Temporal lobectomy in acute complicated herpes simplex encephalitis: technical case report.
OBJECTIVE
Herpes virus encephalitis is a rare, life-threatening complication of therapy in patients with brain tumors. A surgical therapeutic approach may be needed because the infection can be resistant to acyclovir in immunocompromised patients, and complications and long-term sequelae are frequent.


METHODS
We present the case of a right-handed, 6-year-old girl with a brainstem tumor who had herpes virus encephalitis with refractory seizures while on immunosuppressive treatment. The virus was resistant to acyclovir but responded to gancyclovir. The patient developed local refractory brain edema with right uncal herniation.


METHODS
To reduce the intracranial pressure, internal decompressive craniotomy was performed, which consisted of a right temporal lobectomy that allowed us to remove the focal necrotic-hemorrhagic tissue, decrease inflammation, and avoid subsequent chronic gliotic scarring. Clinical improvement was clear with prompt recovery and acute control of seizures. The only remaining deficits were mild memory and attention impairments. Seizures did not recur in the next 6 months.


CONCLUSIONS
Antiviral resistance should be suspected in immunocompromised patients with herpes virus encephalitis if there is no early response to acyclovir. If uncal herniation of the nondominant temporal lobe develops, temporal lobectomy, as an internal decompressive procedure, can be lifesaving. Lobectomy stopped the acute refractory seizures and can be considered a good approach to prevent later epilepsy, with only mild residual cognitive deficits.
Sánchez-Carpintero
Rocío
R
Department of Paediatrics, Paediatric Neurology Unit, University Clinic of Navarra, University of Navarra, Pamplona, Spain. rsanchezc@unav.es
Aguilera
Sergio
S
Idoate
Miguel
M
Bejarano
Bartolomé
B
D000212:Acyclovir / Q000627:therapeutic use; D038481:Anterior Temporal Lobectomy; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use; D020295:Brain Stem Neoplasms / Q000150:complications* / Q000628:therapy; D002648:Child; D004569:Electroencephalography; D020803:Encephalitis, Herpes Simplex / Q000150:complications* / Q000188:drug therapy / Q000601:surgery*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D011878:Radiotherapy; D012640:Seizures / Q000209:etiology / Q000601:surgery; D013702:Temporal Lobe / Q000473:pathology / Q000601:surgery*
D000998:Antiviral Agents; D000212:Acyclovir