Shefali Aggarwal, MD
Physician
Phoenix Children's Hospital
Phoenix, Arizona, United States
Disclosure information not submitted.
Tara Mangum, DO
Physician
Phoenix Children's Hospital, United States
Disclosure information not submitted.
Title: Unraveling the mystery: therapies for pediatric cerebral vasospasm in a case of bacterial meningitis
Case Report Body: Cerebral vasospasm in the setting of bacterial meningitis is rarely reported in pediatrics. There are few guidelines for management of vasospasm due to meningitis in children. We present a case of cerebral vasospasm in a child with infectious angiitis from bacterial meningitis and invasive sinus disease.
Introduction: 12-year-old female presenting with 2-week history of headache and emesis. She acutely developed right-sided hemiparesis, ataxia and slurred speech. On exam, she was arousable without cranial nerve deficits, but had right-sided weakness with positive Babinski. MRI brain showed severe sinus disease with meningeal spread, bilateral ischemic strokes, and hydrocephalus. Severe stenosis of bilateral internal carotid arteries (ICAs) was seen on MRA. Transcranial doppler ultrasound (TCD) confirmed vasospasm in bilateral anterior circulation. Empiric antibiotic therapy and anticonvulsants were started. She underwent a sinus washout and ventriculostomy placement. Nimodipine was initiated along with hypervolemia and permissive hypertension for management of vasospasm, but intravenous milrinone and intrathecal (IT) nicardipine were added as adjunct therapies. By day 4, she underwent cerebral angiography with intra-arterial (IA) verapamil administration for refractory moderate-to-severe vasospasm, with substantial response. Serial TCDs and electroencephalograms (EEGs) were used for neuromonitoring, due to her poor neurologic exam. Vasospasm resolved by week 2, after 3 treatments with IA verapamil and therapies were de-escalated. On day 14, her EEG showed decreased amplitude on right with progressive worsening, prompting an MRI brain. Unfortunately, she suffered a right hemispheric infarction from right ICA thrombosis. Care was subsequently withdrawn due to the devastating neurologic insult.
Conclusion: We highlight some key points for clinicians with our case. Infectious angiitis due to bacterial meningitis involves transmural arterial inflammation, which produces local vasospasm and hypercoagulability. In such cases, management should address vasospasm, hypercoagulability, and underlying infection. IT and IA vasodilator therapy are effective treatments for cerebral vasospasm secondary to bacterial meningitis. Single agent anti-platelet therapy should strongly be considered, given local hypercoagulability and risk of thrombosis.