FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 345:1727-1733 December 13, 2001 Number 24 Next

	Full Text PDF Editorial by Steigbigel, N. H. Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background In adults with suspected meningitis clinicians routinely order computed tomography (CT) of the head before performing a lumbar puncture.

Methods We prospectively studied 301 adults with suspected meningitis to determine whether clinical characteristics that were present before CT of the head was performed could be used to identify patients who were unlikely to have abnormalities on CT. The Modified National Institutes of Health Stroke Scale was used to identify neurologic abnormalities.

Results Of the 301 patients with suspected meningitis, 235 (78 percent) underwent CT of the head before undergoing lumbar puncture. In 56 of the 235 patients (24 percent), the results of CT were abnormal; 11 patients (5 percent) had evidence of a mass effect. The clinical features at base line that were associated with an abnormal finding on CT of the head were an age of at least 60 years, immunocompromise, a history of central nervous system disease, and a history of seizure within one week before presentation, as well as the following neurologic abnormalities: an abnormal level of consciousness, an inability to answer two consecutive questions correctly or to follow two consecutive commands, gaze palsy, abnormal visual fields, facial palsy, arm drift, leg drift, and abnormal language (e.g., aphasia). None of these features were present at base line in 96 of the 235 patients who underwent CT scanning of the head (41 percent). The CT scan was normal in 93 of these 96 patients, yielding a negative predictive value of 97 percent. Of the three misclassified patients, only one had a mild mass effect on CT, and all three subsequently underwent lumbar puncture, with no evidence of brain herniation one week later.

Conclusions In adults with suspected meningitis, clinical features can be used to identify those who are unlikely to have abnormal findings on CT of the head.

Source Information

From the Departments of Internal Medicine (R.H., V.J.Q.), Diagnostic Radiology (J.A.), and Epidemiology and Public Health (J.J.), Yale University School of Medicine, New Haven, Conn.

Address reprint requests to Dr. Quagliarello at LCI 800, Yale University School of Medicine, New Haven, CT 06520-8022.

Full Text of this Article

This article has been cited by other articles:

• Hoffman, O., Weber, J. R. (2009). Review: Pathophysiology and treatment of bacterial meningitis. Therapeutic Advances in Neurological Disorders 2: 401-412 [Abstract]  
• Karam, G. H. (2009). Nervous System Infections and Catheter Infections. ACCP Crit Care Med Brd Rev 20: 41-74 [Full Text]  
• Mateen, F. J., Mohr, D. N. (2008). 45-Year-Old Woman With Recurrent Headache and Photophobia. Mayo Clin Proc. 83: 951-954 [Full Text]  
• Breen, D.P., Duncan, C.W., Pope, A.E., Gray, A.J., Al-Shahi Salman, R. (2008). Emergency department evaluation of sudden, severe headache. QJM 101: 435-443 [Abstract] [Full Text]  
• Logan, S. A E, MacMahon, E. (2008). Viral meningitis. BMJ 336: 36-40 [Full Text]  
• Schut, E. S, de Gans, J., van de Beek, D. (2008). Community-acquired bacterial meningitis in adults. PN 8: 8-23 [Abstract] [Full Text]  
• Joffe, A. R. (2007). Lumbar Puncture and Brain Herniation in Acute Bacterial Meningitis: A Review. J Intensive Care Med 22: 194-207 [Abstract]  
• Gjini, A.B., Stuart, J.M., Cartwright, K., Cohen, J., Jacobs, M., Nichols, T., Ninis, N., Prempeh, H., Whitehouse, A., Heyderman, R.S. (2006). Quality of in-hospital care for adults with acute bacterial meningitis: a national retrospective survey.. QJM 99: 761-769 [Abstract] [Full Text]  
• Straus, S. E., Thorpe, K. E., Holroyd-Leduc, J. (2006). How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?. JAMA 296: 2012-2022 [Abstract] [Full Text]  
• Abrahamian, F. M., Moran, G. J., Talan, D. A., Gupta, M., Cooper, R. J., Hoffman, J. R., Johnston, A. M., Carr, B., Gay, T., Read, W. L., van de Beek, D. (2006). Community-acquired bacterial meningitis.. NEJM 354: 1429-1432 [Full Text]  
• Greig, P R, Goroszeniuk, D (2006). Role of computed tomography before lumbar puncture: a survey of clinical practice.. Postgrad. Med. J. 82: 162-165 [Abstract] [Full Text]  
• Reilly, B. M., Evans, A. T. (2006). Translating Clinical Research into Clinical Practice: Impact of Using Prediction Rules To Make Decisions. ANN INTERN MED 144: 201-209 [Abstract] [Full Text]  
• van de Beek, D., de Gans, J., Tunkel, A. R., Wijdicks, E. F.M. (2006). Community-Acquired Bacterial Meningitis in Adults. NEJM 354: 44-53 [Full Text]  
• Proulx, N., Frechette, D., Toye, B., Chan, J., Kravcik, S. (2005). Delays in the administration of antibiotics are associated with mortality from adult acute bacterial meningitis. QJM 98: 291-298 [Abstract] [Full Text]  
• van de Beek, D., de Gans, J., Spanjaard, L., Weisfelt, M., Reitsma, J. B., Vermeulen, M. (2004). Clinical Features and Prognostic Factors in Adults with Bacterial Meningitis. NEJM 351: 1849-1859 [Abstract] [Full Text]  
• Ginsberg, L (2004). DIFFICULT AND RECURRENT MENINGITIS. J. Neurol. Neurosurg. Psychiatry 75: i16-21 [Full Text]  
• Oliver, W. J., Shope, T. C., Kuhns, L. R. (2003). Fatal Lumbar Puncture: Fact Versus Fiction--An Approach to a Clinical Dilemma. Pediatrics 112: e174-176 [Abstract] [Full Text]  
• Haberl, R., Wenisch, C., Malaviya, A. N., Siegel, D. M., Pirzada, O. M., Mushlin, S. B. (2003). Case 33-2002: A 28-Year-Old Woman with Ocular Inflammation, Fever, and Headache. NEJM 348: 474-476 [Full Text]  
• Flansbaum, B. E., Huddleston, J. M. (2002). Update in Hospital Medicine. ANN INTERN MED 137: 814-822 [Abstract] [Full Text]  
• de Gans, J., van de Beek, D., the European Dexamethasone in Adulthood Bacterial, (2002). Dexamethasone in Adults with Bacterial Meningitis. NEJM 347: 1549-1556 [Abstract] [Full Text]  
• Kvalsvig, A.J., Unsworth, D.J., Arkava, T., Luszczak, M., Kanegaye, J. T., Bradley, J. S. (2002). Lumbar Punctures and Meningitis. Pediatrics 110: 1028-1028 [Full Text]  
• CHADWICK, D.R., LEVER, A.M.L. (2002). The impact of new diagnostic methodologies in the management of meningitis in adults at a teaching hospital. QJM 95: 663-670 [Abstract] [Full Text]  
• Kastenbauer, S., Winkler, F., Pfister, H.-W., Bruzzi, J. F., Brennan, D. D., Tokuda, Y., Nakazato, N., Segal, S., Tattevin, P., Bruneel, F., Regnier, B., Hasbun, R., Quagliarello, V., Steigbigel, N. H. (2002). Cranial CT before Lumbar Puncture in Suspected Meningitis. NEJM 346: 1248-1251 [Full Text]  
• (2002). Do We Need CT Before LP in the Evaluation of Meningitis?. JWatch Emergency Med. 2002: 2-2 [Full Text]  
• (2002). When Is CT Important Before Lumbar Puncture for Suspected Meningitis?. JWatch Neurology 2002: 1-1 [Full Text]  
• (2002). Is CT Necessary Before Lumbar Puncture in Suspected Meningitis?. JWatch Infect. Diseases 2002: 5-5 [Full Text]  
• (2001). When Is It Safe to Omit Head CT Before Lumbar Puncture?. JWatch General 2001: 3-3 [Full Text]  
• Steigbigel, N. H. (2001). Computed Tomography of the Head before a Lumbar Puncture in Suspected Meningitis -- Is It Helpful?. NEJM 345: 1768-1770 [Full Text]