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Ventriculitis

Summary

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  • Inflammation of the cerebral ventricles, often associated with meningitis or intraventricular haemorrhage
  • Characterised by ependymal enhancement and intraventricular debris on imaging
  • Requires prompt diagnosis and treatment to prevent complications and neurological sequelae

Pathophysiology

  • Caused by bacterial, viral, or fungal infections
  • Common pathogens:
    • Gram-negative bacteria (e.g., E. coli, Klebsiella)
    • Staphylococcus species
    • Streptococcus species
  • Inflammation leads to:
    • Ependymal cell damage
    • Increased permeability of blood-brain barrier
    • Accumulation of inflammatory cells and debris in ventricles
  • Can result in hydrocephalus and increased intracranial pressure

Demographics

  • Risk factors:
    • Neurosurgical procedures (e.g., ventriculostomy, shunt placement)
    • Intraventricular haemorrhage
    • Prematurity in neonates
    • Immunocompromised status
  • Incidence:
    • 0.8-5.5% following external ventricular drain placement
    • Higher in neonates with intraventricular haemorrhage

Diagnosis

  • Clinical presentation:
    • Fever
    • Altered mental status
    • Headache
    • Neck stiffness
    • Seizures
  • Laboratory findings:
    • Elevated CSF white blood cell count
    • Decreased CSF glucose
    • Elevated CSF protein
  • Microbiological culture of CSF
  • Molecular techniques (e.g., PCR) for pathogen identification

Imaging

  • CT findings:
    • Ventricular dilatation
    • Periventricular hypodensity
    • Intraventricular debris or air bubbles
  • MRI findings:
    • T1-weighted images:
    • Ependymal enhancement with gadolinium
    • Intraventricular debris (hyperintense)
    • T2-weighted images:
    • Periventricular hyperintensity (oedema)
    • Intraventricular debris (hypointense)
    • FLAIR:
    • Hyperintense signal in ventricles
    • Periventricular oedema
  • Advanced techniques:
    • Diffusion-weighted imaging: Restricted diffusion in purulent material
    • MR spectroscopy: Elevated lactate and lipid peaks

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Treatment

  • Antimicrobial therapy:
    • Empiric broad-spectrum antibiotics initially
    • Tailored based on culture results and antibiotic susceptibility
  • Neurosurgical interventions:
    • External ventricular drainage
    • Intraventricular antibiotic administration
    • Removal of infected shunts or devices
  • Supportive care:
    • Management of increased intracranial pressure
    • Seizure prophylaxis
  • Duration of treatment:
    • Typically 2-3 weeks, depending on clinical response and CSF sterilization
  • Monitoring:
    • Serial neuroimaging
    • CSF analysis to assess treatment response

Differential diagnosis

Differential Diagnosis Differentiating Feature
Intraventricular haemorrhage Blood products on CT (hyperdense) and MRI (evolving signal); no ependymal enhancement
Leptomeningeal carcinomatosis Diffuse leptomeningeal and ependymal nodular enhancement; no intraventricular pus or restricted diffusion