DELAYED CEREBRAL VASOSPASM SECONDARY TO BACTERIAL MENINGITIS AFTER LUMBOSACRAL SPINAL SURGERY

Severe Form of Bacterial Meningitis After Spine Surgery: A Case Report and Review of the Literature

Meningitis after spine surgery is a rare complication. In this report, we aim to discuss the case of a male patient who developed this rare condition after undergoing cervical spine surgery with devastating outcomes. We also engage in a review of the relevant literature. A 17-year-old boy presented with post-traumatic cervical kyphotic deformity with signs of cord compression. He was operated in three stages, all conducted in a single sitting. There was an incidental cerebrospinal fluid (CSF) leak, which was primarily repaired. On the fourth postoperative day, the patient developed altered sensorium and seizures. Evaluations for clinical signs of meningitis such as neck rigidity and Kernig's sign were inconclusive. CSF analysis confirmed the diagnosis of meningitis. Thereafter, the patient developed hydrocephalus and intractable infection, for which multiple procedures were done. Finally, we succeeded in controlling the infection, but the patient developed a neurological deficit, which did not resolve even after 2.5 years of follow-up. The clinical signs and symptoms of meningitis after cervical spine surgery are not very clear or suggestive. A strong index of suspicion should be maintained for the early detection of this condition to prevent devastating complications that result from it.

Intra-arterial infusion of fasudil hydrochloride to treat post-traumatic cerebral vasospasm

Background

The effect of intra‐arterial infusion of fasudil hydrochloride in patients with post‐traumatic cerebral vasospasm remains unclear. Here we report a case of intra‐arterial infusion of fasudil hydrochloride for post‐traumatic cerebral vasospasm.

Case presentation

A 47‐year‐old man was transferred to our hospital with a fractured skull and traumatic subarachnoid hemorrhage. As rhinorrhea of cerebrospinal fluid had not improved, repair surgery was carried out on day 4. Aphasia appeared on day 13. Magnetic resonance imaging and angiography showed an ischemic region in the left temporal lobe and vasospasm of the left middle cerebral artery. We immediately carried out angiography and diagnosed severe vasospasm of the M1 region of the left middle cerebral artery. After placing a microcatheter into the proximal middle cerebral artery, we injected fasudil hydrochloride intra‐arterially. Vasospasm improved and aphasia resolved.

Conclusion

In this case, intra‐arterial infusion of fasudil hydrochloride was effective against post‐traumatic cerebral vasospasm.

Diffuse vasospasm after transcortical temporal lobectomy for intractable epilepsy

Cerebral delayed ischemia due to arterial vasospasm is a rare complication following epilepsy surgery. Here we report the third known case and first of diffuse vasospasm. A 48-year-old woman underwent a transcortical anterior left temporal lobectomy. Eleven days later, she had new-onset expressive aphasia with narrowing of the anterior, middle, and posterior cerebral arteries, and increased velocities via transcranial Doppler. She was treated with fluids, nimodipine, and permissive hypertension. At 6 months, her speech was near baseline. Cerebral vasospasm may represent a rare cause of morbidity after anterior temporal lobectomy; a literature review on the subject is presented.

A Delayed Cerebral Vasospasm with Infarction Is Secondary to Listeria monocytogenes Meningitis: MRI and MRA Are Diagnostically Useful

Among patients with bacterial meningitis, a cerebral vasospasm typically occurs during the acute phase. We experienced a case of delayed cerebral vasospasm with infarction that was secondary to Listeria monocytogenes meningitis. An 82-year-old woman with Listeria monocytogenes meningitis, whose symptoms had been improving after the initiation of antibacterial therapy, fell into a coma on day 15 and developed generalized seizure. Magnetic resonance imaging (MRI) and MR angiography (MRA) indicated a cerebral vasospasm with multiple infarctions. The risk of vascular complications following acute bacterial meningitis requires close follow-up to identify neurological changes and a low threshold for vascular evaluation. In such cases, MRI and MRA have diagnostic utility.

Cerebral vasospasm after transsphenoidal resection of pituitary macroadenomas: report of 3 cases and review of the literature

BACKGROUND

Delayed ischemic events due to vasospasm are a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). Severe vasospasm in other neurosurgical settings is not as well recognized. Delay in diagnosis and treatment of vasospasm in such settings may be associated with significant neurological morbidity.

OBJECTIVE

To present three cases of symptomatic delayed cerebral vasospasm after transsphenoidal resection of pituitary macroadenomas.

METHODS

Transsphenoidal resection in all cases was complicated by peritumoral hemorrhage with extension into the subarachnoid space. Two of the 3 patients required re-operation to evacuate the hematoma in the tumor bed because of progressive worsening neurological deficits.

RESULTS

All 3 patients developed vasospasm of the intracranial vessels, starting as early as postoperative day 5 and appearing as late as postoperative day 10. Comparisons to the non-vascular pre-operative magnetic resonance imaging studies confirmed the "de-novo" nature of the vasospasm based on the caliber of the flow voids.

CONCLUSION

Transsphenoidal surgery complicated by peritumoral hemorrhage is associated with a significant risk of neurological morbidity because of delayed cerebral vasospasm. Early recognition and management according to guidelines used for postaneurysmal SAH may help to improve outcomes in these patients.

Percutaneous transluminal angioplasty in a patient with vasospasm due to staphylococcal meningitis

Arterial large vessel vasculopathy is an unusual complication of bacterial meningitis in adults that may result in cerebral ischemia and severe neurological sequelae. Previous therapy has included antimicrobials with no specific vascular interventions. The authors report their experience with a patient with bacterial meningitis who developed a vasculopathy with neurological deficits. Percutaneous intracranial intervention was used successfully with anatomical and functional improvement.

Cerebrovasospasm following endoscopic cerebrospinal fluid leak repair

Endoscopic repair of spinal fluid leaks is a commonly performed procedure with low morbidity. However, this is the first report of cerebrovasospasm, following endoscopic repair of a cerebrospinal fluid (CSF) leak. A 51-year-old woman underwent endoscopic repair of a spontaneous CSF leak. She subsequently developed symptomatic cerebrovasospasm on postoperative day 3. This was successfully treated with intraarterial verapamil infusion.

Inflammation and cerebral vasospasm after subarachnoid hemorrhage

Morbidity and mortality of patients with aneurysmal subarachnoid hemorrhage (aSAH) is significantly related to the development of chronic cerebral vasospasm. Despite extensive clinical and experimental research, the pathophysiology of the events that result in delayed arterial spasm is not fully understood. A review of the published literature on cerebral vasospasm that included but was not limited to all PubMed citations from 1951 to the present was performed. The findings suggest that leukocyte-endothelial cell interactions play a significant role in the pathophysiology of cerebral vasospasm and explain the clinical variability and time course of the disease. Experimental therapeutic targeting of the inflammatory response when timed correctly can prevent vasospasm, and supplementation of endothelial relaxation by nitric oxide-related therapies and other approaches could result in reversal of the arterial narrowing and improved outcomes in patients with aSAH.

Role of inflammation (leukocyte-endothelial cell interactions) in vasospasm after subarachnoid hemorrhage

BACKGROUND

Delayed vasospasm is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). This phenomenon was first described more than 50 years ago, but only recently has the role of inflammation in this condition become better understood.

METHODS

The literature was reviewed for studies on delayed vasospasm and inflammation.

RESULTS

There is increasing evidence that inflammation and, more specifically, leukocyte-endothelial cell interactions play a critical role in the pathogenesis of vasospasm after aSAH, as well as in other conditions including meningitis and traumatic brain injury. Although earlier clinical observations and indirect experimental evidence suggested an association between inflammation and chronic vasospasm, recently direct molecular evidence demonstrates the central role of leukocyte-endothelial cell interactions in the development of chronic vasospasm. This evidence shows in both clinical and experimental studies that cell adhesion molecules (CAMs) are up-regulated in the perivasospasm period. Moreover, the use of monoclonal antibodies against these CAMs, as well as drugs that decrease the expression of CAMs, decreases vasospasm in experimental studies. It also appears that certain individuals are genetically predisposed to a severe inflammatory response after aSAH based on their haptoglobin genotype, which in turn predisposes them to develop clinically symptomatic vasospasm.

CONCLUSION

Based on this evidence, leukocyte-endothelial cell interactions appear to be the root cause of chronic vasospasm. This hypothesis predicts many surprising features of vasospasm and explains apparently unrelated phenomena observed in aSAH patients. Therapies aimed at preventing inflammation may prevent and/or reverse arterial narrowing in patients with aSAH and result in improved outcomes.