Skip to main content

Advertisement

SpringerLink
Log in

Comparison of international guidelines for CT prior to lumbar puncture in patients with suspected meningitis

  • Original Article
  • Published:
Emergency Radiology Aims and scope Submit manuscript

Abstract

Purpose

To compare the performance of multiple international guidelines in selecting patients for head CT prior to lumbar puncture (LP) in suspected meningitis, focusing on identification of potential contraindications to immediate LP.

Methods

Retrospective study of 196 patients with suspected meningitis presenting to an emergency department between March 2013 and March 2023 and undergoing head CT prior to LP. UK Joint Specialist Society Guidelines (UK), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Infectious Diseases Society of America (IDSA) guidelines were evaluated by cross-referencing imaging criteria with clinical characteristics present at time of presentation. Sensitivity of each guideline for recommending neuroimaging in cases with brain shift on CT was evaluated, along with the number of normal studies and incidental or spurious findings.

Results

2/196 (1%) patients had abnormal CTs with evidence of brain shift, while 14/196 (7%) had other abnormalities on CT without brain shift. UK, ESCMID and IDSA guidelines recommended imaging in 10%, 14% and 33% of cases respectively. All three guidelines recommended imaging pre-LP in 2/2 (100%) cases with brain shift. IDSA guidelines recommended more CT studies with normal findings (59 vs 16 and 24 for UK and ESCMID guidelines respectively) and CT abnormalities without brain shift (4 vs 1 and 2 respectively) than the other guidelines.

Conclusion

UK, ESCMID and IDSA guidelines are all effective at identifying the small cohort of patients who benefit from a head CT prior to LP. Following the more selective UK/ESCMID guidelines limits the number of normal studies and incidental or spurious CT findings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Ellis J, Harvey D, Defres S et al (2022) Clinical management of community-acquired meningitis in adults in the UK and Ireland in 2017: a retrospective cohort study on behalf of the National Infection Trainees Collaborative for Audit and Research (NITCAR). https://doi.org/10.1136/bmjopen-2022-062698. BMJ Open 12:

  2. Salazar L, Hasbun R (2017) Cranial imaging before lumbar puncture in adults with community-acquired meningitis: clinical utility and adherence to the Infectious Diseases Society of America Guidelines. Clin Infect Dis 64:1657–1662. https://doi.org/10.1093/cid/cix240

    Article  PubMed  PubMed Central  Google Scholar 

  3. Imtiaz A, Toomath R (2019) Computed tomography head scans prior to lumbar punctures in suspected meningitis. Intern Med J 49:55–58. https://doi.org/10.1111/imj.13997

    Article  PubMed  Google Scholar 

  4. Van Crevel H, Hijdra A, De Gans J (2002) Lumbar puncture and the risk of herniation. when should we first perform CT?

  5. Joffe AR (2007) Lumbar puncture and brain herniation in acute bacterial meningitis: a review. J Intensive Care Med 22:194–207

    Article  PubMed  Google Scholar 

  6. Michael B, Menezes BF, Cunniffe J et al (2010) Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J 27:433–438. https://doi.org/10.1136/emj.2009.075598

    Article  PubMed  Google Scholar 

  7. Bodilsen J, Brandt CT, Sharew A et al (2018) Early versus late diagnosis in community-acquired bacterial meningitis: a retrospective cohort study. Clin Microbiol Infect 24:166–170. https://doi.org/10.1016/j.cmi.2017.06.021

    Article  CAS  PubMed  Google Scholar 

  8. Gopal AK, Whitehouse JD, Simel DL, Corey, G Ralph (1999) Cranial Computed Tomography Before Lumbar Puncture A Prospective Clinical Evaluation

  9. Schuh S, Lindner G, Exadaktylos AK et al (2013) Determinants of timely management of acute bacterial meningitis in the ED. Am J Emerg Med 31:1056–1061. https://doi.org/10.1016/j.ajem.2013.03.042

    Article  PubMed  Google Scholar 

  10. Bodilsen J, Dalager-Pedersen M, Schønheyder HC, Nielsen H (2016) Time to antibiotic therapy and outcome in bacterial meningitis: a Danish population-based cohort study. BMC Infect Dis 16:392. https://doi.org/10.1186/s12879-016-1711-z

    Article  PubMed  PubMed Central  Google Scholar 

  11. Tunkel AR, Hartman BJ, Kaplan SL et al (2004) Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 39:1267–1284. https://doi.org/10.1086/425368

    Article  PubMed  Google Scholar 

  12. van de Beek D, Cabellos C, Dzupova O et al (2016) ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect 22:S37–S62. https://doi.org/10.1016/j.cmi.2016.01.007

    Article  PubMed  Google Scholar 

  13. McGill F, Heyderman RS, Michael BD et al (2016) The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect 72:405–438. https://doi.org/10.1016/j.jinf.2016.01.007

    Article  CAS  PubMed  Google Scholar 

  14. Glimåker M, Sjölin J, Åkesson S, Naucler P (2018) Lumbar puncture performed promptly or after neuroimaging in Acute bacterial meningitis in adults: a prospective National Cohort Study evaluating different guidelines. Clin Infect Dis 66:321–328. https://doi.org/10.1093/cid/cix806

    Article  PubMed  Google Scholar 

  15. Costerus JM, Lemmens CMC, van de Beek D, Brouwer MC (2020) Cranial imaging and lumbar puncture in patients with suspected central nervous system infection. Clin Infect Dis 70:2469–2475. https://doi.org/10.1093/cid/ciz694

    Article  PubMed  Google Scholar 

  16. Park N, Nigo M, Hasbun R (2022) Comparison of Four International guidelines on the utility of cranial imaging before lumbar puncture in adults with bacterial meningitis. Clin Neuroradiol 32:857–862. https://doi.org/10.1007/s00062-022-01143-4

    Article  PubMed  Google Scholar 

  17. Glimåker M, Johansson B, Bell M et al (2013) Early lumbar puncture in adult bacterial meningitis - rationale for revised guidelines. Scand J Infect Dis 45:657–663

    Article  PubMed  Google Scholar 

  18. Cauley KA (2015) Fluoroscopically guided lumbar puncture. Am J Roentgenol 205:W442–W450. https://doi.org/10.2214/AJR.14.14028

    Article  Google Scholar 

  19. Health Information and Quality Authority (2023) Report of an inspection against the National Standards for Safer Better Healthcare. Dublin

  20. Hasbun R, Abrahams J, Jekel J, Quagliarello VJ (2001) Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 345:1727–1733. https://doi.org/10.1056/NEJMoa010399

    Article  CAS  PubMed  Google Scholar 

  21. Davis LE (2018) Acute bacterial meningitis. CONTINUUM: Lifelong Learn Neurol 24:1264–1283. https://doi.org/10.1212/CON.0000000000000660

    Article  Google Scholar 

  22. Winkler F, Kastenbauer S, Yousry TA et al (2002) Discrepancies between brain CT imaging and severely raised intracranial pressure proven by ventriculostomy in adults with pneumococcal meningitis. J Neurol 249:1292–1297. https://doi.org/10.1007/s00415-002-0844-8

    Article  PubMed  Google Scholar 

  23. Larsen L, Poulsen FR, Nielsen TH et al (2017) Use of intracranial pressure monitoring in bacterial meningitis: a 10-year follow up on outcome and intracranial pressure versus head CT scans. Infect Dis 49:356–364. https://doi.org/10.1080/23744235.2016.1269265

    Article  Google Scholar 

  24. Costerus JM, Brouwer MC, Sprengers MES et al (2018) Cranial computed tomography, lumbar puncture, and clinical deterioration in bacterial meningitis: a Nationwide Cohort Study. Clin Infect Dis 67:920–926. https://doi.org/10.1093/cid/ciy200

    Article  PubMed  Google Scholar 

  25. Sturdy S, Miller F, Hogarth S et al (2020) Half a Century of Wilson & Jungner: reflections on the Governance of Population Screening. Wellcome Open Res 5:158. https://doi.org/10.12688/wellcomeopenres.16057.2

    Article  PubMed  PubMed Central  Google Scholar 

  26. JEFFERSON G (1938) THE TENTORIAL PRESSURE CONE. Arch Neurol Psychiatry 40:857. https://doi.org/10.1001/archneurpsyc.1938.02270110011001

    Article  Google Scholar 

  27. April MD, Long B, Koyfman A (2017) Emergency medicine myths: computed tomography of the Head prior to lumbar puncture in adults with suspected bacterial meningitis – due diligence or antiquated practice? J Emerg Med 53:313–321. https://doi.org/10.1016/j.jemermed.2017.04.032

    Article  PubMed  Google Scholar 

  28. Erbay SH, O’Callaghan MG, Bhadelia R (2005) Is lumbar puncture contraindicated in patients with Chiari I malformation? AJNR Am J Neuroradiol 26:985

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland

    Fergus O’ Herlihy, Philip J Dempsey, Dora Gorman & Brian Gibney

  2. Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland

    Eavan G Muldoon

Authors
  1. Fergus O’ Herlihy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Philip J Dempsey
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dora Gorman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eavan G Muldoon
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Brian Gibney
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Fergus O’Herlihy, Philip Dempsey and Dora Gorman. The first draft of the manuscript was written by Fergus O’Herlihy and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Fergus O’ Herlihy.

Ethics declarations

Ethics approval and consent to participate

The authors did not receive support from any organization for the submitted work.

Consent for publication

The authors have no relevant financial or non-financial interests to disclose.

Competing interests

This quality improvement initiative was approved by the hospital’s Clinical Audit and Effectiveness Committee. As this was a retrospective review informed consent was waived by the committee.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Herlihy, F.O., Dempsey, P.J., Gorman, D. et al. Comparison of international guidelines for CT prior to lumbar puncture in patients with suspected meningitis. Emerg Radiol 31, 373–379 (2024). https://doi.org/10.1007/s10140-024-02234-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10140-024-02234-0

Keywords

Search

Navigation