Fatal cerebral herniation following lumbar puncture in a patient with a normal computed tomography scan

A. K. Shetty, B. C. Desselle, R. C. Craver, R. W. Steele

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Abstract

Cerebral edema and resulting elevated intracranial pressure (ICP) is a well-known complication of acute pyogenic meningitis. A diagnostic lumbar puncture (LP) may then precipitate herniation or coning of the brain, often with fatal outome. A computed tomography (CT) scan of the brain is therefore recommended prior to LP whenever raised ICP is suspected. We describe a 15-year-old adolescent who presented with signs and symptoms of acute bacterial meningitis. Following a normal CT scan, a diagnostic LP was performed and 15 minutes later, the patient clinically deteriorated with symptoms consistent with a cerebral herniation. The opening pressure (OP) at the time of LP was not measured. A blood culture was obtained and subsequently, intravenous ceftriaxone and vancomycin was empirically begun. Fluids were restricted. The patient was mechanically hyperventilated and received a trial of mannitol therapy with no benefit. Resuscitation attempts were unsuccessful and the patient died 12 hours after admission. Blood, urine, and CSF cultures were sterile. Autopsy findings confirmed the diagnosis of purulent meningitis, cerebral edema and tonsillar herniation. In conclusion, physicians should recognize the possibility of herniation within a few hours following diagnostic LP in children with meningitis. Furthermore, herniation can occur with normal CT scan. Measurement of OP at time of diagnostic LP can identify elevated ICP that would allow treatment to prevent herniation. LP should be avoided in children with suspected meningitis in whom there is clinical evidence of raised ICP or early coning, although such a policy should not lead to delayed antibiotic treatment. Early diagnosis, and prompt treatment of raised ICP complicating acute meningitis is warranted avoid mortality.

Original languageEnglish
JournalJournal of Investigative Medicine
Volume47
Issue number2
Publication statusPublished - 01-01-1999
Externally publishedYes

All Science Journal Classification (ASJC) codes

  • Medicine(all)
  • Biochemistry, Genetics and Molecular Biology(all)

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