REHABILITATION OF MODERATE TO SEVERE TBI: NEUROLOGICAL DISORDERS: INTRACRANIAL COMPLICATIONS: INFECTIOUS COMPLICATIONS  

  1. Meningitis
    • Symptoms: include headache, fever, stiff neck, and confusion, but usually no focal signs
    • Diagnosis:
      • CT scan to rule out abscess, empyema, or other mass lesion
      • Lumbar puncture reveals CSF pleocytosis with lowered glucose (<1/3 in most patients)
    • Treatment:
      • Penicillin to treat pneumococcal infection, the most common type of meningitis, and usually the type in adults following nonpenetrating brain injury
      • Broader-spectrum antibiotics to treat staphylococcal and gram-negative infection, more common in late presenting meningitis

  2. Subdural Empyema
    • Symptoms: fever, headache, obtundation, focal signs, seizures, and possibly periorbital swelling or tenderness over the sinuses or mastoid
    • Diagnosis: CT or MRI scan
    • Treatment:
      • Antibiotics to treat multiple organisms, including streptococci, or one organism, usually staphylococci
      • Burr drainage or, in the case of large size, midline shift, parafalcine or posterior fossa location, and loculation, craniotomy is preferred

  3. Brain Abscess is common in penetrating injuries, compound depressed skull fractures, and wound complications
    • Symptoms: can include increased ICP, focal signs, fever, headache, vomiting, seizures, and/or changes in mental status
    • Diagnosis - depends on which of 4 stages:
      • Early cerebritis - radioisotope brain scan and MRI are more sensitive than CT in imaging the developing necrotic center and surrounding edema
      • Late cerebritis - CT scan shows increase in low-density center with a thin rim of enhancement and increasing edema
      • Early capsule - CT scan shows a ring-enhancing capsule and decrease in central lucency
      • Late capsule - CT shows prominent ring enhancement and a low-density center; MRI shows the capsule as low signal on T2-weighted images
    • Treatment:
      • Antibiotics based on anticipated polymicrobial etiology, including anaerobes
      • Steroids to decrease edema, although steroids may decrease ring enhancement and require monitoring treatment response by size on CT scan rather than enhancement
      • Surgery, including CT-guided stereotactic aspiration or excision if abscess is in a surgically inaccessible location, in the cerebritis stage, or in a patient in poor neurologic or medical condition

Based on information in Medical Rehabilitation of Traumatic Brain Injury, L.J. Horn and N.D. Zasler, eds. St. Louis, MO, Mosby, 1996, except for information where other papers are cited.