Surgical Management in Herpes Simplex Encephalitis: Illustrative Case Report and Systematic Review of the Literature

• Published in: Neurosurgery Vol. 92; no. 5; p. 915
• Main Authors: Bhave, Varun M, Bernstock, Joshua D, Carlson, Julia M, Kappel, Ari D, Torio, Erickson F, Chen, Jason A, Essayed, Walid Ibn, Gawelek, Kara L, DiToro, Daniel F, Izzy, Saef, Cosgrove, G Rees
• Format: Journal Article
• Language: English
• Published: United States 01.05.2023
• Subjects: Acyclovir - therapeutic use; Anterior Temporal Lobectomy; Encephalitis, Herpes Simplex - diagnosis; Encephalitis, Herpes Simplex - drug therapy; Encephalitis, Herpes Simplex - surgery; Female; Humans; Middle Aged; Seizures - surgery; Status Epilepticus - drug therapy; Status Epilepticus - surgery
• ISSN: 1524-4040
• DOI: 10.1227/neu.0000000000002334

Herpes simplex virus (HSV) is a common cause of viral encephalitis and can result in refractory seizures. Although HSV encephalitis (HSVE) is treated primarily with acyclovir, surgery can play a role in medically intractable cases. To systematically review cases describing surgery for the treatment of severe HSVE. We also present an illustrative case of anterior temporal lobectomy (ATL) for refractory status epilepticus in a patient with unilateral HSVE. This case demonstrates one clinical context in which surgery can be a useful adjunct. We performed a systematic review using PubMed and Google Scholar, including case reports and series describing surgical interventions for HSVE. Clinical data were extracted from 54 publications that incorporated 67 patient cases. Surgical decompression occurred at a wide range of times after the onset of illness, although most patients were operated on 4 or more days after HSVE symptoms began. Numerous reports indicated that decompressive craniectomy, temporal lobectomy, and hematoma removal could treat intractably elevated intracranial pressure because of HSVE with favorable long-term outcomes. We describe an additional case in which a 52-year-old woman with HSVE developed refractory right temporal lobe seizures. After ATL, the seizures resolved with significant clinical improvement. Surgical treatment can be a useful adjunct for treatment of HSVE. There is substantial variability in the timing of surgical decompression in patients with HSVE, which can be necessary up to approximately 3 weeks after illness onset. ATL should be considered for refractory status epilepticus in HSVE with a unilateral seizure focus.