Decompressive craniectomy and duraplasty in severe bacterial encephalitis

Introduction: Severe encephalitis may be associated with brain oedema and elevation of intracranial pressure. The control of intracranial pressure is crucial to combat a fatal course. If conventional therapy fails, in cerebral infarction or severe head injury decompressive craniectomy is used with increasing frequency. Even in children encouraging results of this procedure are published. There are, however, only few reports published concerning operative therapy of elevated intracranial pressure in encephalitis.

Case report: A before healthy five year-old boy was presented to his paediatrician because of earache. Acute otitis media was excluded. Within few hours, fever rose considerably; the boy developed dysarthria, he got an epileptic seizure and started to vomit. At arrival in the hospital the boy was somnolent. Spinal tap showed pleocytosis and increased protein content in cerebrospinal fluid. Cranial MRI disclosed a one-sided, incipiently space-occupying brain oedema. Therapy with antibiotics, acyclovir and dexamethason was started. But the boy's clinical state got worse, and one day after the MRI cranial CT showed increasing hemispheric brain oedema with imminent brain-stem herniation. We decided to perform one-sided decompressive craniectomy combined with duraplasty. In blood culture Streptococcus mitis was detected. 12 days after craniectomy, MRI disclosed a consistently severe brain oedema. Only after further 6 days, MRI was clearly improved. Also the neurological symptoms started to ameliorate now. During the following rehabilitation, the boy made further good progress. The removed bone flap was re-implanted after three months. Remaining hemiparesis and speech disorder receded during the following months. Later the foudroyant course of the encephalitis was explained by a hereditary immunodeficiency (complement factor-I-deficiency).

Conclusion: In severe brain oedema, decompressive craniectomy and duraplasty may be a life-saving procedure resulting in favourable neurological outcome, also in encephalitis.