Computed tomography before lumbar puncture in acute meningitis: a review of the risks and benefits
Brian D. Archer, BA, MD
Objective: To determine the indications, if any, for routine computed tomography (CT) of the brain before lumbar puncture in the management of acute meningitis. Data sources: Original research papers, reviews and editorials published in English from 1965 to 1991 were retrieved from MEDLINE. The bibliographies of these articles and of numerous standard texts were examined for pertinent references. A survey of local neurologists was conducted, and legal opinion was sought from the Canadian Medical Protective Association. Data extraction: There were no studies directly assessing the risks of lumbar puncture in meningitis; however, all sources were culled for other pertinent information. Results: No cases could be found of patients with acute meningitis deteriorating as a result of lumbar puncture. The neurologic consensus refuted the need for CT in typical acute meningitis. All sources stressed speedy lumbar puncture and the early institution of appropriate antibiotic therapy to minimize the severity of the illness and the risk of death. Conclusions: (a) There is no evidence to recommend CT of the brain before lumbar puncture in acute meningitis unless the patient shows atypical features, (b) for patients with papilledema the risks associated with lumbar puncture are 10 to 20 times lower than the risks associated with acute bacterial meningitis alone, (c) CT may be necessary if there is no prompt response to therapy for meningitis or if complications are suspected, (d) the inability to visualize the optic fundi because of cataracts or senile miosis is not an indication for CT and (e) there are no Canadian legal precedents suggesting liability if physicians fail to perform CT in cases of meningitis.

Objectif: Preciser, le cas echeant, s'il y a lieu d'effectuer de routine une tomodensitom& trie du cerveau avant la ponction lombaire dans le traitement de la meningite aigue. Sources de donnees: Documents de recherches originales, recensions et editoriaux publies en anglais de 1965 a 1991 extraits de MEDLINE. Les bibliographies de ces articles et de nombreux textes d'autorite ont ete examines pour relever les references pertinentes. Les auteurs ont effectue un sondage aupres des neurologues locaux et obtenu une opinion juridique de l'Association canadienne de protection medicale. Extraction des donnees: Il n'existait pas d'etude dans laquelle on evaluait directement
les risques de la ponction lombaire dans la meningite. Toutefois, toutes les sources ont ete analysees pour y trouver d'autres renseignements pertinents. Resultats: Nous n'avons trouve aucun cas de patients ou la meningite aigue s'etait
Dr. Archer is a radiology resident and master's student in clinical epidemiology and biostatistics at McMaster University, Hamilton, Ont.

Reprint requests to: Dr. Brian D. Archer, Department ofRadiology, McMaster University Medical Centre, 1200 Main St. W, Hamilton, ON L8N 3Z5

For prescribing information see page 1071

CAN MED ASSOC J 1993; 148 (6)


The practice of "CT then LP" has increased with the proliferation of fast. by Korein. Cravioto and Leicach. often before laboratory confirmation of the diagnosis.' In some centres computed tomography (CT) of the brain is part of the routine investigation of meningitis. Two interesting articles presented opposing philosophies and described findings on lumbar puncture in patients with documented intracranial hypertension. 148(6) LE 15 MARS 1993 B acterial meningitis is a medical emergency 962 . on insistait sur la rapidite de la ponction lombaire et sur l'adoption sans retard d'une antibiotherapie appropriee afin de reduire la gravite de la maladie et le risque de deces. however laudable. broader topic of lumbar puncture in the presence of was methodologically much more sound than DufCAN MEDASSOCJ 1993. The study by Korein.ill before the lumbar puncture. It described the results of lumbar puncture in a cohort of 129 patients with papilledema or documented intracranial hypertension (opening pressure > 240 mm H20): 5 had neurologic worsening. ture. Dans toutes les sources. clinical trials or references of noted there was great uncertainty about its role in any sort supporting a causal relation between lumbar the deaths. The standard management consists of a lumbar puncture for analysis of cerebrospinal fluid (CSF) followed immediately by intravenous therapy with high doses of antibiotics (usually penicillin or a derivative). A representative opposing view was presented Results of MEDLINE search by Duffy9 in 1969. il n'est pas necessaire d'effectuer une tomodensitometrie dans les cas types de meningite aigue. The first paper. ignore the limitations of CT and the pathophysiologic features of bacterial meningitis. and as the authors vealed no case reports. fulminant meningitis can still rapidly prove fatal. He reported on a case series of 30 patients with increased intracranial pressure who A reasonable approach to these questions is to had deteriorated within 12 hours after lumbar puncbegin with a look at the available research findings. Even in an era when antibiotics outnumber potential pathogens. despite its flaws." "make sure there's no mass lesion" or "see if there is raised intracranial pressure" . sauf si le patient manifeste des sympt6mes atypiques. With its associated litany of indications . As far back as the turn of the century.3 appeared in 1959. they exaggerate the risk of lumbar puncture. (b) chez les patients qui presentent un oedeme papillaire.aggravee par suite d'une ponction lombaire. Most of A computerized MEDLINE search from 1965 to the patients described in both articles were critically 1991 with the use of various search strategies re. (c) la tomodensitometrie peut etre necessaire s'il n'y a pas de reponse rapide a la therapie anti-meningite ou si on craint des complications. Few patients in the articles reviewed had meningitis or even symptoms of infection. more important. 15 during or just after the procedure. "rule out an abscess. for an overall deterioration rate of 6%.3'9 Both papers were written well before Hounsfield's invention of "computerized axial transverse scanning" in the early 1970s'0 but still provide a useful perspective on the risk of lumbar puncture. les risques associes a la ponction lombaire sont de 10 a 20 fois plus faibles que ceux lies a la meningite purulente aigue seule. and under what circumstances will a CT scan alter these risks or change management? increased intracranial pressure as well as an interesting historical perspective.2'8 For many years there was considerable debate over this recommendation. noting the potentially fatal consequences. et (e) il n'existe au Canada aucun precedent juridique laissant entrevoir une responsabilite si le medecin n'effectue pas une tomodensitometrie dans un cas de meningite. Despite the lack of research on this specific subject the not as rigorous as its modern counterparts. and 3 died within 48 hours after lumbar puncture. Except in cases of benign intracranial hypertension (pseudotumour cerebri) a lumbar puncture in the presence of raised intracranial pressure has been taboo for many decades. people such as Dandy and Cushing had proscribed has become a ritual before lumbar puncture. D'apres le consensus des neurologues. Cravioto and Leicach was puncture and poor outcome in meningitis. just what is it that the scan will reveal? What are the potential risks of lumbar puncture in meningitis. readily available high-resolution CT scanners and seems so cautious and reasonable that it is difficult to dispute. requiring rapid recognition and institution of therapy. particularly in the face of lifethreatening disease. but it search still provided numerous articles related to the was essentially a cohort study and. but these reports and studies still contain some pertinent information. These goals. (d) I'incapacite de voir le fond de l'oeil en raison de cataractes ou d'une myose senile ne constitue pas une indication pour la tomodensitometrie. Conclusions: (a) Aucune preuve ne permet de recommander la tomodensitometrie du cerveau avant la ponction lombaire dans les cas de meningite aigue. The conclusion was that even in these patients at high risk lumbar puncture was quite safe.

when the CSF is under increased pressure (normal values 65 to 195 mm H20) and there is obstruction of free flow between the supratentorial space and the thecal sac surrounding the spinal cord. Almost all patients with meningitis have high intracranial pressure. in benign intracranial hypertension lumbar puncture is used therapeutically to lower the intracranial pressure.'2-'6 This rate is amazingly low and leads one to re-evaluate the disproportionate anxiety currently surrounding lumbar puncture. but this does not preclude lumbar puncture (nor could one easily diagnose the high pressure from the CT scan). a negative or atypical result from the CSF examination or a lack of response to therapy each suggest that the patient may have more than straightforward bacterial meningitis. If a lumbar puncture cannot be done within 30 minutes of presentation in a case of suspected meningitis. Most physicians would agree that a patient with suspected meningitis who is unconscious. Another comment was that often the neurologist is not responsible for the initial management of these patients and that this makes it important for internists and emergency physicians to be aware of current recommendations. Particularly pertinent to this discussion are the few patients in these studies who presented with symptoms of infection. Cravioto and Leicach: between 0% and 5% in patients with documented papilledema of any cause (unpublished data). 1). 1993 various atypical features that do indicate urgent imaging.'7 This is unlikely to complicate the diagnosis. but there are MARCH 15. but this alone does not place the patient at greater risk during lumbar puncture.'8 The only modification of the course's algorithm should be that instead of recommending CT in cases of meningitis with "suspected increased intracranial pressure" it would be more accurate to simply recommend CT in atypical cases and provide a few examples (Fig. lumbar puncture is very dangerous. Current practice In a recent survey of local neurologists 14 of 17 responded. It is expected that most. impinging on the brainstem. if not all. even though the yield will still be quite low. but the cerebellum would herniate through the foramen magnum. A similar sequence would occur if the obstruction to flow were in the posterior fossa. The results of this survey are quite consistent with the teaching in the Advanced Neurologic Life Support Course.2 Although there is no evidence suggesting a worse outcome for patients with meningitis after immediate lumbar puncture there is abundant evidence of the potential lethality of meningitis: the rates range from 5% in children to 43% in adults. Other concomitant findings may also lead to referral for tomography on a more or less urgent basis.2 Legal implications What about the frequently voiced concern that there may be litigation if a patient deteriorates or dies after having undergone a lumbar puncture without CT? The Canadian Medical Protective Association reports that since 1976 there have been eight legal actions "in which lumbar puncture was performed and was relatively central to the outcome of the action" (Dr. 148 (6) 963 . 1991). Robert Robson.2 The research findings do not support CT of the brain in straightforward meningitis. Comments generally focused on the need for rapid initiation of antibiotic therapy and for CT in the patient with atypical features.'7 At the very least. and the judgement favoured the physician.2'3'9 Theoretically. and all recommended that in straightforward meningitis of acute onset CT is not required. One of these went to trial. patients with bacterial meningitis will have markedly elevated intracranial pressure (> 1S80 mm H2O) as a result of the infection. Immune compromise. antibiotic administration should be started without delay and followed as soon as possible by lumbar puncture. Removing spinal CSF under these circumstances would decrease the pressure below the tentorium cerebelli and allow the temporal lobes to herniate downward."7 The early introduction of antibiotics is critical. Senile miosis or cataracts obscuring the optic fundi are common and do not constitute focal findings. Those in whom the onset of meningitis was acute suffered no ill effects from their initial lumbar puncture.3.fy's. creating a "pressure cone" (colloquially referred to as "coning"). this is 10 to 20 times the risk of complications associated with lumbar puncture in patients with papilledema.for instance. One was related to a delay in treatment that caused CAN MED ASSOC J 1993. Increased intracranial pressure without the obstruction of CSF circulation does not have this catastrophic effect . Underlying the concern about lumbar puncture is the possibility of transtentorial herniation.'8 In these cases it is crucial that CT not delay antibiotic therapy. Generally." Most studies have reported complication rates similar to or lower than that of Korein. patients with symptoms of infection deteriorated only after several punctures and several days of inadequate therapy. None of the cases concerned failure to perform CT before a lumbar puncture was done. since the features of the CSF in bacterial meningitis will be markedly abnormal despite many hours of antibiotic therapy. otitis or sinusitis. depending on the severity of the presenting symptoms. shows focal neurologic deficits or has papilledema should undergo CT as soon as possible. assistant secretarytreasurer: personal communication.

Surg Clin North Am 1946. Archer was financially supported by the Radiological Society of North America as a research resident in 199192. CT may be necessary during the treatment of findings had an abnormal CT scan. 4th ed. Cravioto H. Victor M: Principles of Neurology. sinusitis and otitis). Sanford JP: Guide to Antimicrobial Therapy. The risk of complications associated with series of pediatric'9 and adult20 meningitis have been lumbar puncture. cerebral and cerebellar herniation as a result of cerebral 4. in addition to intensive monitoring of vital signs. 1989: 5-15. should be avoided unless there is compelling doubt palsies. 1951: 14701478 7.. any abnormal results. papilledema. Durand and associates20 stated that "a CT scan is indicated before the performance of a lumbar puncture in patients with suspected meningitis and signs of increased intracranial pressure or focal Presentation (clinical meningitis) Atypical features: focal findings. and in 8 there was evidence of therapy or if hydrocephalus or abscess is suspected. We have a responsibility to be both financially and medically aware. By reducing the number of Conclusions procedures that are medically unjustified or submit1. unconsciousness etc. 26: 78-90 6. Philadelphia. Cushing H: Some aspects of pathological physiology of intracranial tumors. 9: 290-297 4. lumbar puncture No unusual features findings on neurologic examination. which led to CT evaluation. Philadelphia. All the available literature supports urgent CT evaluation for patients with an atypical history or findings on physical examination. No unusual features. Neurology 1959. Addendum (c) papilledema or (d) other atypical features (e." This again inappropriately emphasizes elevated intracranial pressure.of herniation "from several minutes to several hours after tute a focal finding and in isolation is not an a lumbar puncture. In the former series about one-third of the is 10 to 20 times lower than the risks associated with patients underwent CT of the brain: 50% of the scans gave acute bacterial meningitis alone. Ann Otol Rhinol Laryngol 1937. including administration of antibiotics within 30 minutes after presentation. Verbrugghen A: Spinal puncture. delay in obtaining CSF or initiating treatment generalized Most of these patients had a focal or neurologic abnormality. Dr. 5." Though not explicitly stated these patients probably had symptoms severe enough to warrant indication for CT. (b) focal findings. its Principles and Practice. Inc.g. 1991: 4-6 2. 1991. published. 1: Management of clinical meningitis. Nash CS: Cerebellar herniation as a cause of death. Five of these eight patients had had clinical signs because of cataracts or senile miosis does not consti. 148 (6) . There is no evidence (anecdotal or from ting for evaluation those that could prove worth clinical trials) to recommend CT of the brain be. Md. McGraw.. with prompt and aggressive treatment when required. Loeb RF (eds): Textbook of Medicine. Saunders. 1908: 17276 LE 15 MARS 1993 |Intravenous antibiotic therapy antibiotic therapy Lumbar puncture Intravenous antibiotic therapy Computed tomography (urgent) Lumbar puncture contingent on scan result Fig. the public and especially the fore lumbar puncture for patients with suspected patient a great service.while we do ourselves. immune compromise. Leicach M: Reevaluation of lumbar puncture: a study of 129 patients with papilledema or intracranial hypertension. In Keen WW (ed): Surgery. West Bethesda. Only 27 autopsy bacterial meningitis if there is no prompt response to reports were available. neurologic status and urine output. Boston Med Surg J 1909. acute meningitis unless there are any of the following features: (a) unconsciousness.3'7 Therefore. In the second series 19 of 39 patients with focal 3. Since this article was accepted. 504-589 3. even in patients with papilledema. Cushing H: Surgery of the head. There are no Canadian legal precedents in the CT before the lumbar puncture. unavoidably delayed Lumbar 30 |~ min 111111 ~~~~~~~~~puncture Intravenous References 1. Korein J. Antimicrobial Therapy. perform CT in cases of acute meningitis. 46: 673-680 8. such as coma or nerve about the diagnosis. New York. 141: 71-80 5. Adams RD.death (although the delay was not the result of past 15 years suggesting liability if physicians fail to waiting for CT). The inability to visualize the optic fundi edema. which is a typical feature of meningitis. two pertinent case 2. particularly focal neurologic abnormalities. and 16% led to surgery or changes in management. In Cecil RL. Walker AE: Intracranial tumors.'8 964 CAN MED ASSOC J 1993. Saunders.

Friedland IR. 9-11. Baycrest Centre for Geriatric Care. 1990: 289-290 11. BC V6B 5C6. Lubec. 15: 544-547 18. 10. European coordinator. fax (604) 681-2503 MARCH 15. 4-10. Arch Neurol Psychiatry 1954. president. 645-375 Water St. Rinderknecht S et al: Cranial computed tomographic scans have little impact on management of bacterial meningitis. Can Med Assoc J 1938. N Engl J Med 1993. 1993: Modelling of the Structure and Metabolism of Proteins and Amino Acids Workshop . 26-28. fax (604) 681-2503 Sept. Student Manual. 23-27. fax (306) 585-4815 Aug. England. Ont. 1: 407-409 10. 146: 1484-1487 20. 148 (6) 965 . ON M6A 2E1. Chicago. tel 011-44-1-71-387-4499. Bryan CS. Murry RC: Christensen's Physics of Diagnostic Radiology. 500-10216-124 St. Marotta JT: Brain tumor and lumbar puncture. Department of Paediatrics. Dowdey JE. Toronto. University of Copenhagen. 72: 568-572 14. 27-29. 1993: 2nd International Congress on Peer Review in Biomedical Publication (sponsored by the American Medical Association) Chicago Annette Flanagin. tel (306) 585-4190. North American coordinator. 645-375 Water St. 328: 21-28 Conferences continuedfrom page 957 Aug. tel (403) 482-1965. 29-Sept. Lea & Febiger. To learn the clinical course and prognosis of disease. J Neurol Psychopathol 1933. University of Regina. Res Nerv Ment Dis Proc 1927. 7-10.. 8: 422-429 17. Austria Professor M. Wahringer Giirtel 18. A 1090 Vienna. with a review of 200 cases in which lumbar puncture was done. BMJ. England Aug. tel (312) 464-2432. fax 011-44-1-71-383-6418 Economics Regina Deadline for abstracts: Mar. Congress Secretary. Vancouver. ext. 2nd rev ed. Philadelphia. fax 011-65227-0257 continued on page 984 CAN MED ASSOC J 1993. Ann Emerg Med 1986. fax (403) 482-4194 Oct. Sybil Gilinsky. Continuing Education Department. 336 Smith St. c/o Edmonton Board of Health. c/o Department of Economics. Herlev Hospital. Lubic LG. Reynolds KL. or Jane Smith. 1993: 3rd International Congress on Amino Acids and Analogues Crete. North York. McMaster University Health Sciences Centre: How to read clinical journals: III.. Crosby J: Advanced Neurologic Life Support Course. Peer Review Congress. 06-302. 4th ed. Crout L: Promptness of antibiotic therapy in acute bacterial meningitis. 1993: 5th Canadian Conference on Health Sept. BMJ 1969. Greece Dr. 1993: 1st International Conference on Community Health Nursing Research Edmonton Shirley Stinson or Karen Mills. 3560 Bathurst St. 515 N State St. 1993: 3rd Congress of the Asian Pacific Society of Respirology (organized by the Singapore Thoracic Sept. Spencer W: Lumbar puncture in the presence of papilledema. London WC1N IEH. Edmonton. tel (604) 681-5226. fax 011-43-1-40400-3238 Aug. BC V6B 5C6. Institute of Child Health. 1991 19. DK-2730 Herlev. Denmark Christian Nolsoe. Durand ML. 7-10. Duffy GP: Lumbar puncture in the presence of raised intracranial pressure... Vancouver. IL 60610. Schaller WF: Propriety of diagnostic lumbar puncture in intracranial hypertension. Calderwood SB. tel (604) 681-5226. Am J Dis Child 1992.. 39: 449-450 15. 1993: 6th International Congress on Interventional Ultrasound Copenhagen. Masson CB: The dangers of diagnostic lumbar puncture in increased intracranial pressure due to brain tumor. tel 011-65-227-9811. 1993 Society) Singapore Secretariat. 1993: Health Care Aide Clinic Day North York. 23-27. 1993 Dr. Peer Review Congress. tel (416) 789-5131.9. Canadian Health Economics Research Association. AB T5N 4A3. University of Vienna.3rd International Congress on Amino Acids Vienna. 23: 808-810 13. Tavistock Square. Weber DJ et al: Acute bacterial meningitis in adults: a review of 493 episodes. JAMA. 4. New Bridge Centre. Regina. London WC1 H 9JR. Denmark Sept. Hjelm. 31. G. 14: 116-123 16. Singapore 0105. 124: 869-872 12. SK S4S 0A2. Curry TS. Can Med Assoc J 1981. J Mt Sinai Hosp 1956. fax (312) 464-5824. Department of Clinical Epidemiology and Biostatistics. 2365 Sept. 3rd Congress of the Asian Pacific Society of Respirology. 1993: 15th World Congress of Neurology (sponsored by the World Federation of Neurology and the Canadian Neurological Society) Vancouver Secretariat. Paris MM. Austria. Department of Ultrasound. 1993: 13th International Congress of EEG and Clinical Neurophysiology (sponsored by the International Federation of Clinical Neurophysiology) Vancouver Secretariat. Hepburn JJ: Risk of spinal puncture. BMA House. Jack Boan.

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