Management of elevated intracranial pressure in patients with cryptococcal meningitis
Management of elevated intracranial pressure in patients with cryptococcal meningitis
复制标题
DOI：
10.1097/00042560-199802010-00006
复制
发表时间：
1998-02-01
期刊：
影响因子：
--
通讯作者：
Diaz, FG
中科院分区：
文献类型：
--
作者：
Fessler, RD;Sobel, J;Diaz, FG
背景资料：HIV相关隐球菌脑膜炎患者早期死亡率最重要的预测因素是就诊时的精神状态;精神状态改变的患者死亡率高达25%。从历史上看，在HIV阴性的隐球菌脑膜炎患者和颅内压升高（ICP）的迹象，脑脊液（CSF）转移提高了生存率。为了影响HIV相关隐球菌脑膜炎患者的生存率和发病率，我们已经开始积极管理颅内压升高的患者局灶性神经功能缺损，精神迟钝，或both.Methods：我们确定了10例HIV相关隐球菌脑膜炎患者的症状与颅内压升高一致，包括头痛，精神迟钝，视神经乳头水肿，颅神经麻痹。在腰椎穿刺过程中，升高的开放压力被定义为>20 cm CSF。在具有局灶性神经功能缺损或连续腰椎穿刺难治性精神状态变化的开放压升高患者中，管理包括立即放置腰椎引流管以持续引流CSF，以维持正常ICP（10 cm CSF）。腰椎引流后持续升高的脊神经轴压力的患者进行了腰椎腹膜分流安置。结果：所有患者的ICP正常化后恢复到基线意识水平。2例患者停用腰椎引流。8例患者最终需要放置腰椎腹膜分流术;尽管成功进行了抗真菌治疗，但ICP持续升高。随访1 ~ 15个月。一个分流感染发生，一个腰椎腹膜分流转换为脑室腹腔分流，一个分流被removed.Conclusions：ICP升高的HIV相关隐球菌脑膜炎患者是一个显着的发病率和死亡率的来源。在HIV相关隐球菌脑膜炎患者ICP升高的治疗中，使用腰椎引流和选择性放置腰椎腹膜分流管可以改善ICP升高的后遗症。
Background: The most important predictor of early mortality in patients with HIV-associated cryptococcal meningitis is mental status at presentation; patients who present with altered mental status have up to 25% mortality. Historically, cerebrospinal fluid (CSF) diversion in HIV-negative patients with cryptococcal meningitis and signs of elevated intracranial pressure (ICP) has improved survival. In an effort to affect survival and morbidity rates in patients with HIV-associated cryptococcal meningitis, we have initiated aggressive management of elevated ICP in patients with focal neurologic deficits, mental obtundation, or both.Methods: We identified 10 patients with HIV-associated cryptococcal meningitis who presented with symptoms consistent with elevated ICP, including headache, mental obtundation, papilledema, and cranial nerve palsies. Elevated opening pressure was defined as >20 cm CSF during lumbar puncture. In patients with elevated opening pressures who had focal neurologic deficits or mental status changes refractory to serial lumbar puncture, management consisted of immediate placement of lumbar drains for continuous drainage of CSF to maintain normal ICP (10 cm CSF). Patients with persistent elevations of spinal neuraxis pressure following lumbar drainage underwent placement of lumbar peritoneal shunts.Results: All patients returned to their baseline level of consciousness following normalization of ICP. Two patients were weaned from lumbar drainage. Eight patients eventually required placement of lumbar peritoneal shunt; for persistently elevated ICP despite successful antifungal therapy. Follow-up ranged from 1 to 15 months. One shunt infection occurred, one lumbar peritoneal shunt was converted to a ventriculoperitoneal shunt, and one shunt was removed.Conclusions: Elevated ICP in patients with HIV-associated cryptococcal meningitis is a significant source of morbidity and mortality. The use of lumbar drainage and selective placement of lumbar peritoneal shunts in the management of elevated ICP in patients with HIV-associated cryptococcal meningitis can ameliorate the sequelae of elevated ICP.