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Characterization of Chemical Meningitis after Neurological Surgery
Abstract
We reviewed the records of 70 consecutive adult patients with meningitis after a neurosurgical procedure, to determine the
characteristics that might help to distinguish a sterile postoperative chemical meningitis from bacterial infection. The spinal
fluid profiles in bacterial and chemical meningitis are similar. The exceptions are that a spinal fluid white blood cell count
>7500/µL (7500 × 106/L) and a glucose level of <10 mg/dL were not found in any case of chemical meningitis. The clinical setting and clinical
manifestations were distinct enough that no antibiotic was administered after lumbar puncture to 30 (43%) of the 70 patients
with postoperative meningitis. Chemical meningitis was infrequent after surgery involving the spine and sinuses. Patients
with chemical meningitis did not have purulent wound drainage or significant wound erythema or tenderness, coma, new focal
neurological findings, or onset of a new seizure disorder. They rarely had temperatures >39.4°C or cerebrospinal fluid rhinorrhea
or otorrhea.
... Post-EIS meningitis can be either bacterial or aseptic [1,2]. Symptoms of both types of meningitis are similar and include fever, neck stiffness, decreased level of consciousness, and headache [3][4][5][6][7][8]. However, the symptoms of bacterial meningitis tend to be more severe than those of aseptic meningitis [3]. ...
... Symptoms of both types of meningitis are similar and include fever, neck stiffness, decreased level of consciousness, and headache [3][4][5][6][7][8]. However, the symptoms of bacterial meningitis tend to be more severe than those of aseptic meningitis [3]. Meningitis without any of these symptoms is very unlikely [3,4]. ...
... However, the symptoms of bacterial meningitis tend to be more severe than those of aseptic meningitis [3]. Meningitis without any of these symptoms is very unlikely [3,4]. A diagnosis of meningitis is made based on clinical symptoms and/or positive cerebrospinal fluid (CSF) bacterial cultures [9,10]. ...
Meningitis is a potential complication of elective intracranial surgery (EIS). The prevalence of meningitis after EIS varies greatly in the literature. The objective of this study was to estimate the overall pooled prevalence of meningitis following EIS. Four databases (PubMed, Scopus, Web of Science, and Embase) were searched to identify relevant studies. Meta-analyses of proportions were used to combine data. Cochran's Q and I² statistics were used to assess and quantify heterogeneity. Additionally, several subgroup analyses were conducted to investigate the source of heterogeneity and examine differences in the prevalence based on variables such as geographical regions, income level, and meningitis type. The meta-analysis included 83 studies (30 959 patients) from 26 countries. The overall pooled prevalence of meningitis after EIS was 1.6% (95% CI 1.1–2.1), with high heterogeneity present (I² = 88%). The pooled prevalence in low- to middle-income countries and high-income countries was 2.7% (95% CI 1.6–4.1) and 1.2% (95% CI 0.8–1.7), respectively. Studies that reported only aseptic meningitis had a pooled prevalence of 3.2% (95% CI 1.3–5.8). The pooled prevalence was 2.8% (95% CI 1.5–4.5) in studies that reported only bacterial meningitis. Similar prevalence rates of meningitis were observed in the subgroups of tumor resection, microvascular decompression, and aneurysm clipping. Meningitis is a rare but not exceptional complication following EIS, with an estimated prevalence of 1.6%.
Supplementary Information
The online version contains supplementary material available at 10.1186/s40001-023-01141-3.
... The diagnosis of CNS infections is commonly conducted with evaluation of cerebral spinal fluid (CSF) for derangements of protein, glucose, cell count, gram stain, and culture. However, in nosocomial ventriculitis, patients can have abnormal CSF parameters from underlying CNS pathologies, complicating diagnosis [5,6]. Furthermore, pleocytosis can occur secondary to CNS hemorrhages and from chemical meningitis [2,6]. ...
... However, in nosocomial ventriculitis, patients can have abnormal CSF parameters from underlying CNS pathologies, complicating diagnosis [5,6]. Furthermore, pleocytosis can occur secondary to CNS hemorrhages and from chemical meningitis [2,6]. Obstinately, patients with hemorrhages and noninfectious ventriculitis often have similar symptoms, such as fever, headache, and altered mental status [2,6]. ...
... Furthermore, pleocytosis can occur secondary to CNS hemorrhages and from chemical meningitis [2,6]. Obstinately, patients with hemorrhages and noninfectious ventriculitis often have similar symptoms, such as fever, headache, and altered mental status [2,6]. Consequently, symptoms and traditional diagnostic CSF testing parameters (cell count, protein level, and glucose level) have significantly less specificity and sensitivity in nosocomial ventriculitis compared to community-acquired meningitis [7]. ...
Ventriculitis is a severe complication of indwelling neurosurgical devices that is associated with significant morbidity and mortality. The incidence rate of ventriculitis is approximately 10% with external ventricular drains. Obstinately, patients with these indwelling neurosurgical devices are prone to have traditional cerebral spinal fluid parameters that lack sensitivity and specificity in diagnosing nosocomial ventriculitis. In addition, diagnosis can be arduous given that indolent pathogens are commonly implicated. Therefore, diagnosis is difficult but paramount to thwart the morbidity and mortality associated with this infectious condition as well as to reduce the prolonged use of broad-spectrum antibiotics. As we extrapolate from prosthetic joint infections, for which diagnosis can also be challenging, we learn that the use of α-defensins as a diagnostic biomarker for nosocomial ventriculitis may hold promise. Herein, the viewpoint of using α-defensins as a diagnostic biomarker for nosocomial ventriculitis is discussed.
... Meningitis is a known complication of neurosurgical procedures. Aseptic meningitis (also known as chemical meningitis) after neurosurgical procedures is diagnosed when clinical presentation and cerebrospinal fluid (CSF) analysis results are consistent with meningitis, but bacterial cultures are negative [1]. It is often difficult to differentiate between aseptic and bacterial meningitis based on clinical presentation and CSF chemistry and cytology [1]. ...
... Aseptic meningitis (also known as chemical meningitis) after neurosurgical procedures is diagnosed when clinical presentation and cerebrospinal fluid (CSF) analysis results are consistent with meningitis, but bacterial cultures are negative [1]. It is often difficult to differentiate between aseptic and bacterial meningitis based on clinical presentation and CSF chemistry and cytology [1]. Molecular microbiologic techniques, such as bacterial 16S rRNA PCR amplification and sequencing, are now increasingly utilized when infection is highly suspected and cultures are non-diagnostic. ...
... Although it was first described in the early 1920s by Cushing et al., little is known about its pathogenesis. Proposed pathogenesis, including inflammation caused by breakdown of RBCs or from surgical materials, is nebulous and unproven [1]. Further, both aseptic and bacterial meningitis after neurosurgery present with fever, meningismus, headache and CSF pleocytosis, making them difficult to differentiate clinically or by CSF chemistry and cytology [1]. ...
Both bacterial and aseptic meningitis can complicate neurosurgery, but they are often difficult to distinguish clinically or by cerebrospinal fluid (CSF) analysis. We present an adolescent with subacute meningitis after neurosurgery, eventually diagnosed with meningitis caused by Roseomonas mucosa via 16S rRNA gene sequencing after two negative CSF cultures. He was treated successfully with intravenous meropenem with full recovery. This case shows that distinguishing bacterial from aseptic meningitis is important to allow directed antibiotic therapy. We recommend considering bacterial meningitis in the differential diagnosis of aseptic meningitis complicating neurosurgery, and to perform molecular diagnostics such as bacterial sequencing if the suspicion of bacterial meningitis is high.
... В то же время при условии чет кого установления иной локализации инфекционного очага исследование СМЖ не требуется. Изменения по казателей СМЖ могут быть незначительными [9], что су щественно усложняет дифференциальную диагностику между возможным развитием инфекции и изменениями, связанными с основным заболеванием, по поводу кото рого был установлен катетер, или ранее выполненным нейрохирургическим вмешательством [54,55]. ...
... В ряде других исследований ассоци ация между инфекцией ликворопроводящей системы и эозинофилией ставится под сомнение [58]. Изменение количества лейкоцитов в ликворе может быть обуслов лено недавним нейрохирургическим вмешательством, вследствие которого в СМЖ попала кровь или разви лась неспецифическая воспалительная реакция, так на зываемый химический менингит [54]. ...
... Однако количество лейкоцитов в СМЖ, превышающее 7500/мм 3 , или концентрация глюкозы в ликворе менее 10 мг/дл с большой веро ятностью указывают на наличие инфекции. В одном из исследований наличие высокой (>40°C) или длительной (>1 недели) температуры с большей вероятностью ука зывало на инфекционный генез менингита [54]. Однако ограничением данного исследования был тот факт, что не было выявлено ни одного признака, позволяющего на его основании точно дифференцировать бактериаль ный менингит от асептического на момент выявления синдрома поражения мозговых оболочек. ...
Healthcare-associated meningitis and ventriculitis are a common problem of modern public health, which are characterized by diverse etiological spectrum of multidrug resistant microorganisms, presented by difficulties for early diagnosis and adequate treatment, and are often accompanied by a high risk of secondary complications and an unfavorable outcome. This article presents the clinical guidelines of the American Society of Infectious Diseases (IDSA) for the diagnosis and treatment of healthcare-associated meningitis and ventriculitis published in 2017 and may be useful for professionals working with this category of patients.
... CSF leukocytosis is a more specific measure for CSF infection and was observed in this group of patients. However, this can also occur in the setting of uninfected post-surgical inflammation, which presents a significant confounder as the post-surgical period is also the highest risk for shunt infection [42]. CSF protein was elevated in our cohort; unfortunately, prior studies have shown that CSF protein levels cannot distinguish aseptic post-surgical inflammation from shunt infection [42]. ...
... However, this can also occur in the setting of uninfected post-surgical inflammation, which presents a significant confounder as the post-surgical period is also the highest risk for shunt infection [42]. CSF protein was elevated in our cohort; unfortunately, prior studies have shown that CSF protein levels cannot distinguish aseptic post-surgical inflammation from shunt infection [42]. While hypoglycorrhachia occurred in our patients, this is again unable to differentiate post-surgical chemical meningitis from shunt infection [42]. ...
... CSF protein was elevated in our cohort; unfortunately, prior studies have shown that CSF protein levels cannot distinguish aseptic post-surgical inflammation from shunt infection [42]. While hypoglycorrhachia occurred in our patients, this is again unable to differentiate post-surgical chemical meningitis from shunt infection [42]. In this population where infection most commonly occurs within 30 days of surgery, it is crucial to be able to differentiate post-surgical inflammation from shunt infection. ...
Background
Cerebrospinal fluid (CSF) shunt placement is frequently complicated by bacterial infection. Shunt infection diagnosis relies on bacterial culture of CSF which can often produce false-negative results. Negative cultures present a conundrum for physicians as they are left to rely on other CSF indices, which can be unremarkable. New methods are needed to swiftly and accurately diagnose shunt infections. CSF chemokines and cytokines may prove useful as diagnostic biomarkers. The objective of this study was to evaluate the potential of systemic and CSF biomarkers for identification of CSF shunt infection.
Methods
We conducted a retrospective chart review of children with culture-confirmed CSF shunt infection at Children’s Hospital and Medical Center from July 2013 to December 2015. CSF cytokine analysis was performed for those patients with CSF in frozen storage from the same sample that was used for diagnostic culture.
Results
A total of 12 infections were included in this study. Patients with shunt infection had a median C-reactive protein (CRP) of 18.25 mg/dL. Median peripheral white blood cell count was 15.53 × 10³ cells/mL. Those with shunt infection had a median CSF WBC of 332 cells/mL, median CSF protein level of 406 mg/dL, and median CSF glucose of 35.5 mg/dL. An interesting trend was observed with gram-positive infections having higher levels of the anti-inflammatory cytokine interleukin (IL)-10 as well as IL-17A and vascular endothelial growth factor (VEGF) compared to gram-negative infections, although these differences did not reach statistical significance. Conversely, gram-negative infections displayed higher levels of the pro-inflammatory cytokines IL-1β, fractalkine (CX3CL1), chemokine ligand 2 (CCL2), and chemokine ligand 3 (CCL3), although again these were not significantly different. CSF from gram-positive and gram-negative shunt infections had similar levels of interferon gamma (INF-γ), tumor necrosis factor alpha (TNF-α), IL-6, and IL-8.
Conclusions
This pilot study is the first to characterize the CSF cytokine profile in patients with CSF shunt infection and supports the distinction of chemokine and cytokine profiles between gram-negative and gram-positive infections. Additionally, it demonstrates the potential of CSF chemokines and cytokines as biomarkers for the diagnosis of shunt infection.
... [8,13] Chemical meningitis is a form of aseptic meningitis, not caused by a virus, and presents with similar symptoms as infectious meningitis, but is differentiated by a negative spinal fluid Gram stain, negative results of spinal fluid cultures, and failure of antibiotics to improve the patient's condition. [9,22] Chemical meningitis as a complication of posterior fossa surgery is not a rare complication; however, development of such a severely protracted course following the surgical removal of a posterior fossa epidermoid cyst has not been described. [10,22] Here, we present a patient case following the resection of a fourth ventricular epidermoid cyst and resultant protracted course of aseptic meningitis that was further complicated by hydrocephalus requiring CSF diversion, a posterior fossa wound revision, a prolonged comatose state, and a need for extended duration of supraphysiologic steroid administration followed by a long course of neurorehabilitation. ...
... [20,24] Characteristic symptoms of aseptic meningitis include headaches, vomiting, fevers, meningismus, and cognitive impairment. [9,10,22] Diagnostic signs are obtained through lumbar puncture which often demonstrates an elevated CSF white cell count, protein, reduced glucose, negative Gram stain and culture results (diagnosis can be confirmed after three consecutive negative results), as well as CT and MRI imaging with associated hydrocephalus and meningeal enhancement. [4,10,19,22] Complications of posterior fossa surgery, other than aseptic meningitis, include a CSF leak, hydrocephalus, and the formation of a pseudomeningocele. ...
Background
Chemical meningitis, a subtype of aseptic meningitis, as a complication of posterior fossa surgery is not a rare complication. However, the description of a severe protracted course following the surgical resection of an epidermoid cyst has not been described in the current literature. Chemical meningitis is thought to be associated with a hyperreactive inflammatory response, mediated in part by interleukin (IL)-10, IL-1β, and tumor necrosis factor-α, to the postoperative keratin debris from the spontaneous leakage or surgical release of epidermoid contents into subarachnoid spaces, which ultimately can result in patient symptoms of meningitis and hydrocephalus. Often, this remains mild and the recommended management includes a short course administration of corticosteroids.
Case Description
The authors report such a case in a patient who underwent a redoresection for a fourth ventricular epidermoid cyst. Postoperatively, the patient returned several times with symptoms of meningitis and hydrocephalus requiring multiple hospitalizations in the ensuing months. The patient required emergent cerebrospinal fluid diversion, further posterior fossa exploration and an extended high-dose corticosteroid treatment regimen.
Conclusion
The authors summarize the current understanding of the biochemical processes involved for the rare presentation of postoperative chemical meningitis.
... Given the adverse clinical outcomes [10,11], empiric antibiotic therapy is usually initiated in the absence of bacteriologic findings. Cerebrospinal fluid (CSF) cytochemical parameters, including cell count, glucose, protein and lactate suffer from a lack of specificity [12,13]. The lack of widely recognized cutoff values for these markers makes their interpretation difficult. ...
... The lack of widely recognized cutoff values for these markers makes their interpretation difficult. Sensitivity for Gram staining is unacceptably low [7,12,13]. Culture, the gold standard, has an inherent delay of several days to obtain results. A sensitive and reliable biomarker is therefore required. ...
Background:
The sensitive and accurate diagnosis of nosocomial meningitis and ventriculitis is still a critical problem. This study was designed to explore the diagnostic value of cerebrospinal fluid heparin-binding protein (HBP) in nosocomial meningitis and ventriculitis in comparison with procalcitonin and lactate.
Methods:
In this observational study, 323 suspected patients were enrolled, of which 42 participants were excluded because they could not be accurately grouped, 131 subjects who were eventually diagnosed with nosocomial meningitis or ventriculitis and 150 patients in whom infection was ultimately ruled out were included in the final analysis. The main results are expressed as medians (interquartile ranges). The Chi-squared test was used to compare the baseline characteristics. The Mann-Whitney U-test was used for group and subgroup analyses. The area under the receiver operating characteristic curve was calculated to describe the diagnostic accuracy of the biomarkers. Spearman's partial correlation was used to analyze associations between the biomarkers. Statistical significance was set when p value < 0.05.
Results:
HBP achieved the largest area under the receiver operating characteristic curve, which was 0.99 (95% confidence interval 0.98-1.00) compared with 0.98 (95% confidence interval 0.96-0.99) for lactate and 0.69 (95% confidence interval 0.62-0.75) for procalcitonin. With a cutoff level at 23 ng/mL, HBP achieved a sensitivity of 97%, a specificity of 95%, a positive predictive value of 93% and a negative predictive value of 98%. The levels of HBP presented no significant discrepancy between patients who received previous empiric anti-infective therapy and those who did not (p > 0.05). Higher concentrations of HBP were present in patients with positive microbiological findings (p < 0.05). Levels of HBP positively correlated with polymorphonuclear cell count (Spearman's rho = 0.68, p < 0.01), white blood cell count (Spearman's rho = 0.57, p < 0.01) and lactate (Spearman's rho = 0.34, p < 0.01).
Conclusions:
Cerebrospinal fluid heparin-binding protein is a reliable auxiliary diagnostic marker that is preferable over lactate and procalcitonin in identifying nosocomial meningitis and ventriculitis, and it also contributes to solving the diagnostic difficulties caused by empiric antibiotherapy.
... Due to inadequate culture techniques, C. acnes shunt infection has likely been underdiagnosed in the past, since many cases of shunt malfunction are likely related to C. acnes infection (22,(27)(28)(29). In the absence of a positive culture, diagnosis of CSF shunt infection relies on CSF indices, which are nonspecific and can be difficult to interpret in the setting of recent shunt placement, which elicits an initial inflammatory response arising from local tissue damage (11,17,(30)(31)(32)(33). ...
... Although neutrophils were significantly increased in the brain parenchyma surrounding C. acnes-infected catheters, they were minimal in the CSF. This finding supports clinical dogma that infection may not translate to robust neutrophil influx or CSF pleocytosis (11,(30)(31)(32)44). Therefore, clinicians should retain a high index of suspicion for shunt infection despite the absence of pleocytosis, especially if patient symptoms are consistent with infection. ...
Cutibacterium acnes ( C. acnes ) is the third most common cause of cerebrospinal fluid (CSF) shunt infection and is likely underdiagnosed due to the difficulty in culturing this pathogen. Shunt infections lead to grave neurologic morbidity for patients especially when there is a delay in diagnosis. Currently the gold standard for identifying CSF shunt infections is microbiologic culture. However, C. acnes infection often results in falsely negative cultures; therefore, new diagnostic methods are needed. To investigate potential CSF biomarkers of C. acnes CSF shunt infection we adapted a rat model of CSF catheter infection to C. acnes. We found elevated levels of IL-1β, IL-6, CCL2 and IL-10 in the CSF and brain tissues of animals implanted with C. acnes- infected catheters compared to sterile controls at day 1 post-infection. This coincided with modest increases in neutrophils in the CSF and to a greater extent the brain tissue of animals with C. acnes infection, which closely mirrors the clinical findings in patients with C. acnes shunt infection. Mass spectrometry revealed that the CSF proteome is altered during C. acnes shunt infection and changes over the course of disease, typified at day 1 post-infection by an acute phase and pathogen neutralization response evolving to a response consistent with wound resolution at day 28, compared to sterile catheter placement. Collectively, these results demonstrate that it is possible to distinguish C. acnes infection from sterile post-operative inflammation and CSF proteins could be useful in a diagnostic strategy for this pathogen that is difficult to diagnose.
... Italic values highlight those with a significant correlation NS neurosurgical Differentiating between infected and non-infected CSF in a child with a history of neurosurgical procedures is not trivial [6,13,17]. Fever, headache, vomiting, irritability, somnolence, and nuchal rigidity may often be part of a postoperative course and do not necessarily indicate an active CSF infection [6,7]. CSF parameters such as cell count, glucose, and protein levels are all affected by recent surgery, due to significant shifts in CSF volume (drainage and irrigation), spillage of Bsurgical debris^such as blood and tissue particles, or by a postoperative non-infectious inflammatory reaction to any of the above [7,17]. ...
... Fever, headache, vomiting, irritability, somnolence, and nuchal rigidity may often be part of a postoperative course and do not necessarily indicate an active CSF infection [6,7]. CSF parameters such as cell count, glucose, and protein levels are all affected by recent surgery, due to significant shifts in CSF volume (drainage and irrigation), spillage of Bsurgical debris^such as blood and tissue particles, or by a postoperative non-infectious inflammatory reaction to any of the above [7,17]. Additionally, many children are treated during surgery or for a few days after, either with antibiotics, affecting the reliability of the CSF cultures, and/or with steroids, affecting the immune response to infection and inflammation. ...
Purpose
Diagnosis of cerebrospinal fluid (CSF) infections in patients following neurosurgical procedures can be challenging. CSF lactate (LCSF) has been shown to assist in differentiating bacterial from non-bacterial meningitis in non-neurosurgical patients. The use of lactate in diagnosing CSF-related infections following neurosurgical procedures has been described in adults. The goal of this study was to describe the role of LCSF levels in diagnosing CSF-related infections among neurosurgical children.
Methods
We retrospectively collected data for all pediatric patients treated at a large tertiary pediatric neurosurgical department, for whom CSF samples were collected over a 2-year period. Lactate levels were correlated with other CSF parameters, surgical parameters, presence of CSF infection, and source of CSF sample (lumbar, ventricular, or pseudomeningocele).
Results
A total of 215 CSF samples from 162 patients were analyzed. We found a correlation between lactate levels and other CSF parameters. Lactate levels displayed an inconsistent correlation with infection depending on sample origin. Irrespective of the CSF source, lactate levels could not sufficiently discriminate between those with or without infection. Lactate levels were correlated with recent surgery, and, in some of the subgroups, to the extent of blood in CSF.
Conclusions
LCSF levels are influenced by many factors, including the source of sample, recent surgery, and the presence of subarachnoid or ventricular blood secondary to surgery. The added value of LCSF for diagnosing CSF infections in children with a history of neurosurgical procedures is unclear and may be influenced by the extent of blood in the CSF.
... Approximately 4.71 million deaths are attributed to AMR yearly, which is projected to rise to 8.22 million by 2050 [3]. Other factors complicating SSI treatment can include delayed symptom presentation, unreliable or lengthy culture periods to identify pathogenic species, sample contamination by skin flora, and non-specific clinical scores/indices that limit rapid and accurate infectious diagnoses [4][5][6][7][8]. In some cases, SSIs may not be identified in patients until months following their initial procedure [9]. ...
Biofilms are bacterial communities surrounded by a polymeric matrix that can form on implanted materials and biotic surfaces, resulting in chronic infection that is recalcitrant to immune- and antibiotic-mediated clearance. Therefore, biofilm infections present a substantial clinical challenge, as treatment often involves additional surgical interventions to remove the biofilm nidus, prolonged antimicrobial therapy to clear residual bacteria, and considerable risk of treatment failure or infection recurrence. These factors, combined with progressive increases in antimicrobial resistance, highlight the need for alternative therapeutic strategies to circumvent undue morbidity, mortality, and resource strain on the healthcare system resulting from biofilm infections. One promising option is reprogramming dysfunctional immune responses elicited by biofilm. Here, we review the literature describing immune responses to biofilm infection with a focus on targets or strategies ripe for clinical translation. This represents a complex and dynamic challenge, with context-dependent host-pathogen interactions that differ across infection models, microenvironments, and individuals. Nevertheless, consistencies among these variables exist, which could facilitate the development of immune-based strategies for the future treatment of biofilm infections.
... However, with prolonged usage these drains can predispose patients to be at risk for ventriculitis. Moreover, given the intracranial hemorrhages, these patients typically have cerebral spinal fluid (CSF) that has increased concentrations of proteins and polymers compared to normal CSF [7][8][9]. Consequently, the increase in polymers may predispose these patients to be at risk to form bacterial aggregates similar to those seen in synovial fluid, but there is a dearth of research evaluating the propensity of bacteria to form CSF aggregates in static and dynamic environments. As a result, the aim of this study was to evaluate if four different bacteria species form CSF aggregates under various conditions and the clinical relevance of these aggregates. ...
Bacteria can form aggregates in synovial fluid that are resistant to antibiotics, but the ability to form aggregates in cerebral
spinal fluid (CSF) is poorly defined. Consequently, the aims of this study were to assess the propensity of four bacterial
species to form aggregates in CSF under various conditions. To achieve these aims, bacteria were added to CSF in microwell
plates and small flasks at static and different dynamic conditions with the aid of an incubating shaker. The aggregates
that formed were assessed for antibiotic resistance and the ability of tissue plasminogen activator (TPA) to disrupt these
aggregates and reduce the number of bacteria present when used with antibiotics. The results of this study show that under
dynamic conditions all four bacteria species formed aggregates that were resistant to high concentrations of antibiotics.
Yet with static conditions, no bacteria formed aggregates and when the CSF volume was increased, only Staphylococcus
aureus formed aggregates. Interestingly, the aggregates that formed were easily dispersed by TPA and significant (p < 0.005)
decreases in colony-forming units were seen when a combination of TPA and antibiotics were compared to antibiotics alone.
These findings have clinical significance in that they show bacterial aggregation does not habitually occur in central nervous
system infections, but rather occurs under specific conditions. Furthermore, the use of TPA combined with antibiotics may
be advantageous in recalcitrant central nervous system infections and this provides a pathophysiological explanation for an
unusual finding in the CLEAR III clinical trial.
... This report was based on a mixed adult and paediatric populations, but as we demonstrate, the causes of fever among the two groups significantly differ. We found that the most common cause of fever in paediatric patients was aseptic meningitis, which is often perplexing in its similarity of presentation to pyogenic meningitis [16][17][18][19]. It has been observed in some studies that the presence of more than 6000 cells/μL in the CSF, along with a markedly lower CSF glucose, is more suggestive of bacterial meningitis [20]. ...
Purpose
Postoperative fever is a common problem following neurosurgery but data on the causes among paediatric patients is sparse. In this report, we determined the incidence, causes, and outcomes of postoperative fever in paediatric neurosurgical patients (< 18 years), and contrasted the findings with an adult cohort published recently from our unit.
Methods
We recruited 61 patients who underwent 73 surgeries for non-traumatic neurosurgical indications over 12 months. A standard protocol was followed for the evaluation and management of postoperative fever. We prospectively collected data pertaining to operative details, daily maximal temperature, clinical features, and use of surgical drains, urinary catheters, and other adjuncts. Elevated body temperature of > 99.9 °F or 37.7 °C for > 48 h or associated with clinical deterioration or localising features was considered as “fever”; elevated temperature not meeting these criteria was classified as transient elevation in temperature (TET).
Results
Twenty-six patients (35.6%) had postoperative fever, more frequent than in adult patients. TET occurred in 12 patients (16.4%). The most common causes of fever were aseptic meningitis (34.6%), followed by urinary tract infections (15.4%), pyogenic meningitis, COVID-19, and wound infections. Postoperative fever was associated with significantly longer duration of hospital admission and was the commonest cause of readmission.
Conclusion
In contrast to adults, early temperature elevations in paediatric patients may portend infectious and serious non-infectious causes of fever, including delayed presentation with aseptic meningitis, a novel association among paediatric patients. Investigation guided by clinical assessment and conservative antibiotic policy in keeping with the institutional microbiological profile provides the most appropriate strategy in managing paediatric postoperative fever.
... indices do not differentiate bacterial from chemical meningitis (7) and CSF cultures often remain negative due to perioperative antibiotic prophylaxis or concomitant treatment of systemic infections (8)-a reliable diagnostic marker would be of great value. ...
... 3 Furthermore, diagnosis of nosocomial ventriculitis can be difficult because classic cerebral spinal fluid (CSF) parameters lack specificity and sensitivity compared to community-acquired meningitis. 2,6,7 This is secondary to the indolent bacteria and biofilms on EVDs being implicated in EVDassociated ventriculitis. Herein, we report a rare case of Sphingomonas paucimobilis ventriculitis in an immunocompetent host. ...
... We found that the most common cause of fever in paediatric patients was aseptic meningitis, which is often perplexing in its similarity of presentation to pyogenic meningitis. [2,7,15,22] It has been observed in some studies that the presence of more than 6,000 cells/µL in the CSF, along with a markedly lower CSF glucose is more suggestive of bacterial meningitis. [25] CSF lactate has emerged as a biomarker to distinguish the two entities, with > 90% sensitivity and speci city for predicting bacterial meningitis, [24] while CSF procalcitonin may be a sensitive marker of postoperative bacterial meningitis. ...
Purpose: Postoperative fever is a common problem following neurosurgery but data on the causes among paediatric patients is sparse. In this report, we determined the incidence, causes and outcomes of postoperative fever in paediatric neurosurgical patients (<18 years), and contrasted the findings with an adult cohort published recently from our unit.
Methods: We recruited 61 patients operated for non-traumatic neurosurgical indications over 12 months. A standard protocol was followed for the evaluation and management of postoperative fever, collecting data regarding operative details, daily maximal temperature, clinical features, and use of surgical drains, urinary catheters, and other adjuncts. Elevated body temperature of >99.9°F or 37.7°C for >48 hours or associated with clinical deterioration or localising features was considered as “fever”; elevated temperature not meeting these criteria were classified as transient elevation in temperature (TET).
Results: Twenty-five patients (34.2%) had postoperative fever, more frequent than in adult patients. TET occurred in 12 patients (16.4%). The most common causes of fever were aseptic meningitis (36%), followed by urinary tract infections (16%), pyogenic meningitis, COVID-19 and wound infections. Postoperative fever was associated with significantly longer duration of hospital admission and was the commonest cause of readmission.
Conclusion: In contrast to adults, early temperature elevations in paediatric patients may portend infectious and serious non-infectious causes of fever, including delayed presentation with aseptic meningitis, a novel association among paediatric patients. Investigation guided by clinical assessment and conservative antibiotic policy in keeping with the institutional microbiological profile provide the most appropriate strategy in managing paediatric postoperative fever.
... When a culture is negative, diagnosis of CSF shunt infection relies on CSF indices, which are non-specific and can be difficult to interpret in the setting of recent shunt placement due to the inflammation associated with the surgery (14)(15)(16)(17). Currently there is no rapid and accurate method of diagnosing shunt infection; therefore, there is a critical need to identify a new rapid, and accurate method for diagnosis of CSF shunt infection with broad bacterial species coverage to improve the long-term outcomes of children suffering from these infections. ...
Background
Cerebrospinal fluid (CSF) shunt infection is a common and devastating complication of the treatment of hydrocephalus. Timely and accurate diagnosis is essential as these infections can lead to long-term neurologic consequences including seizures, decreased intelligence quotient (IQ) and impaired school performance in children. Currently the diagnosis of shunt infection relies on bacterial culture; however, culture is not always accurate since these infections are frequently caused by bacteria capable of forming biofilms, such as Staphylococcus epidermidis, Cutibacterium acnes, and Pseudomonas aeruginosa resulting in few planktonic bacteria detectable in the CSF. Therefore, there is a critical need to identify a new rapid, and accurate method for diagnosis of CSF shunt infection with broad bacterial species coverage to improve the long-term outcomes of children suffering from these infections.
Methods
To investigate potential biomarkers that would discriminate S. epidermidis, C. acnes and P. aeruginosa central nervous system (CNS) catheter infection we leveraged our previously published rat model of CNS catheter infection to perform serial CSF sampling to characterize the CSF proteome during these infections compared to sterile catheter placement.
Results
P. aeruginosa infection demonstrated a far greater number of differentially expressed proteins when compared to S. epidermidis and C. acnes infection and sterile catheters, and these changes persisted throughout the 56-day time course. S. epidermidis demonstrated an intermediate number of differentially expressed proteins, primarily at early time points that dissipated over the course of infection. C. acnes induced the least amount of change in the CSF proteome when compared to the other pathogens.
Conclusions
Despite the differences in the CSF proteome with each organism compared to sterile injury, several proteins were common across all bacterial species, especially at day 5 post-infection, which are candidate diagnostic biomarkers.
... Forgacs et al. proposed specific clinical and CSF findings to distinguish chemical meningitis from a bacterial infection, and concluded that chemical meningitis can be differentiated from bacterial meningitis using their proposed criteria. 29 However, other authors have provided contradicting statements and have proposed to treat patients with clinical and laboratory features of post-operative meningitis as a bacterial infection, due to the high burden of morbidity and mortality from delays in initiation of therapy. 30 In this series, two patients demonstrated increasing CSF WBC counts and persistent low glucose concentrations but with sterile CSF cultures during the course of treatment. ...
Background: Intraventricular antimicrobial therapy (IVT), defined as the direct installation of antimicrobial agents into the lateral ventricles has been utilized as the last therapeutic option for the treatment of multidrug-resistant ventriculitis. The aim of this case series is to report our institution’s experience with IVT in pediatric patients with ventriculitis. Material and Methods: Retrospective chart review was done. The demographic data, cerebrospinal fluid (CSF) culture isolates, treatment regimens, and clinical outcomes of these patients were collected and described. Results: Between 2016 to 2018, seven (7) pediatric patients diagnosed with ventriculitis caused by multidrug-resistant organisms underwent intraventricular antimicrobial therapy in combination with intravenous therapy. The median age was 1 year (range 1 month to 17 years old, mean: 4.4 years). Fifty-seven (57) percent of the patients were females. The isolated pathogens were Acinetobacter baumannii MDRO (n = 3), Klebsiella pneumoniae MDRO (n = 2), Methicillin-resistant Staphylococcus aureus (n = 1), and Methicillin-resistant Staphylococcus epidermidis (n = 2).One patient had mixed isolates on CSF culture (Acinetobacter baumannii and MRSE). The antimicrobial agents for IVT used were colistin (n = 4), vancomycin (n = 2), and gentamicin (n = 1). The mean time to initiation of intraventricular therapy from the diagnosis of ventriculitis was 19 days. The mean duration of IVT therapy was 15 days. The survival rate was 57%. Conclusion: Ventriculitis caused by drug-resistant organisms is an emerging concern. Optimal therapy is not yet established and experience with IVT is limited. This series showed that there were no adverse effects related to IVT thus it may be considered an option for MDRO ventriculitis. Gram negative organisms are more common causes of ventriculitis in our institution.
... One of the most frequent transient complications mentioned in our review is meningitis, although in all cases the cultures remained sterile. This could possibly indicate the presence of chemical meningitis instead of a bacterial meningitis, which has been described in the literature after neurosurgical procedures as well [25]. Despite the introduction of the NUA, which has expanded the treatment spectrum of neuroendoscopy, the options in neuroendoscopic surgery are still limited. ...
The development of minimally invasive neuroendoscopy has advanced in recent years. The introduction of the neuroendoscopic ultrasonic aspirator (NUA) increased the treatment spectrum of neuroendoscopy. This review aimed to present a systematic overview of the extent of resection, lesion characteristics, technical aspects, complications, and clinical outcomes related to using the NUA. Articles were identified by searching the PubMed/Medline, Embase, and Web of Science database through June 2022 with restriction to the last 20 years. We included case series, case reports, clinical trials, controlled clinical trials, meta-analyses, randomized controlled trials, reviews, and systematic reviews written in English. Studies reporting on endonasal approach or hematoma evacuation using the NUA were excluded. The references of the identified studies were reviewed as well. Nine full-text articles were included in the analysis, with a total of 40 patients who underwent surgery for a brain tumor using NUA. The most common underlying pathology treated by NUA was colloid cyst (17.5%), pilocytic astrocytoma (12.5%), subependymal giant cell astrocytoma (7.5%), subependymoma (7.5%), and craniopharyngioma (7.5%). Complete or near-total resection was achieved in 62.5%. The most frequently reported postoperative complication was secondary hydrocephalus (10%), meningitis/-encephalitis (7.5%), cognitive impairment (7.5%), and subdural hygroma (7.5%). In one case (2.5%), surgery-related death occurred due to a severe course of meningoencephalitis. According to the preliminary data, NUA seems to be a safe and efficient minimally invasive alternative to conventional microscopic resection of brain tumors. Further studies to investigate advantages and disadvantages of using the NUA are needed.
... 34 A CSF analysis could be a reference to suspect bacterial meningitis, but an abnormal CSF profile is common for postoperative cases. 37,38 Therefore, clinicians cannot help but depend on the conventional CSF culture test alone for infection diagnosis, although it has a low diagnostic yield due to empirical antibiotic use. 39 Meanwhile, as our results showed, 16S amplicon sequencing further detected 48% (12/25) of the genuine infections in the cases with postoperative fever at the initial tests. ...
Objective:
Nosocomial bacterial meningitis is one of the major complications after neurosurgery. We performed nanopore 16S amplicon sequencing from cerebrospinal fluid (CSF) to evaluate bacterial meningitis in patients who underwent neurosurgery.
Methods:
Among the patients who visited the neurosurgery department of Seoul National University Hospital between July 2017 and June 2020, those with clinically suspected bacterial meningitis were included. 16S rDNA PCR was performed from the CSF, and nanopore sequencing was performed for up to 3 h. The reads were aligned to the BLAST database. In each case, the culture and the 16S rRNA gene amplicon analysis were simultaneously performed and compared with each other, and we retrospectively reviewed the medical records. Genuine infection was determined by the identical results between conventional culture study and the sequencing, or clinically determined in cases with inconsistent results between the two methods.
Results:
Of the 285 samples obtained from 178 patients who had 16S rDNA PCR, 41 samples (14.4%) were diagnosed with genuine infection. A total of 56.1% (23/41) of the samples with genuine infection showed a false-negative culture test. In particular, 16S amplicon sequencing was useful in evaluating patients at the initial tests who had infection with intraventricular hemorrhage (Culture false-negative rate = 100%), subarachnoid hemorrhage (Culture false-negative rate = 77.8%), and systemic cancer (Culture false-negative rate = 100%), which are risk factors for central fever. Moreover, 16S amplicon sequencing could suggest the possibility of persistent bacterial meningitis in empirical antibiotic use.
Conclusion:
CSF nanopore 16S sequencing was more effective than conventional CSF culture studies in postoperative bacterial meningitis and may contribute to evidence-based decisions for antibiotic maintenance and discontinuation.
... The physiological activity of the choroid epithelium and utilization by bacterial pathogens and leukocytes leads to diminished CSF glucose (Watson et al. 1995). The count of white blood cells (>7500 cells/mm 3 ) and estimations of glucose (<10 mg/dL) levels are separated from chemical meningitis (Forgacs et al. 2001). ...
An attempt was made to analyze the cerebrospinal fluid (CSF) for a cytological and biochemical profile to identify etiological agents from children with suspected acute bacterial meningitis. The cerebrospinal fluid (CSF) samples from 371 suspected meningitis cases were examined, and the highest bacterial meningitis was found in 52(14.0%) cases in this study. Among a total of 371 samples of CSF, 272(73.3%) were crystal clear, 52(14.0%) were moderately turbid, 47(12.7%) highly turbid. The total leukocyte cell count of the CSF was proportionate to the turbidity. In the case of crystal clear CSF’s, total leukocyte counts (TLC) were normally ranging from <5 to 45 per mm3 with predominant lymphocytes. Moderately turbid fluid showed 46 to 500 cells per mm3 and highly turbid fluid showed from 501 to more than 10,00 cells/mm3. In the latter cases, differential counts demonstrated polymorphonuclear predominance. In addition, about 100% (52 cases) of positive and 12.5% (40/319) of negative cases had CSF protein concentration >100 mg/dL. CSF protein concentration greater than 100 mg/dl and sugar level below 40 mg/dl were considered as suspected bacterial meningitis in this study. Surprisingly, the C-Reactive Protein (CRP) values were found to be >40 mg/dL in both culturally positive and negative cases. Most of meningitis positive cases showed increased total cell counts as well as protein concentration, and decreased serum sugar concentrations. J. Asiat. Soc. Bangladesh, Sci. 47(2): 137-147, December 2021
... Although its pathophysiology is not yet completely known, it is hypothesized that after the dura and arachnoid transection, substances secondary to red blood cells lysis or from surgical materials lead to a meningeal inflammatory reaction 6 . Previous studies have found that postoperative pachymeningeal and leptomeningeal thickening with gadolinium-enhancement can be found for up to 5 or 6 years after the surgery 7 , depending on the type of surgery performed. ...
Posterior fossa tumors are relatively common in children, and the meningeal dissemination of these tumors is well established in the literature. Although leptomeningeal dissemination is more common in high-grade tumors, even low-grade tumors can generate meningeal metastases. In this case report, we would like to discuss the importance of leptomeningeal dissemination assessment of posterior fossa tumors in children, in the preoperative period, through the entire neuroaxis magnetic resonance imaging (MRI). This is important since transient meningeal thickening is very common in the postoperative periods of neurosurgical patients, and can be found for up to 5 or 6 years after surgery, causing these patients to undergo prolonged follow-ups and repeated MRIs and lumbar punctures.
... Neutrophil CSF pleocytosis can be present in various infectious and non-infectious forms of meningitis as a consequence of subarachnoid-space inflammation. [5][6][7] Up to 50% of patients with clinical signs of meningitis have already been treated with steroids or antibiotics, at the time of lumbar puncture. 4,8 Standard CSF studies (i.e., gram staining and determinations of leukocyte count and glucose and protein concentration) are unreliable for the diagnosis of BM after neurosurgery. ...
Background:To distinguish post-neurosurgical bacterial meningitis (PNBM) from aseptic meningitis is difficult. Inflammatory and biochemical cerebrospinal fluid (CSF) changes mimic those classically observed after CNS surgery. CSF lactate assay has therefore been proposed as a useful PNBM marker. Objective:To determine the value of cerebrospinal fluid (CSF) lactate level for the identification of bacterial meningitis following cranial surgery. Methods:Between January 2016 and December 2016, a prospective clinical study was done in Department of Neurosurgery, in which all patients with clinical suspicion of PNBM were enrolled. Patients with clinical suspicion of bacterial meningitis BM were categorized, according to preset criteria, into 3 groups: (1) proven BM; (2) presumed BM, and (3) nonbacterial meningeal syndrome. CSF markers were plotted in a receiver operating curve (ROC) to evaluate their diagnostic accuracy. Results:The study included 70 patients. We obtained 65 CSF samples from patients with clinical suspicion of BM by CSF analysis. 20 corresponded to proven BM, 7 to probable BM and 38 to excluded BM. Mean lactate in CSF was: 8.4 ±3.0 mmol /l for proven BM, 4.8 ± 0.99 mmol /l for probable BM and 2.08 ± 0.822 mmol/l for excluded BM (P < .001). Conclusion: CSF lactate level has good predictive value to distinguish BM from aseptic meningitis with sensitivity of 90% and specificity: 87% at cut-off value: 4.0 mmol/l.
... While intracranial neurenteric cysts are uncommon congenital lesions, chemical meningitis as a post-operative complication is considered even more rare. Chemical or aseptic meningitis is defined as meningitis with sterile cerebrospinal fluid Gram stain and culture, and resolution of symptoms without antibiotic therapy [12] . The mechanism of action is believed to be secondary to the leakage of cyst contents into the subarachnoid space [2] . ...
Intracranial neurenteric cysts are rare congenital lesions that, though benign, are difficult to diagnose radiologically given their similar imaging appearance to other intracranial cystic lesions. We present a case of a 21-year-old female with a pathologically proven, symptomatic neurenteric cyst in the premedullary cistern. Superimposed on this uncommon diagnosis were also rare post-operative complications of chemical meningitis and vagal nerve injury. We review the current literature surrounding intracranial neurenteric cysts, their imaging characteristics, differential diagnosis, therapeutic options, and potential complications related to their resection.
... We regarded the following as criteria for chemical meningitis: (1) an acute-onset high fever (≥39 • C) starting on the postoperative day (POD)0-1; (2) lasting ≤7 days; (3) no apparent wound infection; (4) pneumonia or urinary tract infection ruled out using a chest X-ray, urine examinations, and urinary culture; and (5) no need for additional antibiotics [22,23]. All patients were regularly administered cefazolin, with a dose of 20 mg/kg for those patients with a bodyweight of <50 kg and 1 g/kg for those with a body weight of ≥50 kg, diluted with 50 mL of saline within 30 min of making the initial skin incision. ...
Background: A corpus callosotomy (CC) is a procedure in which the corpus callosum, the largest collection of commissural fibers in the brain, is disconnected to treat epileptic seizures. The occurrence of chemical meningitis has been reported in association with this procedure. We hypothesized that intraventricular pneumocephalus after CC surgery represents a risk factor for postoperative chemical meningitis. The purpose of this study was to analyze the potential risk factors for postoperative chemical meningitis in patients with medically intractable epilepsy who underwent a CC. Methods: Among the patients who underwent an anterior/total CC for medically intractable epilepsy between January 2009 and March 2021, participants were comprised of those who underwent a computed tomography scan on postoperative day 0. We statistically compared the groups with (c-Group) or without chemical meningitis (nc-Group) to determine the risk factors. Results: Of the 80 patients who underwent a CC, 65 patients (25 females and 40 males) met the inclusion criteria. Their age at the time of their CC procedure was 0–57 years. The c-Group (17%) was comprised of seven females and four males (age at the time of their CC procedure, 1–43 years), and the nc-Group (83%) was comprised of 18 females and 36 males (age at the time of their CC procedure, 0–57 years). Mann–Whitney U-tests (p = 0.002) and univariate logistic regression analysis (p = 0.001) showed a significant difference in pneumocephalus between the groups. Conclusion: Postoperative pneumocephalus identified on a computed tomography scan is a risk factor for post-CC chemical meningitis.
... 6 The pathogenesis of this complication remains to be fully elucidated, but an inflammatory reaction in response to the breakdown of red blood cells, surgical materials such as dural substitutes, or bone dust is thought to be implicated. 38,39 For unclear reasons, aseptic meningitis occurs much more commonly after surgery in the posterior fossa 40,41 and may be affected by the subtype of dural graft used. 42 The condition is often self-limited and recovery can be accelerated with the use of steroids. ...
Background:
Post-operative Emergency Department (ED) visits following suboccipital decompression in CM-1 patients are not well described. We sought to evaluate the magnitude, etiology, and significance of post-operative ED service utilization in adult CM-1 patients at a tertiary referral center.
Methods:
A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was also compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS).
Results:
In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%), and concentration disturbance at presentation was the only factor significantly associated with a post-operative ED visit (p=0.023). The occurrence of a post-operative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted OR of CCOS≥13=0.35, p=0.021; adjusted OR of CCOS≥14=0.38, p=0.016).
Conclusion:
Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of post-operative ED visits, which are mostly due to pain-related complaints. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of post-operative ED service utilization are warranted.
... Prophylactic antibiotics for neurosurgery procedure are conventionally administered, and frequently, the antibiotics use is prolonged or upgraded in cases with postoperative fever (POF). However, whether a high body temperature sufficiently precisely indicates the presence of a central nervous system (CNS) infection after neurosurgery is still controversial [1][2][3]. ...
Objective
Postoperative fever (POF), associated with posterior cranial fossa (PCF) surgery, occurs commonly and is a potential intracranial infection indicator of perioperative antibiotics prolongation and advancement. The existing prophylactic approaches to balancing the risk between intracranial infection and antibiotics abuse are debatable.
Methods
We retrospectively assessed 100 patients subjected to PCF tumor resection between December 2015 and December 2018 at a single institution. Forty febrile patients were selected for further analysis. Of them, 16 received basic and 24 advanced antibiotics and were subjected to prophylactic antibiotic assessment.
Results
The total POF rate of PCF tumor resection was 49.4%. POF occurred from day 1 to day 5, along with the abnormalities of cerebrospinal fluid (CSF) profiles and the mild meningeal irritation symptom. CSF cultures of all selected patients were negative. In the comparison between the basic and advanced antibiotic therapy, we found no statistically significant differences in the results of the average and dynamic analysis of the body temperature and CSF profiles. Negative results of outcome studies were also obtained in the duration of fever, duration of hospitalization, and total hospitalization expenses. However, the expenses were substantially increased in the advanced antibiotic treatment.
Conclusions
Although POF is a common symptom after PCF tumor resection, definite intracranial infection is rare. A high body temperature and significant abnormal CSF profiles at an early stage may not be a specific and sufficient indicator of intracranial infection to upgrade antibiotics therapy when standard prophylactic protocols have been accurately achieved.
... So besides bacterial infection, many factors could lead to decreased level of CSF glucose, including blood glucose 12 , blood-stained 13 , meningeal disseases 14 , long-time exposure to air. Furthermore, post-neurosurgical in ammatory response can be seen due to the stimulation of blood, dust bone, implant material, sloughing tissue, surgical manipulation and so on in which the CSF pro les are similar to those in bacterial meningitis 15 . As the golden diagnostic standard of bacterial meningitis, CSF bacterial cultures remain very low positive rate, reported only about 10% or even lower 16,17 and it takes up to days for organism identi cation. ...
Background: Post-neurosurgical bacterial meningitis (PNBM) is a severe complication with high morbidity and mortality. Rapid and accurate diagnosis of PNBM is difficult. Therefore, it is necessary to find more reliable markers to assist the diagnosis. This study aims to evaluate the predictive value of cerebrospinal fluid (CSF) lactate for PNBM diagnosis and treatment efficacy.
Methods: Total 105 cases were enrolled in patients with clinically suspected PNBM who underwent neurosurgeries during October 2015 to December 2016. CSF lactate as well as CSF routine and biochemistry test was measured. Receivers operating characteristic (ROC) curve analysis was used to evaluate the diagnostie power of CSF lactate for PNBM. To assess the predictive value of CSF lactate for treatment efficacy, a linear regression was used and tendency diagrams of CSF lactate and glucose for each patient were drawn.
Results: Fifty-four of 105 patients were diagnosed with PNBM. CSF lactate level was significantly higher in PNBM than in non-PNBM patients (p < 0.001). The ROC curve analysis showed a great diagnostic power of CSF lactate for PNBM, and the cut-off value was 4.15 mmol/L (AUC = 0.92, sensitivity, 92.6%; specificity, 74.5%). The combination of CSF lactate and glucose showed better diagnostic efficacy (AUC = 0.97, sensitivity, 94.4%; specificity, 90.2%). The linear regression showed thatΔCSF lactate inversely correlated with ΔCSF glucose and directly correlated with ΔCSF leucocyte (both p < 0.001). The tendency diagrams showed CSF lactate a better predictor for PNBM treatment efficacy than CSF glucose.
Conclusion: Our study showed CSF lactate had an excellent discriminatory power in distinguishing between PNBM and non-PNBM. The combination of CSF lactate and glucose had a better diagnostic accuracy than other CSF parameters alone. CSF lactate was a reliable predictor of treatment efficacy in PNBM patients.
... One theory is that patients with a DC obtained antibiotics for sepsis syndrome, as a result of which the diagnosis of meningitis was understated. On the other hand, our meningitis rate could have been overestimated, as we have taken into account all cases of inflammation of the cerebrospinal fluid, including potentially chemical meningitis [9]. In an ICP-related infection sample, 68 test tips were cultivated: 13.2% had a positive culture without clinical signs of infection and 2.9% had a positive culture with clinical signs of ventriculitis [10]. ...
Background: Haematoma volume is a strong predictor of morbidity and mortality in a spontaneous intracerebral hematoma. Timing of surgery, amount of clot removal, GCS on admission, pupillary abnormality and amount of bone removal of such cases are strong variables. A large amount of blood is causing impending herniation which is life-threatening and should be addressed immediately to reverse the situation. Objective: The main goal of this study is to assess the predictive analysis in decompressive craniotomy for haemorrhagic stroke. Method: A total of 72 cases were included in this study. This retrospective study was conducted in three private hospitals from 2009 to 2018. Male: Female was 3:2. Surgical outcome predictors were analyzed by using different variables- the timing of surgery, amount of clot removal, GCS on admission, pupillary abnormality, age of the patients and amount of bone removal. Results: 8 patients died, 2 patients were in a vegetative state, 1 patient developed osteomyelitis in a bone flap and 1 had CSF leak and meningitis. Conclusion: Decompressive craniotomy for large intracerebral hematoma is lifesaving. Among the variables- the timing of surgery and the amount of bone removal are strong predictors of the outcome of the surgery. Keywords: Haematoma; Craniotomy; Decompressive; Intracerebral
... Meningeal irritation can occur due to local inflammation (reaction to blood lysis, sutures, tissue breakdown or chemicals) or perioperative bacterial inoculation. Determining the cause of post-operative meningitis (POM) is crucial to prevent permanent neurological sequelae or death because the course of treatment for local inflammation varies from that of infection [2][3][4][5]. Practitioners often pre-emptively start empirical antimicrobial therapy before collecting cerebrospinal fluid (CSF) for diagnostic testing due to the high morbidity and mortality of POM. Antecedent antimicrobial use can inhibit bacterial growth, rending cultures negative [6]. ...
Introduction:
Post-operative meningitis (POM) is a life-threatening complication of neurosurgery. Diagnosis is often difficult due to pre-existing inflammation and antecedent antimicrobial use. Bacterial cerebrospinal fluid (CSF) cultures may reveal no growth, but empiric antibiotics are typically given due to the high morbidity and mortality associated with POM. 16S rRNA gene PCR/sequencing is a molecular methodology that can identify the presence of bacteria regardless of viability for culture.
Case presentation:
A patient presented with a rapid onset of fever associated with headache, neck pain, nausea and altered mental status 11 days after undergoing laser interstitial thermal therapy for treatment of recurrent astrocytoma at another hospital. Based on clinical presentation and imaging, POM was suspected, and empiric antibacterial therapy was started. Microbiological stains and cultures of CSF were negative. Due to persistent fevers, 16S rRNA gene PCR/sequencing was done on CSF; it detected a member of the order Enterobacteriales most closely resembling Serratia species. All antimicrobials were stopped except for cefepime, which was given for 2 weeks. The patient's mental status fully recovered.
Conclusion:
The application of 16S rRNA gene PCR/sequencing in the setting of POM is of value by improving the quality of patient care and decreasing costs by antimicrobial de-escalation. Further studies regarding the positive and negative predictive values of this test are required.
... Level of CSF glucose decreased due to modification in the physiological functioning of the choroid epithelium as well as from utilization of leukocytes and bacterial pathogens [25] . By level of CSF glucose (< 10 mg/dl) and CSF WBC values (> 7500 cells/mm 3 ) differential diagnosis between chemical meningitis and bacterial meningitis can be possible [26] . Greater than 200 mg/dl level of protein considered extremely significant for bacterial meningitis with interference of the blood CSF or blood brain barrier [27] . ...
... 21 This recommendation has not met with universal approval. 22,23 We have adopted this approach to the management of AM since 2008 and have not encountered any failure with this protocol. ...
Objective:
To study the effect of a staphylococcal decolonization regime (SDR) and change in antibiotic prophylaxis regime on postoperative meningitis (bacterial and aseptic) rates in patients undergoing elective cranial surgeries.
Methods:
Data of elective craniotomies (supratentorial and infratentorial) were collected retrospectively over a total period of 4 years - two years prior to (2011-12; Group A) and two years after (2014-15; Group B) initiation of a SDR and a change in antibiotic prophylaxis regime (from chloramphenicol to ceftriaxone) in a neurosurgical unit of a tertiary care hospital. SDR consisted of a 4% chlorhexidine scrub bath once a day and 10% betadine ointment application intra-nasally twice a day, for at least 2 days prior to surgery.
Results:
A total of 1349 patients (Group A, n=622; Group B, n=727) were included in the study, of which 59.7% (n=806) were males. 43 patients developed postoperative meningitis (3.2%), of whom 8 (0.6%) had bacterial meningitis (BM) and 35 (2.6%) had aseptic meningitis (AM). There was reduction in both BM and AM in Group B but the reduction was statistically significant for only AM (p=0.48 for BM and p=0.019 for AM). Multivariate analysis showed that initiation of SDR conferred a significant protective effect against developing postoperative AM (p=0.005, RR=0.31, 95% CI: 0.14-0.70).
Conclusion:
Our data shows that incidence of aseptic meningitis can be reduced with SDR and appropriate antibiotic prophylaxis. It lends support to the suspicion that aseptic meningitis might be a form of low-grade bacterial meningitis possibly due to staphylococcal infection.
BACKGROUND AND OBJECTIVES
Diagnosing ventriculostomy-related infection (VRI), a common complication after external ventricular drainage (EVD), is challenging and often associated with delayed initiation of antibiotic therapy. We aimed to develop a stewardship score to help in the decision of antibiotic therapy initiation when VRI is suspected.
METHODS
This retrospective, single-center cohort study included patients admitted to the intensive care unit after EVD placement who were suspected of having healthcare-associated ventriculitis and/or meningitis between January 1, 2012, and August 31, 2022. A multiple logistic regression model was used to identify factors associated with the development of healthcare-associated meningitis or ventriculitis after EVD placement.
RESULTS
A total of 331 patients were included. Eighty-one (23%) patients developed VRI between January 1, 2012, and August 31, 2022, whereas 250 (77%) did not (from January 1, 2018, to August 31, 2022). VRI-associated factors were EVD count >1 (odds ratio [OR] 3.69, P < .001), EVD duration >8 days (OR 6.71, P < .001), immunosuppression (OR 3.45, P = .028), recent neurosurgery (OR 7.74, P < .001), cerebrospinal fluid leak (OR 6.08, P < .001), and prophylactic antimicrobials (OR 0.26, P < .001). The VEntriculostomy-Related Infection score (VERI) score categorized VRI risk into 4 levels, with an area under the curve of 0.84.
CONCLUSION
The VERI score is a robust, predictive tool for assessing the risk of VRI in patients with EVD, potentially guiding more judicious use of antibiotic therapy in the intensive care unit setting.
Background : Combined spinal-epidural(CSE)anesthesia is a frequently used technique in surgeries of the lower limbs with very low complication rates, but it can also cause severe neurological damage. We present a case of motor and sensory disturbances in both lower extremities following CSE anesthesia.
Case presentation : A 46-year-old woman underwent a transpositional acetabulor osteotomy under CSE anesthesia. The patient returned to the ward after successful surgery without any intraoperative anesthetic problems. However, motor and sensory disturbances in both lower limbs became apparent the next day. Based on physical findings, frequent spinal fluid analyses, imaging studies, and nerve conduction velocity tests, chemical meningitis and lumbar radiculitis secondary to local anesthetic administration into the subarachnoid space were diagnosed.
Conclusion : This is a rare case in which the cause of the neurological disorder following CSE anesthesia was confirmed by careful examination and investigation.
Neurosurgical CNS infections refer to infectious diseases of the skull and spinal canal secondary to neurosurgical disease or requiring neurosurgical management; sometimes, early diagnosis is difficult and diagnostic imaging can provide an important diagnostic basis. Post-neurosurgical infections are predominantly bacterial, including post-neurosurgical epidural abscesses, subdural pus, brain abscesses, meningitis, and ventriculitis; cranial infections are due to cranial trauma, ventricular and lumbar pool external drainage, shunts, and implant-related meningitis or ventriculitis. This chapter focuses on postoperative infections and chemical meningitis to provide valuable imaging information for clinical diagnosis.
This practical question and answer book contains two full-length practice exams that mimic the tone and scope of the American Board of Psychiatry and Neurology’s certifying exam in neurocritical care. It covers aspects of neurology, neurosurgery, general critical care, and emergency medicine, with rationale and discussion provided in the answers section at the end of each exam. This useful study guide will help prepare critical care fellows and residents from a variety of backgrounds for the ABPN exam, and help test their critical care competencies in general.
Neuroimaging provides rapid, noninvasive visualization of central nervous system infections for optimal diagnosis and management. Generalizable and characteristic imaging patterns help radiologists distinguish different types of intracranial infections including meningitis and cerebritis from a variety of bacterial, viral, fungal, and/or parasitic causes. Here, we describe key radiologic patterns of meningeal enhancement and diffusion restriction through profiles of meningitis, cerebritis, abscess, and ventriculitis. We discuss various imaging modalities and recent diagnostic advances such as deep learning through a survey of intracranial pathogens and their radiographic findings. Moreover, we explore critical complications and differential diagnoses of intracranial infections.
A woman in her 50s developed meningitis following an endoscopic, endonasal resection of a clival meningioma which was complicated by a cerebrospinal fluid (CSF) leak through the nose. CSF analysis showed a raised white cell count, and Capnocytophaga sputigena was isolated. This organism is an oral commensal and is implicated in periodontal disease; the CSF leak explains the portal of entry. C. sputigena is rarely isolated, and this is the first report of a central nervous system (CNS) infection caused by this organism. A worsening of our patient’s dermatological condition, urticaria pigmentosa, coincided with empiric treatment with vancomycin and meropenem, which were therefore discontinued. Treatment was continued with chloramphenicol for 3 weeks, and the patient made a full recovery. Systemic chloramphenicol is uncommonly used in contemporary UK practice, but remains an excellent antibiotic for CNS penetration and it has excellent bioavailability. We anticipate increased chloramphenicol use as the number of multiresistant Gram-negative infection increases.
Background
Autologous fat grafting is considered a simple, safe technique for reconstructing and optimizing dural closure in skull base surgeries rarely associated with complications. It showed successful results after skull base vestibular schwannoma and meningiomas resection. This article reports a rare case of postoperative lipoid meningitis and surgical site subcutaneous air collection following subarachnoid fat migration from an autologous fat graft after retrolabyrinthine acoustic neuroma resection.
Case description
63-year-old woman who underwent resection of a right vestibular schwannoma via a right retrolabyrinthine pre-sigmoid approach. Intraoperatively, a free fat graft was harvested from the right buttock to close the craniotomy defect. One month later, she returned to the emergency department with intermittent headaches, low-grade fever, neck stiffness, and general malaise. No signs of cerebrospinal fluid leakage were noted on examination. Based on laboratory investigations and imaging, she was admitted under suspicion of bacterial meningitis and treated with antibiotics accordingly. However, no organisms were observed in the culture and staining tests. Ultimately, multiple locules of fat were observed throughout the brain, leading to a final diagnosis of lipoid meningitis, in addition to the presence of unexplained, unusual subcutaneous air collection in the surgical cavity.
Conclusion
This case report demonstrates rare complications following subarachnoid fat migration from an autologous fat graft after retrolabyrinthine acoustic neuroma resection. Similarly, it illustrates the clinical presentation and appropriate treatments for lipoid meningitis, informing physicians of the need to distinguish bacterial meningitis from lipoid meningitis.
S. epidermidis cerebrospinal fluid (CSF) shunt infection is a common complication of hydrocephalus treatment, creating grave neurologic consequences for patients especially when diagnosis is delayed. The current method of diagnosis relies on microbiologic culture; however, awaiting culture results may cause treatment delays or fail to identify infection altogether so newer methods are needed. To investigate potential CSF biomarkers of S. epidermidis shunt infection we developed a rat model allowing for serial CSF sampling. We found elevated levels of IL-10, IL-1β, CCL2, and CCL3 in the CSF of animals implanted with S. epidermidis infected catheters compared to sterile controls at day 1 post-infection. Along with increased chemokine and cytokine expression early in infection, neutrophil influx was significantly increased in the CSF of animals with infected catheters, suggesting that coupling leukocyte counts with inflammatory mediators may differentiate infection from sterile inflammation. Mass spectrometry analysis revealed that the CSF proteome was similar in sterile versus infected animals at day 1; however, by day 5 post-infection there was an increase in the number of differently expressed proteins in the CSF of infected compared to sterile groups. The expansion of the proteome at day 5 post-infection was interesting as bacterial burdens began to decline by this point, yet the CSF proteome data indicated that the host response remains active, especially with regard to the complement cascade. Collectively, these results provide potential biomarkers to distinguish S. epidermidis infection from sterile post-operative inflammation.
El manejo adecuado de las infecciones del sitio operatorio (ISO) en neurocirugía es fundamental para la disminución de la carga de morbilidad y mortalidad en estos pacientes.La sospecha y confirmación diagnóstica asociadas al aislamiento microbiológico son esenciales para asegurar el tratamiento oportuno y el adecuado gerenciamiento de antibióticos. En esta revisión se presenta de forma resumida los puntos fundamentales para la prevención y el tratamiento de infecciones del sitio operatorio en neurocirugía y se incluye un apartado sobre el uso de antibióticos intratecales/intraventriculares.
Brucellosis, also known as “undulant fever,” “Mediterranean fever,” or “Malta fever,” is an important human zoonosis and a major public health issue in many parts of the world especially in the Mediterranean countries of Europe, North and East Africa, the Middle East, South and Central Asia, and Central and South America [1].
Healthcare-associated meningitis and cerebral ventriculitis are infections following craniotomies, spine surgeries, CSF shunt, CSF drain surgeries, and otorhinological surgeries. Gram-positive cocci like Staphylococcus epidermidis and S. aureus are the most common pathogens, followed by gram-negative rods and anaerobes like C. acnes (formerly P. acnes). Other noninfectious neurologic conditions and neurosurgeries can cause similar clinical and CSF findings making the diagnosis difficult. The management of these infections often requires surgical interventions and may need intraventricular or intrathecal administration of antimicrobials, when they don’t respond to IV antimicrobials alone. Periprocedural antimicrobials, antimicrobial-impregnated CSF catheters, and infection prevention protocols during insertion and maintenance of CSF shunts and drains have been shown to reduce infection rates.
Healthcare-associated meningitis or cerebral ventriculitis are infections complicating neurosurgeries, CSF shunt, and CSF drain surgeries. It is different in clinical presentation, pathogenesis, and management from community-acquired meningitis. Gram-positive cocci like Staphylococcus epidermidis and S. aureus are the most common pathogens, followed by Gram-negative rods and anaerobes like P. acnes. The diagnosis can be difficult as other noninfectious neurologic conditions and neurosurgeries can cause similar clinical and CSF findings. The management of these infections often requires surgical interventions and may need intraventricular or intrathecal administration of antimicrobials, as the organisms can be refractory to IV antimicrobials alone. Periprocedural antimicrobials and antimicrobial impregnated CSF catheters have been shown to reduce infection rates.
Resumo
Objetivo: Averiguar se as características hidrodinâmicas das válvulas se alteram significativamente quando os dimensionamentos originais são violados e a possível repercussão clínica desse fato. Métodos: Foi utilizada uma bancada de testes automatizada, conforme a norma ISO 7197. Um sistema valvular foi testado inicialmente com os componentes preconizados e embalados originalmente com o produto. A seguir, substituiu-se o cateter peritoneal original por diversos dimensionamentos encontrados no mercado nacional. Nos testes para a avaliação da influência do diâmetro do cateter no escoamento, foi utilizado sempre o mesmo comprimento original do cateter. Aplicou-se o mesmo raciocínio lógico para a análise do comprimento do cateter. Nove perfis hidrodinâmicos foram obtidos para as diferentes montagens valvulares. Resultados: Diminuições imperceptíveis no diâmetro do cateter peritoneal alteraram o perfil hidrodinâmico do sistema valvular testado. Alterações de 0,1 mm no diâmetro de um cateter peritoneal aumentaram o efeito resistivo do sistema valvular suficientemente para que ele funcionasse fora do perfil hidrodinâmico preconizado; o efeito resistivo se acentuou conforme o diâmetro diminuiu, e vice-versa. A diminuição do comprimento do cateter também influenciou significativamente no desempenho hidráulico da válvula, de um regime inicial de alta pressão para um regime de média pressão. Conclusão: Alterações de dimensionamento em cateteres peritoneais trazem complicações para o paciente e desorientam o julgamento clínico do neurocirurgião no período pós-implante, pois o sistema valvular funcionará em regime hidráulico fora do especificado, e o raciocínio lógico do neurocirurgião também se torna comprometido. Esse fato pode ser crítico principalmente em crianças e neonatos. Não foram identificados relatos desse fato na literatura que antecede esta apresentação.
The specific form of aseptic meningitis to be presented here occasionally follows operations on the central nervous system. The condition has received little attention in surgical literature, although its syndrome must have been an occasional cause for concern to all neurosurgeons of experience. When the nature and characteristics of this inflammatory process are recognized it can be readily distinguished from bacterial meningitis.
In the syndrome of acute postoperative aseptic leptomeningitis there are recurring bouts of fever, rigidity of the neck and pleocytosis. Each reaction is of sudden, dramatic onset, but of short duration, and is preceded and followed by intervals relatively free from symptoms.
The condition is troublesome rather than dangerous, for it prolongs the convalescent period by two to six weeks, without leaving serious residual complications. It occurs most often after operations in the posterior fossa which open the cisterna magna or after supratentorial operations which have left the
This article has no abstract; the first 100 words appear below.
NOWHERE have the effects of the introduction of antimicrobial agents during the past two decades been more dramatically exhibited than in bacterial meningitis. Whereas formerly untreated pyogenic meningitis was fatal with rare exceptions,¹ in the antibiotic era there has been a gratifying lowering of the mortality rate.²³⁴⁵ But during the past eight to ten years, there has been no outstanding change in the mortality rate in the principal types of bacterial meningitis. Although it might appear that a plateau has been reached in the treatment of this disease, we are unwilling to accept this view without exploring fully the basis . . .
*From the departments of Medicine and Neurology, Harvard Medical School, and the Medical (Infectious Disease Unit), Neurological and Children's services and the Joseph P. Kennedy, Jr., Laboratories of the Massachusetts General Hospital.
Supported in part by grants (5T1 AI 215–03 and NB 5236–06) from the United States Public Health Service.
Source Information
BOSTON
† Assistant professor of medicine, Harvard Medical School; chief, Infectious Disease Unit, Massachusetts General Hospital.
‡ Assistant professor of neurology, Harvard Medical School; neurologist and pediatrician, Massachusetts General Hospital.
Four hundred and seventy patients who had undergone neurosurgical operations were studied prospectively. After defining post-operative infection so that is included all the infective complications irrespective of location occurring after surgery, the overall infection rate was 17%. The infection rate in 413 cases without pre-existing infection was 15%. Wound infection was recorded in 5% and meningitis in 6%. Risk factors which lead to a significant increase in the incidence of postoperative infection were found to be altered sensorium, multiple operations, pre-existing infection, emergency surgery, duration of surgery more than 4 hours, urinary catheterisation, cerebrospinal fluid leak, and ventilatory support.
The incidence of craniotomy infections, usually less than 5%, is dependent on many factors, such as how the information is collected and how the percentage is calculated. Because these factors may vary from report to report, incidence figures should be read with skepticism. It is difficult to prove that a given factor contributes to infection. Most routines are based more on personal convictions than on solid evidence. CSF leak is one factor known to have great impact; it should be avoided with painstaking technique and, if it occurs, it should be treated promptly. Solid evidence favoring prophylactic antibiotics for persistent CSF leak is not available; but, until a well-designed randomized study tells otherwise, the high risk of meningitis justifies prophylaxis. Penicillin is adequate for leaks through the nose or the ear. For leaks through the skin, the antibiotic should be effective against staphylococci. The infection register should provide information about prevailing bacteria. In many hospitals, the prophylaxis should cover gram-negative bacilli. CRP is a useful diagnostic aid for detecting postoperative infections. The operation, however, also causes a CRP rise. Daily CRP monitoring, at least for patients with elevated temperature, is recommended. The third-generation cephalosporins are a welcome contribution to the treatment of bacterial meningitis. To avoid side effects, and to keep them potent when they are really needed, they should be used with caution. Most postoperative cases of meningitis are in fact aseptic. If the patient is moderately ill, chloramphenicol is still eligible as the first choice antibiotic. When the bacterial culture is negative, the antibiotic should be stopped. The standard treatment for bone flap infection is removal of the bone flap. The bone flap is essentially devascularized and comparable to a foreign body. The justification of vancomycin prophylaxis has been shown in a randomized study.
In the patient with a basilar skull fracture and CSF leak, the risk of meningitis is greatly increased. The diagnosis of both leak and infection can be obscured by the patient's other injuries, and requires aggressive investigation of symptoms that suggest infection. Although the diagnosis is made with CSF cultures, when clinically suspected, treatment should begin after appropriate cultures have been obtained. Treatment should be directed against the most likely organisms, Streptococcus pneumoniae, Haemophilus influenzae, and the other organisms common to the upper respiratory tract. There are no good indications for prophylactic antibiotic usage in patients with known CSF leaks.
The patient with a shunt or other CNS prosthetic device may have various manifestations of infection, depending on the type of device and its termination. Frank meningitis or ventriculitis is not always present. Diagnosis requires direct culturing of the shunt milieu, with the most frequent isolates being staphylococcal species and gram-negative enteric bacilli. The most effective therapy, for both eradication of the infection and minimization of the duration and morbidity of therapy, involves removal of the infected shunt, external drainage during parenteral antibiotic therapy, and complete replacement of hardware at the time of internalization.
The postsurgical patient will not develop meningitis very frequently, but like the posttrauma patient, concurrent factors can make the diagnosis difficult. Differentiating infectious from chemical meningitis must often be initially based on CSF cell counts and chemistries alone. Treatment to cover the most likely organism, staphylococcal species and respiratory flora, should be started before the culture results are finalized.
Patients presenting with recurrent meningitis from an unknown source should be evaluated for the presence of occult lesions that may require neurosurgical intervention.
Neurotologic and skull base procedures that include dissection within the subarachnoid space carry with them the potential for meningitis. Postoperative aseptic leptomeningitis occurs more frequently than purulent bacterial meningitis. Differentiation between these two conditions early in the postoperative period is important to avoid delay in or unnecessary treatment. The definitive diagnosis is made with cerebral spinal fluid culture. Early differentiation between postoperative aseptic leptomeningitis and purulent bacterial meningitis on the basis of results of cerebral spinal fluid profile before cerebral spinal fluid culture would result in earlier appropriate therapy.
The differentiation of bacterial from aseptic meningitis in postoperative neurosurgical patients has traditionally been based on the clinical setting, a recent history of steroid administration, and cerebrospinal fluid (CSF) studies, including the total and differential leukocyte counts, Gram stain, glucose, and total protein. Recent reports questioning both the validity of a relative CSF lymphocytosis in excluding bacterial meningitis and the usefulness of standard CSF testing prompted the authors to reevaluate these standard criteria. The type of operation, the presence of a foreign body, use of steroids, postoperative day on which symptoms developed, altered mental status, neck stiffness, headache, and nausea were not helpful in the differential diagnosis. High fever, new neurological deficits, an active CSF leak, and elevated leukocyte counts in the CSF and peripheral blood favored a bacterial etiology. The CSF glucose level and the differential leukocyte count were less helpful. No criterion or combination of criteria was sensitive and specific enough to reliably differentiate aseptic from bacterial meningitis in the majority of patients. The possibility of improving diagnostic accuracy with newer tests, such as CSF lactate, ferritin, total amino acids, C-reactive protein, and amyloid-A, should be assessed.
Between 1974 and 1986, eleven of 114 patients undergoing trans-sphenoidal removal of pituitary tumours developed meningitis despite prophylaxis, usually with chloramphenicol. Nine patients had cerebrospinal fluid rhinorrhoea and one died. A variety of pathogens was isolated, including enterobacteria, and four of the eleven were resistant to the antibiotics given as prophylaxis. Enterobacterial meningitis was always associated with infection of the sphenoidal sinus involving the muscle graft or nasal pack (five cases), and removal of the muscle graft was necessary in three cases despite the use of appropriate antibiotics.
Neurosurgical patients with post-operative meningitis often present with negative bacterial cultures. The symptoms and signs as well as laboratory findings are identical to those with verified bacterial meningitis. The aim of this study was to find out whether we are dealing with a sterile reaction, and antimicrobial treatment can safely be stopped.
24 patients with post-operative meningitis with negative bacterial cultures were randomized into two groups. Both were initially treated with chloramphenicol until the results of the bacterial cultures were available. Treatment was then withdrawn in one group and continued in the other. Chloramphenicol had no effect on the outcome and can therefore safely be stopped when adequate bacterial cultures are reported negative.
A case-control analysis was performed to evaluate the association of 15 potential risk factors with postoperative infection in neurosurgical patients. All infections that developed postoperatively on the neurosurgical service at the University of Minnesota from January, 1970, to March, 1984, were identified. Among the 9202 operations performed during that time, 101 infections occurred for a rate of 1.1%. Three risk factors showed significant association with postoperative infection: cerebrospinal fluid (CSF) leak, concurrent noncentral nervous system (CNS) infection, and perioperative antibiotic therapy. The presence of a CSF leak and a concurrent non-CNS infection increased the estimated relative risk of infection to 13:1 and 6:1, respectively. The use of perioperative antibiotics was associated with a decrease in the risk of infection to approximately 20% of the control level. Three other risk factors (paranasal sinus entry, placement of a foreign body, and use of a postoperative drain) appeared to be associated with increased risk of infection, although statistical significance was not demonstrated. None of the remaining nine risk factors studied showed any suggestion of increased risk of infection.
The files of 1143 neurosurgical patients, operated on between November 1, 1979 and June 4, 1981 were examined for records of post-operative infections. Eighty-three patients had developed infections (7%). In addition there were 33 instances of aseptic meningitis. Patients with a shunt were prone to infection (12%). Bone flap infections accounted for more than half of all infections after supratentorial craniotomy. Bacterial meningitis accounted for more than half of all infections after suboccipital craniotomy and translabyrinthine operations. In these patients bacterial meningitis was six times more common, and aseptic meningitis three times more common than in those who had had supratentorial operations. Shunt infection was more common after repeated shunt operations in quick succession. Craniotomy increased the risk of a shunt becoming infected. Antibiotic prophylaxis should be used not only in shunt operations but in all operations performed on patients with a shunt. If bacteria are recovered in a suspected shunt infection, immediate removal of the shunt is the best treatment. However, if the shunt's removal or replacement is exceptionally difficult intraventricular antibiotic treatment may be tried. The age of the patient, the duration of the operation, the individual surgeon and the number of operations did not affect the rate of infection. Clinical signs and conventional laboratory tests, apart from bacterial culture, cannot differentiate between bacterial and aseptic meningitis, but a drop in the level of consciousness suggests bacterial meningitis.
The authors have prospectively examined the occurrence of postoperative wound infection following clean neurosurgery in 936 patients. Fewer than 1% received perioperative antibiotic prophylaxis. The overall rate of deep wound infection was 2.6%; no deaths were directly attributable to these infections. Deep wound infections occurred significantly more frequently following craniotomy (4.3%) than following spinal (0.9%) or other clean neurosurgery. Among craniotomies, the deep wound infection rate varied significantly from 11% following repeat operations for recurrent gliomas to 2.5% following non-tumor surgery. Risk of deep wound infection varied more than 11-fold depending on the type of clean neurosurgical operation. It is most feasible to demonstrate the potential efficacy of perioperative antibiotics in clean neurosurgical procedures with the greatest risk of postoperative wound infection. The potential benefit from such prophylaxis would be greatest for patients undergoing these high-risk operations.
The results of suboccipital craniectomy for varying types of posterior fossa pathology in 50 children are reported. Thirty five (70%) experienced aseptic meningitis postoperatively, with spiking fever and meningismus; cerebrospinal fluid (CSF) studies revealed pleocytosis, high protein values, and depression of glucose. The absence of bacterial pathogens in serial CSF cultures distinguishes this syndrome from septic meningitis. Aseptic meningitis does not respond to antibiotics, but steroids in suitable doses will modify or suppress the clinical and CSF picture. This syndrome may predispose to postoperative hydrocephalus, but steroid therapy may diminish this risk.
HEMOGENIC meningitis is the name proposed for the aseptic meningitis due to blood usually occurring one to five days after a subarachnoid hemorrhage, which may follow intracranial operations, craniocerebral injuries or ruptured or leaking intracranial aneurysms. The purpose of this paper is to present experimental evidence that specific breakdown products of blood are responsible for the aseptic meningeal reactions and hyperthermia observed when blood is present in the subarachnoid space.
LITERATURE
1. Clinical Review. —The literature contains reports of aseptic meningeal irritation following spontaneous subarachnoid hemorrhage¹ and leaking or ruptured aneurysms.²Mallory³ reported a case of intracranial varicosities in which symptoms of meningeal irritation followed each episode of rupture. Such a clinical picture is not unlike that seen in patients with leaking aneurysms.2bThe cerebrospinal fluid is usually pink to xanthochromic, but may be colorless.⁴Aseptic meningeal reactions are often seen following craniocerebral injuries. Spurling
The cerebrospinal fluid and its relation to the blood: a physiologic and clinical study
- S Katzenelbogen
Katzenelbogen S. The cerebrospinal fluid and its relation to the blood:
a physiologic and clinical study. Baltimore: Johns Hopkins University
Press, 1935:379-84.