From the Guidelines
The management of suspected extra-parenchymal etiology, such as meningitis or subarachnoid hemorrhage, requires immediate stabilization of the patient's airway, breathing, and circulation, followed by prompt evaluation and targeted interventions, including empiric antibiotic therapy and lumbar puncture if no contraindications exist, as recommended by the UK Joint Specialist Societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1.
Key Management Steps
- Stabilization of the patient's airway, breathing, and circulation should be an immediate priority, with a decision regarding the need for senior review and/or intensive care admission made within the first hour 1.
- Blood cultures should be taken as soon as possible and within 1 hour of arrival at hospital, followed by empiric antibiotic therapy, which should be commenced immediately after the lumbar puncture has been performed, and within the first hour 1.
- Lumbar puncture should be performed within 1 hour of arrival at hospital, provided that it is safe to do so, and treatment should be commenced immediately after the lumbar puncture has been performed, and within the first hour 1.
- In patients with suspected meningitis, a CT scan should only be performed if there are clinical signs suggestive of a shift of brain compartments, and the patient's conscious level should be documented using the Glasgow coma scale 1.
Treatment Considerations
- The typical regimen for empiric antibiotic therapy includes vancomycin (15-20 mg/kg IV every 8-12 hours) plus a third-generation cephalosporin such as ceftriaxone (2g IV every 12 hours) or cefotaxime (2g IV every 4-6 hours), with ampicillin (2g IV every 4 hours) added for patients over 50 years or immunocompromised to cover Listeria.
- Dexamethasone (0.15 mg/kg IV every 6 hours for 2-4 days) should be administered before or with the first antibiotic dose to reduce inflammation and improve outcomes.
- For suspected subarachnoid hemorrhage, management includes blood pressure control, pain management, nimodipine (60mg orally every 4 hours for 21 days) to prevent vasospasm, and neurosurgical consultation for potential aneurysm securing via coiling or clipping.
Monitoring and Follow-up
- Both conditions require ICU-level monitoring, careful neurological assessments, and management of increased intracranial pressure if present.
- Early diagnosis through appropriate imaging (CT/MRI) and cerebrospinal fluid analysis is crucial for directing specific treatment and improving patient outcomes, as highlighted by the UK Joint Specialist Societies guideline 1 and supported by the rationale for the management of acute meningitis and meningococcal sepsis in immunocompetent adults 1.
From the FDA Drug Label
In animal experiments, nimodipine had a greater effect on cerebral arteries than on arteries elsewhere in the body perhaps because it is highly lipophilic, allowing it to cross the blood-brain barrier; concentrations of nimodipine as high as 12. 5 ng/mL have been detected in the cerebrospinal fluid of nimodipine-treated subarachnoid hemorrhage (SAH) patients. Nimodipine has been shown, in 4 randomized, double-blind, placebo-controlled trials, to reduce the severity of neurological deficits resulting from vasospasm in patients who have had a recent subarachnoid hemorrhage (SAH).
The management approach for suspected extra-parenchymal etiology, such as meningitis or subarachnoid hemorrhage, involves the use of nimodipine to reduce the severity of neurological deficits resulting from vasospasm. The recommended oral dose is 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days 2. It is essential to commence oral nimodipine therapy as soon as possible within 96 hours of the onset of subarachnoid hemorrhage 2. Key considerations include:
- Dosage adjustment in patients with severely disturbed liver function, particularly liver cirrhosis 2
- Avoidance of grapefruit juice due to potential drug interactions 2
- Monitoring of blood pressure and heart rate in patients with impaired liver function or those taking CYP3A4 inhibitors 2
From the Research
Management Approach for Suspected Extra-Parenchymal Etiology
The management approach for suspected extra-parenchymal etiology, such as meningitis or subarachnoid hemorrhage, involves several key steps:
- Diagnosis: Rapid and accurate diagnosis with neuroimaging, such as computed tomography (CT) and computed tomography angiography (CTA) 3
- Control of hypertension: Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers 3
- Correction of coagulopathy: Correction of any coagulopathy if present 3
- Assessment of need for surgical intervention: Assessment of the need for surgical intervention, such as stereotactically guided drainage of intraparenchymal hemorrhage (IPH) with intraventricular hemorrhage (IVH) 3
- Monitoring: Patients should be monitored for seizures and intracranial pressure issues 3
Treatment of Bacterial Meningitis
The treatment of bacterial meningitis involves the use of antibiotics, such as ceftriaxone, which has been shown to be safe and effective when administered once daily 4, 5
- Ceftriaxone: Ceftriaxone has been shown to have excellent antibacterial activity and can be used to treat bacterial meningitis, given as a single daily intravenous dose of 100 mg/kg on day one, followed by 80 mg/kg daily 4
- Cefotaxime: Cefotaxime has also been shown to be effective in treating bacterial meningitis, with a dosage of 50 mg/kg 6 hourly 5
Subarachnoid Hemorrhage
The management of subarachnoid hemorrhage involves several key steps:
- Diagnosis: Diagnosis with CT scanning and lumbar puncture if CT is negative 6
- Treatment of aneurysm: Occlusion of the aneurysm to prevent rebleeding 6
- Prevention of delayed cerebral ischemia: Measures to prevent delayed cerebral ischemia, such as a liberal supply of fluids, avoidance of antihypertensive drugs, and administration of nimodipine 6