Comparison of Four International Guidelines on the Utility of Cranial Imaging Before Lumbar Puncture in Adults with Bacterial Meningitis

Background: International guidelines exist for obtaining a head computed tomography (CT) scan before a lumbar puncture (LP) in adults with suspected meningitis but there are no studies comparing them in their ability to identify intracranial abnormalities. Methods: A retrospective study of 202 cases of adults with community-acquired bacterial meningitis at 16 hospitals in Houston from December 2004 until May 2019 to compare the 4 guidelines’ ability in identifying minor and major intracranial findings, cases in which CT findings changed management, and patients who suffered cerebral herniation. Results: Minor and major intracranial findings were seen in 69 (34.1%) and in 24 (11.8%) of the patients, respectively. A total of nine (37.5%) of the major intracranial findings prompted a neurosurgical intervention. A total of four (1.9%) patients had cerebral herniation. The Infectious Diseases of America (IDSA), the United Kingdom (UK), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), and the Swedish guidelines for cranial imaging were met in 92.1%, 54%, 41.6%, and in 23.3% of the patients, respectively. The IDSA, UK, European, and the Swedish guidelines missed 0%, 20.8%, 41.7%, and 70.8% of the major intracranial findings and 0, 1, 3 and 4 of the 9 patients that prompted a neurosurgical intervention, respectively. All four patients with cerebral herniation met the criteria for all four guidelines. Conclusion: Out of the four international guidelines, only the IDSA recommendations for cranial imaging did not miss any major intracranial abnormality or any finding that prompted a neurosurgical intervention but all guidelines identified herniation.