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

Abstract

* Abbreviations: ICP = : intracranial pressure • LP = : lumbar puncture • CT = : computed tomography • OP = : opening pressure • CSF = : cerebrospinal fluid Cerebral edema and resulting elevated intracranial pressure (ICP) is a well-known complication of acute pyogenic meningitis.1 ,2 A diagnostic lumbar puncture (LP) may then precipitate herniation or coning of the brain, often with fatal outcome.3–8 A computed tomography (CT) scan of the brain is therefore recommended before LP whenever raised ICP is suspected, particularly if the possibility of a mass or space-occupying lesion exists.9–11 We describe a 15-year-old adolescent with bacterial meningitis with a normal CT scan who developed signs of herniation immediately after a subsequent LP. To the best of our knowledge this is the second documented report of herniation found at postmortem examination in a child with a normal CT scan. A previously healthy 12-year-old white boy presented to a community hospital emergency department with a 1-hour history of single generalized tonic-clonic seizure and a 2-day complaint of fever, headache, vomiting, and increasing somnolence. He received acetaminophen at home with no resolution of his symptoms. There was no trauma, drug abuse, or alcohol abuse. Family history was noncontributory. On initial evaluation at the emergency department, the patient was lethargic with a temperature of 101.8°F, pulse of 124 beats per minute, respiratory rate of 18 breaths per minute, and a blood pressure of 104/64 mm Hg. Meningeal signs were present; he flexed his limbs in response to painful stimuli and had normal plantar responses and pupillary reflex to light. Fundoscopy was normal with no evidence of papilledema. Clinically, bacterial meningitis was suspected. An emergent unenhanced CT scan of the brain was obtained, that was interpreted as normal after which a diagnostic LP was performed. The opening pressure (OP) was not measured at the time of LP. A blood culture was obtained and subsequently, intravenous ceftriaxone (3.8 g every 8 hours) and vancomycin (850 mg every 8 …