Cushing's triad in pneumococcal meningitis due to brainstem ischemia: early detection by diffusion-weighted MRI

Area of Science:

• Pediatric Neurology
• Neuroimaging
• Infectious Diseases

Background:

• Pneumococcal meningitis can lead to severe neurological complications.
• Raised intracranial pressure (ICP) is a critical concern in pediatric meningitis.
• Standard neuroimaging may not always detect early ischemic changes.

Observation:

• An infant diagnosed with pneumococcal meningitis exhibited clinical signs of increased ICP, including altered consciousness, hypertension, bradycardia, and respiratory depression.
• Initial diagnostic workup, including emergency computed tomography (CT) scan and lumbar puncture for ICP measurement, yielded normal results.
• The discrepancy between clinical presentation and initial imaging findings prompted further investigation.

Findings:

• Diffusion-weighted magnetic resonance imaging (DW-MRI) was crucial in identifying multiple brainstem lesions characterized by restricted diffusion.
• These DW-MRI findings were indicative of acute ischemia in the brainstem, correlating with the observed clinical signs.
• Notably, these ischemic lesions were not apparent on conventional T2-weighted MRI sequences at the time of examination.

Implications:

• DW-MRI is a sensitive tool for detecting early ischemic changes in the brainstem associated with meningitis.
• This case highlights the importance of advanced MRI techniques when clinical signs suggest a neurological emergency despite normal initial investigations.
• Timely identification of ischemia through DW-MRI can potentially influence management strategies and patient outcomes in pediatric meningitis.