What is the management of meningitis presenting with decerebrate posture?

Management of Meningitis with Decerebrate Posturing

Patients with meningitis presenting with decerebrate posturing require immediate aggressive management of increased intracranial pressure (ICP) along with standard antimicrobial therapy to reduce mortality and improve neurological outcomes.

Initial Assessment and Management

• Decerebrate posturing in meningitis indicates severe increased intracranial pressure and is an absolute contraindication to immediate lumbar puncture 1
• Blood cultures should be obtained immediately before initiating empiric antimicrobial therapy 1
• Empiric antimicrobial therapy must be started immediately without waiting for diagnostic procedures 1
• Head CT scan should be performed urgently before considering any lumbar puncture 1

Management of Increased Intracranial Pressure

Basic Measures (Implement Immediately)

• Maintain euvolemia to support normal hemodynamic parameters 1
• Elevate head of bed to 30° to promote venous drainage 1
• Target mean arterial pressure (MAP) of ≥65 mmHg to maintain adequate cerebral perfusion pressure 1
• In patients with evidence of cerebral edema, consider higher MAP targets (70 mmHg) to improve cerebral perfusion pressure 1
• Avoid hyperthermia, hyponatremia, and maintain normocapnia and normoglycemia 1

Advanced Measures

• If hypotensive shock persists despite fluid resuscitation, use norepinephrine as the initial vasopressor 1
• Consider hydrocortisone (200 mg daily) for patients with persistent hypotensive shock 1
• Treat suspected or proven seizures immediately with appropriate anticonvulsants 1
• For patients with suspected or proven status epilepticus, implement EEG monitoring 1

Specific ICP Management

• Crystalloids are the initial fluid of choice; avoid fluid restriction as this does not help reduce cerebral edema 1
• Consider albumin in patients with persistent hypotensive shock despite corrective measures 1
• In severe cases with refractory intracranial hypertension, consider consultation for possible decompressive craniectomy 2, 3
• While routine ICP monitoring is not recommended for all meningitis cases, it may be beneficial in selected severe cases with clinical evidence of increased ICP 1, 4, 3

Antimicrobial and Adjunctive Therapy

• Administer empiric antibiotics based on patient age and predisposing conditions 1
• Consider adjunctive dexamethasone therapy, which has been shown to decrease mortality in bacterial meningitis in high-income countries 5
• Continue antimicrobial therapy based on culture results and susceptibility patterns 1

Monitoring and Follow-up

• Monitor neurological status closely, including pupillary responses, level of consciousness, and motor function 1
• For patients with fluctuating GCS or subtle abnormal movements, consider EEG monitoring to detect non-convulsive status epilepticus 1
• Normalize lactate levels and maintain urine output at ≥0.5 ml/kg/h as indicators of adequate resuscitation 1

Important Caveats

• Lumbar puncture is absolutely contraindicated in patients with decerebrate posturing until ICP is controlled 1
• Delay in antimicrobial therapy increases mortality; therefore, antibiotics must be given before diagnostic procedures 1
• Brain herniation can occur rapidly in meningitis with increased ICP, with most cases occurring within 8 hours after lumbar puncture in untreated patients 1, 6
• Notify public health authorities of all meningitis cases regardless of etiology 1