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Bhave VM, Bernstock JD, Carlson JM, Kappel AD, Torio EF, Chen JA, Essayed WI, Gawelek KL, DiToro DF, Izzy S, Cosgrove GR. Surgical Management in Herpes Simplex Encephalitis: Illustrative Case Report and Systematic Review of the Literature. Neurosurgery 2023; 92:915-933. [PMID: 36700784 DOI: 10.1227/neu.0000000000002334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Herpes simplex virus (HSV) is a common cause of viral encephalitis and can result in refractory seizures. Although HSV encephalitis (HSVE) is treated primarily with acyclovir, surgery can play a role in medically intractable cases. OBJECTIVE To systematically review cases describing surgery for the treatment of severe HSVE. We also present an illustrative case of anterior temporal lobectomy (ATL) for refractory status epilepticus in a patient with unilateral HSVE. This case demonstrates one clinical context in which surgery can be a useful adjunct. METHODS We performed a systematic review using PubMed and Google Scholar, including case reports and series describing surgical interventions for HSVE. Clinical data were extracted from 54 publications that incorporated 67 patient cases. RESULTS Surgical decompression occurred at a wide range of times after the onset of illness, although most patients were operated on 4 or more days after HSVE symptoms began. Numerous reports indicated that decompressive craniectomy, temporal lobectomy, and hematoma removal could treat intractably elevated intracranial pressure because of HSVE with favorable long-term outcomes. We describe an additional case in which a 52-year-old woman with HSVE developed refractory right temporal lobe seizures. After ATL, the seizures resolved with significant clinical improvement. CONCLUSION Surgical treatment can be a useful adjunct for treatment of HSVE. There is substantial variability in the timing of surgical decompression in patients with HSVE, which can be necessary up to approximately 3 weeks after illness onset. ATL should be considered for refractory status epilepticus in HSVE with a unilateral seizure focus.
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Affiliation(s)
| | - Joshua D Bernstock
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julia M Carlson
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ari D Kappel
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Erickson F Torio
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason A Chen
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walid Ibn Essayed
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kara L Gawelek
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel F DiToro
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - G Rees Cosgrove
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Tamura G, Inagaki T. Prognostic Factors for Pediatric Acute Encephalopathy Associated with Severe Brain Edema. Pediatr Neurosurg 2021; 56:221-228. [PMID: 33827101 DOI: 10.1159/000515037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Acute encephalopathy is a life-threatening brain dysfunction in children, often associated with a preceding infection and diffuse noninflammatory brain edema. At present, the role of decompressive craniectomy (DC) over the swollen area of the brain is unclear. The risk factors for predicting clinical deterioration also need clarification. METHODS A retrospective study of pediatric patients admitted between 2015 and 2019 with acute cerebral encephalopathy was carried out. Patients were classified according to: (1) the preceding pathogens, (2) the syndromic classification, and (3) the extent of brain edema. The syndromic classification is a relatively new classification of acute encephalopathy proposed in 2016 and divides patients into 3 groups: those with systemic inflammatory reactions or "cytokine storms" (group 1), those with status epilepticus but no cytokine storm (group 2), and others (group 3). Glasgow Outcome Scale (GOS) scores of 1-3 were defined as unfavorable, while a GOS score of 4 or 5 was defined as a favorable outcome in this study. DC was performed for select patients with life-threatening signs of brainstem compression. RESULTS Nineteen patients (mean age: 23.3 months) were included in the study, 8 (42.1%) of whom had an unfavorable outcome. There was no significant correlation between the types of pathogens and outcome. Unfavorable outcomes were observed in significantly more patients in group 1 (87.5%) than group 2 (14.3%) and group 3 (0%). There was a significant association between diffuse brain edema and unfavorable outcomes (72.7%). Neurosurgical DC was performed in 2 patients to alleviate life-threatening brainstem compression: one with a cytokine storm and diffuse bilateral brain edema, and the other with prolonged status epilepticus causing diffuse right-sided brain edema. The GOS score was 3 and 4, respectively. CONCLUSION The risk factors for clinical deterioration in pediatric acute encephalopathy were evaluated based on a variety of classifications, including the new syndromic classification. Laboratory features of cytokine storms and radiological evidence of diffuse brain edema were associated with unfavorable outcomes. The role of surgical decompression is still controversial and should be assessed on a case-by-case basis.
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Affiliation(s)
- Goichiro Tamura
- Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Japan
| | - Takayuki Inagaki
- Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Japan
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Todeschi J, Gubian A, Wirth T, Coca HA, Proust F, Cebula H. Multimodal management of severe herpes simplex virus encephalitis: A case report and literature review. Neurochirurgie 2018; 64:183-189. [PMID: 29730051 DOI: 10.1016/j.neuchi.2017.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/28/2017] [Accepted: 10/29/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) is the most frequent sporadic encephalitis in the world. In severe cases of HSE, the pathology usually progresses with an increase in intracranial pressure secondary to cerebral edema and/or hemorrhagic necrosis. Currently no high-power studies exist regarding the management of severe HSE and most of the papers reported in the literature are case reports. Decompressive craniectomy, effective in some cases of pharmaco-resistant intracranial hypertension (ICH) resulting from other causes, may be suggested in severe HSE, with several good results reported in the literature. CASE DESCRIPTION The case of a 26-year-old man with severe HSE and a subsequent ICH is reported. In dealing with an ICH rebellious to conservative treatment, it was decided to perform a right decompressive hemicraniectomy, associated with a right temporal polectomy. The postoperative evolution was satisfactory, with normal neuropsychological tests and a Glasgow Outcome Scale of 1. CONCLUSION Although herpes simplex encephalitis is sometimes devastatingly complicated by intracranial hypertension, its management lacks consensus and reliable data in the literature remains scarce. Surgical as well as conservative treatment, used together in a multimodal approach, may hold the key to a greater control of intracranial pressure, thus resulting in a better outcome. In this multimodal management, the window of opportunity where surgery may be considered is small, and must be discussed further and more precisely in future articles.
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Affiliation(s)
- J Todeschi
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
| | - A Gubian
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - T Wirth
- Department of neurology, hôpital de Hautepierre, 67200 Strasbourg, France
| | - H-A Coca
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - F Proust
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - H Cebula
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
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Singhi P, Saini AG, Sahu JK, Kumar N, Vyas S, Vasishta RK, Aggarwal A. Unusual Clinical Presentation and Role of Decompressive Craniectomy in Herpes Simplex Encephalitis. J Child Neurol 2015; 30:1204-7. [PMID: 25156666 DOI: 10.1177/0883073814546688] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 07/01/2014] [Indexed: 11/17/2022]
Abstract
Decompressive craniectomy in pediatric central nervous infections with refractory intracranial hypertension is less commonly practiced. We describe improved outcome of decompressive craniectomy in a 7-year-old boy with severe herpes simplex encephalitis and medically refractory intracranial hypertension, along with a brief review of the literature. Timely recognition of refractory intracranial hypertension and surgical decompression in children with herpes simplex encephalitis can be life-saving. Additionally, strokelike atypical presentations are being increasingly recognized in children with herpes simplex encephalitis and should not take one away from the underlying herpes simplex encephalitis.
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Affiliation(s)
- Pratibha Singhi
- Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arushi Gahlot Saini
- Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jitendra Kumar Sahu
- Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nuthan Kumar
- Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Vyas
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar Vasishta
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Pérez-Bovet J, Garcia-Armengol R, Buxó-Pujolràs M, Lorite-Díaz N, Narváez-Martínez Y, Caro-Cardera JL, Rimbau-Muñoz J, Joly-Torta MC, Castellví-Joan M, Martín-Ferrer S. Decompressive craniectomy for encephalitis with brain herniation: case report and review of the literature. Acta Neurochir (Wien) 2012; 154:1717-24. [PMID: 22543444 DOI: 10.1007/s00701-012-1323-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 03/07/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) has been sporadically used in cases of infectious encephalitis with brain herniation. Like for other indications of DC, evidence is lacking regarding the beneficial or detrimental effects for this pathology. METHODS We reviewed all the cases of viral and bacterial encephalitis treated with decompressive craniectomy reported in the literature. We also present one case from our institution. These data were analyzed to determine the relation between clinical and epidemiological variables and outcome in surgically treated patients. RESULTS Of 48 patients, 39 (81.25 %) had a favorable functional recovery and 9 (18.75 %) had a negative course. Only two patients (4 %) died after surgical treatment. A statistically significant association was found between diagnosis (viral and bacterial encephalitis) and outcome (GOS) in surgically treated patients. Viral encephalitis, usually caused by herpes simplex virus (HSV), has a more favorable outcome (92.3 % with GOS 4 or 5) than bacterial encephalitis (56.2 % with GOS 4 or 5). CONCLUSIONS Based on this literature review, we consider that, due to the specific characteristics of infectious encephalitis, especially in case of viral infection, decompressive craniectomy is probably an effective treatment when brain stem compression threatens the course of the disease. In patients with viral encephalitis, better prognosis can be expected when surgical decompression is used than when only medical treatment is provided.
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Affiliation(s)
- Jordi Pérez-Bovet
- Neurosurgery Department, Universitary Hospital Dr. Josep Trueta, Carretera de França S/N, 17007, Girona, Girona, Spain.
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Sánchez-Carpintero R, Aguilera S, Idoate M, Bejarano B. Temporal lobectomy in acute complicated herpes simplex encephalitis: technical case report. Neurosurgery 2008; 62:E1174-5; discussion E1175. [PMID: 18580790 DOI: 10.1227/01.neu.0000325885.00033.c3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
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. CLINICAL PRESENTATION 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. INTERVENTION 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. CONCLUSION 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.
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Affiliation(s)
- Rocío Sánchez-Carpintero
- Department of Paediatrics, Paediatric Neurology Unit, University Clinic of Navarra, University of Navarra, Pamplona, Spain.
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Sánchez-Carpintero R, Aguilera S, Idoate M, Bejarano B. TEMPORAL LOBECTOMY IN ACUTE COMPLICATED HERPES SIMPLEX ENCEPHALITIS. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000310701.82347.4b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Adamo MA, Deshaies EM. Emergency decompressive craniectomy for fulminating infectious encephalitis. J Neurosurg 2008; 108:174-6. [DOI: 10.3171/jns/2008/108/01/0174] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓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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Affiliation(s)
- Matthew A. Adamo
- 1Department of Surgery, Division of Neurosurgery, Albany Medical Center, Albany, New York; and
| | - Eric M. Deshaies
- 2University of Miami, Department of Neurosurgery, Lois Pope LIFE Center, Miami, Florida
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