Table 2.

Intracranial pressure management for cryptococcal meningitis in HIV-infected patients

Meningitis/meningoencephalitis

Aggressive control of intracranial pressurea

Management options

Therapeutic lumbar punctureb (usually selected in most cases)

Lumbar drain insertion

Ventriculostomy

Ventriculoperitoneal shuntc

Medical treatment i.e. corticosteroidd, mannitol, and acetazolamide are ineffective

Cryptococcoma

Management as in meningitis/meningoencephalitis

Corticosteroids may be used in cryptococcoma with significant brain edema

Cryptococcal IRIS

Management as in meningitis/meningoencephalitis

Corticosteroids may be used in severe IRIS

^aBrain imaging before the procedure should be considered for patients with alteration of consciousness and/or focal neurological deficits. Lumbar puncture should be performed whenever symptoms of increased intracranial pressure arise. Persistently increased intracranial pressure should be managed by daily lumbar puncture until symptoms abate and normal opening pressure is obtained for >2 days

^bTherapeutic lumbar punctures to achieve closing pressure below 20 cm H2O or 50% of initial opening pressure are recommended

^cCan be performed without a need for CSF sterilization before the procedure

^dThe use of steroids was associated with higher risks of disability, higher adverse events, and reduced sterilizing power of amphotericin B plus fluconazole during the induction phase