Costerus Joost M, Brouwer Matthijs C, Sprengers Marieke E S, Roosendaal Stefan D, van der Ende Arie, de Beek Diederik van
Amphia Ziekenhuis, afd. Neurologie, Breda.
Amsterdamse UMC, afd. Neurologie, locatie AMC.
Ned Tijdschr Geneeskd. 2019 Feb 7;163:D3328.
Investigate how often cerebral herniation occurs following lumbar puncture (LP) in patients with bacterial meningitis, and whether cranial computed tomography (CT) can be used to identify patients at a higher risk of cerebral herniation.
Prospective, nationwide cohort study covering the period March 2006 - November 2014.
We identified patients with community-acquired bacterial meningitis who showed signs of clinical deterioration, possibly caused by LP. For systematic evaluation of contraindications for LP on cranial CT, the included patients were matched to bacterial meningitis patients without deterioration. Four experts, blinded for patient outcome, scored cranial CT scan imaging for the cases as well as control patients in relation to contraindications for LP. Inter-assessor reliability was determined with Fleiss' generalized κ.
Of the 1533 bacterial meningitis patients included, 47 (3.1%) exhibited clinical deterioration possibly caused by LP. Two patients deteriorated within 1 hour after LP (0.1%). In 43 of 47 patients that showed signs of clinical deterioration, cranial CT was performed prior to LP. The inter-rater reliability of assessment of contraindications for LP on cranial CT was moderate (Fleiss' generalized κ = 0.47). A contraindication for LP was reported by all four raters in 6 patients with clinical deterioration (14%) and in 5 patients without clinical deterioration (11%).
LP can be performed safely in the large majority of patients with bacterial meningitis, as it only very rarely results in cerebral herniation. Cranial CT can be considered a screening method to identify patients who are at a higher risk of cerebral herniation, but the inter-rater reliability of the CT scan assessment for contraindications of LP is moderate.
调查细菌性脑膜炎患者腰椎穿刺（LP）后发生脑疝的频率，以及头颅计算机断层扫描（CT）是否可用于识别脑疝风险较高的患者。
2006年3月至2014年11月期间的全国性前瞻性队列研究。
我们确定了社区获得性细菌性脑膜炎且出现可能由LP导致临床恶化迹象的患者。为了系统评估头颅CT上LP的禁忌症，将纳入的患者与未恶化的细菌性脑膜炎患者进行匹配。四位对患者结局不知情的专家对病例以及对照患者的头颅CT扫描影像进行LP禁忌症评分。用Fleiss广义κ系数确定评估者间信度。
在纳入的1533例细菌性脑膜炎患者中，47例（3.1%）出现可能由LP导致的临床恶化。2例患者在LP后1小时内病情恶化（0.1%）。在47例出现临床恶化迹象的患者中，43例在LP前进行了头颅CT检查。头颅CT上LP禁忌症评估的评估者间信度为中等（Fleiss广义κ系数=0.47）。在6例临床恶化患者（14%）和5例未临床恶化患者（11%）中，所有四位评估者均报告了LP的禁忌症。
大多数细菌性脑膜炎患者进行LP是安全的，因为其极少导致脑疝。头颅CT可被视为一种筛查方法，以识别脑疝风险较高的患者，但CT扫描评估LP禁忌症的评估者间信度为中等。
