When should patients with bacterial meningitis be referred to a neurosurgical unit?

The case records of 97 patients with proven bacterial meningitis who were referred to a regional neurosurgical unit between 1964 and 1991 were reviewed. Mortality declined from 34% in the first cohort referred between the years 1964-82 to 5% for 1983-91 (X2 = 11.78; p < 0.001). Fewer patients were admitted in coma, (X2 = 4.43; p < 0.05), or with focal neurological signs (X2 = 7.57; p < 0.01) in the second cohort. The rate of referral increased in the later period but the incidence of unsuspected brain abscess (16% and 15%) did not change. There was a strong correlation between coma on admission and death, (X2 = 17.3; p < 0.001) and with brain abscess and death (X2 = 6.73; p < 0.01). In conclusion patients with known or suspected bacterial meningitis coupled with a decreasing level of consciousness or focal neurological signs should be referred to a neurosurgical centre.