Fulminant Meningoencephalitis as the First Clinical Sign of an Invasive Pituitary Macroadenoma

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Abstract

We report the case of a young woman who presented with an acute fulminant meningoencephalitis as the first sign of an invasive pituitary macroadenoma. This rare and dramatic complication is described in detail, and the different management steps, from the lumbar puncture to the bifrontal craniectomy, are discussed. In conclusion, this clinical presentation highlights the importance of early diagnosis and urgent management of this uncommon complication.

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Most cited references 17

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Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience.

Tyler Smith, D Richard, R J Toohill … (2004)

The management of cerebrospinal fluid (CSF) rhinorrhea has evolved in recent years. The purpose of this comprehensive retrospective study is to assess issues related to the management of skull base defects associated with CSF rhinorrhea involving the nose and paranasal sinuses. A retrospective review of CSF leak management was conducted. This study included patients with CSF rhinorrhea managed by the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, from 1992 to 2002. Data collected included site of leak, surgical approach, and any recurrence of leak. Fifty-seven CSF leaks occurred in 53 patients with CSF rhinorrhea originating from the nose or paranasal sinuses. Twenty-eight of the 53 had iatrogenic injuries resulting in CSF rhinorrhea, 16 had leaks from trauma, and 13 developed spontaneous CSF leaks. Ten patients responded to nonoperative management with bed rest with or without lumbar drain placement. Forty-three patients with 47 leaks underwent surgical repair of CSF rhinorrhea, of which 38 resolved after initial repair. Five of these patients developed recurrent CSF leaks at the repair site but resolved with subsequent surgery. Of these, two initially presented with spontaneous CSF leaks, one patient had a gunshot wound with massive skull base injury, and two recurred after repair of an iatrogenic injury. Factors associated with failure included lateral sphenoid leaks and elevated body mass index (BMI). Multiple approaches to the management of CSF rhinorrhea can be successful. An endoscopic repair results in resolution of CSF rhinorrhea in the majority of cases. Patients with spontaneous CSF rhinorrhea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for recurrence. Alternative management options may need to be considered in these cases.

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Reducing intracranial pressure may increase survival among patients with bacterial meningitis.

Leif Gothefors, Lars-Owe D Koskinen, Clas Ahlm … (2004)

We reported findings concerning continuous intracranial pressure (ICP) and cerebral perfusion pressure (CPP) measurements and mortality in patients with severe bacterial meningitis treated on the basis of an ICP-targeted approach. Eighteen patients with severe bacterial meningitis were admitted for neurointensive care at Umeå University Hospital (Umeå, Sweden). In 15 patients, ICP was measured continuously through an ICP measuring device. During care, all patients but one developed intracranial hypertension with an ICP of >or=15 mm Hg (14 [93%] of 15 patients). Ten (67%) of 15 patients survived and were discharged, and 5 patients (33%) died. Mean ICP was significantly higher and CPP was markedly decreased in nonsurvivors, compared with survivors. Among the survivors, ICP was gradually reduced. Treatment of patients with severe bacterial meningitis should include neurointensive care and continuous ICP measurement. Increased ICP may be reduced by using the ICP-targeted therapy that closely resembles the "Lund concept."

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Emergency decompressive craniectomy for fulminating infectious encephalitis.

Matthew A. Adamo, Eric Deshaies (2008)

In patients who develop fulminant cerebral edema and elevated intracranial pressures, viral encephalitis can result in devastating neurological and cognitive sequelae despite antiviral therapy. The benefits of decompressive craniectomy, if any, in this group of patients are unclear. In this manuscript, the authors report their experience with 2 patients who presented with herpes simplex virus requiring surgical decompression resulting in excellent neurocognitive outcomes. They also review the literature on decompressive craniectomy in patients with fulminating infectious encephalitis. Four published articles consisting of 13 patients were identified in which the authors had reported their experience with decompressive craniectomy for fulminant infectious encephalitis. Herpes simplex virus was confirmed in 6 cases, Mycoplasma pneumoniae in 2, and an unidentified viral infection in 5 others. All patients developed clinical signs of brainstem dysfunction and underwent surgical decompression resulting in good (Glasgow Outcome Scale [GOS] Score 4) or excellent (GOS Score 5) functional recoveries. The authors conclude that infectious encephalitis is a neurosurgical disease in cases in which there is clinical and imaging evidence of brainstem compression. Surgical decompression results in excellent recovery of functional independence in both children and adults despite early clinical signs of brainstem dysfunction.

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Author and article information

Journal

Journal ID (nlm-ta): Case Rep Neurol

Journal ID (publisher-id): CRN

Title: Case Reports in Neurology

Publisher: S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.ch )

ISSN (Electronic): 1662-680X

Publication date Collection: Sep-Dec 2010

Publication date (Electronic): 03 November 2010

Publication date PMC-release: 03 November 2010

Volume: 2

Issue: 3

Pages: 133-138

Affiliations

[1] ^aDepartment of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

[2] ^bDepartment of Neuroradiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

Author notes

*Dr. Thomas Robert, Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, CH-1011 Lausanne (Switzerland), Tel. +41 21 314 2602, Fax +41 21 314 2605, E-Mail Thomas.Robert@ 123456chuv.ch

This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License ( www.karger.com/OA-license), applicable to the online version of the article only. Distribution for non-commercial purposes only.

Article

Publisher ID: crn0002-0133

DOI: 10.1159/000321844

PMC ID: 2988847

PubMed ID: 21113283

SO-VID: e16bd0af-1fa9-4a41-bcd9-17619ce1bf0f

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This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial-No-Derivative-Works License ( http://creativecommons.org/licenses/by-nc-nd/3.0/). Users may download, print and share this work on the Internet for noncommercial purposes only, provided the original work is properly cited, and a link to the original work on http://www.karger.com and the terms of this license are included in any shared versions.

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Fulminant Meningoencephalitis as the First Clinical Sign of an Invasive Pituitary Macroadenoma

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Karger: Neurology and Neuroscience

Most cited references 17

Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience.

Reducing intracranial pressure may increase survival among patients with bacterial meningitis.

Emergency decompressive craniectomy for fulminating infectious encephalitis.

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