- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss Allee 11, 93053 Regensburg, Germany
- Department of Pediatrics, University Medical Center Regensburg, Franz-Josef-Strauss Allee 11, 93053 Regensburg, Germany
Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss Allee 11, 93053 Regensburg, Germany
DOI:10.4103/2152-7806.154776Copyright: © 2015 Hoehne J. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Hoehne J, Friedrich M, Brawanski A, Melter M, Schebesch K. Decompressive craniectomy and early cranioplasty in a 15-year-old boy with N. meningitidis meningitis. Surg Neurol Int 09-Apr-2015;6:58
How to cite this URL: Hoehne J, Friedrich M, Brawanski A, Melter M, Schebesch K. Decompressive craniectomy and early cranioplasty in a 15-year-old boy with N. meningitidis meningitis. Surg Neurol Int 09-Apr-2015;6:58. Available from: http://sni.wpengine.com/surgicalint_articles/decompressive-craniectomy-early-cranioplasty-15%e2%80%91year%e2%80%91old-boy-n-meningitidis-meningitis/
Background:Intracranial hypertension is a well-known life-threatening complication of bacterial meningitis. Investigations on decompressive craniectomy after failure of conservative management are scarce, but this surgical treatment should be considered and performed expeditiously, as it lowers the intracranial pressure and improves brain tissue oxygenation. Early cranioplasty can further aid the rehabilitation.
Case Description:A 15-year-old boy was admitted to our emergency department because of sudden onset of neurologic decline and consecutive loss of consciousness. Clinical examination and imaging showed elevated intracranial pressure, leading to the suspected diagnosis of meningitis. Intracranial pressure monitoring was installed, but the initiated conservative management failed. Finally, the patient underwent bilateral decompressive craniectomy. The microbiological test showed growth of Neisseria meningitidis. After full neurologic recovery, cranioplasty with two CAD/CAM titanium implants was conducted successfully.
Conclusions:This unique report shows that decompressive craniotomy with duroplasty may be a crucial therapeutic approach in bacterial meningitis with refractory increased intracranial pressure and brainstem compression. Early cranioplasty with a patient-specific implant allowed the early and full reintegration of the patient.
A 15-year-old Turkish boy was admitted to the emergency department after loss of consciousness. 3 days prior to admission, he had experienced fever and ague with a gradual decline of his general condition. When presenting to his primary care physician, he was treated with nonsteroidal antiinflammatory drugs (NSAIDs) and antitussives for a suspected viral infection. Because his condition had not improved and he had developed nausea and vomiting, the patient presented to an emergency physician the night prior to hospital admission. This time, paracetamol and antiemetics were administered. During the day he was tired, disoriented, and somnolent. The next morning, he was found unconscious and was subsequently admitted to the emergency department. No clinical signs of epileptic seizures could be detected.
On admission, the patient was not adequately responsive, showing a Glasgow Coma Score of 9 including neck stiffness. The body core temperature was 36.5°C. Pupils were equal, round, as well as reactive to light and accommodation. No additional neurological abnormality was present.
The initial computed tomography (CT)-scan showed generalized brain edema [
At the neurological department, the patient was initially treated with corticosteroids (10 mg dexamethasone), antibiotics (2 g ceftriaxone and 400 mg ampicillin), and antiviral medication (750 mg aciclovir) because of suspected meningitis. Relatives and people in close contact with the patient were treated accordingly. An intracranial pressure (ICP) probe was implanted for ICP monitoring. Despite maximal osmotic management, the patient developed intractable ICP with values up to 36 mmHg. Because the patient failed to response to maximal conservative treatment, the team of pediatrics, neurologists, and neurosurgeons decided to conduct bilateral craniectomy and durotomy to control the extensively elevated ICP.
Immediately after decompressive surgery, the ICP decreased significantly but increased again few hours after the first surgery, while the right pupil became dilated consecutively. The immediate CT-scan showed an epidural hematoma and subgaleal blood collection. The hemorrhage was evacuated instantly [Figures
Despite the initial antibiotic and antiviral treatment without prior lumbar puncture, microbial testing of cerebrospinal fluid at a later stage showed Neisseria meningitidis type W/Y-135; the polymerase chain reaction (PCR) test for herpes simplex (HS) virus type 1/2 was negative. Uncomplicated pneumonia was treated successfully with antibiotics but prolonged the intubation period. Two weeks after admission, inflammatory hematological parameters had improved significantly, and the boy was extubated. Rapidly, the patient's general condition improved, hence he was discharged on day 45 without any neurologic deficit and soon afterwards returned to school.
After 4 weeks, patient specific CAD/CAM titanium cranioplasties (CL instruments, Attendorn, Germany) were implanted bilaterally. Wound healing was uneventful and postoperative imaging showed accurate fitting without relevant artifacts [
Basically, permanent neurological deterioration due to meningitis is reported for up to 16% of affected children with neurologic sequelae; this rate refers to survivors in developed countries, irrespective of maximal conservative treatment.[
Most other patients described in the literature had viral infections.[
The titanium implant offers complete restoration of cosmesis and good defect closure to prevent neurologic sequelae.[
Decompressive craniectomy has been shown beneficial in certain conditions other than severe traumatic brain injury resulting in severe refractory ICP. In this unique case of a 15-year-old boy suffering from bacterial meningitis with N. meningitidis, bilateral decompressive craniectomy was conducted as last resort because of generalized brain edema and massively increased ICP that was refractory to any conservative and osmotic treatment. Bilateral preformed titanium cranioplasty implants were used at an early stage, and neurological recovery was excellent.
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