Kofler Mario, Schiefecker Alois, Beer Ronny, Sohm Florian, Broessner Gregor, Rhomberg Paul, Lackner Peter, Pfausler Bettina, Thomé Claudius, Schmutzhard Erich, Helbok Raimund
Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
Neurocrit Care. 2016 Oct;25(2):273-81. doi: 10.1007/s12028-016-0272-8.
Viral encephalitis is an emerging disease requiring intensive care management in severe cases. Underlying pathophysiologic mechanisms are incompletely understood and may be elucidated using invasive multimodal neuromonitoring techniques in humans.
Two otherwise healthy patients were admitted to our neurological intensive care unit with altered level of consciousness necessitating mechanical ventilation. Brain imaging and laboratory workup suggested viral encephalitis in both patients. Invasive neuromonitoring was initiated when head computed tomography revealed generalized brain edema, including monitoring of intracranial pressure, brain metabolism (cerebral microdialysis; CMD), brain tissue oxygen tension (in one patient), and cerebral blood flow (in one patient).
Brain metabolism revealed episodes of severe neuroglucopenia (brain glucose <0.7 mM/l) in both patients, which were not attributable to decreased cerebral perfusion or hypoglycemia. CMD-glucose levels changed depending on variations in insulin therapy, nutrition, and systemic glucose administration. The metabolic profile, moreover, showed a pattern of non-ischemic metabolic distress suggestive for mitochondrial dysfunction. Both patients had a prolonged but favorable clinical course and improved to a modified Rankin Scale Score of 1 and 0 three months later.
Invasive multimodal neuromonitoring is feasible in poor-grade patients with viral meningoencephalitis and may help understand pathophysiologic mechanisms associated with secondary brain injury. The detection of neuroglucopenia and mitochondrial dysfunction may serve as treatment targets in the future.
病毒性脑炎是一种新发疾病，重症病例需要重症监护管理。其潜在的病理生理机制尚未完全明确，可通过对人类使用侵入性多模态神经监测技术来阐明。
两名原本健康的患者因意识水平改变需机械通气而入住我们的神经重症监护病房。脑部影像学和实验室检查提示两名患者均患有病毒性脑炎。当头部计算机断层扫描显示广泛性脑水肿时，开始进行侵入性神经监测，包括监测颅内压、脑代谢（脑微透析；CMD）、脑组织氧分压（一名患者）和脑血流量（一名患者）。
两名患者的脑代谢均显示出严重神经低血糖症发作（脑葡萄糖<0.7 mM/l），这并非由脑灌注减少或低血糖所致。CMD葡萄糖水平根据胰岛素治疗、营养和全身葡萄糖给药的变化而改变。此外，代谢谱显示出一种提示线粒体功能障碍的非缺血性代谢窘迫模式。两名患者的临床病程均较长但预后良好，三个月后改良Rankin量表评分为1分和0分。
侵入性多模态神经监测在病毒性脑膜脑炎病情较差的患者中是可行的，可能有助于了解与继发性脑损伤相关的病理生理机制。神经低血糖症和线粒体功能障碍的检测未来可能作为治疗靶点。
