Management of Aseptic Meningitis

Pathophysiology and Management of ICP

Patients with meningitis may develop increased intracranial pressure (ICP) due to cerebral edema, which requires appropriate management to prevent mortality 2
Basic measures to control raised ICP and maintain cerebral perfusion pressure should be implemented, including maintaining euvolemia 3, 2
The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) recommends head elevation, avoiding hyperthermia and hyponatremia, maintaining normocarbia and normoglycemia, and targeting appropriate mean arterial pressure (MAP) (≥65 mmHg) 2, 3

The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) explicitly states that routine adjuvant therapy with mannitol is not recommended for bacterial meningitis 1
Fluid restriction to reduce cerebral edema is not recommended in meningitis 3

Patients should be kept euvolemic to maintain normal hemodynamic parameters 3
When intravenous fluid therapy is required, crystalloids are the initial fluid of choice 3
For patients with persistent hypotensive shock, albumin should be considered 3
Early treatment of seizures is recommended as they occur in approximately 15% of patients with acute bacterial meningitis and are associated with worse outcomes 2

Control of raised ICP is essential to prevent mortality, though the optimal method remains unclear 2
Routine use of ICP monitoring is not recommended in meningitis 3, 2
In cryptococcal meningitis, the principal intervention for reducing elevated ICP is percutaneous lumbar drainage, not mannitol 4

If mannitol is used despite these recommendations, serum osmolality should be monitored to ensure it remains below 320 mOsm/L 5, 6