MANAGEMENT OF ELEVATED INTRACRANIAL-PRESSURE IN PATIENTS WITH CRYPTOCOCCAL MENINGITIS

Background: The most important predictor of early mortality in patient s with HIV-associated cryptococcal meningitis is mental status at pres entation; patients who present with altered mental status have up to 2 5% mortality. Historically, cerebrospinal fluid (CSF) diversion in HIV -negative patients with cryptococcal meningitis and signs of elevated intracranial pressure (ICP) has improved survival. In an effort to aff ect survival and morbidity rates in patients with HIV-associated crypt ococcal meningitis, we have initiated aggressive management of elevate d ICP in patients with focal neurologic deficits, mental obtundation, or both. Methods: We identified 10 patients with HIV-associated crypto coccal meningitis who presented with symptoms consistent with elevated ICP, including headache, mental obtundation, papilledema, and cranial nerve palsies. Elevated opening pressure was defined as >20 cm CSF du ring lumbar puncture. In patients with elevated opening pressures who had focal neurologic deficits or mental status changes refractory to s erial lumbar puncture, management consisted of immediate placement of lumbar drains for continuous drainage of CSF to maintain normal ICP (1 0 cm CSF). Patients with persistent elevations of spinal neuraxis pres sure following lumbar drainage underwent placement of lumbar peritonea l shunts. Results: All patients returned to their baseline level of co nsciousness following normalization of ICP. Two patients were weaned f rom lumbar drainage. Eight patients eventually required placement of l umbar peritoneal shunt; for persistently elevated ICP despite successf ul antifungal therapy. Follow-up ranged from 1 to 15 months. One shunt infection occurred, one lumbar peritoneal shunt was converted to a ve ntriculoperitoneal shunt, and one shunt was removed. Conclusions: Elev ated ICP in patients with HIV-associated cryptococcal meningitis is a significant source of morbidity and mortality. The use of lumbar drain age and selective placement of lumbar peritoneal shunts in the managem ent of elevated ICP in patients with HIV-associated cryptococcal menin gitis can ameliorate the sequelae of elevated ICP.