Correct!
2. Cushing’s reflex is a typically-seen sign of intracranial hypertension.
Cushing’s reflex (hypertension and bradycardia) is a sign of intracranial hypertension seen in only a minority of patients. Our patient’s initial vomiting followed by severe hypertension and respiratory distress were likely all early findings of progressive intracranial hypertension. Papilledema was likely present, but ophthalmological examination was not performed.
It is perplexing that although cerebral edema and related intracranial hypertension are thought to be the primary cause of many of the life-threatening neurological complications of bacterial meningitis, little research has been performed regarding management of ICH in such patients. Emerging literature suggests that aggressive management of ICH including EVD placement with CSF drainage may improve outcomes.
On the sixth hospital day, a brain perfusion study (Figure 3) showed no appreciable blood flow above the skull base and a “Hot nose sign” consistent with extracranial shunting. These findings supported the clinical diagnosis of brain death. The ventilator was withdrawn.
Figure 3. Nuclear perfusion study of our patient’s brain, consistent with brain death.
Community-acquired bacterial meningitis is a medical emergency with untreated mortality approaching 100% and a high failure rate even when therapy is appropriate. Rapid initiation of appropriate antibiotics is the most important aspect of treatment. Our patient’s unfortunate course highlights pitfalls in the early recognition of community-acquired bacterial meningitis, and the proper timing of adjunctive dexamethasone therapy. Our institution has an active neurosurgical team, and we will strongly consider aggressive ICP management the next time we encounter an encephalopathic patient with suspected community-acquired bacterial meningitis.
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