Glimåker Martin, Johansson Bibi, Bell Max, Ericsson Mats, Bläckberg Jonas, Brink Magnus, Lindquist Lars, Sjölin Jan
Unit for Infectious Diseases, Department of Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
Scand J Infect Dis. 2013 Sep;45(9):657-63. doi: 10.3109/00365548.2013.799289. Epub 2013 Jul 1.
Current international guidelines recommend cerebral computerized tomography (CT) before lumbar puncture (LP) in many adults with suspected acute bacterial meningitis (ABM), due to concern about LP-induced cerebral herniation. Despite guideline emphasis on early treatment based on symptoms, performing CT prior to LP implies a risk of delayed ABM treatment, which may be associated with a fatal outcome. Firm evidence for LP-induced herniation in adult ABM is absent and brain CT cannot discard herniation. Thus, the recommendation to perform CT before LP may contribute to an avoidable delay of LP and ABM treatment. The inappropriate use of the diagnostic treatment sequence of brain CT scan, followed by LP, followed by antibiotics and corticosteroids should be avoided in adults with suspected ABM by omitting needless contraindications for LP, thus eliminating an unnecessary fear of immediate LP. Revised Swedish guidelines regarding early LP are presented, and the background documentation and reasons for omitting impaired consciousness, new onset seizures, and immunocompromised state as contraindications to LP are discussed.
由于担心腰椎穿刺（LP）诱发脑疝，目前国际指南建议，许多疑似急性细菌性脑膜炎（ABM）的成年人在进行腰椎穿刺前先进行脑部计算机断层扫描（CT）。尽管指南强调基于症状的早期治疗，但在LP之前进行CT意味着ABM治疗延迟的风险，这可能与致命后果相关。目前尚无确凿证据表明成人ABM中LP会诱发脑疝，且脑部CT无法排除脑疝。因此，在LP之前进行CT的建议可能会导致LP和ABM治疗不必要的延迟。对于疑似ABM的成年人，应避免不恰当地使用脑部CT扫描、随后LP、再使用抗生素和皮质类固醇的诊断治疗顺序，通过省略LP不必要的禁忌证，从而消除对立即进行LP的不必要恐惧。本文介绍了瑞典修订后的早期LP指南，并讨论了省略意识障碍、新发癫痫和免疫功能低下状态作为LP禁忌证的背景文件及原因。
