of purpura. The pathognomonic feature of WFS-hemorrhage into the adrenal glands-if present, was not extensive, as he did not require steroid supplementation. Though cerebrospinal fluid latex agglutination was negative, his serum was positive for group C Neisseria and admission blood cultures grew Neisseria meningitidis. Thromboembolic complications were systemic with the highest morbidity peripherally in the lower extremities. Care for these injuries involved every rung of the reconstructive ladder-from local wound care and skin grafts to local flaps and microvascular transplantation.

Surgical management of life-threatening and disfiguring sequelae of fulminant meningococcemia.

In recent years, because of prompt diagnosis and effective, aggressive resuscitation, the majority of infants and children with fulminant meningococcemia are surviving. From 1974 through 1984, 135 patients with this diagnosis were treated, and 126 of them survived. Although a purpuric skin rash developed in almost all of these patients initially, in eight of them it progressed to multiple confluent areas of cutaneous gangrene, usually associated with extensive necrosis of underlying subcutaneous fat, fascia, skeletal muscle, and even bone. Tissue necrosis seemed to be most extensive in regions of reduced blood flow, such as the extremities, but it almost never followed a pattern of anatomic vascular distribution. A most significant microscopic finding was the presence of multiple fibrin thrombi in vessels, often in close proximity with the foci of tissue necrosis. Five children who ranged in age from 6 months to 12 years required operation. Initially, all surface wounds were treated like full-thickness burns with silver sulfadiazene (Silvadene) dressings. Once the patient's condition had stabilized and the extent of tissue necrosis was apparent, all necrotic tissue was excised and the resulting wounds were temporarily covered with biologic dressings to assure a clean, viable base for skin grafting. Because the resulting quality of life postoperatively in all five surviving patients has been satisfactory, we recommend an aggressive surgical approach in patients with fulminating meningococcemia, despite what may initially appear to be devastating and even lethal complications of this disease.