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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.
Patients with meningitis have greater risk of harboring mass lesions. Midline shift, loss of suprachiasmatic and basilar cisterns, obliteration of the fourth ventricles, or obliteration of the superior cerebellar and quadrigeminal cisterns with sparing of the ambient cisterns are ominous signs and LP should be avoided.4 Although LP is usually a safe procedure, there is enough risk to warrant careful evaluation of these parameters.
The data presented by Attia et al are beneficial for diagnosing adult patients with meningitis. However, clinical suspicion must lead physicians to treat patients empirically and obtain an emergency CT scan of the head before performing an LP.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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