Recovery after Clinical and Radiological Signs of Coning

We present a case of a previously healthy 19-year-old man who was admitted to our intensive care unit (ICU) with meningitis and signs of cerebral coning. Investigation confirmed raised intracranial pressure (ICP) with cerebellar tonsillar herniation and cerebral venous thrombosis. Blood polymerase chain reaction (PCR) demonstrated evidence of Neisseria meningitides, serogroup Y. Besides antibiotics and steroids, treatment included intubation and ventilation to maintain a PaO₂ >11 kPa, PaCO₂ approximately 4.5 kPa, maintenance of a mean arterial pressure >80 mm Hg, regular IV mannitol, therapeutic anticoagulation and an external ventricular drain. Three weeks following admission, he was fully alert and orientated with no focal neurological deficits. Although elevated ICP is expected in cases of meningitis, we have demonstrated that aggressive measures to reduce ICP are worthwhile, even in the presence of clinical signs of coning, which in this case resulted in a good outcome.