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To the Editor: Dr Attia and colleagues¹ concluded that in the presence of the sensitive clinical signs in adults with possible meningitis, the physician should proceed directly with lumbar puncture (LP) in high-risk patients. Although we agree with this statement we would like to emphasize that lethal complications, such as cerebral herniation, may be caused by LP.² An axial computed tomographic (CT) scan of the head must be obtained to identify those patients at risk. The American Academy of Neurology² indicated that CT is better than clinical examination in predicting the risk of herniation and death in those patients with increased intracranial pressure due to a mass lesion or obstruction of the ventricular system. It has been shown that clinical examination and presence of papilledema are not adequate to exclude the possibility of cerebral herniation.³ Structural characteristics defined by CT provide valuable information about the pressure gradient between different compartments . . . [Full Text of this Article]

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Does This Adult Patient Have Acute Meningitis?
John Attia, Rose Hatala, Deborah J. Cook, and Jeffrey G. Wong
JAMA. 1999;282(2):175-181.
ABSTRACT | FULL TEXT