Impaired Cerebral Autoregulation in a Case of Severe Acute Encephalitis

CASE REPORT Impaired Cerebral Autoregulation in a Case of Severe Acute Encephalitis Sung-Chun Tang, Sheng-Jean Huang, 1 Ming-Jang Chiu,* Ping-Keung Yip The status of cerebral autoregulation (CA) is an important prognostic factor for acute head trauma, but the role of CA in patients with acute encephalitis has not been previously discussed. We present the case of a 30-year-old woman with severe acute encephalitis who underwent craniectomy for intractable increased intracranial pressure (ICP). Preoperatively, adjustments of blood pressure (BP) with simultaneous recording of changes in cerebral blood flow velocity with transcranial Doppler indicated increased ICP and impaired CA. Postoperatively, ICP declined remarkably but CA remained impaired when the relationship between spontaneous fluctuation of mean BP and ICP was analyzed. Increased ICP recurred again within 24 hours of the decompression surgery and caused death of the patient. We propose that evaluating the status of CA could be of prognostic importance in patients with severe encephalitis. [J Formos Med Assoc 2007;106(2 Suppl):S7 S12] Key Words: cerebral autoregulation, craniectomy, encephalitis, intracranial pressure Under physiologic conditions, cerebral autoregulation (CA) maintains a constant cerebral blood flow (CBF) despite fluctuations in cerebral perfusion pressure, which normally ranges from to 1 mmhg. 1 In some pathologic conditions, CA may be impaired or lost, rendering the patients vulnerable to either cerebral ischemia or hyperperfusion injury. Several studies have documented an association between disturbed CA and unfavorable outcome after head injury. 2 5 However, the role of CA in patients with acute encephalitis has not been discussed. Recently, several methods have been devised to evaluate the state of CA either by clinical testing such as the leg-cuff test 6,7 and norepinephrine infusion test 8,9 or by analysis of the physiologic signals. 2 5 Some studies used transcranial Doppler (TCD) sonography as a noninvasive measurement for evaluation of human CA. By using inotropic agent or changing body position, we can manipulate the blood pressure (BP) during simultaneous recording of CBF 8,9 with continuous TCD monitoring. Impaired CA is defined as when the flow velocity changes are proportional to the BP changes. The status of CA can also be represented by the pressure reactivity index (PRx), which is the relationship between the spontaneous fluctuation of BP and the increased intracranial pressure (ICP). 2 5 The PRx is obtained by calculating the correlation coefficient between the mean BP and ICP; the value ranges between 1 and +1. A negative value reflects a normally reactive vascular bed, whereas a positive value reflects passive and nonreactive vessels. We report a case of severe acute encephalitis who underwent craniectomy for medically 2007 Elsevier & Formosan Medical Association....................................................... Departments of Neurology and 1 Neurosurgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan. Received: December 9, 2005 Revised: February 22, 2006 Accepted: April 4, 2006 *Correspondence to: Dr Ming-Jang Chiu, Department of Neurology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan. E-mail: mjchiu@ntumc.org S7

S.C. Tang, et al Figure 1. (A) Magnetic resonance imaging (MRI) of the brain performed at the emergency service shows multiple lesions of high signal intensity in the white matter of bilateral cerebral hemispheres. (B) Follow-up MRI shows aggravated brain swelling and extension of the brain lesions. A A2 B B2 uncontrolled ICP. We demonstrate the clinical condition as well as CA status with the PRx. Case Report After an influenza-like respiratory tract infection, a 30-year-old woman had acute-onset headache, impaired consciousness, and unsteady gait. She did not have any major systemic disease or relevant drug, trauma, or travel history. On admission, she was mildly drowsy and could not follow commands well. Her body temperature was normal, and the physical examination did not find any significant abnormality. The neurologic examination found bilateral papilledema and symmetric pupil size with prompt light responses. Her brainstem reflexes including corneal, oculocephalic, and cough reflexes were all preserved. There was no gaze limitation or focal motor weakness. The plantar responses were extensor bilaterally. Magnetic resonance imaging (MRI) showed multiple lesions of high-signal intensity mainly in the deep and subcortical white matter of bilateral cerebral hemispheres, medulla, and right cerebellum on T2- and gadolinium-enhanced T1-weighted images (Figure 1A). Diffuse brain swelling was also noted. MR angiography and venography did not reveal any vascular abnormality. Cerebral spinal fluid (CSF) study on the same day indicated an elevated ICP (26 mmhg), a cell count of 16 lymphocytes, a protein level of 73.5 mg/dl, and a glucose level of 76 mg/dl. Bacterial and fungal cultures of serum and CSF were negative. Virus isolation and antibody testing and polymerase chain reaction for herpes simplex virus DNA from a CSF sample were negative. Serum immunologic studies were unremarkable and C-reactive protein level was 0.25. S8

Cerebral autoregulation and acute encephalitis A 125 75 B 200 1 25 0 0 25 Figure 2. Transcranial Doppler monitoring shows: (A) reverse of diastolic flow; and (B) hyperemic flow as the mean blood pressure increased from 90 mmhg to around 130 mmhg. Electroencephalography showed diffuse slow waves occurring bilaterally intermittently without epileptiform discharges. After admission, the patient was treated with intravenous acyclovir, pulse steroid, and osmotic diuretics therapies and her condition stabilized with an oriented level of consciousness. However, acute deterioration of the consciousness level occurred 4 days after admission. Intubation with mechanical ventilation was performed for acute respiratory distress. A repeated head MRI study showed aggravated brain swelling and extension of the previously noticed lesions (Figure 1B). At that time, TCD of the middle cerebral artery (MCA) showed reversed diastolic blood flow consistent with severely raised ICP (Figure 2A). Within a short period of time, as mean BP increased from 90 mmhg to around 130 mmhg under inotropic agent therapy, the Doppler signals shifted to a hyperemic flow pattern (high systolic and diastolic velocity with low flow resistance) (Figure 2B). The change in flow pattern could not be simply explained by reduction in ICP or increase in BP; thus the impression of impaired CA was obtained. Her condition improved (Glasgow coma scale changed from E1M2V1 to E1M5V1) after resuscitation and intensive care. Unilateral craniectomy with ICP monitoring was performed to further control the increased ICP. ICP decreased from 58 mmhg before to 18 mmhg after the operation. To assess the status of postoperative CA, PRx was calculated through continuous monitoring of arterial BP and ICP at around 6 and 12 hours after the operation. 2,3 Three average values of the arterial BP and ICP were calculated for 5-second intervals using waveform time integration. The PRx was obtained by a moving linear (Pearson s) correlation coefficient between the most recent consecutive 5-second averages of the mean BP and ICP. At about 6 hours after craniectomy, the PRx was at near-zero to mild positive values (Figure 3A). At about 12 hours after craniectomy, progressively increasing ICP with positive values of PRx (approximately 1.0) was noted despite aggressive medical treatment (Figure 3B). Although PRx data were not available at about 8 hours (mean arterial BP [MABP] 96 102 mmhg, ICP 25 27 mmhg, mean flow velocity [MFV] 86.4 m/s, pulsatility index [PI] 0.725 in the left MCA) and 10 hours after craniectomy (MABP 85 96 mmhg, ICP 15 18 mmhg, MFV 131 cm/s, PI 0.675 in the left MCA after manitol), both TCD data indicated a hyperemic flow pattern with high flow velocities and low resistance. Within 24 hours, ICP increased gradually to 70 mmhg with MABP between 80 85 mmhg and poor MCA flow. During the postoperative course, hourly transcranial colorcoded sonography (TCCS) studies did not detect rapid change in midline shift, abnormal hyperechoic regions, or asymmetry of PI in the MCA, so the possibility of massive intracranial hemorrhage was very scant. 10 14 Due to the grave prognosis, her family refused craniectomy on the other side or any further aggressive treatment and the patient died. S9

S.C. Tang, et al A 180 140 60 200 160 120 80 40 30 20 1 0.6 0.2 0.2 0.6 PRx ICP mmhg FV cm/s ABP mmhg ICP mmhg FV cm/s ABP mmhg 180 140 60 200 160 120 80 40 30 20 1 0.6 0.2 0.2 0.6 Time 3 min 10 min B PRx Time Figure 3. Observations of changes in intracranial pressure (ICP), arterial blood pressure (ABP), flow velocity (FV) in the middle cerebral artery, and pressure reactivity index (PRx). (A) At about 6 hours after craniectomy, the ICP remains low but the PRx is at around zero to mild positive levels. (B) At about 12 hours after craniectomy, the ICP has progressively increased and the PRx is close to 1. Discussion The patient had acute encephalitis with diffuse brain swelling. Based on the clinical presentation, imaging findings and results of laboratory studies on serum and CSF, postinfectious acute disseminated encephalitis or virus encephalitis were the most probable etiology. The patient received pulse steroid therapy, intravenous acyclovir, and osmotic diuretics after admission but her level of consciousness declined 4 days later. On the 1 st day of admission, CSF study was performed to clarify the underlying etiology, so the possibility of lumbar puncture induced acute herniation should be considered. However, there was no contraindication to lumbar puncture for the patient at the time of CSF study and the change in neurologic status occurred several days after the puncture. 15,16 Therefore, progression of the underlying encephalitis and increased ICP could be the most possible causes responsible for neurologic deterioration after admission. Craniectomy has been used as a treatment for brain edema due to severe encephalitis. 17,18 All of the reported cases had received maximum medical treatment for elevated ICP while brainstem compression signs later appeared. Unilateral craniectomy was performed in nine patients and bilateral craniectomy was performed in one patient to control ICP, either unilateral or bilateral craniectomy was effective. Both articles concluded that craniectomy was life-saving in the acute stage of the disease and was also able to protect the brain tissue of patients with severe encephalitis. In this case, craniectomy was performed because the increased ICP could not be controlled by medical therapy. Although the ICP decreased remarkably after the craniectomy, it elevated again within 24 hours despite concomitant intensive medical therapy. In addition to the underlying S10

Cerebral autoregulation and acute encephalitis malignant process of the disease, persistently impaired CA throughout the course of treatment could be an important factor in this fatal outcome. Determination of CA depends on accurate assessment of CBF, which could be difficult in clinical practice. 19 Therefore, measurement of flow velocity instead of CBF by TCD is often used as a surrogate marker considered proportional to CBF. Thus, TCD sonography has been used as a noninvasive measurement to evaluate CA in human subjects and clinical population. 8,9 As already mentioned, CA can be represented by PRx which has the advantage of continuous monitoring of cerebrovascular pressure reactivity without artificial manipulation of the MAP. Another strength of this global index of cerebrovascular pressure reactivity is that it reflects graded loss of autoregulation, not just present or absent. Previous studies have shown a significant correlation between PRx and outcome after head injury, which included a time-dependent element: if PRx persisted above 0.2 for more than 6 hours, this was usually associated with fatal outcome. 2 In this case, before the craniectomy, a rapid shift of Doppler signals from reversed diastolic flow to hyperemic flow within a small range of BP on TCD highly suggested either loss of CA or a narrowed CA plateau. At about 6 hours after the craniectomy, assessment of the PRx revealed persistently impaired CA despite decreased ICP. The CA was further impaired as ICP increased again. Under the condition of impaired CA, it is very difficult to maintain an optimal cerebral perfusion even with aggressive medical therapy and surgical intervention. Therefore, persistently disturbed CA, as in this case, would easily cause hyperperfusion or ischemic injury, which resulted in the unfavorable outcome. There are several limitations of this report. First, postmortem examination was not performed to confirm the clinical diagnosis. Second, we depended on TCCS rather than head computed tomography (CT) to rule out postoperative massive intracranial hemorrhage. However, transporting the patient to undergo head CT in such a critical condition could easily aggravate the patient s intracranial hypertension. Besides, TCCS has been shown to be a reliable method to image the brain parenchyma, ventricular system, and also measure the intracranial flow velocity and resistance especially in patients with craniectomy, 10 14 so the possibility of postcraniectomy massive intracranial hemorrhage in this patient was scant. Finally, this is an observation from a single case; we need to study more cases to confirm the prognostic significance of CA in patients with severe encephalitis. In conclusion, we reported a case of severe encephalitis complicated with intractable increased ICP. Impaired CA was found throughout the course of treatment. We propose that evaluation of the status of CA is of prognostic importance in patients with severe encephalitis as it is in patients with acute head trauma. In this report, we have demonstrated the status of CA in different stages of a case with fatal encephalitis. References 1. Chillon JM, Baumbach GL. Autoregulation: arterial and intracranial pressure. In: Edvinsson L, Krause DN, eds. Cerebral Blood Flow and Metabolism, 2 nd edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2002:395 412. 2. Czosnyka M, Smielewski P, Kirkpatrick P, et al. Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery 1997;41:11 9. 3. Czosnyka M, Smielewski P, Piechnik S, et al. Cerebral autoregulation following head injury. J Neurosurg 2001; 95:756 63. 4. Czosnyka M, Smielewski P, Kirkpatrick P, et al. Continuous monitoring of cerebrovascular pressure-reactivity in head injury. Acta Neurochir Suppl 1998;71:74 7. 5. Steiner LA, Czosnyka M, Piechnik SK, et al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med 2002; 30:733 8. 6. Aaslid R, Lindegaard KF, Sorteberg W, et al. Cerebral autoregulation dynamics in humans. Stroke 1989;20:45 52. 7. Giller CA. A bedside test for cerebral autoregulation using transcranial Doppler ultrasound. Acta Neurochir (Wien) 1991;108:7 14. 8. Jansen GF, Krins A, Basnyat B, et al. Cerebral autoregulation in subjects adapted and not adapted to high altitude. Stroke 2000;31:2314 8. S11

S.C. Tang, et al 9. Sundgreen C, Larsen FS, Herzog TM, et al. Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke 2001;32:128 32. 10. Maurer M, Shambal S, Berg D, et al. Differentiation between intracerebral hemorrhage and ischemic stroke by transcranial color-coded duplex-sonography. Stroke 1998; 29:2563 7. 11. Seidel G, Kaps M, Dorndorf W. Transcranial color-coded duplex sonography of intracerebral hematomas in adults. Stroke 1993;24:1519 27. 12. Tang SC, Huang SJ, Jeng JS, et al. Third ventricle midline shift due to spontaneous supratentorial intracerebral hemorrhage evaluated by transcranial colorcoded sonography. J Ultrasound Med 2006;25: 203 9. 13. Mayer SA, Thomas CE, Diamond BE. Asymmetry of intracranial hemodynamics as an indicator of mass effect in acute intracerebral hemorrhage: a transcranial Doppler study. Stroke 1996;27:1788 92. 14. Tang SC, Jeng JS, Yip PK, et al. Transcranial color-coded sonography for the detection of middle cerebral artery stenosis. J Ultrasound Med 2005;24:451 7. 15. Oliver WJ, Shope TC, Kuhns LR. Fatal lumbar puncture: fact versus fiction an approach to a clinical dilemma. Pediatrics 2003;112:174 6. 16. van Crevel H, Hijdra A, de Gans J. Lumbar puncture and the risk of herniation: when should we first perform CT? J Neurol 2002;249:129 37. 17. Schwab S, Junger E, Spranger M, et al. Craniectomy: an aggressive treatment approach in severe encephalitis. Neurology 1997;48:412 7. 18. Taferner E, Pfausler B, Kofler A, et al. Craniectomy in severe, life-threatening encephalitis: a report on outcome and longterm prognosis of four cases. Intensive Care Med 2001; 27:1426 8. 19. Steiner LA, Czosnyka M. Should we measure cerebral blood flow in head-injured patients? Br J Neurosurg 2002; 16:429 39. S12