Correspondence
Cranial CT before Lumbar Puncture in Suspected Meningitis
N Engl J Med 2002; 346:1248-1251April 18, 2002
- Article
To the Editor:
Hasbun et al. (Dec. 13 issue)1 show that in adults with suspected meningitis, clinical findings can guide the decision to perform cranial computed tomography (CT) before lumbar puncture. However, the results should not form the basis for recommendations in adults with bacterial meningitis, because only 2 of their 235 patients had documented bacterial meningitis.
We analyzed the records of 75 adults with proven pneumococcal meningitis treated in our department. Patients with focal neurologic signs, seizures, or a reduced level of consciousness (score on the Glasgow Coma Scale, ≤12) were more likely to have cerebral abnormalities on the CT scan obtained on admission than were patients without these clinical findings (Table 1Table 1
Presence or Absence of Cerebral Complications on Cranial CT on Admission in Adults with Pneumococcal Meningitis.). CT scans showing a severe mass effect prompted the decision not to perform lumbar puncture in four patients. However, cerebral herniation occurred in 10 patients, and it could not be predicted by the presence of cerebral abnormalities on CT (seen in 2 of 10 patients with herniation vs. 27 of 65 patients without herniation; P=0.30), focal signs (3 of 10 vs. 17 of 65, respectively; P=1.00), seizures (3 of 10 vs. 11 of 65, respectively; P=0.38), or a score on the Glasgow Coma Scale of 12 or below (7 of 10 vs. 43 of 65, respectively; P=1.00).Thus, among patients with pneumococcal meningitis, clinical and CT examinations fail to identify a substantial proportion of the patients who later have cerebral herniation. However, CT should guide the decision to perform lumbar puncture in patients with focal neurologic signs, seizures, or a reduced level of consciousness, because these patients often have pathologic findings on cranial CT.
2 ReferencesStefan Kastenbauer, M.D.
Frank Winkler, M.D.
Hans-Walter Pfister, M.D.
Ludwig-Maximilians-Universität, 81377 Munich, Germany
pfister@nefo.med. uni-muenchen. de 1
Hasbun R ,Abrahams J ,Jekel J ,Quagliarello VJ . Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 2001;345:1727-1733
Full Text | Web of Science | Medline2
Pfister HW ,Feiden W ,Einhaupl KM . Spectrum of complications during bacterial meningitis in adults: results of a prospective clinical study. Arch Neurol 1993;50:575-581
Web of Science | Medline
To the Editor:
In the prospective study of 301 patients with suspected meningitis, reported by Hasbun et al., it is unclear how many patients underwent funduscopy. A thorough neurologic assessment in a busy emergency department can be difficult to perform, but documentation of the presence or absence of papilledema might have been useful for further stratification of the 11 neurologic characteristics assessed in the study, according to their diagnostic importance.
John F. Bruzzi, M.D.
Darren D. Brennan, M.D.
Mater Misericordiae Hospital, Dublin 7, Ireland
bruzzij@hotmail.com To the Editor:
Although the article by Hasbun et al. provides important insights into the use of clinical features to determine the safety of lumbar puncture in patients with suspected meningitis, we are interested in any data they have about the rate of spontaneous venous pulsation in the optic fundi. The presence of spontaneous venous pulsation suggests that the cerebrospinal fluid pressure is not likely to be elevated.1
1 ReferencesYasuharu Tokuda, M.D.
Nobuhiko Nakazato, M.D.
Okinawa Chubu Hospital, Okinawa 904-2293, Japan
tokuyasu@orange.ocn. ne. jp To the Editor:
In his editorial about diagnostic lumbar puncture, Steigbigel1 suggests that when there is a high clinical suspicion of elevated intracranial pressure, physicians should use small spinal needles to reduce the amount of cerebrospinal fluid removed. This is prudent advice. Headache after dural puncture is less prevalent after puncture with small needles than it is after puncture with large needles, probably because there is less leakage of cerebrospinal fluid.2 There is an even greater reduction in the risk of headache when pencil-point needles (Sprotte or Whitacre) are used in preference to cutting-point needles (Quincke).2 In vitro studies show that there is less leakage of cerebrospinal fluid with pencil-point needles than with cutting-point needles of equal or even smaller diameter.3,4 Though pencil-point needles were originally manufactured only in very small diameters (25-gauge to 29-gauge), 22-gauge pencil-point needles are now available; they provide adequate flow for diagnostic lumbar puncture and may further reduce the possibility of cerebral herniation.
4 ReferencesScott Segal, M.D.
Brigham and Women's Hospital, Boston, MA 02115
bssegal@zeus.bwh. harvard. edu 1
Steigbigel NH . Computed tomography of the head before a lumbar puncture in suspected meningitis -- is it helpful? N Engl J Med 2001;345:1768-1770
Full Text | Web of Science | Medline2
Halpern S ,Preston R . Postdural puncture headache and spinal needle design: metaanalyses. Anesthesiology 1994;81:1376-1383
CrossRef | Web of Science | Medline3
Holst D ,Mollmann M ,Ebel C ,Hausman R ,Wendt M . In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg 1998;87:1331-1335
CrossRef | Web of Science | Medline4
Cruickshank RH ,Hopkinson JM . Fluid flow through dural puncture sites: an in vitro comparison of needle point types. Anaesthesia 1989;44:415-418
CrossRef | Web of Science | Medline
To the Editor:
In the study by Hasbun et al., none of the seven patients with a mass effect on CT who underwent lumbar puncture had brain herniation the following week. The authors' findings suggest that the risk associated with lumbar puncture is negligible in such patients, even in those with a mild or moderate mass effect on CT.
We retrospectively studied 94 consecutive patients with a bacterial brain abscess who were admitted to a single intensive care unit between 1980 and 1999 (unpublished data). We were surprised to observe that 55 patients (59 percent) underwent lumbar puncture, even though CT revealed a focal brain lesion in all of them and a mass effect in 65 percent of them. In only 1 of the 55 patients did brain herniation develop within six hours after lumbar puncture. In published reports on series of patients with a brain abscess, the rates have been similar (Table 1Table 1
Studies of Lumbar Puncture in Patients with a Brain Abscess.).1-4 Obviously, lumbar puncture is not recommended in patients with a brain abscess. The diagnostic value of lumbar puncture in such patients is usually low (Table 1). Most of the lumbar punctures listed in Table 1 were performed before a brain abscess was diagnosed. However, the findings confirm that the risk of brain herniation as a consequence of lumbar puncture is low, even in patients with a bacterial brain abscess.
4 ReferencesPierre Tattevin, M.D.
Fabrice Bruneel, M.D.
Bernard Régnier, M.D., Ph.D.
Hôpital Bichat–Claude Bernard, 75877 Paris CEDEX 18, France
pierre.tattevin@chu-rennes. fr 1
Yang SY . Brain abscess: a review of 400 cases. J Neurosurg 1981;55:794-799
CrossRef | Web of Science | Medline2
Chun CH ,Johnson JD ,Hofstetter M ,Raff MJ . Brain abscess: a study of 45 consecutive cases. Medicine (Baltimore) 1986;65:415-431
CrossRef | Web of Science | Medline3
Schliamser SE ,Backman K ,Norrby SR . Intracranial abscesses in adults: an analysis of 54 consecutive cases. Scand J Infect Dis 1988;20:1-9
CrossRef | Web of Science | Medline4
Seydoux C ,Francioli P . Bacterial brain abscesses: factors influencing mortality and sequelae. Clin Infect Dis 1992;15:394-401
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: It is gratifying to observe the degree of interest among colleagues worldwide in the use of cranial CT before lumbar puncture in adults with suspected meningitis. Kastenbauer and colleagues point out that although 83 of the 301 patients in our study (28 percent) had meningitis (defined as the presence of more than 5 white cells per milliliter of cerebrospinal fluid), only 5 patients had proven bacterial meningitis. This is true, but it does not negate the applicability of the results of our study, since clinicians obtain head CT scans before lumbar puncture in the heterogeneous group of patients with clinically suspected meningitis, not just in the subgroup with proven bacterial meningitis. The data that Kastenbauer et al. report on 75 patients with pneumococcal meningitis are intriguing, although it would be of interest to know whether further classification of the “cerebral abnormalities” on CT (e.g., the severity of brain edema) might have better predicted the risk of herniation.
Bruzzi and Brennan raise the issue of papilledema, and Tokuda and Nakazato mention spontaneous venous pulsation on funduscopy as a potentially valuable clinical sign for predicting increased intracranial pressure and the presence of abnormalities on cranial CT. We agree, but we avoided the use of these approaches in our study, for two reasons. First, although 269 patients underwent funduscopy before CT, papilledema was observed in only 1. Second, there is likely to be substantial variability among physicians in the detection of papilledema and venous pulsations, and this issue has not been rigorously studied. This is precisely the reason we used the Modified National Institutes of Health Stroke Scale in our study: it has been shown to have a high rate of interobserver agreement.1,2
We agree with Segal that small needles, resulting in less leakage of cerebrospinal fluid, would be desirable. However, it remains unclear whether such a reduction in cerebrospinal fluid leakage would actually reduce the incidence of cerebral herniation when there is a severe mass effect. It is gratifying to see the data presented by Tattevin et al., showing the low risk of brain herniation after lumbar puncture in patients with a documented brain abscess. Their experience corroborates that described in our study, as well as the experience reported in the literature before the advent of CT scanning.3
3 ReferencesRodrigo Hasbun, M.D.
Tulane University School of Medicine, New Orleans, LA 70112-2699Vincent Quagliarello, M.D.
Yale University School of Medicine, New Haven, CT 065201
Goldstein LB ,Samsa GP . Reliability of the National Institutes of Health Stroke Scale: extension to non-neurologists in the context of a clinical trial. Stroke 1997;28:307-310
CrossRef | Web of Science | Medline2
Goldstein LB ,Bertels C ,Davis JN . Interrater reliability of the NIH Stroke Scale. Arch Neurol 1989;46:660-662
Web of Science | Medline3
Korein J ,Cravioto H ,Leicach M . Reevaluation of lumbar puncture: a study of 129 patients with papilledema or intracranial hypertension. Neurology 1959;9:290-297
Web of Science | Medline
Author/Editor Response
The editorialist replies:
To the Editor: Segal's comments regarding the advantages of pencil-point needles as compared with cutting-point needles are appreciated, particularly because pencil-point needles are not familiar to most physicians other than anesthesiologists, who perform many lumbar punctures,1 or because they are considered too expensive. Pencil-point needles enter the subarachnoid space primarily by bluntly separating the fibers of the membranes with less tearing than cutting-point needles, leaving behind a less discrete channel for leakage of cerebrospinal fluid after needle removal.2,3 Although there is no published evidence that these features are associated with a reduction in the likelihood of cerebral herniation after lumbar puncture for suspected meningitis, it is reasonable to assume that there is such an association. It would still be prudent to follow general precautions with regard to lumbar puncture, such as those discussed in my editorial, even with the use of pencil-point needles.
3 ReferencesNeal H. Steigbigel, M.D.
Montefiore Medical Center, Bronx, NY 10467
nhs427@earthlink.net 1
Birnbach DJ ,Kuroda MM ,Sternman D ,Thys DM . Use of atraumatic spinal needles among neurologists in the United States. Headache 2001;41:385-390
CrossRef | Web of Science | Medline2
Kreuscher H ,Sandmann G . Die Minderung des postspinalen Kopfschmerzes durch Verwendung der Whitacre-Kanüle: Experimentelle Untersuchungen. Reg Anaesth 1989;12:43-45
Medline3
Holst D ,Mollmann M ,Ebel C ,Hausman R ,Wendt M . In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg 1998;87:1331-1335
CrossRef | Web of Science | Medline
- Citing Articles (7)
Citing Articles
1
A. J. Stockdale, M. P. Weekes, S. H. Aliyu. (2011) An audit of acute bacterial meningitis in a large teaching hospital 2005-10. QJM
CrossRef2
J de Campo, EV Villanueva. (2005) Diagnostic Imaging Clinical Effectiveness fact sheet: Suspected meningitis - role of lumbar puncture and computed tomography. Australasian Radiology 49:3, 252-253
CrossRef3
Fabrice Bruneel, Jean-Pierre Bédos. (2005) Stratégie de l’antibiothérapie devant une méningite bactérienne de l’adulte. Le Praticien en Anesthésie Réanimation 9:3, 193-203
CrossRef4
Brad Spellberg. (2005) Is Computed Tomography of the Head Useful Before Lumbar Puncture?. Clinical Infectious Diseases 40:7, 1061-1061
CrossRef5
(2005) Prognostic Factors in Adults with Bacterial Meningitis. New England Journal of Medicine 352:5, 512-515
Full Text6
S. Kastenbauer. (2003) Pneumococcal meningitis in adults: Spectrum of complications and prognostic factors in a series of 87 cases. Brain 126:5, 1015-1025
CrossRef7
Uwe Koedel, William Michael Scheld, Hans-Walter Pfister. (2002) Pathogenesis and pathophysiology of pneumococcal meningitis. The Lancet Infectious Diseases 2:12, 721-736
CrossRef
