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Case Report

Decompressive craniectomy in herpes simplex

encephalitis

2
1
3
Muhammed Jasim Abdul Jalal , Shirley Joan Fernandez , Prithvi Varghese , Murali Krishna Menon 2
1 Department of Family Medicine, Lakeshore Hospital and Research Centre, Kochii 682040, Kerala, India.
2 Department of Neurology, Lakeshore Hospital and Research Centre, Kochii 682040, Kerala, India.
3 Department of Neurosurgery, Lakeshore Hospital and Research Centre, Kochii 682040, Kerala, India.
ABSTRA CT

Intracranial hypertension is a common cause of morbidity in herpes simplex encephalitis (HSE). HSE is the most common form of
acute viral encephalitis. Hereby we report a case of HSE in which decompressive craniectomy was performed to treat refractory
intracranial hypertension. A 32‑year‑old male presented with headache, vomiting, fever, and focal seizures involving the right upper
limb. Cerebrospinal fluid‑meningoencephalitic profile was positive for herpes simplex. Magnetic resonance image of the brain showed
swollen and edematous right temporal lobe with increased signal in gray matter and subcortical white matter with loss of gray, white
differentiation in T2‑weighted sequences. Decompressive craniectomy was performed in view of refractory intracranial hypertension.
Decompressive surgery for HSE with refractory hypertension can positively affect patient survival, with good outcomes in terms of
cognitive functions.

Key words: Decompressive craniectomy, herpes simplex encephalitis, refractory intracranial hypertension

INTRODUCTION and a localized lesion in the temporal lobe usually
reflects HSE, but other diseases can also mimic this
Herpes simplex encephalitis (HSE) is the most common condition. Cerebrospinal fluid (CSF) examination
[7]
form of acute viral encephalitis. HSE is caused by is indicated for suspected HSE patients even if the
[1]
herpes simplex virus types 1 and 2 (HSV-1 and HSV-2), intracranial pressure is increased. [7]
two DNA viruses of the Herpesviridae family. HSV is
the most frequent agent of sporadic fatal encephalitis Herpes simplex virus usually causes a mild disease
with an annual incidence of 1 in 250,000-500,000. restricted to the skin and mucosa. Much less
[2]
Untreated HSE has an extremely high mortality rate of commonly, it causes severe encephalitis. While
70%. Early diagnosis and treatment can reduce the HSV-1 is typically transmitted via the oro-labial route,
[3]
mortality rate to 19%. [4,5] Morbidity in HSE is mainly HSV-2 is transmitted venereally. HSV-1 strains are
due to intracranial hypertension. Therefore, we report etiological agents in over 90% of cases of HSE. HSV-2
[4]
a rare case of HSE, which required decompressive strains are more commonly isolated in congenitally
craniectomy to treat severe refractory intracranial acquired neonatal HSV meningoencephalitis. After
hypertension. initial replication in skin and mucosa, the HSV-1
virus infects the sensory nerve endings innervating
Patients with HSE usually present with headache, the infected territory and migrates along retrograde
confusion, fever, and seizures. Failure to diagnose axonal flow toward the trigeminal ganglia where it
[6]
this serious disease early may result in permanent remains latent.
disability or death. The presence of clinical symptoms
The mechanisms whereby HSV-1 penetrates the
Access this article online nervous system, evades the immune response and
Quick Response Code: causes encephalitis are incompletely understood. HSV
Website: could enter into the brain by reactivation of the viral
www.nnjournal.net
genome in the trigeminal ganglion with axonal spread
DOI: via the trigeminal nerve into the temporal and frontal
10.4103/2347-8659.158460 lobes. Furthermore, HSV-1 can primarily infect the
central nervous system.

Corresponding Author: Dr. Muhammed Jasim Abdul Jalal, Department of Family Medicine, Lakeshore Hospital and Research
Centre, NH‑47 Bypass, Maradu, Nettoor, Kochii 682040, Kerala, India. E‑mail: poolspuff@gmail.com

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