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S Hippokrates’ times, it has been known that fever and even more, hyperpyrexia in a potentially fatally ill neurocritical care patients, in particular in severe central nervous system (CNS) infections is detrimental, heralding poor prognosis, and adding to morbidity and mortality.[1] Aggressive management of body temperature is commonly agreed to be essential and is suggested to improve outcome in patients with intracranial pathologies. [2] Both acute bacterial meningitis (ABM) and viral encephalitis may– rather early in their course – lead to diffuse brain edema,[3-5] thereby increasing the intracranial pressure (ICP) and reducing the cerebral perfusion pressure, both through increased ICP and decreased mean arterial pressure, the latter frequently being part of an accompanying sepsis syndrome or, even worse, septic shock syndrome.[6] Brain tissue hypermetabolism may be part of early hyperpyrexia whereas subsequent hypometabolism may indicate that tissue/cells already have suffered from substantial damage. Both fludeoxyglucose positron emission tomography (PET) and cerebral microdialysis have yielded results in favor of exactly this course of metabolism, i.e., an early hypermetabolic state being followed by a late hypometabolic state within the encephalitic brain.[7,8] In patients suffering from impaired consciousness due to ABM, up to two-thirds show increased ICP when measured early.[4] Aggressive reduction of this increased ICP has been shown to reduce mortality from 30% to 10%;[4] in bacterial meningitis, beside diffuse brain edema, hyperemia of brain areas and secondary disturbance of microcirculation within the affected intracranial structures leading to, highly impaired arterial/arteriolar microcirculation, as well as partially occluded/thrombosed venules/venous vasculature add to increased ICP with the potential of severe secondary damage of brain tissue.[3]

brain circulation

Hyperpyrexia in life-threatening central nervous system infection – It is the timepoint of fever which matters: A plea to select the best timing and optimal methods of temperature management