Treatment of Persistent Pyogenic Ventriculitis with Active Exchange of Cerebrospinal Fluid: a report of two cases

Introduction: Pyogenic ventriculitis is a rare, but fatal complication associated with community acquired meningitis and invasive procedures. The blood-brain barrier poses a major challenge for intravenous (IV) and intrathecal (IT) antibiotics to adequately treat infections confined to the ependyma of the ventricles. Historically, ventricular and lumbar catheters and endoscopic irrigation of the ventricles with antibiotics have been attempted to treat pyogenic ventriculitis. New technique of active exchange of CSF (IRRAflow) has recently been emerged for treatment of pyogenic ventriculitis although there is limited evidence-based literature to validate its use.

Methods: This case report highlights the effective utilization of active CSF exchange to treat two severe cases of pyogenic ventriculitis. The first case was an 83-year-old male with extensive cardiovascular history and spinal stenosis who developed pyogenic ventriculitis secondary to epidural injections resulting in epidural and intradural abscesses. Persistent ventriculitis was treated successfully with active CSF exchange with IT tobramycin. The second case is that of a 60-year-old female who developed pyogenic ventriculitis in the setting of EVD placement for large left thalamic intracerebral hemorrhage with intraventricular extension at a different institution. Active CSF exchange and IT tobramycin application was used.

Results: First patient had unremarkable recovery. Radiologic cure of ventriculitis was achieved in second patient, however, family decided to withdraw care.

Conclusion : The high mortality rates and treatment failure with IV and IT antibiotics can be mitigated by utilizing active CSF exchange, which allows for the continuous irrigation of the ventricles by any antibiotic of choice. A larger high-quality study is needed to further elucidate the efficacy of this device.