Ependymal Petechial Hemorrhages in Bacterial Meningitis

A 28-year-old male patient with a history of subacute sclerosing panencephalitis (SSPE), secondary to measles infection as an infant, presented to our Neurology department with increasing gait difficulty and poor bladder control. An Ommaya reservoir was placed in the right frontal horn for intrathecal interferon therapy at the time of SSPE diagnosis 19 years ago. About a month before the current complaints, the patient experienced acute onset of seizures. This reservoir was removed at that time because of a clinical suspicion of bacterial meningitis and a lumbar puncture was positive for elevated protein with a decreased CSF-to-serum glucose ratio. A brain MRI scan ordered by the neurologist showed markedly enlarged lateral and third ventricles, consistent with aqueductal stenosis. Neurosurgery was consulted for further evaluation and treatment of this noncommunicating hydrocephalus. A right frontal endoscopic third ventriculostomy performed a few weeks later was technically successful. At surgery, we entered the third ventricle by passing through the right interventricular foramen. We observed these small, acute-appearing reddish petechial hemorrhages along the ependymal surface of the third ventricle near the mammillary bodies (Figure 1) as we created a 4 mm channel through the ventricular floor (Figure 2). These lesions were likely a post-meningitis inflammatory effect, mechanistically similar to the characteristic skin rash seen in late-stage bacterial meningitis. Eight months later his hydrocephalus has radiographically resolved with resolution of his presenting symptoms.

Figure 1.

Endoscopic view of petechial hemorrhages along the arachnoid and ependymal space on the floor of the third ventricle—the mammillary bodies are seen through the ependyma.

Figure 2.

Superior aspect of endoscopic third ventriculostomy, enlarged with the endoscope and wire guide to a diameter of approximately 4 mm.

Meningitis is a well-known complication of indwelling Ommaya reservoirs, occurring in 5–8% of all patients.^1,2 Petechial rashes, indicative of blood extravasation from subcutaneous capillaries, are a common feature of severe meningococcal meningitis.³ The mechanism of this extravasation in the context of infection is most often vascular injury due to bacterial toxin effects directly on the endothelium or through modulation of the immune system.^4,5 In theory, the capillaries of the arachnoid and ependyma should be subject to these same processes. After reviewing the literature and consulting colleagues about their experiences, however, we believe that this is the first report of such petechial hemorrhages visualized intraoperatively.