To the Editor: Dr Attia and colleagues1 concluded that in the presence of the sensitive
clinical signs in adults with possible meningitis, the physician should proceed
directly with lumbar puncture (LP) in high-risk patients. Although we agree
with this statement we would like to emphasize that lethal complications,
such as cerebral herniation, may be caused by LP.2
An axial computed tomographic (CT) scan of the head must be obtained to identify
those patients at risk. The American Academy of Neurology2
indicated that CT is better than clinical examination in predicting the risk
of herniation and death in those patients with increased intracranial pressure
due to a mass lesion or obstruction of the ventricular system. It has been
shown that clinical examination and presence of papilledema are not adequate
to exclude the possibility of cerebral herniation.3
Structural characteristics defined by CT provide valuable information about
the pressure gradient between different compartments of the brain.
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