Emergency Medicine Myths: Computed Tomography of the Head Prior to Lumbar Puncture in Adults with Suspected Bacterial Meningitis - Due Diligence or Antiquated Practice?

Michael D. April, Brit Long, Alex Koyfman

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background: Various sources purport an association between lumbar puncture and brainstem herniation in patients with intracranial mass effect lesions. Several organizations and texts recommend head computed tomography (CT) prior to lumbar puncture in selected patients. Objective: To review the evidence regarding the utility of obtaining head CT prior to lumbar puncture in adults with suspected bacterial meningitis. Discussion: Observational studies report a risk of post-lumbar puncture brainstem herniation in the presence of intracranial mass effect (1.5%) that is significantly lower than that reported among all patients with bacterial meningitis (up to 13.3%). It is unclear from existing literature whether identifying patients with intracranial mass effect decreases herniation risk. Up to 80% of patients with bacterial meningitis experiencing herniation have no CT abnormalities, and approximately half of patients with intracranial mass effect not undergoing lumbar puncture herniate. Decision rules to selectively perform CT on only those individuals most likely to have intracranial mass effect lesions have not undergone validation. Despite recommendations for immediate antimicrobial therapy prior to imaging, data indicate an association between pre-lumbar puncture CT and antibiotic delays. Recent data demonstrate shortened door-to-antibiotic times and lower mortality from bacterial meningitis after implementation of new national guidelines, which restricted generally accepted CT indications by removing impaired mental status as imaging criterion. Conclusions: Data supporting routine head CT prior to lumbar puncture are limited. Physicians should consider selective CT for those patients at risk for intracranial mass effect lesions based on decision rules or clinical gestalt. Patients undergoing head CT must receive immediate antibiotic therapy.

Original languageEnglish (US)
JournalJournal of Emergency Medicine
DOIs
StateAccepted/In press - 2017

Fingerprint

Bacterial Meningitides
Spinal Puncture
Emergency Medicine
Head
Tomography
Anti-Bacterial Agents
Brain Stem
Observational Studies
Organizations
Guidelines
Physicians
Mortality

Keywords

  • Bacterial meningitis
  • Brain computed tomography
  • Brainstem herniation
  • Evidence-based medicine
  • Lumbar puncture

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

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title = "Emergency Medicine Myths: Computed Tomography of the Head Prior to Lumbar Puncture in Adults with Suspected Bacterial Meningitis - Due Diligence or Antiquated Practice?",
abstract = "Background: Various sources purport an association between lumbar puncture and brainstem herniation in patients with intracranial mass effect lesions. Several organizations and texts recommend head computed tomography (CT) prior to lumbar puncture in selected patients. Objective: To review the evidence regarding the utility of obtaining head CT prior to lumbar puncture in adults with suspected bacterial meningitis. Discussion: Observational studies report a risk of post-lumbar puncture brainstem herniation in the presence of intracranial mass effect (1.5{\%}) that is significantly lower than that reported among all patients with bacterial meningitis (up to 13.3{\%}). It is unclear from existing literature whether identifying patients with intracranial mass effect decreases herniation risk. Up to 80{\%} of patients with bacterial meningitis experiencing herniation have no CT abnormalities, and approximately half of patients with intracranial mass effect not undergoing lumbar puncture herniate. Decision rules to selectively perform CT on only those individuals most likely to have intracranial mass effect lesions have not undergone validation. Despite recommendations for immediate antimicrobial therapy prior to imaging, data indicate an association between pre-lumbar puncture CT and antibiotic delays. Recent data demonstrate shortened door-to-antibiotic times and lower mortality from bacterial meningitis after implementation of new national guidelines, which restricted generally accepted CT indications by removing impaired mental status as imaging criterion. Conclusions: Data supporting routine head CT prior to lumbar puncture are limited. Physicians should consider selective CT for those patients at risk for intracranial mass effect lesions based on decision rules or clinical gestalt. Patients undergoing head CT must receive immediate antibiotic therapy.",
keywords = "Bacterial meningitis, Brain computed tomography, Brainstem herniation, Evidence-based medicine, Lumbar puncture",
author = "April, {Michael D.} and Brit Long and Alex Koyfman",
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language = "English (US)",
journal = "Journal of Emergency Medicine",
issn = "0736-4679",
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AU - Long, Brit

AU - Koyfman, Alex

PY - 2017

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N2 - Background: Various sources purport an association between lumbar puncture and brainstem herniation in patients with intracranial mass effect lesions. Several organizations and texts recommend head computed tomography (CT) prior to lumbar puncture in selected patients. Objective: To review the evidence regarding the utility of obtaining head CT prior to lumbar puncture in adults with suspected bacterial meningitis. Discussion: Observational studies report a risk of post-lumbar puncture brainstem herniation in the presence of intracranial mass effect (1.5%) that is significantly lower than that reported among all patients with bacterial meningitis (up to 13.3%). It is unclear from existing literature whether identifying patients with intracranial mass effect decreases herniation risk. Up to 80% of patients with bacterial meningitis experiencing herniation have no CT abnormalities, and approximately half of patients with intracranial mass effect not undergoing lumbar puncture herniate. Decision rules to selectively perform CT on only those individuals most likely to have intracranial mass effect lesions have not undergone validation. Despite recommendations for immediate antimicrobial therapy prior to imaging, data indicate an association between pre-lumbar puncture CT and antibiotic delays. Recent data demonstrate shortened door-to-antibiotic times and lower mortality from bacterial meningitis after implementation of new national guidelines, which restricted generally accepted CT indications by removing impaired mental status as imaging criterion. Conclusions: Data supporting routine head CT prior to lumbar puncture are limited. Physicians should consider selective CT for those patients at risk for intracranial mass effect lesions based on decision rules or clinical gestalt. Patients undergoing head CT must receive immediate antibiotic therapy.

AB - Background: Various sources purport an association between lumbar puncture and brainstem herniation in patients with intracranial mass effect lesions. Several organizations and texts recommend head computed tomography (CT) prior to lumbar puncture in selected patients. Objective: To review the evidence regarding the utility of obtaining head CT prior to lumbar puncture in adults with suspected bacterial meningitis. Discussion: Observational studies report a risk of post-lumbar puncture brainstem herniation in the presence of intracranial mass effect (1.5%) that is significantly lower than that reported among all patients with bacterial meningitis (up to 13.3%). It is unclear from existing literature whether identifying patients with intracranial mass effect decreases herniation risk. Up to 80% of patients with bacterial meningitis experiencing herniation have no CT abnormalities, and approximately half of patients with intracranial mass effect not undergoing lumbar puncture herniate. Decision rules to selectively perform CT on only those individuals most likely to have intracranial mass effect lesions have not undergone validation. Despite recommendations for immediate antimicrobial therapy prior to imaging, data indicate an association between pre-lumbar puncture CT and antibiotic delays. Recent data demonstrate shortened door-to-antibiotic times and lower mortality from bacterial meningitis after implementation of new national guidelines, which restricted generally accepted CT indications by removing impaired mental status as imaging criterion. Conclusions: Data supporting routine head CT prior to lumbar puncture are limited. Physicians should consider selective CT for those patients at risk for intracranial mass effect lesions based on decision rules or clinical gestalt. Patients undergoing head CT must receive immediate antibiotic therapy.

KW - Bacterial meningitis

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KW - Evidence-based medicine

KW - Lumbar puncture

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