- If you think CT will show a cause for the headache, do a CT
- If a CT is indicated for other reasons (depressed conscious level, focal neurology), do a CT
- If a GCS 15 patient is to undergo LP for suspected (or to rule out) meningitis, and they have a normal neurological exam (including fundi), and are not elderly or immunosuppressed, there is no need to do a CT first.
- If you’re seriously worried about meningitis and are intent on getting a CT prior to LP, don’t let the imaging delay antimicrobial therapy.
- CNS infection should be considered in all patients with a headache, neck stiffness, fever, altered sensorium, or diffuse or focal neurological findings.
- pneumoniae is one of the two leading causes of bacterial meningitis in adults. Mortality from S. pneumoniae is 30%.
- pay close attention to cranial nerves 2, 3, 4, and 6
- Altered mental status in a patient with suspected meningitis can be a sign of increased ICP or encephalitis.
- You’ve got to get the LP! Only true way to assess for meningitis
- Early initiation of empirical antimicrobial therapy is recommended in cases of suspected acute CNS infection. Antibiotic administration should not be delayed for CSF analysis or performance of neuroimaging studies.
- Antibiotic chemoprophylaxis should be assured for close contacts of patients with meningitis resulting from N. meningitidis or H. in uenza.
- Concomitant CNS infection should be strongly considered in any symptomatic patient with another severe systemic infection, such as urinary tract infection or pneumonia.
- First line treatment for bacterial meningitis is ceftriaxone plus vancomycin.
- Acyclovir is recommended for patients with suspected meningoencephalitis.
- Dexamethasone is recommended prior to treatment with antibiotics in adults (controversial)
A thunderclap headache (TCH) has been defined as a “headache that reaches 7 (out of 10) or more in intensity within less than one minute.”
Tips for Interpreting the CSF Opening Pressure
How useful are physical examination manoeuvres for an adult patient with suspected meningitis?
The Kernig, Brudzinski and Jolt Accentuation signs have limited utility in assessing patients with acute meningitis. The poor sensitivities mean that meningitis cannot be ruled out if the signs are not present (remember sn[out]). The relatively high specificities mean that your suspicion might increase if the signs are present (remember sp[in]) but unfortunately the associated low positive likelihood ratios show that no exam manoeuvre can reliably rule in the diagnosis. All three must be used with caution and in conjunction with other supporting laboratory and historical data.