The role of decompressive craniectomy in treating malignant cerebral oedema in patients with herpes simplex encephalitis

Herpes simpleks virus uzročnik je 10-20% svih encefalitisa. Uvođenjem aciklovira u liječenje ove bolesti smanjena je smrtnost, no ona i dalje ostaje značajna, uglavnom zbog razvoja edema i hernijacije mozga. ----- Dekompresijska kranijektomija opisana je kao metoda liječenja edema mozga u moždanom udaru, traumatskim ozljedama mozga, subarahnoidalnom krvarenju, no jedini objavljeni radovi vezani uz ulogu ovog neurokirurškog postupka u encefalitisu su prikazi slučajeva. ----- U ovom radu prikazani su slučajevi dvaju odraslih bolesnica koje su zbog herpes simpleks encefalitisa liječene u Klinici za infektivne bolesti „dr.Fran Mihaljević“, uz potvrdu dijagnoze nalazom cerebrospinalnog likvora. U obje bolesnice je bolest progredirala uz poremećaj svijesti te respiratornu insuficijenciju. Neuroradiološkom slikovnom dijagnostikom utvrđen je edem mozga koji se pogoršavao do prijeteće hernijacije mozga, kada je indicirana i učinjena dekompresijska kranijektomija. Nakon operacije je uslijedio zamjetan fizički oporavak, no u obje bolesnice su prisutni trajni neuropsihološki poremećaji. ----- Prikazi ovih slučajeva doprinose dosadašnjim saznanjima o pozitivnoj ulozi dekompresijske kranijektomije u smanjenju mortaliteta od malignog edema kao komplikacije encefalitisa. Potrebna su daljnja, veća istraživanja kako bi se jasno definirale indikacije i vrijeme postupka, kao i kriteriji za praćenje oporavka.Herpes simplex virus is the most common cause of encephalitis, making up to 10-20% of all cases. Introduction of acyclovir into the treatment of this infectious disease significantly reduced mortality, however mortality still remains significant, mostly as a consequence of brain oedema and subsequent herniation. ----- Decompressive craniectomy has been described in the treatment of brain oedema consequential to stroke, traumatic brain injury and subarachnoid hemorrhage. In the setting of encephalitis, however, this procedure has only been described in case reports. ----- This dissertation includes case reports of two adult female patients suffering from Herpes simplex viral encephalitis, treated in University Hospital for Infectious Diseases „Fran Mihaljević“. Diagnosis was confirmed with lumbar punction results. Both patients' condition worsened with deteriorating level of consciousness and respiratory insufficiency. Neuroradiological imaging confirmed brain oedema which progressed to threatening herniation, when decompressive craniectomy was indicated and performed. Postoperatively, physical recovery was remarkable; however, both patients remain permanently psychologically impaired. ----- These two case reports contribute to the current scarce amount of published work on the positive effect decompressive craniectomy has on reducing mortality from brain oedema as a complication of encephalitis. Further, larger research is necessary to define clear indications and timing of this procedure, as well as recovery criteria