What type of meningitis can cause intracerebral hemorrhage?

Types of Meningitis That Cause Intracerebral Hemorrhage

Bacterial meningitis, particularly pneumococcal meningitis, is the most common type of meningitis associated with intracerebral hemorrhage as a complication. 1

Bacterial Meningitis Types Associated with Intracerebral Hemorrhage

• Pneumococcal meningitis (Streptococcus pneumoniae) is frequently linked to cerebrovascular complications including intracerebral hemorrhage 1, 2
• Meningococcal meningitis (Neisseria meningitidis) can cause severe sepsis with coagulopathy leading to hemorrhagic complications 1
• Anthrax meningoencephalitis (Bacillus anthracis) has a high incidence of intracranial hemorrhage, including both subarachnoid and intracerebral hemorrhage 3
• Brucellosis (Brucella species) can cause neurobrucellosis with meningovascular complications including intracerebral hemorrhage from presumed mycotic aneurysms 4
• Tuberculous meningitis can lead to vascular complications including intracerebral hemorrhage, particularly through the development of pseudoaneurysms 5

Pathophysiological Mechanisms

• Cerebrovascular complications occur frequently during bacterial meningitis and can include cerebral infarctions, subarachnoid hemorrhage, intracerebral hemorrhage, and venous sinus thrombosis 1
• The development of intracerebral hemorrhage has been specifically associated with the use of anticoagulants in patients with bacterial meningitis 1
• Inflammatory responses during meningitis can damage blood vessel walls, potentially leading to weakening and rupture 2
• In meningococcal disease, coagulopathy from severe sepsis can contribute to hemorrhagic complications 1
• Formation of mycotic aneurysms (infectious aneurysms) that subsequently rupture is another mechanism for intracerebral hemorrhage in bacterial meningitis 4

Risk Factors for Severe Complications

• Rapidly progressing rash in meningococcal disease 1
• Coma or altered mental status 1
• Hypotension and shock 1
• Elevated lactate levels (>4 mmol/L) 1
• Low/normal peripheral white blood cell count 1
• Low platelets and coagulopathy 1
• Absence of meningitis symptoms (in cases of primarily septic presentations) 1

Diagnostic Considerations

• Cranial imaging (preferably MRI, but CT if MRI is not readily available) is indicated when neurological deterioration occurs in patients with bacterial meningitis 1
• In patients with focal neurological deficits, new-onset seizures, or severely altered mental status, brain imaging should be performed before lumbar puncture 6
• Blood cultures should be obtained and empiric antibiotics started immediately if lumbar puncture is delayed 6

Management Implications

• When intracerebral hemorrhage is detected on cranial imaging in a patient with bacterial meningitis, neurosurgical intervention may be warranted to prevent cerebral herniation 1
• Early and appropriate antibiotic therapy is crucial, ideally within 1 hour of clinical suspicion 6
• For adults aged 18-50 years with suspected bacterial meningitis, empiric therapy includes ceftriaxone or cefotaxime plus vancomycin or rifampicin 6
• For adults over 50 years or immunocompromised patients, ampicillin/amoxicillin/penicillin G should be added to cover Listeria monocytogenes 6
• Intensive care referral is indicated for patients with rapidly evolving rash, GCS ≤12, cardiovascular instability, respiratory compromise, frequent seizures, or altered mental state 6

Prognosis and Complications

• Neurological deficits occur in approximately 50% of adults with bacterial meningitis 6
• Hearing loss occurs in 5-35% of patients with bacterial meningitis 6
• Intracerebral hemorrhage as a complication of bacterial meningitis carries a high risk of mortality and morbidity 2
• The simultaneous presence of meningitis and intracerebral hemorrhage is rare, but prompt identification and treatment of both conditions is essential to maximize outcomes 7

Remember that bacterial meningitis with intracerebral hemorrhage is a medical emergency requiring immediate intervention with appropriate antibiotics and potential neurosurgical management to improve survival and reduce long-term neurological sequelae.