How does a CT scan help diagnose meningitis. What are the benefits and limitations of CT imaging for suspected meningitis cases. When should CT scans be performed for meningitis patients. What do alternative imaging methods like MRI offer for meningitis diagnosis.

Understanding Meningitis and the Role of Imaging in Diagnosis

Meningitis is a serious inflammatory condition affecting the protective membranes covering the brain and spinal cord. Accurate and timely diagnosis is crucial for proper treatment and prevention of severe complications. While lumbar puncture remains the gold standard for diagnosing meningitis, imaging techniques like computed tomography (CT) scans play an important role in certain clinical scenarios.

CT scans can provide valuable information about potential complications or alternative diagnoses in patients with suspected meningitis. However, the appropriate use and timing of CT imaging in the diagnostic workup has been a subject of debate among medical professionals.

What is the primary purpose of CT scans in meningitis cases?

CT scans in meningitis cases serve several key purposes:

• Identifying potential contraindications to lumbar puncture
• Detecting complications like brain abscesses or hydrocephalus
• Ruling out alternative diagnoses that may mimic meningitis symptoms
• Guiding further management decisions in complex cases

Evaluating the Benefits and Limitations of CT Scans for Meningitis

While CT scans can provide useful information in certain cases, their routine use in all suspected meningitis patients has been questioned. Recent research suggests that the benefits of CT scanning may be more limited than previously thought, especially when weighed against potential drawbacks.

What are the potential drawbacks of routine CT scans in meningitis cases?

Routine CT scans for suspected meningitis can have several drawbacks:

1. Delays in diagnosis and treatment initiation
2. Exposure to ionizing radiation
3. Increased healthcare costs
4. Potential for overdiagnosis or unnecessary interventions
5. False sense of security if results are negative

A prospective study conducted in Sweden compared different guidelines for neuroimaging in acute bacterial meningitis (ABM) cases. The research found that more conservative use of CT scans, as recommended by updated Swedish guidelines, was associated with improved patient outcomes compared to broader indications for CT scanning suggested by other guidelines.

Comparing International Guidelines on CT Use in Meningitis

Different countries and medical societies have varying recommendations regarding the use of CT scans in suspected meningitis cases. Understanding these differences can help clinicians make more informed decisions about when to order neuroimaging studies.

How do Swedish, European, and American guidelines differ regarding CT use in meningitis?

The main differences in CT scan recommendations for meningitis cases are:

• Swedish guidelines (revised 2009): Omit impaired mental status and new-onset seizures as indications for CT before lumbar puncture
• European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines (2016): Lowered the level of consciousness on the Glasgow Coma Scale indicating need for CT before lumbar puncture
• Infectious Diseases Society of America (IDSA) guidelines (2004): More conservative, recommending CT before lumbar puncture for “abnormal mental status”

The Swedish study found that adhering to the more restrictive Swedish guidelines resulted in better patient outcomes, including lower in-hospital mortality rates and more favorable outcomes after 2-6 months, compared to following ESCMID or IDSA guidance.

Optimizing the Use of CT Scans in Meningitis Diagnosis

Given the potential drawbacks of routine CT scanning and the evidence supporting more selective use, it’s important for healthcare providers to carefully consider when neuroimaging is truly necessary in suspected meningitis cases.

When should CT scans be performed in patients with suspected meningitis?

CT scans may be appropriate in the following situations:

• Focal neurological deficits
• Papilledema or other signs of significantly elevated intracranial pressure
• History of central nervous system disease or recent neurosurgery
• Severe immunocompromise (though this indication is debated)
• Suspicion of alternative diagnoses requiring immediate intervention

It’s important to note that even in these cases, the benefits of CT scanning should be weighed against the potential for treatment delays. In many instances, empiric antibiotic therapy can be safely initiated before or concurrent with neuroimaging studies.

Alternative Imaging Modalities for Meningitis Diagnosis

While CT scans are often the first-line imaging study in suspected meningitis cases due to their widespread availability and speed, other neuroimaging techniques can provide valuable information in certain clinical scenarios.

How does magnetic resonance imaging (MRI) compare to CT for meningitis diagnosis?

MRI offers several advantages over CT for meningitis diagnosis:

• Superior soft tissue contrast, allowing better visualization of meningeal enhancement
• No ionizing radiation exposure
• Better detection of early cerebritis, small abscesses, and subtle parenchymal changes
• Ability to perform advanced techniques like diffusion-weighted imaging and spectroscopy

However, MRI also has limitations, including longer scan times, higher cost, and potential issues with patient claustrophobia or metal implants. In acute settings, CT remains the more practical choice for initial evaluation in most cases.

Balancing Diagnostic Accuracy and Treatment Urgency in Meningitis

One of the key challenges in managing suspected meningitis cases is striking the right balance between obtaining accurate diagnostic information and initiating timely treatment. Delays in antibiotic administration can significantly impact patient outcomes, especially in bacterial meningitis.

How can clinicians balance the need for diagnostic certainty with the urgency of treatment in meningitis cases?

To optimize meningitis management, clinicians should consider the following approach:

1. Perform a thorough clinical assessment to determine the likelihood of meningitis and potential complications
2. Initiate empiric antibiotic therapy promptly if bacterial meningitis is suspected, even before diagnostic tests are completed
3. Obtain blood cultures and other relevant laboratory studies
4. Consider lumbar puncture as soon as possible, unless there are clear contraindications
5. Reserve CT scanning for cases with specific high-risk features or when alternative diagnoses are strongly suspected
6. Continuously reassess the clinical picture and adjust management based on evolving information

By following this approach, clinicians can minimize unnecessary delays in treatment while still obtaining crucial diagnostic information to guide further management.

Future Directions in Meningitis Imaging and Diagnosis

As medical knowledge and technology continue to advance, new approaches to meningitis diagnosis and management are likely to emerge. These developments may further refine the role of imaging studies in the diagnostic workup of suspected meningitis cases.

What emerging technologies or approaches may improve meningitis diagnosis in the future?

Several promising areas of research may enhance meningitis diagnosis:

• Advanced MRI techniques: New protocols may improve the detection of subtle meningeal inflammation and associated complications
• Point-of-care ultrasound: Bedside assessment of optic nerve sheath diameter may help identify elevated intracranial pressure non-invasively
• Biomarker panels: Rapid blood or cerebrospinal fluid tests may allow faster differentiation between bacterial and viral etiologies
• Machine learning algorithms: AI-assisted image analysis could improve the accuracy and efficiency of neuroimaging interpretation
• Molecular diagnostic techniques: Next-generation sequencing and other advanced methods may enable more precise pathogen identification

As these technologies develop and are validated in clinical studies, they may help further refine the diagnostic approach to meningitis, potentially reducing the need for CT scans in many cases while improving overall patient outcomes.

In conclusion, while CT scans can provide valuable information in certain cases of suspected meningitis, their routine use has been increasingly questioned. By carefully considering the indications for neuroimaging and prioritizing prompt treatment initiation, clinicians can optimize the management of this serious condition. As diagnostic technologies continue to evolve, a more nuanced and personalized approach to meningitis evaluation is likely to emerge, further improving patient care and outcomes.

Benefit of CT scan ‘minimal’ in patients with suspected meningitis

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CT scans can cause a delay in diagnosis and therapy for patients with acute bacterial meningitis.

Source: Shutterstock.com

In a prospective study, adhering to Swedish guidelines about when to perform neuroimaging in patients with suspected acute bacterial meningitis was associated with decreased mortality and increased favorable outcome compared with U.S. guidance.

Researchers in Sweden compared the impact of adherence to three different sets of guidelines regarding early management of acute bacterial meningitis (ABM), which they said remains deadly in up to 30% of cases and carries a high risk of persistent neurologic or hearing deficits, making early adequate treatment pivotal.

According to the researchers, treatment for ABM is sometimes delayed so that a CT scan can be performed in patients with suspected intracranial pressure and cerebral mass lesion because lumbar puncture (LP) — which is used to diagnose the condition — may increase the risk for brain herniation. “However, firm evidence that LP may cause herniation is lacking, and the natural course of ABM or brain abscess may itself result in herniation,” they wrote in Clinical Infectious Diseases.

In an evaluation of 815 adult patients with ABM prospectively registered in Sweden between 2008 and 2015, the researchers compared newer Swedish and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidance with Infectious Diseases Society of America (IDSA) recommendations that were published in 2004.

According to the researchers, Swedish guidelines were revised in 2009 to omit impaired mental status and new-onset seizures as indications for CT scan before LP, and ESCMID revised its guidelines in 2016 to lower the level of consciousness on the Glasgow Coma Scale that indicates performing a CT before LP. By comparison, the IDSA guidelines are more conservative because they recommend CT before LP if “abnormal mental status” is observed in the patient.

In the study, indications for neuroimaging before LP existed in 7% of patients when following Swedish guidance compared with 32% of patients when following ESCMID guidance and 65% of patients when adhering to IDSA guidance. Adhering to Swedish guidance produced an adjusted OR of 0.48 for in-hospital mortality compared with 0.68 and 1.09, respectively, when ESCMID or IDSA guidelines were followed. Swedish guidance led to an aOR of 1.52 for favorable outcome after 2 to 6 months compared with 1.05 and 0.59, respectively, when ESCMID or IDSA guidance was followed.

Moreover, in contrast to Swedish guidance, both the ESCMID and IDSA guidelines recommend CT before LP in patients who are severely immunocompromised or who have experienced new-onset seizures, according to the researchers. But the Swedish study concluded that prompt LP was beneficial regardless of mental status and immunosuppression.

PAGE BREAK

In an interview, Rodrigo Hasbun, MD, MPH, associate professor of infectious diseases at the University of Texas Health Science Center, said physicians in the U.S. are ordering too many CT scans in patients with suspected meningitis and “should definitely change their practice.”

Hasbun co-authored a study published in The New England Journal of Medicine in 2001 that was used in writing the IDSA guidelines published in 2004. He was not part of the Swedish study, but said he reviewed the article for Clinical Infectious Diseases and agreed with its conclusions.

“The benefit of a CT scan is really minimal,” he said. “It’s a waste of resources to be doing cranial imaging in patients without any indications.”

Hasbun said there has been a push to review IDSA guidelines on the matter but that no such review is currently underway. He said he was invited to help revise the guidelines once that process takes place.

“I’m in favor of decreasing the use of CT scans,” Hasbun said. “The reality is, in the United States, the majority of patients with or without an indication are still getting CT scans and that’s causing delays in diagnosis and therapy.” – by Gerard Gallagher

References:

Glimåker M, et al. Clin Infect Dis. 2017;doi:10.1093/cid/cix806.

Tunkel AR, et al. Clin Infect Dis. 2004;doi:10.1086/425368.

Disclosures:
Hasbun and the researchers report no relevant financial disclosures.

C2. Meningitis Diagnosed With Computed Tomography Scan of Brain

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CT brain for meningitis

Content

Meningitis is an infection of the meninges of the brain and spinal cord caused by a virus or bacteria. This disease can develop in any patient, but is most common in infants, young children, adolescents, and young adults. Without proper treatment, bacterial meningitis can be a very dangerous condition that poses a potential risk to a person’s life. It can cause life-threatening blood poisoning and permanent damage to brain tissue or nerves. There are a number of vaccinations available to children at an early age that provide some protection against meningitis.

Symptoms of meningitis

Symptoms of meningitis come on suddenly and may include:

These symptoms may appear in any order and in any combination.

Symptoms of viral and bacterial meningitis may initially be similar. However, the symptoms of bacterial meningitis are usually more severe and age related.

Symptoms of viral meningitis

Viral meningitis in infants causes:

• loss of appetite
• irritability
• vomiting
• diarrhea
• rash
• respiratory symptoms.

In adults, viral meningitis causes:

• headaches
• fever
• neck stiffness
• convulsions
• sensitivity to bright light
• drowsiness
• nausea and vomiting
• loss of appetite.

Causes of meningitis

Meningitis is usually caused by a bacterial or viral infection. Bacterial meningitis is less common but more dangerous than viral meningitis. Infections that cause meningitis can be transmitted through:

• sneezing
• kiss
• Sharing crockery, cutlery and toothbrushes.

Complications

The following complications are commonly associated with meningitis:

• convulsions
• hearing loss
• loss of vision
• forgetfulness
• migraine
• brain injury
• hydrocephalus
• subdural empyema.

Meningitis and pneumonia

Pneumococcal meningitis is a rare but serious and life-threatening form of bacterial meningitis. Sometimes bacteria manage to cross the blood-brain barrier and cause inflammation and infection in the brain and spinal cord or directly in the surrounding fluids. Symptoms include:

• chills
• high temperature
• vomiting
• photosensitivity
• headache
• stiff neck muscles
• weakness
• disorientation.

Risk factors

Risk factors for meningitis include:

• reduced immunity
• HIV/AIDS
• autoimmune diseases
• chemotherapy
• organ or bone marrow transplantation
• cancer
• immunosuppressants
• pregnancy
• age.

CT scan of the brain to diagnose meningitis

Patients with suspected meningitis are usually admitted to the emergency room and tested at the hospital to confirm the diagnosis and check whether the condition is the result of a viral or bacterial infection. Diagnosis of meningitis begins with a history and physical examination. An infectious disease specialist or neurologist will look for the following: fever, skin problems, rapid pulse, neck stiffness, decreased consciousness. The doctor will also order a lumbar puncture, which allows you to analyze the cerebrospinal fluid, which contains a number of signs of infection.

For the differential diagnosis of the disease, the doctor will prescribe other tests:

• blood cultures detect bacteria that can get from the blood to the brain
• chest x-ray showing pneumonia, tuberculosis or fungal infections

CT scan of the brain shows problems such as brain abscess or intracranial pressure, the presence of cerebral edema.

Diagnosis of complications of meningitis

Diagnosis of complications of meningitis will require additional examinations:

• loss of hearing or vision, which may be partial or complete – diagnosis: ENT visit and ear CT
• problems with memory and concentration – diagnosis: appointment with a neurologist and MRI of the brain
• recurrent seizures – diagnosis: appointment with a neurologist and MRI of the brain
• coordination, movement and balance problems – diagnosis: appointment with a neurologist and MRI of the brain
• loss of limbs – sometimes amputation of the affected limbs is necessary – diagnosis: visit with a surgeon and CT scan of the soft tissues of the limbs.

Meningitis Outlook

Viral meningitis usually resolves on its own and rarely causes any long-term problems. Most people with bacterial meningitis who are treated quickly also make a full recovery, although some remain with serious long-term problems. Overall, up to 1 in 10 cases of bacterial meningitis is estimated to be fatal.

Meningitis vaccines

Vaccines offer some protection against certain causes of meningitis.

These include:

• Meningitis vaccine B
• Vaccine 6-B-1
• pneumococcal vaccine
• Hib/MenC vaccine
• MMR Vaccine
• Meningitis Vaccine ACWY

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1. Belyakov V.D., Semenenko T.A., Shraga M.Kh. Introduction to the epidemiology of human infectious and non-infectious diseases. — M.: Medicine, 2001.-p.30.
2. Vengerov Yu.Ya., Beloborodov V.B., Bronyakin Yu.V. Clinical and pathogenetic features of meningococcal and pneumococcal meningitis. // Owls. medical-1989, no. 11. -WITH. 104-109.
3. Demina A.A., Pokrovsky V.I., Ilyina T.V. Etiology of purulent bacterial meningitis. // Microbiol., epidemiol. and immunobiol. – 1984, No. 12 S.32-36.
4. Koroleva I.S., Beloshitsky G.V., Svistunova T.S. Influence of early antibiotic therapy of purulent meningitis on the effectiveness of bacteriological diagnosis.// Epidemiol. and infectious diseases 2002, No. 4. – S.37-41.
5. Platonov A.E., Shipulin G.A., Koroleva I.S. Prospects for the diagnosis of bacterial meningitis. // J. Microbiol. 1999, #2. – P.71-76.
6. Berestov A.I. Infectious-toxic lesions of the nervous system in children: (clinic, diagnosis, pathogenesis, treatment). Abstract for the competition step, Ph.D. – Moscow. – 1990 – 27 p.
7. Vengerov Yu.Ya. Meningitis // Attending physician. -1999. No. 2-3. – S. 17-23
8. Vengerov Yu.Ya., Pokrovskaya N.Ya., Petrunin Yu.P., Rainer M.A., Ilyina T.V. Pneumococcal meningitis. // Sat. abstract report “Meningococcal infection and purulent meningitis (diagnosis, prevention and treatment)” – Arkhangelsk, 1986. S. 140-142
9. Mikhailova E. V. Meningitis of enteroviral etiology in children: modern approaches to diagnosis and features of the clinical course / E. V. Mikhailova, A. V. Shteinberg, I. G. Eremeeva // Infectious Diseases. 2008. – No. 1. P. 31-34
10. Pokrovsky V.I. Purulent meningitis (diagnosis, clinic, treatment): Abstract of the thesis. dis. .doctor, med. Sciences. M., 1966.
11. Sorokina M.N., Skripchenko N.V., Ivanova M.V. et al. Meningitis caused by Haemophilus influenzae type B: diagnosis, clinic and treatment. //J. Epidemiology and infectious diseases. 1998. No. 6. – S. 37-40.

Meningitis on MRI 🚩 Will it show the signs and what does meningitis look like?

Meningitis is a combined inflammation of the pia mater and arachnoid. The disease has an infectious nature, often the prognosis is unfavorable. Meningitis develops as a complication of trauma, systemic viral, bacterial and fungal infections. In rare cases, pathology occurs as a result of a stroke.

The disease can occur in acute and chronic forms. Meningitis is most often diagnosed in children. Babies under the age of 1 year are difficult to tolerate pathology. As complications, the development of hydrocephalus, brain abscess, empyema (diffuse purulent process), vein thrombosis, heart attacks and hemorrhagic strokes is possible.

Signs of meningitis on an MRI scan of the head

The prognosis depends on the form, etiology, course, stage of the disease, general condition of the body. Early detection of pathology and correctly prescribed treatment increase the chances of recovery.

Puncture with bacteriological analysis of cerebrospinal fluid has the main diagnostic value. Brain imaging by MRI is used as an additional procedure. The study provides information about the localization and extent of the pathological process, allows you to identify complications and take appropriate measures in time.

Signs of meningitis

Cryptococcal meningitis associated with HIV infection on MRI

Manifestations depend on the pathogen and the form of the disease. In the foreground – general infectious symptoms, as a result of intoxication of the body. These include fever, weakness, drowsiness, chills, lack of appetite.

Signs of inflammation of the meninges are headaches, photophobia, sensitivity to sounds, soreness of the eyeballs, irritability. Rigidity of the occipital muscles forces the patient to take a forced posture (on his side, with his head thrown back).

The spread of the infectious process to the brain tissue provokes vivid neurological symptoms. The patient develops psychomotor agitation, turning into apathy and drowsiness. As a rule, there is constant nausea and vomiting that does not bring relief. Muscle pains are soon replaced by convulsions.

Will an MRI show meningitis?

Magnetic resonance imaging is used in the complex diagnosis of infectious and inflammatory diseases of the brain. The procedure allows you to get layer-by-layer images of the organ in three planes. On the images, the doctor can identify signs characteristic of the inflammatory process in the membranes and nervous tissue.

Information about the features of pathological changes helps to determine the stage of the disease, choose the right therapeutic tactics, and prevent complications. Repeated MRI scans of the brain make it possible to evaluate the effectiveness of treatment, to identify foci of purulent changes. Angioregime and contrasting are informative regarding vascular thrombosis, cerebral edema, early diagnosis of heart attacks and strokes. To the question “Will an MRI show meningitis?” radiologists give an affirmative answer. Each stage of the development of the disease has characteristic MR signs. But the diagnosis is established on the basis of the results of a lumbar puncture and CSF analysis.

Rheumatoid meningitis with stroke-like MRI: DWI (a), ADC map (b), FLAIR (c), T1 WI with contrast (d)

Meningitis MRI, what does it show?

The result of magnetic resonance imaging is a series of monochrome images of the medulla, taken in layers with a step of 1 mm. The images alternate dark and light areas of varying degrees of intensity. Shade transitions correspond to the contours of internal tissues. Knowledge of anatomy and experience in the field of radiology allows the doctor to distinguish one anatomical structure from another, to assess the compliance with the norm of their boundaries and sizes.

In meningitis, inflammation develops in the meninges, accompanied by thickening of the latter, impaired CSF flow, exudation, widening of the sulci and interhemispheric fissure, and other nonspecific changes. Scanning with contrast shows characteristic staining of inflammatory lesions and pathological effusions. MRI after meningitis provides information about the presence or absence of complications, allows you to assess the usefulness of the restoration of brain tissue.

What does meningitis look like on an MRI?

Pneumococcal meningitis with myelitis (pathological changes are indicated by arrows)

Radiologists interpret images based on the intensity of the signal from certain tissues using different scanning modes. MRI signs of meningitis are:

• isointense response from exudate to T1 WI;
• hyperintense signal from the same areas on T2 VI;
• signs of hydrocephalus or increased intensity of impulses from sulci and cisterns;
• characteristic staining of the structures surrounding the abscesses after contrasting;
• hyperintense signal from abscesses, visually visible capsule;
• narrowing of the lumen of the arteries or occlusive changes during angioscanning;
• venous thrombosis on magnetic resonance venography.