Herpes simplex virus encephalitis requiring emergency surgery

Herpes simplex virus encephalitis requiring emergency surgery

182 revue neurologique 169 (2013) 173–183 Herpes simplex virus encephalitis requiring emergency surgery Ence´phalite herpe´tique fulminante ne´cessi...

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revue neurologique 169 (2013) 173–183

Herpes simplex virus encephalitis requiring emergency surgery Ence´phalite herpe´tique fulminante ne´cessitant une de´compression chirurgicale


A 38-year-old woman was hospitalized three days after onset of headache, fever, olfactory hallucinations, speech alteration. Brain scanner showed diffuse cerebral edema. Cerebrospinal fluid (CSF) analysis revealed lymphocytic meningitis. Treatment with amoxicillin (12 g/day) and acyclovir (30 mg/kg per day) was immediately begun. Amoxicillin was discontinued when positive herpes simplex virus PCR was found. Six days later, her medical condition was worsening with Glasgow coma scale (GCS) at 12. Brain MRI was performed and showed voluminous left temporal hematoma (Fig. 1A). She was admitted in intensive care unit. A few hours later, GCS declined to 3 with bilateral mydriasis. Emergency decompressive

craniotomy was performed with evacuation of left temporal hematoma (Fig. 1B). GCS was at 8 after surgery. Neurological evaluation after surgery revealed aphasia, left deviation of the eyes and right hemiplegia. Mydriasis had disappeared and pupils were reactive to light. Four days later, the patient presented respiratory failure with severe hypoxemia, related to right basal pneumonia. Despite treatment with antibiotics, mechanic ventilation, then extra corporal respiratory support, the patient died 17 days after admittance. HSV encephalitis (HSVE) is a severe disease resulting in 70% mortality at three months if not treated. Acyclovir has dramatically improved prognosis, but mortality rate remains elevated (19%–28%). Less than 50% of patients can return to a normal life after HSVE. Factors predicting poor outcome are: age over 30 years, initiation of antiviral treatment more than four days after first symptoms, GCS score of 6 points or less, detection of abnormal lesions on brain scanner at initiation of antiviral treatment and presence of more than 100 copies/mL of HSV-DNA in the initial CSF (Taira et al., 2009).

Fig. 1 – A. Axial brain MRI (flair and T2* sequences) showing voluminous left temporal hematoma and edema with brainstem compression. B. Brain CT after craniotomy and evacuation of hematoma.


revue neurologique 169 (2013) 173–183

There are 11 reported cases of brain hematoma related to HSVE, which occurred between 1st and 19th day of evolution of the disease (Takeuchi and Takasato, 2011). Only three of those patients underwent decompressive surgery with hematoma evacuation. Brain edema is a more common complication of HSVE, which can occur during the first days of evolution as well as later (until 20th day after the beginning). As HSVE affects almost temporal lobe, both edema and hematoma can result in brainstem compression. Adamo and Deshaies (2008) reported two cases of HSVE with massive edema that underwent emergency surgery with good outcome. Schwab et al. (1997) also observed excellent outcome when they performed hemicraniectomy in six cases of viral encephalitis with signs of uncal herniation (one was a proven HSVE). Barnett et al. (1988) measured intracranial pressure in 10 patients with encephalitis (eight had HSVE proven after biopsy). They showed that the peak of intracranial pressure occurred on average at 12th day after onset of the disease. Patients suffering of HSVE with risk factors predicting a poor outcome should be hospitalized in intensive care unit. Cerebral edema and hematoma are potentially lifethreatening conditions. They can happen lately in the evolution of the disease despite acyclovir treatment. Conservative medical treatment (osmotic agents, corticosteroids, hyperventilation. . .) is most of the time sufficient, but surgery should be quickly considered in case of secondary neurological deterioration.

Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.


Adamo MA, Deshaies EM. Emergency decompressive craniectomy for fulminating infectious encephalitis. Report of two cases. J Neurosurg 2008;108:174–6. Barnett GH, Ropper AH, Romeo J. Intracranial pressure and outcome in adult encephalitis. J Neurosurg 1988;68:585–8. Schwab S, Ju¨nger E, Spranger M, Do¨rfler A, Albert F, Steiner HH, et al. Craniectomy: an aggressive treatment approach in severe encephalitis. Neurology 1997;48:412–7. Taira N, Kamei S, Morita A, Ishihara M, Miki K, Shiota H, et al. Predictors of a prolonged clinical course in adult patients with herpes simplex virus encephalitis. Intern Med 2009;48(2):89–94. Takeuchi S, Takasato Y. Herpes simplex virus encephalitis complicated by intracerebral hematoma. Neurol India 2011;59(4):594–6.

F. Battaglia* R. Noudel P.-H. Roche Service de neurochirurgie, Aix-Marseille universite´, hoˆpital Nord, chemin des Bourrelys, 13915 Marseille cedex 20, France *Corresponding author. E-mail address: [email protected] (F. Battaglia) Received 16 April Received in revised form 2 May Accepted 8 May Published online 6 September

2012 2012 2012 2012

0035-3787/$ – see front matter # 2012 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.neurol.2012.05.010