Volume 4, Number 40;  October 13, 2005

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Patient: 44 year old HIV+ African-American female with history of migraine, presenting with several days' worsening headache, nausea, and diplopea.  LP displayed high opening and closing pressures.

Session Handout:

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Mathews MK. Sergott RC. Savino PJ. Pseudotumor cerebri. [Review] [87 refs] [Journal Article. Review. Review, Tutorial] Current Opinion in Ophthalmology. 14(6):364-70, 2003 Dec.

UI: 14615641

Clinical Question: 

1) Which patients should have a CT scan prior to lumbar puncture?

Readings:

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<2>

Unique Identifier [PMID]: 11985377

Authors: van Crevel H. Hijdra A. de Gans J.

Institution: Academic Medical Centre, Department of Neurology, Amsterdam, The Netherlands.

Title: Lumbar puncture and the risk of herniation: when should we first perform CT?. [Review] [67 refs]

Source: Journal of Neurology. 249(2):129-37, 2002 Feb.

Abstract: Death following lumbar puncture (LP) is feared by physicians. Many opinions are found in literature on the question whether computed cranial tomography (CT) should be performed before LP, to prevent herniation. These opinions are mainly based on retrospective studies and pathophysiological reasoning. In this review the difficulties in the decision whether we should perform CT before LP are discussed. It is explained that the concept of "raised intracranial pressure" is confusing, and that the less ambiguous terms "brain shift" and "raised CSF pressure" should be used instead. Brain shift is a contraindication to LP, whether CSF pressure is raised or not, and whether papilloedema is present or not. Subsequently, recommendations are offered for indications to perform CT before LP, grouped according to the safety and clinical utility of LP. [References: 67]

Publication Type: Journal Article. Review. Review, Tutorial.

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<4>

Unique Identifier [PMID]: 11742046

Authors: Hasbun R. Abrahams J. Jekel J. Quagliarello VJ.

Institution: Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.

Title: Computed tomography of the head before lumbar puncture in adults with suspected meningitis.[see comment].

Source: New England Journal of Medicine. 345(24):1727-33, 2001 Dec 13.

Abstract: BACKGROUND: In adults with suspected meningitis clinicians routinely order computed tomography (CT) of the head before performing a lumbar puncture. METHODS: We prospectively studied 301 adults with suspected meningitis to determine whether clinical characteristics that were present before CT of the head was performed could be used to identify patients who were unlikely to have abnormalities on CT. The Modified National Institutes of Health Stroke Scale was used to identify neurologic abnormalities. RESULTS: Of the 301 patients with suspected meningitis, 235 (78 percent) underwent CT of the head before undergoing lumbar puncture. In 56 of the 235 patients (24 percent), the results of CT were abnormal; 11 patients (5 percent) had evidence of a mass effect. The clinical features at base line that were associated with an abnormal finding on CT of the head were an age of at least 60 years, immunocompromise, a history of central nervous system disease, and a history of seizure within one week before presentation, as well as the following neurologic abnormalities: an abnormal level of consciousness, an inability to answer two consecutive questions correctly or to follow two consecutive commands, gaze palsy, abnormal visual fields, facial palsy, arm drift, leg drift, and abnormal language (e.g., aphasia). None of these features were present at base line in 96 of the 235 patients who underwent CT scanning of the head (41 percent). The CT scan was normal in 93 of these 96 patients, yielding a negative predictive value of 97 percent. Of the three misclassified patients, only one had a mild mass effect on CT, and all three subsequently underwent lumbar puncture, with no evidence of brain herniation one week later. CONCLUSIONS: In adults with suspected meningitis, clinical features can be used to identify those who are unlikely to have abnormal findings on CT of the head.

Publication Type: Evaluation Studies. Journal Article.

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<5>

Unique Identifier [PMID]: 10597758

Authors: Gopal AK. Whitehouse JD. Simel DL. Corey GR.

Institution: Department of Medicine, Duke University, Durham, NC, USA. agopal@u.washington.edu

Title: Cranial computed tomography before lumbar puncture: a prospective clinical evaluation.[see comment][erratum appears in Arch Intern Med 2000 Nov 27;160(21):3223].

Comments Comment in: Arch Intern Med. 2000 Oct 9;160(18):2868-70; PMID: 11025802

Source: Archives of Internal Medicine. 159(22):2681-5, 1999 Dec 13-27.

Abstract: OBJECTIVE: To prospectively identify which patients can safely undergo lumbar puncture (LP) without screening cranial computed tomography (CT). METHODS: Emergency department physicians examined patients before CT. Examiners recorded the presence or absence of 10 clinical findings and answered 8 additional questions. The criterion standard was noncontrast cranial CT interpreted by staff radiologists. Clinical findings were prospectively compared with those of CT. RESULTS: One hundred thirteen consecutive adults with the urgent need for LP (median age, 42 years) were studied. Fifteen percent of patients meeting entrance criteria had new CT-documented lesions, with 2.7% having lesions that contraindicated LP. Sensitivity, specificity, and likelihood ratios (LRs) were measured for the clinical findings. Three statistically significant predictors of new intracranial lesions were identified: altered mentation (positive LR, 2.2; 95% confidence interval [CI], 1.5-3.2), focal neurologic examination (positive LR, 4.3; 95% CI, 1.9-10), and papilledema (positive LR, 11.1; 95% CI, 1.1-115). No single item adequately predicted the absence of CT abnormalities, but the clinical screening items in aggregate significantly predicted the results (negative LR, 0; upper 95% confidence limit, 0.6). The overall clinical impression had the highest predictive value in identifying patients with CT-defined contraindications to LP (positive LR, 18.8; 95% CI, 4.8-43). CONCLUSIONS: Because of the low prevalence of lesions that contraindicate LP, screening cranial CT solely to establish the safety of performing an LP typically provides limited additional information. Physicians can use their overall clinical impression and 3 clinical predictors to identify patients with the greatest risk of having intracranial lesions that may contraindicate LP.

Publication Type: Journal Article.

Resident Report / Department of Medicine & Grady Branch Library

Emory University School of Medicine

2005 Edition

Participating Faculty:  Carlos Del Rio MD  / Joyce Doyle MD / Lorenzo Difrancesco MD / Erich Folch MD / Alicia Hidron  MD  

Contact: Karl Woodworth