Continuous monitoring and intervention for cerebral ischemia in tuberculous meningitis.
OBJECTIVE
Tuberculous meningitis (TBM) is a massive global problem. The mortality and morbidity associated with the severe form of the disease are exceptionally high. Even when increased intracranial pressure is treated and full conventional therapy is commenced, cerebral ischemia can develop and is associated with a particularly poor prognosis. We sought to evaluate our experience with two patients with severe TBM and cerebral oxygenation monitoring.


METHODS
Case report.


METHODS
Red Cross Children's Hospital, Cape Town.


METHODS
Two comatose patients with TBM.


METHODS
Targeted interventions against low cerebral oxygenation in one patient.


RESULTS
Cerebral tissue oxygenation (Ptio2) was measured. In both patients, Ptio2 monitoring demonstrated delayed cerebral ischemia despite the institution of full conventional therapy and the control of intracranial pressure. These data confirm that the vascular involvement in TBM is potentially progressive and that failure to diagnose infarction initially is not merely due to a delay in the radiologic appearance. The first patient developed extensive infarction, consistent with Ptio2 readings, and subsequently died after treatment withdrawal. Intervention in the second patient successfully reversed a precipitous decline of the Ptio2 readings and may have prevented infarction in this patient.


CONCLUSIONS
The development of delayed cerebral ischemia in TBM despite treatment is confirmed in these two patients. The reversal of a decline in Ptio2 readings suggests a possible benefit for cerebral oxygenation monitoring in selected patients with severe TBM.
Division of Neurosurgery, School of Child and Adolescent Health, University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa. anthony.figaji@uct.ac.za
Anthony A
AA
Figaji
Simon I J
SI
Sandler
A Graham
AG
Fieggen
Peter D
PD
Le Roux
Jonathan C
JC
Peter
Andrew C
AC
Argent
D000995:Antitubercular Agents / Q000627:therapeutic use; D020520:Brain Infarction / Q000209:etiology / Q000628:therapy; D002545:Brain Ischemia / Q000209:etiology / Q000517:prevention & control*; D002557:Cerebrospinal Fluid Shunts; D002560:Cerebrovascular Circulation; D003128:Coma / Q000209:etiology; D017809:Fatal Outcome; D006801:Humans; D002534:Hypoxia, Brain / Q000209:etiology / Q000517:prevention & control; D007223:Infant; D007427:Intracranial Pressure; D008297:Male; D008991:Monitoring, Physiologic; D014390:Tuberculosis, Meningeal / Q000150:complications / Q000503:physiopathology / Q000628:therapy*
D000995:Antitubercular Agents