Cranial computed tomographic scans have little impact on management of bacterial meningitis

Fatal lumbar puncture: fact versus fiction--an approach to a clinical dilemma

Recent reports and commentaries have emphasized the alleged risk of cerebral herniation complicating lumbar puncture performed to diagnose acute bacterial meningitis. Instead, knowledge of facts relevant to the disease process can provide a rational and reassuring approach to management. All cases of purulent meningitis are associated with increased intracranial pressure, but herniation is a rare complication (5%). Despite suggestions to the contrary, cranial computed tomography (CT) is normal in most cases of purulent meningitis, including those with subsequent herniation. Additionally, CT may be associated with long-term radiation effects. An accurate clinical history combined with recognition of the early systemic and neurologic findings of bacterial meningitis will indicate a safe setting for performance of a diagnostic lumbar puncture with little likelihood of complicating herniation. In contrast, in patients in whom the disease process has progressed to the neurologic findings associated with impending cerebral herniation, a delay of the diagnostic procedure is indicated. In this latter circumstance, a different approach in management can be developed.

Emergency cranial computed tomography in the management of acute febrile encephalopathy in children

OBJECTIVE

Evaluation of the influence of emergency cranial computed tomography on the management of acute febrile encephalopathy in children.

METHODS

A retrospective study in children with acute febrile encephalopathy who underwent emergency cranial computed tomography within 12 hours of admission to the paediatric intensive care unit. All scans were evaluated by two independent radiologists.

RESULTS

Thirty nine children were included. Fourteen scans were abnormal and two had clinically insignificant incidental findings. Four children with focal neurological signs had scans demonstrating extra-axial collections. None required neurosurgical intervention. Clinically, raised intracranial pressure was present in 10 patients. Only five had cerebral oedema on computed tomography; these five children died. Emergency cranial computed tomography influenced subsequent management in no child without focal neurological signs and in only one child with focal neurology.

CONCLUSION

Emergency cranial computed tomography in acute febrile encephalopathy in children without focal neurological signs has little influence on subsequent management. Where cranial computed tomography is thought to be necessary, it should be carried out when the child's clinical condition has been stabilised.

Recognition, treatment and complications of meningococcal disease

Meningococcal disease remains a major cause of death in young children. A decrease in mortality requires recognition and treatment of the disease at a number of stages in the illness. Life-threatening meningococcal disease usually presents as septicaemia rather than meningitis. The cardinal feature of meningococcal septicaemia is the purpuric rash. Many parents recognise the rash and seek medical advice because of it. When primary care physicians recognise the rash, the administration of parenteral penicillin may decrease mortality. However, antibacterials are not given promptly if there is no rash or if the disease presents in an atypical form. In hospital, antibacterial therapy with a third-generation cephalosporin should be given. Disease severity needs to be assessed by a valid method, such as the Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS). This can identify those patients who need intensive care and/or might benefit from new therapies. The 2 life-threatening complications are septic shock and meningoencephalitis with raised intracranial pressure. Despite numerous case reports of success with potential new treatments, none has been proven safe and/or effective by controlled trials. Although it is tempting to focus on new treatments, the early recognition of severe meningococcal disease by parents, primary care physicians and junior hospital doctors is equally, if not more, important as a potential means of decreasing mortality.