Diagnosis and management of increased intracranial pressure in patients with AIDS and cryptococcal meningitis

This study was undertaken to characterize the laboratory and clinical cours e of patients with AIDS and cryptococcal meningitis who had normal or eleva ted cerebrospinal fluid (CSF) pressure. Data were obtained retrospectively from a randomized multicenter quasifactorial phase III study comparing amph otericin B with or without flucytosine in primary treatment of cryptococcal meningitis. CSF pressure was measured before treatment and at 2 weeks. Rep eated lumbar punctures were done to drain CSF and to reduce pressure, Patie nts with the highest baseline opening pressures (greater than or equal to 2 50 mm H2O) were distinguished by higher titers of cryptococcal capsular pol ysaccharide antigen in CSF; more frequently positive India ink smears of CS F; and more frequent headache, meningismus, papilledema, hearing loss, and pathological reflexes. After receiving antifungal therapy, those patients w hose CSF pressure was reduced by >10 mm or did not change had more frequent clinical response at 2 weeks than did those whose pressure increased >10 m m (P <.001), Patients with pretreatment opening pressure greater than or eq ual to 250 mm H2O had increased short-term survival compared with those wit h higher pressure, We recommend that opening pressures greater than or equa l to 250 mm H2O be treated with large-volume CSF drainage.