ABSTRACT

Background

Many authors have strongly cautioned against the performance of lumbar puncture in patients with suspected or likely infective intracranial mass lesions due to the dubious value of the CSF analysis so obtained, and due to the inherent danger of clinical deterioration precipitated by a pressure cone.

Objective

To assess the role of lumbar puncture (LP) in aiding diagnosis and influencing outcome in patients with intracranial brain abscess or subdural empyema.

Methods

The records of patients admitted with space occupying intracranial infective mass lesions (brain abscess and subdural empyema) to the neurosurgical unit at Wentworth Hospital, Durban, over a 15 year period, were retrospectively reviewed. Of the 1411 patients admitted with intracranial suppurative disorders (brain abscess = 712) and subdural empyemas (699), 422 (29.9%) underwent diagnostic LP prior to referral to our unit. The records of these 422 patients were studied in more detail with regard to the result of the LP and it’s effect on patient outcome. Results of the LP were analysed in order to determine the contribution of LPto the diagnosis. The impact of the LP on patient outcome was assessed.

Results

The cerebrospinal fluid (CSF) examination was normal in 66 (15.6%) and equivocal in 283 (67.1%). Bacterial meningitis was diagnosed in 73 (17.3%) and organisms cultured in 42 (10.0%). As suspected, 272 patients (64.5%) underwent clinical deterioration following lumbar puncture. In 81 patients (19.2%) the clinical deterioration was directly attributable to the lumbar puncture and 20 patients (4.7%) died as a result of LP.

Conclusion

In patients with brain abscess or subdural empyema, LP contributes little to diagnosis while significantly increasing the risk of clinical deterioration and even death. Patients suspected of harbouring infective intracranial mass lesions should undergo computed tomography (CT) prior to LP or should be placed onto empiric antibiotic therapy until a CTscan can be obtained.

Keywords : cerebrospinal fluid, intracranial brain abscess, lumbar puncture, subdural empyema

RESUME

Introduction

Plusieurs auteurs ont insisté sur le caractère inutile et dangereux de pratiquer une ponction lombaire (PL) lorsque l’on suspecte un processus expansif intracrânien d’origine infecteuse à cause du risque d’engagement..

Objectif

Evaluer le rôle de la PL au plan diagnostique et étudier son influence sur l’évolution des abcès et empyèmes sous – duraux intra-crâniens.

Méthodes

Les dossiers des patients hospitalisés pour des lésions infectieuses intracrâniennes pendant 15 ans et admis dans le département de neurochirurgie du Wentworth Hospital, Durban ont été étudiés rétrospectivement. Sur les 1411 patients hospitalisés pour suppuration intracrânienne (abcès cérébraux = 712) et empyèmes sous – duraux (699), 422 (29,9%) ont subi une PL avant d’être admis dans notre service. Les dossiers de ces 422 patients ont été étudiés.

Résultats

Le liquide cérébro-spinal (LCS) était normal dans 66 cas (15,6%) et équivoque dans 283 cas (67,1%). Une méningite bactérienne a été diagnostiquée dans 73 cas (17,3%) avec présence de germes dans 42 cas (10%). 272 patients (64,5%) eurent une détérioration clinique après la PL. Chez 81 patients (19,2%) l’aggravation clinique était en rapport avec la PL. 20 patients (4,7%) décédèrent à cause de la PL.

Conclusion

Chez les patients ayant un abcès ou un empyème sous – dural intra-crânien la PL accroit de façon significative le risque de détérioration clinique voire la mort. Tout patient suspect de processus expansif intra-crânien doit bénéficier du CT-scan avant de pratiquer une PLou devra béné – ficier d’un traitement antibiotique empirique avant la réalisation du CT-scan.

Mots clés : abcès intracrânien, empyéme sous-dural intra-crânien, liquide cérébro-spinal, ponction lombaire

INTRODUCTION

Computed tomography (CT) was first introduced in South Africa at the neurosurgical unit at Wentworth Hospital, Durban in 1975, and despite it’s increasing availability, lumbar puncture (LP) appears still to be commonly performed in our region as a first diagnostic procedure in patients with brain abscess or subdural empyema. In a 15-year review of patients with brain abscess and subdural empyema treated at our institution between 1983 and 1997, nearly a third had undergone a diagnostic lumbar puncture prior to CT. We therefore evaluated the diagnostic role of lumbar puncture in these patients as well as it’s impact on patient outcome.

PATIENTS & METHODS

During the 15-year period, January 1983 to December 1997, patients with brain abscess and subdural empyema admitted to our neurosurgical unit were evaluated. The neurosurgical unit at Wentworth Hospital in Durban is the sole referral centre for the Province of KwaZulu-Natal and half of the Eastern Cape Province.

The diagnosis of brain abscess or subdural empyema was made on conventional CT criteria in all cases and definitively at surgery in almost all (97.8%) [1, 23]. The investigative procedures which these patients underwent were retrospectively reviewed. Patients undergoing diagnostic lumbar puncture prior to CT were identified and their case notes were carefully analysed with respect to the contribution of cerebrospinal fluid (CSF) analysis to diagnosis and to the impact of lumbar puncture on outcome.

RESULTS

During the 15-year period, a total of 4623 patients with all forms of intracranial infection were admitted to our neurosurgical unit at Wentworth Hospital in Durban, South Africa. Of these, 1411 patients were diagnosed as harbouring purulent infective intracranial mass lesions, in particular 712 with brain abscess and 699 with subdural empyema.

One hundred and forty-two of these 712 patients with brain abscess (19.9%) and 280 of the 699 patients with subdural empyema (40.1%) had undergone diagnostic lumbar punctue prior to CT and, importantly, prior to referral to our unit. Overall, 422 patients (29.9%) were subjected to lumbar puncture as the first diagnostic procedure, prior to CT. [Table 1]

CSF analysis from lumbar puncture revealed a normal CSF in 66 patients (15.6%), bacterial meningitis in a minority 73 (17.3%) and a pleocytosis in 283 (67.1%). In the latter case bacterial meningitis could not be proven and an organism could not be cultured. Typically, the CSF in such a situation revealed white cell counts < 500/cm3 with a predominance of polymorphs, an elevated protein level and, either normal or moderately depressed CSF glucose levels. Overall, therefore the CSF examination was either normal or non-diagnostic in 349 patients (82.7%). An organism was cultured in 42 of the 422 patients (10.0%) and this was predominantly in the group of infant patients with subdural empyema secondary to bacterial meningitis (83.3%). Of great concern and of significance the CSF pressure was only measured in 25 patients (5.9%) and when measured was raised (>20cm) in 15 (60%). [Table 2] As might have been expected 272 patients (64.5%) experienced clinical deterioration (drop in Glasgow Coma Scale (GCS) or development of a new focal sign) at some time following lumbar puncture. However, only in 81 patients (19.2%) could the deterioration predominantly be attributable to lumbar puncture. Twenty of the 81 patients died (4.7%). The fatalities predominantly occurred in patients with abscesses (hemispheric in 10 and cerebellar in 7). In the case of subdural empyema only three cases existed. [Table 3]

DISCUSSION

Many authors, including one of the present group [18] have strongly cautioned against the performance of lumbar puncture in patients with suspected or likely infective intracranial mass lesions due to the dubious value of the CSF analysis so obtained, and due to the inherent danger of clinical deteriorationprecipitated by a pressure cone [6-10,12,13,20-22].

The diagnostic value of CSF findings from lumbar puncture have proved to be limited. Carey et al found that approximately one-third of patients with proven brain abscess did not show any significant CSF pleocytosis, two-thirds had elevated protein levels, and glucose levels were lowered in one-quarter [3]. Gregory et al noted that in three-quarters of brain abscesses, the CSF glucose level was normal, while Yang in an authoritative series of 400 brain abscesses reported that the CSF white cell count was not necessarily elevated, being < 10/mm3 in 21% of cases [21, 22]. Kratimenos et al in a series of 14 patients with multiple brain abscesses noted that the CSF obtained by lumbar puncture did not yield any positive cultures [14]. Galbraith et al and Kaufman et al reported similar findings regarding CSF analysis in patients with subdural empyema [9,13]. It has been proposed that the arachnoid is a significant, hardy layer that protects the CSF from the subdural, extra-arachnoidal collection of pus in patients with subdural empyema. In patients presenting in a delayed fashion, the CSF may however exhibit an equivocal neighbourhood pattern due to prolonged contact of the pus with the arachnoid leading to arachnoiditis with resultant CSF changes .[9, 13] In our series of 422 patients, CSF examination was normal or non-contributory in over 80% of cases. It has been our alarming experience that a normal or equivocal CSF examination often lulls the referring physician into complacency, who then treats the patient as one with viral meningitis or partially treated bacterial meningitis, leading to a delay in diagnosis and appropriate treatment. The dangers of lumbar puncture in patients with infective intracranial mass lesions have been well documented by many [8,9,10,12,13,18]. Gregory (1967), Duffy (1969) and Garfield (1969) have all described clinical deterioration following lumbar puncture[8,10,12]. Garfield described deterioration in the level of consciousness in the ensuing 48 hours in 41 of 140 patients who underwent lumbar puncture [10]. Carey could attribute the deaths of 5 patients (5%) to lumbar puncture. [3] Chun et al described the death of 4 of 27 patients (14.8%) who died within 24 hours of undergoing lumbar puncture [5]. Large series of patients with brain abscess or subdural empyema undergoing diagnostic lumbar puncture have previously been reported. In 1960, Bonnal et al reported 208 cases and, more recently, Yang reported 173 cases [21,22]. Both authors cautioned that lumbar puncture was of limited value and was hazardous. In our series, 20 deaths could be directly attributed to lumbar puncture (4.7%). Seven of the deaths were in patients harbouring cerebellar abscesses where supratentorial hydrocephalus has been documented as a concomitant adverse prognostic factor. [15] One of the 14 patients with infratentorial subdural empyema also died. Associated supratentorial hydrocephalus probably also being a contributory factor in the precipitation of the pressure cone [16]. In addition to pressure cone, lumbar puncture may rarely also precipitate intracerebral or subdural haemorrhage [17,19]. We support the view of Ciarallo et al who cautioned against injudicious lumbar puncture in patients with periorbital cellulitis [4]. We also concur with Garfield who advised that a lumbar puncture should not be performed in patients with meningeal irritation when a convulsion has occurred, or if papilloedema, hemisphere or cerebellar signs are present [10]. Gower et al have recently described contra-indications to lumbar puncture as defined by CT, which would support the clinical view [11]. In addition to Garfield's contra-indications to performance of lumbar puncture, we would recommend that a patient with meningeal signs and who also exhibits evidence of trauma, sinusitis or mastoiditis not undergo lumbar puncture but should rather be firstly investigated by CT. In the absence of readily available CT facilities, we strongly recommend that such a patient be commenced on empirical, highdose, intravenous antibiotics until such time that a CTis obtained. CTis becoming an increasingly accessible modality in our region, with 8 public sector CTscanners already installed in the Province of KwaZulu-Natal, with 6 teleradiologically linked to Wentworth Hospital. Our report of 422 cases, which also represents the largest series reported to date, supports the view that lumbar puncture is of limited use in diagnosis of brain abscess and subdural empyema and, more over, is inherently dangerous and therefore students and practitioners should be advised, and taught, on the dangers. It is hoped that with the ever increasing availability of CT, the iatrogenic conversion of a patient with an eminently treatable brain abscess or subdural empyema into one with secondary irreversible brainstem damage from pressure cone could be avoided [8]. TABLE 2 : CSF ANALYSIS IN 422 PATIENTS UNDERGOING LUMBAR PUNCTURE

TABLE 3 : CLINICAL DETERIORATION FOLLOWING LUMBAR PUNCTURE IN 422 PATIENTS