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Lumbar puncture and brain herniation in acute bacterial meningitis: a review

Ari R Joffe1

  • 1Department of Pediatrics, Divisions of Infectious Diseases and Critical Care, University of Alberta, Edmonton, Canada. ajoffe@cha.ab.ca

Journal of Intensive Care Medicine
|August 23, 2007
PubMed

Insights

Lumbar puncture (LP) may precipitate cerebral herniation in acute bacterial meningitis (ABM). Clinical signs of impending herniation, not just CT scans, guide safe LP decisions in ABM patients.

Area of Science:

  • Neurology
  • Infectious Diseases

Background:

  • Cerebral herniation is a significant complication in acute bacterial meningitis (ABM), contributing to substantial mortality.
  • The role of lumbar puncture (LP) in precipitating cerebral herniation in ABM patients remains a subject of controversy.

Purpose of the Study:

  • To critically review the controversy surrounding LP-induced cerebral herniation in ABM.
  • To identify predictors for delaying LP and outline management priorities in high-risk ABM patients.

Main Methods:

  • Literature review and analysis of pathophysiological arguments.
  • Evaluation of diagnostic tools (CT scans) and clinical signs for herniation risk assessment.

Main Results:

  • Cerebral herniation occurs in approximately 5% of ABM cases and accounts for 30% of mortality.
  • LP is often temporally associated with herniation, suggesting a causative link.
  • Clinical signs like decreased consciousness (GCS ≤ 11), brainstem abnormalities, and recent seizures are critical indicators to delay LP, even with a normal CT scan.

Conclusions:

  • Normal CT scans do not guarantee LP safety in ABM.
  • Clinical assessment of impending herniation is paramount for safe LP performance.
  • In high-risk patients, prioritize airway, breathing, circulation, mannitol, and antibiotics, followed by CT, rather than immediate LP.

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