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the veins, swelling of the endothelial cells and in ltration of the adventitia also occur Subintimal layering, as occurs in arterioles, is not observed, but there may be a diffuse in ltration of the entire wall of the vessel It is in veins so affected that focal necrosis of the vessel wall and mural thrombi are most often found Cortical thrombophlebitis of the larger veins does not usually develop before the end of the second week of the infection The unusual prominence of the vascular changes may be related to their anatomic peculiarities The adventitia of the subarachnoid vessels, both of arterioles and venules, is actually formed by an investment of the arachnoid membrane, which is invariably involved by the infectious process Thus, in a sense, the outer vessel wall is affected from the beginning by the in ammatory process an infectious vasculitis The much more frequent occurrence of thrombosis in veins than in arteries is probably accounted for by the thinner walls and the slower current (possibly stagnation) of blood in the former Although the spinal and cranial nerves are surrounded by purulent exudate from the beginning of the infection, the perineurial sheaths become in ltrated by in ammatory cells only after several days Exceptionally, in some nerves, there is in ltration of the endoneurium and degeneration of myelinated bers, leading to the formation of fatty macrophages and proliferation of Schwann cells and broblasts More often, there is little or no damage to nerve bers Occasionally cellular in ltrations may be found in the optic nerves or olfactory bulbs The arachnoid membrane tends to serve as an effective barrier to the spread of infection into the brain substance, but some secondary reaction in the subdural space may occur nevertheless (subdural effusion) This happens far more often in infants than in adults; according to Snedeker and coworkers, approximately 40 percent of infants with meningitis who are less than 18 months of age develop subdural effusions As a rule, there is no subdural pus, only a sterile yellowish exudate In an even higher percentage of cases, small amounts of brinous exudate are found in microscopic sections that include the spinal dura When brinopurulent exudate accumulates in large quantities around the spinal cord, it blocks off the spinal subarachnoid space Hydrocephalus is produced by exudate in the foramina of Magendie and Luschka or in the subarachnoid space around the pons and midbrain, interfering with the ow of CSF from the lateral recesses of the fourth ventricle and cisterna magna to the basal cisterns and cerebral convexities In the later stages, brous subarachnoid adhesions are an additional and sometimes the most important factor interfering with the circulation of CSF An infrequent late sequela of bacterial meningitis is therefore chronic adhesive arachnoiditis or chronic meningomyelitis In the early stages of meningitis, very little change in the substance of the brain can be detected Neutrophils appear in the Virchow-Robin perivascular spaces but enter the brain only if there is necrosis After several days, microglia and astrocytes increase in number, at rst in the outer zone and later in all layers of the cortex The associated nerve cell changes may be very slight Obviously some disorder of the cortical neurons must take place from the beginning of the infection to account for the stupor, coma, and convulsions that are so often observed, but several days must elapse before any change can be demonstrated microscopically It is uncertain whether these cortical changes are due to the diffusion of toxins from the meninges, to a circulatory disturbance, or to some other factor, such as increased intracranial pressure Restated, the aforementioned changes are not due to invasion of brain substance.

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by bacteria and should therefore be regarded as a noninfectious encephalopathy When macrophages and astrocytes are exposed to endotoxins in vitro, the cells synthesize and release cytokines, among which are interleukin-1 and tumor necrosis factor These cytokines are believed to stimulate and modulate the local immune response but may also affect cortical neurons In the early stages of meningitis, there is little change in the ependyma and the subependymal tissues; but in later stages, conspicuous changes are invariably found The most prominent nding is in ltration of the subependymal perivascular spaces and often of the adjacent brain tissue with neutrophilic leukocytes and later with lymphocytes and plasma cells Microglia and astrocytes proliferate, the latter sometimes overgrowing and burying remnants of the ependymal lining We believe that the bacteria pass through the ependymal lining and set up this in ammatory reaction in part because this sequence of events is favored by a developing hydrocephalus, which stretches and breaks the ependymal lining Collections of subependymal astrocytes then begin to protrude into the ventricle, giving rise to a granular ependymitis, which, if prominent, may narrow and obstruct the aqueduct of Sylvius The choroid plexus is at rst congested, but within a few days it becomes in ltrated with neutrophils and lymphocytes and eventually may be covered with exudate As in the case of the meningeal exudate, lymphocytes, plasma cells, and macrophages later predominate Eventually there is organization of the exudate covering the plexus As any meningitis becomes more chronic, the pia-arachnoid exudate tends to accumulate around the base of the brain (basilar meningitis), obstructing the ow of CSF and giving rise to hydrocephalus The exudate may also encircle cranial nerves and lead to focal cranial neuropathies The reader may question this long digression into matters that are more pathologic than clinical, but only a knowledge of the morphologic features of meningitis enables one to understand the clinical state and its sequelae The meningeal and ependymal reactions to bacterial infection and the clinical correlates of these reactions are summarized in Table 32-1, which may be consulted together with this section.

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Steps in the Migration of WAD Templates (continued)