Neuroimaging

Computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain generally do not
aid in the diagnosis of meningitis. Some patients may show meningeal enhancement, but its absence does not
rule out the condition. Routinely obtaining CT scans of the head may lead to unnecessary delay in the
performance of diagnostic lumbar puncture and the initiation of antibiotic therapy; the latter may be detrimental
to the outcome in these patients.
Cerebral herniation following the lumbar tap procedure is rare in individuals with no focal neurologic deficits and
no evidence of increased ICP. If it occurs, it usually does so within 24 hours after the LP; thus, herniation
should always be considered in the differential diagnosis if the patients neurologic status deteriorates during
that time frame.
According to the Infectious Diseases Society of America guidelines, the following are indications for screening
head CT before LP in adult patients[17] :

Immunocompromised state
History of CNS disease (eg, mass lesion, stroke, or focal infection)
Seizure within 1 week of presentation
Papilledema
Abnormal level of consciousness
Focal neurologic deficit (eg, dilated nonreactive pupil, gaze palsy, or arm or leg drift)
In patients with suspected bacterial meningitis, blood cultures should be obtained and treatment initiated before
imaging studies and LP. Neuroimaging may yield normal results or demonstrate small ventricles, effacement of
sulci, and contrast enhancement over convexities (see the images below). Late findings include venous
infarction and communicating hydrocephalus. Brain abscess, sinus or mastoid infection, skull fracture, and
congenital anomalies must be ruled out. (See Imaging in Bacterial Meningitis.)

Acute bacterial meningitis. This axial nonenhanced

computed tomography scan shows mild ventriculomegaly and sulcal effacement.

Acute bacterial meningitis. This axial T2-weighted

magnetic resonance image shows only mild ventriculomegaly.

Acute bacterial meningitis. This contrastenhanced, axial T1-weighted magnetic resonance image shows leptomeningeal enhancement (arrows).

Finally, neuroimaging studies are helpful in the detection of CNS complications of bacterial meningitis, such as
the following (see the images below):

Hydrocephalus

Cerebral infarct
Brain abscess
Subdural empyema
Venous sinus thrombosis

Chronic mastoiditis and epidural empyema in a

patient with bacterial meningitis. This axial computed tomography scan shows sclerosis of the temporal bone (chronic
mastoiditis), an adjacent epidural empyema with marked dural enhancement (arrow), and the absence of left mastoid air.

Subdural empyema and arterial infarct in a

patient with bacterial meningitis. This contrast-enhanced axial computed tomography scan shows left-sided parenchymal
hypoattenuation in the middle cerebral artery territory, with marked herniation and a prominent subdural empyema.