The role of increased intracranial pressure and its effect on cerebral blood flow in the prognosis of children with bacterial meningitis is reviewed from the Division of Child Neurology, Loma Linda U Sch of Med, Loma Linda, CA. One-third have reduced cerebral flood flow (CBF) associated with cerebral edema and a poor prognosis. In patients with cerebral edema on CT or MRI and increased intracranial pressure (ICP), hyperventilation may reduce the ICP. The early use of diuretics, corticosteriods and mannitol is recommended. Ventriculostomy or ventricular tap may be necessary to decrease CSF volume in patients with increased ICP and signs of mass effect. The majority of subdural effusions require no specific treatment since spontaneous resolution will occur over time. In children with infarction, hyperventilation and diuretics may worsen the tissue injury whereas barbiturates or hypothermia may be of benefit. The authors recommend that interventional strategies must be started early and have a rapid onset of action if they are to be effective. 
COMMENT. This is an excellent review of the pathophysiology of bacterial meningitis and explains the continuing high morbidity despite the marked reduction in mortality resulting from newer antibiotics. Careful monitoring of intracranial pressure and use of neuroimaging in the early stages of meningitis should help in the selection of patients requiring early interventional treatments for the reduction of pressure and improvement in cerebral blood flow.