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Stroke. 1995;26:1399-1403

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(Stroke. 1995;26:1399-1403.)
© 1995 American Heart Association, Inc.

Articles

Clinical Relevance and Frequency of Transient Stenoses of the Middle and Anterior Cerebral Arteries in Bacterial Meningitis

Martin Müller, MD; Stefan Merkelbach, MD; Georg Peter Huss, MD Klaus Schimrigk, MD

From the Department of Neurology, University Hospital of the Saarland, Homburg/Saar, and the Department of Psychiatry, Winnenden (G.P.H.), Germany.

Correspondence to Martin Müller, MD, Department of Neurology, University Hospital of the Saarland, Oscar-Orth-str 3, D-66421 Homburg/Saar, Germany.


*    Abstract
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 *Abstract
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Background and Purpose We sought to examine the frequency and clinical relevance of intracranial artery stenoses in patients with bacterial meningitis in whom the occurrence of stroke has angiographically been reported to be associated with stenoses or occlusions of the large basal cerebral arteries.

Methods Thirty-five unselected patients (24 men, 11 women; mean age, 51±18 years) with bacterial (n=33) or fungal (n=2) meningitis prospectively underwent serial transcranial Doppler sonography recordings of mean blood velocity (MBV) and pulsatility index in the middle (MCA) and anterior (ACA) cerebral arteries, as well as recordings of the ratio of the MBV of the MCA and internal carotid artery (MCA/ICA ratio) on days 1, 3, 5, 8, 14, and 21 after admission. The results were correlated with the Glasgow Coma Scale (days 1 to 14), the occurrence of focal cerebral signs, and the Glasgow Outcome Scale (short-term outcome, day 21). An MCA stenosis was diagnosed by an MBV of 120 cm/s or more or an MCA/ICA ratio of more than 3. An ACA stenosis was diagnosed by an MBV of 100 cm/s or more.

Results Transient stenoses occurred most frequently between days 3 and 5 and were detected in 18 patients (51%). Seventeen patients remained without a stenosis. Patients with stenoses showed a significantly poorer mean Glasgow Coma Scale score from day 3 (9±4) to day 14 (11±4) than patients without a stenosis (day 3: 13±4, P<.01 by t test; day 14: 14±1, P<.05). The mean Glasgow Outcome Scale score was not significantly different between both groups. The occurrence of mainly transient focal cerebral signs was significantly related to the number of narrowed vessels per patient (P<.05, {chi}2 test).

Conclusions Stenoses of the intracranial arteries occur frequently in bacterial meningitis and are associated with a complicated course of the disease.


Key Words: cerebral arteries • meningitis • ultrasonics • vasospasm


*    Introduction
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 *Introduction
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Acute pyogenic infections of the central nervous system caused by bacterial or fungal pathogens are still diseases with a high mortality rate and a high rate of neurological sequelae in the survivors, although specific chemotherapeutic agents have dramatically decreased mortality.1 2 3 4 5 The complications of the inflammation, such as alterations of the cerebral blood flow due to raised ICP, brain edema, hydrocephalus, focal and generalized seizures, abscess, stroke, or dural sinus thrombosis,3 6 7 8 9 are responsible for the occurrence of focal neurological deficits and for poor patient prognosis. The occurrence of stroke in bacterial meningitis was angiographically reported to be accompanied by occlusions or severe stenoses of the large basal cerebral arteries.9 10 11 12 13 14 15 Recently a TCD study in adult patients with bacterial meningitis16 described the MBV in the MCA during a period of 3 weeks, showing an increase in MBV within the first week and its normalization toward the third week. These findings were discussed as a result of either decreasing ICP, metabolic changes, or a narrowing of the proximal MCA. However, the clinical relevance of the MBV pattern in the MCA is not clear. Therefore, we report our experience with the TCD monitoring of patients with pyogenic meningitis with special attention to the clinical aspects.


*    Subjects and Methods
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 *Subjects and Methods
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Thirty-five consecutive patients (24 men, 11 women; mean±SD age, 51±18 years; range, 18 to 81 years) with bacterial (n=33) or fungal (n=2) meningitis were included in the prospective study between June 1992 and January 1995. The clinical diagnosis of meningitis was based on the presence of headache, stiffness of the neck, and fever of more than 38.5°C. The CSF examination routinely included a total leukocyte count, a differential leukocyte count that used smears with May-Grünwald-Giemsa stains, and the measurement of total protein content with the use of a kinetic Biuret method (ASTRA, Beckmann). Bacterial meningitis was assumed when the CSF of the first lumbar puncture exhibited polymorphonuclear leukocytosis and the pathogen could be identified by either culture (CSF, blood sample) or serological antibody titers. When the identification of the pathogen was missed, the polymorphonuclear pleocytosis of the first CSF had to exceed 3000 cells per microliter to classify the patient as suffering from bacterial meningitis. The causative pathogen was identified as Streptococcus pneumoniae (n=14), various staphylococci (n=4), Borrelia burgdorferi (n=3), other streptococci (n=3), tuberculosis (n=2), Neisseria meningitidis (n=1), Listeria monocytogenes (n=1), Corynebacterium diphteroides (n=1), and unknown (n=4). Two patients suffered from Candida albicans meningitis.

Each patient received cranial CT (Siemens Somatom DR) before the first lumbar puncture. Thereafter, a CT scan or MRI was performed when clinically indicated. EEGs were recorded repeatedly during hospitalization. All patients initially received a standard antibiotic therapy consisting of penicillin G, cefotaxime, and gentamycin with adaptation according to the following microbiological susceptibility. Patients with signs of raised ICP or with brain edema on CT scan were treated with hyperosmolar substances. When indicated, mechanical hyperventilation was performed with an arterial blood carbon dioxide tension of 31 mm Hg or more. Dexamethasone therapy was not used.

To correlate the course of the TCD findings with the course of the ICP, the lumbar opening pressure (in millimeters of water) was repeatedly measured by lumbar puncture soon after the TCD examinations in three patients. A fourth patient required surgery for external ventricle drainage due to acute hydrocephalus shortly after admission. In this patient the ICP (in millimeters of water) was recorded continuously with the use of an external ventricle drainage system (EVD Set, PFM), with the drip chamber secured approximately 12 cm above the ventricle level. An ICP of 200 mm H2O or less was considered normal.

According to our study protocol, the first TCD recordings (TC 2-64, EME) were performed within 12 hours after admission of the patients. This included the bilateral insonation of the MCA (at a depth of 50 to 55 mm) and of the ACA (at a depth of 60 to 70 mm) via the temporal approach above the zygomatic arch and of the ICA (at a depth of 35 to 40 mm) via the submandibular approach according to previously published criteria.17 18 The follow-up TCD examinations included the same recordings and were fixed for days 3, 5, 8, 14, and 21 after admission. Additional TCD recordings on the days between were allowed but not necessary. The maximum systolic velocity (Vsystolic), end-diastolic velocity (Vend-diastolic), and MBV were recorded in each artery after blood velocities of 10 cardiac cycles showed a constant velocity steady state. As a vascular resistance index the PI19 was calculated as follows: PI=(Vsystolic-Vend-diastolic)/MBV. Additionally, the recorded blood velocity waveforms were analyzed according to the absence or presence of the diastolic notch, which was found to be present in blood velocity elevation due to a presumed vasospasm but absent in severely increased blood velocities as a result of hyperemia.20

At the time of each TCD recording, the patients were clinically scored with the use of the GCS.21 Additionally, focal cerebral signs such as hemiparesis, aphasia, neglect syndromes, cortical sensory syndromes, focal seizures, and focal slowing or focal epileptic activity on EEG recordings were recorded separately. Because patients with an uncomplicated course of bacterial meningitis have usually recovered after 3 weeks5 and additionally because most hemodynamic disturbances that occur in bacterial meningitis have normalized within 3 weeks,16 22 we chose day 21 after admission to evaluate the short-term outcome using the GOS, as follows: 1, death; 2, persistent vegetative state; 3, severe neurological deficit; 4, slight neurological deficit; and 5, complete recovery.23

Our control group for the TCD recordings consisted of 69 healthy volunteers (34 men, 35 women; mean±SD age, 44±17 years; range, 17 to 80 years) and has been described previously.18 The mean values of MBV and PI for the MCA are 57±13 cm/s and 0.83±0.15, respectively, and for the ACA are 46±11 cm/s and 0.85±0.20, respectively.

Because of the lack of corresponding angiographic and TCD examinations in bacterial meningitis, it is unknown whether a severely increased MBV corresponds to a narrowing of a basal cerebral artery in this condition. In subarachnoid hemorrhage, an MBV in the MCA of 120 cm/s or more or an MCA/ICA ratio of more than 3 corresponds well with angiographically demonstrated vasospasm.24 25 Cerebral hyperemia also elevates the MBV. However, as shown for inspired carbon dioxide, hyperemia increases the MCA/ICA ratio only by approximately 10%.26 In our control subjects, the highest normal MCA/ICA ratio was 3, which is in accordance with a previous report.25 The criterion used for our patients to indicate a narrowing of the MCA was an MBV in the MCA of 120 cm/s or more or an MCA/ICA ratio of more than 3 when the diastolic notch was present in the blood velocity waveform. For an ACA vasospasm, conclusive corresponding data between angiography and TCD do not exist. An MBV of 120 cm/s in the MCA is more than twice the normal MBV of our control subjects. To indicate a stenosis of the ACA, a threshold MBV of 100 cm/s was chosen, which was also more than twice the normal MBV of the ACA in our control subjects. As for the MCA, the diastolic notch had to be present in the ACA blood velocity waveform.

With respect to the total number of narrowed arteries identified during the examination period, the patients were classified into four groups: patients without a stenosis, with stenosis of one artery only, with stenoses of two arteries, and with stenoses of more than two arteries.

Statistical Analysis
All values are reported as mean±SD. The courses of the MCA MBV, the MCA PI, and the MCA/ICA ratio as well as of the ACA MBV and the ACA PI were compared with respect to the presence or absence of a stenosis of the relevant artery by the unpaired t test. This test was also used to compare the GCS score on days 1 to 14 and the GOS score on day 21 between the patients without and those with narrowed arteries. Using the {chi}2 test (after Yates' correction), we analyzed the occurrence of focal cerebral signs with respect to the number of narrowed basal cerebral arteries per patient and with relation to the causative pathogen. The effects of age and of the causative pathogen on the GCS from days 1 to 14 and on the GOS were analyzed by stepwise regression analysis. Regression analysis was also used to correlate CSF total protein content with the presence of narrowing of the MCA.


*    Results
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 *Results
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Twenty-seven of the 35 patients could be insonated bilaterally, and 8 could be insonated only unilaterally because of lack of an adequate "temporal" bone window. The blood velocity waveforms showed a diastolic notch on all TCD recordings. Thus, hyperemic blood flow was not recorded on any of the defined days of TCD examination. The TCD recordings were performed in a total of 58 MCAs and 53 ACAs. Twenty-seven of the 58 MCAs and 10 of the 53 ACAs showed a stenosis according to our TCD criteria. The stenoses could be demonstrated usually for 2 to 4 days except in one patient in whom the narrowing of the MCA persisted until day 21. The MBV and PI of the MCA and ACA as well as the MCA/ICA ratio are shown in Table 1Down, differentiated into MCAs and ACAs with and without stenosis. For the MCA, there were no significant differences of the hemodynamic parameters (MBV, PI, MCA/ICA ratio) on day 1. Thereafter, the MBV and the MCA/ICA ratio increased dramatically and significantly (P<.001) to days 3 and 5 in the MCAs with stenosis, while both parameters showed only a slight increase in the MCAs without stenosis. The difference between the MBV of both groups of MCAs was still significant on day 21 (P<.05). The PI did not differ significantly from days 1 to 21 between both groups of MCAs. The MBV of the ACAs with and without stenosis did not differ on day 1 but was significantly elevated on days 3 and 5 (P<.001) and on day 8 (P<.05) in those ACAs with stenosis compared with the ACAs without stenosis.


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  		Table 1. Course of MBV and PI in the MCA and ACA and the MCA/ICA Ratio in Arteries Without and With Stenosis

An MCA stenosis occurred bilaterally in 9 patients and unilaterally in an additional 9. An ACA stenosis was bilateral in 3 patients and unilateral in 4. Of the 10 ACA stenoses, 9 occurred accompanying an MCA stenosis and 1 was isolated. According to the number of stenoses of the basal cerebral arteries, 17 patients were without a stenosis, 7 patients exhibited 1 stenosis, 6 patients exhibited 2, and 5 patients exhibited more than 2 stenoses. There was no significant correlation between the number of narrowed arteries per patient and the causative pathogen ({chi}2 test). By regression analysis, the occurrence of an MCA stenosis correlated significantly (P<.01) with an increasing CSF total protein content.

In 4 patients repeated measurements of ICP allowed a comparison between the course of the MBV and the course of ICP (Table 2Down). A stenosis in the MCA developed while the ICP was within the normal range (patient 1) or severely increased. Additionally, the MCA/ICA ratio can indicate a stenosis of the MCA before the MBV increase (patients 2 and 3).


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  		Table 2. Relationship Between ICP and the Occurrence of Stenosis in a Basal Cerebral Artery Assessed by TCD in Four Patients

Clinically, the mean GCS score did not differ between the patients with (10±3) and without (12±4) stenoses of the intracranial arteries on day 1. Thereafter, the patients with stenoses of the intracranial arteries exhibited a significantly poorer mean GCS score from day 3 (9±4) to day 14 (11±4) compared with the patients without any stenosis of a basal cerebral artery (day 3: 13±4, P<.01; day 14: 14±1, P<.05). Additionally, by stepwise regression analysis, a lower GCS score on days 1 to 5 was significantly associated with advancing age (P<.01), while the causative pathogen had no effect on the GCS scores from days 1 to 14.

Twenty-two focal cerebral signs were present in 18 patients. An isolated hemiparesis was most frequent (12 of the 22 focal hemispheric signs), followed by aphasia accompanied by a right-sided hemiparesis (2), focal seizures (2), focal slowing on EEG (2), isolated aphasia (2), neglect accompanied by left-sided hemiparesis (2), hemiparesis with accompanying hemisensory disturbances for touch and pain (1), and isolated hemisensory disturbances for touch and pain (1). Six of the 22 focal cerebral signs were already present on day 1, 13 developed between days 2 and 5, and 3 developed between days 7 and 11. With respect to the vascular territories, 20 of the 22 focal cerebral signs could be allocated to the MCA territory and 2 to the ACA territory. By the {chi}2 test, focal cerebral signs were significantly more frequent in patients with an increasing number of narrowed arteries (P<.05). Six of the 22 focal cerebral signs were correlated with pathological changes on CT or MRI scans: small infarctions within the MCA territory in 3 patients, small watershed infarctions in the MCA/ACA border zone in 1 patient, a complete infarction in the MCA territory in 1 patient, and a small subarachnoid hemorrhage (on day 9) within the sylvian fissure in 1 patient. Seventeen focal cerebral signs were transient, disappearing usually within 3 days after their onset. Five focal cerebral signs remained clinically relevant, and all 5 exhibited a correlating brain infarction on CT scan and were accompanied by ipsilateral stenosis of the MCA and/or the ACA.

With respect to the outcome, a poorer GOS score correlated significantly with advancing age (P<.01) but not with the causative pathogen by stepwise regression analysis. The mean GOS score of the patients without a stenosis of an artery (GOS score, 4.05±1.60) did not differ significantly from those with stenoses (GOS score, 3.61±1.50). Including the two patients with fungal meningitis, 6 of the 35 patients died (17%).


*    Discussion
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowSubjects and Methods
 up arrowResults
 *Discussion
down arrowReferences
 
TCD is now a well-established noninvasive technique for monitoring cerebral hemodynamics in a variety of pathological conditions.16 24 25 27 28 29 30 31 However, some of the disadvantages of TCD have to be considered, such as the absence of a bone window, the angle of insonation, the experience of the examiner, and the unknown diameter of the insonated artery, which cannot be determined by this method. TCD and angiographic MCA narrowing correlate well in another common pathological condition of the subarachnoid space, that is, subarachnoid hemorrhage. It has been noted that a rapid increase of the MBV between days 3 and 7 after bleeding can predict the occurrence of an MCA vasospasm.29 32 As a result of previous angiographic reports on stenoses of the basal cerebral arteries in bacterial meningitis, it seems justified to use the TCD criteria developed for subarachnoid hemorrhage for the detection of vessel stenosis in bacterial meningitis.

The vascular complications of bacterial meningitis such as stenosis or occlusion of the large or small vessels, widely distributed wall irregularities of the small vessels, and thrombosis of the veins or sinus are well known.9 10 11 12 13 14 15 The real frequency of a stenosis or an occlusion of the basal cerebral arteries in patients with bacterial meningitis is unknown. Because of the risks of angiography, a serial angiographic study of unselected patients with bacterial meningitis to clarify the frequency and the clinical relevance of stenoses of the basal cerebral artery is not justifiable. Our study consisted of 35 unselected patients with bacterial and fungal meningitis. Eighteen of the 35 patients (51%) exhibited a stenosis of at least one basal cerebral artery that occurred regularly between days 3 and 5. Clinically, the occurrence of vessel stenoses was significantly associated with a poorer GCS score between days 3 and 14. Additionally, the presence of focal cerebral signs between days 2 and 5 was significantly associated with an increasing number of narrowed arteries per patient. These findings are in accordance with two serial angiographic studies of selected patients with bacterial meningitis who underwent angiography because of focal complications or unexplained coma.9 12 In both studies the angiographies were usually performed between days 3 and 5 after admission. They demonstrated isolated or multiple stenoses or occlusions of the large intracranial arteries unilaterally or bilaterally.

Apart from the diameter of the insonated artery, other factors may affect MBV. First, a decrease in ICP has been reported to increase MBV as an index of cerebral blood flow in patients with bacterial meningitis.8 22 An increase in ICP leads to an increase in PI.33 34 35 On days 1 and 3, the inverse relationship between the pattern of the PI and MBV in our patients may therefore reflect a decrease of ICP, with a corresponding increase of MBV. Second, hyperemia increases MBV.20 27 However, the rapid increase of the MCA/ICA ratio is a strong argument against the assumption that the highly elevated MBVs represent hyperemia. Additionally, severe hyperemia should increase ICP and hence the PI. Our corresponding measurements of the ICP and TCD parameters (Table 2Up) demonstrated that the MBV increases did not correlate with ICP. Bode and Harders7 described two infants with bacterial meningitis in whom MBV was severely increased while the repeatedly measured ICP was normal. It is therefore reasonable to assume that the recorded MBV increases in our four patients were independent of ICP.

Most of the focal cerebral signs were transient and without a correlation on imaging scans. This might explain why the outcome was not significantly different between patients with and those without vessel stenosis. Cerebral blood flow studies in patients with bacterial meningitis with the use of single-photon emission clearance techniques or stable enhanced xenon CT36 37 38 have demonstrated brain areas with a reduced regional cerebral blood flow as correlates of clinical focal signs. We found a significant relationship between the number of narrowed vessels per patient and the occurrence of focal cerebral signs. This may suggest that cerebral ischemia due to arterial narrowing may worsen critical metabolic disturbances caused by the inflammatory process.6 37 39 40


*    Selected Abbreviations and Acronyms
 
ACA = anterior cerebral artery
CSF = cerebrospinal fluid
EEG = electroencephalogram
GCS = Glasgow Coma Scale
GOS = Glasgow Outcome Scale
ICA = internal carotid artery
ICP = intracranial pressure
MBV = mean blood velocity
MCA = middle cerebral artery
MCA/ICA ratio = ratio of mean blood velocity between the middle cerebral artery and internal carotid artery
PI = pulsatility index
TCD = transcranial Doppler sonography

Received April 6, 1995; revision received May 15, 1995; accepted May 18, 1995.


*    References
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 *References
 

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