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revue neurologique 169 (2013) 173–183

Herpes simplex virus encephalitis requiring
emergency surgery
Encéphalite herpétique fulminante nécessitant
une décompression chirurgicale

[(Fig._1)TD$IG]

A 38-year-old woman was hospitalized three days after onset
of headache, fever, olfactory hallucinations, speech alteration.
Brain scanner showed diffuse cerebral edema. Cerebrospinal
fluid (CSF) analysis revealed lymphocytic meningitis. Treatment with amoxicillin (12 g/day) and acyclovir (30 mg/kg per
day) was immediately begun. Amoxicillin was discontinued
when positive herpes simplex virus PCR was found. Six days
later, her medical condition was worsening with Glasgow
coma scale (GCS) at 12. Brain MRI was performed and showed
voluminous left temporal hematoma (Fig. 1A). She was
admitted in intensive care unit. A few hours later, GCS declined
to 3 with bilateral mydriasis. Emergency decompressive

craniotomy was performed with evacuation of left temporal
hematoma (Fig. 1B). GCS was at 8 after surgery. Neurological
evaluation after surgery revealed aphasia, left deviation
of the eyes and right hemiplegia. Mydriasis had disappeared
and pupils were reactive to light. Four days later, the
patient presented respiratory failure with severe
hypoxemia, related to right basal pneumonia. Despite
treatment with antibiotics, mechanic ventilation, then extra
corporal respiratory support, the patient died 17 days after
admittance.
HSV encephalitis (HSVE) is a severe disease resulting in 70%
mortality at three months if not treated. Acyclovir has
dramatically improved prognosis, but mortality rate remains
elevated (19%–28%). Less than 50% of patients can return to a
normal life after HSVE. Factors predicting poor outcome are:
age over 30 years, initiation of antiviral treatment more than
four days after first symptoms, GCS score of 6 points or less,
detection of abnormal lesions on brain scanner at initiation of
antiviral treatment and presence of more than 100 copies/mL
of HSV-DNA in the initial CSF (Taira et al., 2009).

Fig. 1 – A. Axial brain MRI (flair and T2* sequences) showing voluminous left temporal hematoma and edema with
brainstem compression. B. Brain CT after craniotomy and evacuation of hematoma.

revue neurologique 169 (2013) 173–183

There are 11 reported cases of brain hematoma related to
HSVE, which occurred between 1st and 19th day of evolution
of the disease (Takeuchi and Takasato, 2011). Only three of
those patients underwent decompressive surgery with hematoma evacuation. Brain edema is a more common complication of HSVE, which can occur during the first days of evolution
as well as later (until 20th day after the beginning). As HSVE
affects almost temporal lobe, both edema and hematoma can
result in brainstem compression. Adamo and Deshaies (2008)
reported two cases of HSVE with massive edema that
underwent emergency surgery with good outcome. Schwab
et al. (1997) also observed excellent outcome when they
performed hemicraniectomy in six cases of viral encephalitis
with signs of uncal herniation (one was a proven HSVE).
Barnett et al. (1988) measured intracranial pressure in
10 patients with encephalitis (eight had HSVE proven after
biopsy). They showed that the peak of intracranial pressure
occurred on average at 12th day after onset of the disease.
Patients suffering of HSVE with risk factors predicting a
poor outcome should be hospitalized in intensive care
unit. Cerebral edema and hematoma are potentially lifethreatening conditions. They can happen lately in the
evolution of the disease despite acyclovir treatment. Conservative medical treatment (osmotic agents, corticosteroids,
hyperventilation. . .) is most of the time sufficient, but surgery
should be quickly considered in case of secondary neurological deterioration.

Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.

183

references

Adamo MA, Deshaies EM. Emergency decompressive
craniectomy for fulminating infectious encephalitis. Report
of two cases. J Neurosurg 2008;108:174–6.
Barnett GH, Ropper AH, Romeo J. Intracranial pressure and
outcome in adult encephalitis. J Neurosurg 1988;68:585–8.
Schwab S, Jünger E, Spranger M, Dörfler A, Albert F, Steiner HH,
et al. Craniectomy: an aggressive treatment approach in
severe encephalitis. Neurology 1997;48:412–7.
Taira N, Kamei S, Morita A, Ishihara M, Miki K, Shiota H, et al.
Predictors of a prolonged clinical course in adult patients with
herpes simplex virus encephalitis. Intern Med 2009;48(2):89–94.
Takeuchi S, Takasato Y. Herpes simplex virus encephalitis
complicated by intracerebral hematoma. Neurol India
2011;59(4):594–6.

F. Battaglia*
R. Noudel
P.-H. Roche
Service de neurochirurgie, Aix-Marseille université, hôpital Nord,
chemin des Bourrelys, 13915 Marseille cedex 20, France
*Corresponding author.
E-mail address: fabrice.battaglia@ap-hm.fr (F. Battaglia)
Received 16 April 2012
Received in revised form 2 May 2012
Accepted 8 May 2012
Published online 6 September 2012
0035-3787/$ – see front matter
# 2012 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.neurol.2012.05.010