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Can You See Meningitis On X Ray

author
Danielle Fletcher
• Wednesday, 28 October, 2020
• 15 min read

When meningitis strikes, it's vital that the health care team determine as quickly as possible if a virus or bacteria caused the disease. If meningitis is suspected, the definitive diagnosis is made by lumbar (low back) puncture, or spinal tap.

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Contents

When done with a contrast dye that is injected during the test, CT scans can highlight brain tissues to determine whether the meninges are inflamed. A CT scan can also show whether there is inflammation of the skull or sinuses, which may be helpful in diagnosing meningitis.

MRI can detect whether there is inflammation in the brain and spinal cord, infection, eye disease, or tumors, among many other disorders. “ X -rays don’t help us diagnose or follow-up meningitis because they can only produce images of the skull, because it is bony, but not the brain,” explained Dr. Lerner.

Acute bacterial meningitis is a medical emergency, and delays in instituting effective antimicrobial therapy result in increased morbidity and mortality. Neuroimaging can identify conditions that may predispose to bacterial meningitis ; thus, it is indicated in patients who have evidence of head trauma, sinus or mastoid infection, skull fracture, and congenital anomalies.

In addition, neuroimaging studies are typically used to identify and monitor complications of meningitis, such as hydrocephalus, subdural effusion, emphysema, and infarction and to exclude parenchymal abscess and ventriculitis. Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis.

This contrast-enhanced, axial T1-weighted magnetic resonance image shows a right frontal parenchymal low intensity (edema), leptomeningitis (arrowheads), and a lentiform-shaped subdural emphysema (arrows). Computed tomography (CT) scanning is often performed first to exclude contraindications for lumbar puncture.

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Unfortunately, while increased intracranial pressure is considered a contraindication to lumbar puncture, normal CT scan findings may not be sufficient evidence of normal intracranial pressure in patients with bacterial meningitis. Nonenhanced CT scans and magnetic resonance images (MRIs) of patients with uncomplicated acute bacterial meningitis may be unremarkable.

MRI is the most sensitive imaging modality, because the presence and extent of inflammatory changes in the meninges, as well as complications, can be detected. MRI is superior to CT scanning in the evaluation of patients with suspected meningitis, as well as in demonstrating leptomeningeal enhancement and distention of the subarachnoid space with widening of the interhemispheric fissure, which is reported to be an early finding in severe meningitis.

Effusion, hydrocephalus, celebrities, and abscess can be evaluated well with CT scanning and ultrasonography (US) in infants; however, MRI is the most effective modality for localizing the level of the pathology. In uncomplicated cases of purulent meningitis, early CT scans and MRIs usually demonstrate normal findings or small ventricles and effacement of such.

The value of CT scanning in the early diagnosis of subdural emphysema is limited because of the presence of bone artifact. This axial nonenhanced computed tomography scan shows mild ventriculomegaly and sultan effacement.

If magnetic resonance venography is not available, a reliable and cost-effective method for detecting venous sinus thrombosis is intravenous digital-subtraction angiography. As many as 50% of patients with pneumococcal meningitis also have evidence of pneumonia on initial chest images.

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The most important role of CT scanning in imaging patients with meningitis is to identify contraindications to lumbar puncture and complications that require prompt neurosurgical intervention, such as symptomatic hydrocephalus, subdural emphysema, and cerebral abscess. Contrast-enhanced CT scans may also help detect complications such as venous thrombosis, infarction, and ventriculitis.

Normal results on CT imaging do not exclude the presence of acute meningitis. This contrast-enhanced, axial computed tomography scan was obtained 1 month after surgery and shows a small, ring-enhanced, hypo attenuating mass (recurrence of abscess) in the left basal ganglia and a left lentiform-shaped subdural fluid collection with enhanced meninges (arrowhead).

Nonenhanced CT scan findings may be normal (>50% of patients), or the studies may demonstrate mild ventricular dilatation and effacement of such, cerebral edema, and focal low-attenuating lesions. This axial nonenhanced computed tomography scan shows mild ventriculomegaly and sultan effacement.

Obliteration of the basal cisterns may result from increased attenuation, perhaps because of the presence of exudate in the subarachnoid space or leptomeningeal hyperemia. Increased attenuation in the CSF spaces due to meningitis may simulate acute subarachnoid hemorrhage on CT scans.

CT scans for patients with suggested meningitis must be performed with dominated contrast material. This contrast-enhanced axial computed tomography scan shows leptomeningitis and parenchymal enhancement (celebrities) with a low-attenuating area (edema) in the left basal ganglia.

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Curvilinear meningeal enhancement over complexities, interhemispheric and Sylvia fissures, and obliteration of basal cisterns are usually seen on contrast-enhanced CT scans. CT's scans have shown that as many as 25-40% of children develop this complication during or after treatment for meningitis.

Important diagnostic features on CT scans are high-attenuating effusions from the CSF and prominent enhancement of the margin of an emphysema. The marked degree of enhancement of an emphysema that is seen on CT scan rarely occurs in cases of a subdural hematoma, although a thin rim of enhancement is not uncommon in imaging of a chronic subdural hematoma.

This contrast-enhanced, axial computed tomography scan was obtained 1 month after surgery and shows a small, ring-enhanced, hypo attenuating mass (recurrence of abscess) in the left basal ganglia and a left lentiform-shaped subdural fluid collection with enhanced meninges (arrowhead). This contrast-enhanced axial computed tomography scan shows left-sided parenchymal hypo attenuation in the middle cerebral artery territory, with marked herniation and a prominent subdural emphysema.

Subdural emphysema and diffuse cerebral edema in a patient with bacterial meningitis. This axial computed tomography scan shows bilateral subdural effusion (emphysema) and parenchymal low-attenuating areas.

This contrast-enhanced, axial computed tomography scan shows a bilateral subdural effusion with cortical surface enhancement (emphysema). In the acute phase (when the clot is dense), a hyperattenuating thrombus can be seen in the sagittal sinus on a nonenhanced scan.

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The so-called empty delta sign, which is a triangle of decreased attenuation in the posterior portion of the affected sinus, can be seen on contrast-enhanced CT scans and is visible only after the clot becomes less dense than the contrast-enhanced blood that flows around it. Infarcts tend to be sharply marginated and confined to a specific arterial vascular territory.

Commonly, multiple lacuna infarcts are seen in the distribution of perforating vessels in the brain stem, basal ganglia, and white matter. This contrast-enhanced axial computed tomography scan shows left-sided parenchymal hypo attenuation in the middle cerebral artery territory, with marked herniation and a prominent subdural emphysema.

Subdural emphysema and diffuse cerebral edema in a patient with bacterial meningitis. This contrast-enhanced computed tomography scan shows diffuse cerebral edema and lacuna infarcts in the thalamus.

In celebrities, CT scans can show ill-defined areas of low attenuation, which are evidence of edema in the affected brain. After the administration of contrast material, the abscess wall and surrounding inflammatory tissue enhancement are ring shaped.

This contrast-enhanced, axial computed tomography scan was obtained 1 month after surgery and shows a small, ring-enhanced, hypo attenuating mass (recurrence of abscess) in the left basal ganglia and a left lentiform-shaped subdural fluid collection with enhanced meninges (arrowhead). This contrast-enhanced axial computed tomography scan shows a ring-enhancing, loculated, hypo attenuating mass (abscess) in the left basal ganglia.

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Some authors suggest performing MRI with a high dose of contrast material (0.3 MML/kg), which is the most important factor. Noncontrast MRIs of patients with uncomplicated acute bacterial meningitis may demonstrate obliterated cisterns and the distention of the subarachnoid space with widening of the interhemispheric fissure, which is reported to be an early finding in severe meningitis or may be unremarkable.

T2-weighted images are sensitive to abnormal tissue water distribution and, thus, may show cortical hyperintensities that are reversible and believed to represent edema. Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis.

This T2-weighted axial magnetic resonance image shows frontal sinusitis, a bone defect (arrow) with adjacent cortical edema (arrowhead), and right occipitoparietal subdural fluid collection (emphysema). This T2-weighted axial magnetic resonance image shows parenchymal focal edema (celebrities).

Contrast-enhanced MRI has been shown to be more sensitive than CT scanning in the detection of meningeal inflammation. Gadolinium-enhanced MRI studies can demonstrate abnormal leptomeningeal enhancement that more closely approximates the extent of inflammatory cell infiltration.

Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis. This contrast-enhanced, axial T1-weighted magnetic resonance image shows a right frontal parenchymal low intensity (edema), leptomeningitis (arrowheads), and a lentiform-shaped subdural emphysema (arrows).

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MRI can help detect inflammatory changes in the paranasal sinuses and mastoid air cells, which are usually depicted as areas of increased signal intensity on T2-weighted images. Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis.

This T2-weighted axial magnetic resonance image shows frontal sinusitis, a bone defect (arrow) with adjacent cortical edema (arrowhead), and right occipitoparietal subdural fluid collection (emphysema). Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis.

This T2-weighted axial magnetic resonance image shows a developing abscess formation with mass effect and bilateral subdural fluid collections (emphysema). Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis.

This contrast-enhanced, axial T1-weighted magnetic resonance image shows a right frontal parenchymal low intensity (edema), leptomeningitis (arrowheads), and a lentiform-shaped subdural emphysema (arrows). Coronal and sagittal thin-section, heavily T2-weighted MRIs may show CSF leaks, which may be the source of infection in cases of recurrent meningitis.

Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis. This T2-weighted axial magnetic resonance image shows a developing abscess formation with mass effect and bilateral subdural fluid collections (emphysema).

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This T2-weighted axial magnetic resonance image shows parenchymal focal edema (celebrities). Effusions may be slightly hyperintense relative to CSF on MRIs and are most commonly located in cerebral complexities and interhemispheric fissures.

Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis. This contrast-enhanced, axial T1-weighted magnetic resonance image shows a right frontal parenchymal low intensity (edema), leptomeningitis (arrowheads), and a lentiform-shaped subdural emphysema (arrows).

Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis. This T2-weighted axial magnetic resonance image shows frontal sinusitis, a bone defect (arrow) with adjacent cortical edema (arrowhead), and right occipitoparietal subdural fluid collection (emphysema).

Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis. This T2-weighted axial magnetic resonance image shows a developing abscess formation with mass effect and bilateral subdural fluid collections (emphysema).

Occasionally, a portion of the medial subject cerebral surface of an effusion demonstrates mild enhancement, presumably from an inflammatory surrounding membrane. In the early stages of subdural emphysema, T2-weighted images can demonstrate a thin hyperintense convexity and interhemispheric collection usually not visible on CT scans.

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Prominent enhancement of the margin of an emphysema is an important diagnostic feature on MRI and results from the formation of a membrane of granulators tissue on the leptomeninges and from inflammation in the subject cerebral cortex. On MRI, even a noninflected subdural hematoma enhances markedly on gadolinium-enhanced T1- and T2-weighted images because of the presence of extracellular met hemoglobin and other forms of iron.

If bacterial celebrities is not successfully treated medically, the affected portion of the brain liquefies and a surrounding capsule of granulation tissue and collagen forms, resulting in abscess formation. The corticomedullary (gray matter–white matter) junction is the most commonly affected location, and the frontal and parietal lobes are the most frequent sites.

This T2-weighted axial magnetic resonance image shows parenchymal focal edema (celebrities). Abscesses may imitate brain tumors and can be differentiated with use of proton magnetic resonance spectroscopy.

Gradient-echo and spin-echo MRIs can demonstrate cortical vein and/or rural sinus thrombosis, as well as the characteristic signal-intensity properties of acute and subacute hemorrhagic infarction. The signal intensity of this condition varies depending on the state of infection, inflammation, and clot evolution.

Frequently, multiple lacuna infarcts are seen in the distribution of the perforating vessels in the brain stem, basal ganglia, and white matter. In ventriculitis associated with meningitis, the infecting organisms enter the ventricles via the choroid plexuses.

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On MRIs, as on CT scans, proteinaceous debris in the trig one or occipital horn of the lateral ventricle and intense enhancement of the eponym are seen. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Echogenic such that appear as a result of the accumulation of inflammatory debris are the most common and transient US finding in meningitis ; these resolve gradually as the exudate is cleared. On US, inflammatory debris in the CSF creates low-level intraventricular echoes in acute ventriculitis.

This appearance may imitate that which is seen in the breakdown of intraventricular hematomas; however, these 2 clinical settings can usually be distinguished because ventriculitis produces other signs of inflammation. Ventriculitis, which is seen in 65-90% of patients, is suggested by the US findings of hydrocephalus, which include a thickened, hyperechoic, irregular ependymal surface and echogenic debris and fibrous septa formation within the enlarged ventricles.

The lesions represent celebrities, infarction, encephalomalacia, or, rarely, abscess formation. Abscesses appear as homogeneous echogenic masses with a hypo echoic center that is surrounded by a thin hyperechoic rim.

Serial transcranial Doppler examinations performed to assess for disease-related arterial narrowing have been described. An association between an unfavorable course of the disease and increased cerebral blood flow velocity in intracranial arteries has been suggested; this probably indicates vasospasm.

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Transcranial Doppler US can potentially be used to identify high-risk patients who may benefit from adjuvant therapeutic interventions. Technetium-99 (99 m Tc) hexamethylpropyleneamine oxide, which is a radionuclide imaging label for leukocytes, and radio labeled polyclonal immunoglobulin antibodies may be helpful in select patients.

Tc-99 m hexamethylpropyleneamine oxide may also be used in the evaluation of the cerebral blood flow velocity and perfusion in bacterial meningitis. In addition, radionuclide historiography may depict CSF leaks, which may be the source in cases of recurrent meningitis. Early lumbar puncture in adult bacterial meningitis --rationale for revised guidelines.

McGill F, Hadrian RS, Michael BD, Defies S, Beaching NJ, Borrow R, et al. The UK joint specialist societies' guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults.

Glimmer M, Join J, Lesson S, Nuclear P. Lumbar Puncture Performed Promptly or After Neuroimaging in Acute Bacterial Meningitis in Adults: A Prospective National Cohort Study Evaluating Different Guidelines. Adult bacterial meningitis : earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture.

Posters JM, Brouwer MC, Springers MES, Roosendaal SD, van der End A, van de Been D. Cranial Computed Tomography, Lumbar Puncture, and Clinical Deterioration in Bacterial Meningitis : A Nationwide Cohort Study. Tunnel AR, Hartman BJ, Kaplan SL, Kaufman BA, Room KL, Sc held WM, et al.

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Khan EA, Choudhury S, Roohullah M, Hash mi I, Nazi R. Recurrent meningitis in children. Spectrum and Prevalence of Pathological Intracranial Magnetic Resonance Imaging Findings in Acute Bacterial Meningitis.

Oliveira CR, Morris's MC, Mist rot JG, Santa JB, Doer CD, Sánchez PJ. Ha zany S, Go JR, Law M. Magnetic resonance imaging of infectious meningitis and ventriculitis in adults.

Range VM, Wells JR, Williams NM, et al. Detectability of early brain meningitis with magnetic resonance imaging. Chen CY, Huang CC, Chang BC, et al. Subdural emphysema in 10 infants: US characteristics and clinical correlates.

Müller M, Merkelbach S, Hermes M, König J, Schimrigk K. Relationship between short-term outcome and occurrence of cerebral artery stenosis in survivors of bacterial meningitis. Haring H, Kampala A, Grubbiest G, Donne miller E, Faster B, Schmutzhard E. Cerebral blood flow velocity and perfusion in purulent meningitis : a comparative TCD and 99M-TC-HMPAO-SPECT study.

Risk factor of complications requiring neurosurgical intervention in infants with bacterial meningitis. This axial computed tomography scan shows sclerosis of the temporal bone (chronic mastitis), an adjacent epidural emphysema with marked rural enhancement (arrow), and the absence of left mastoid air.

Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis. This contrast-enhanced, axial T1-weighted magnetic resonance image shows a right frontal parenchymal low intensity (edema), leptomeningitis (arrowheads), and a lentiform-shaped subdural emphysema (arrows).

Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis. This T2-weighted axial magnetic resonance image shows frontal sinusitis, a bone defect (arrow) with adjacent cortical edema (arrowhead), and right occipitoparietal subdural fluid collection (emphysema).

Frontal sinusitis, emphysema, and abscess formation in a patient with bacterial meningitis. This T2-weighted axial magnetic resonance image shows a developing abscess formation with mass effect and bilateral subdural fluid collections (emphysema).

This contrast-enhanced, axial computed tomography scan was obtained 1 month after surgery and shows a small, ring-enhanced, hypo attenuating mass (recurrence of abscess) in the left basal ganglia and a left lentiform-shaped subdural fluid collection with enhanced meninges (arrowhead). This contrast-enhanced axial computed tomography scan shows leptomeningitis and parenchymal enhancement (celebrities) with a low-attenuating area (edema) in the left basal ganglia.

This contrast-enhanced axial computed tomography scan shows a ring-enhancing, loculated, hypo attenuating mass (abscess) in the left basal ganglia. This contrast-enhanced axial computed tomography scan shows left-sided parenchymal hypo attenuation in the middle cerebral artery territory, with marked herniation and a prominent subdural emphysema.

Subdural emphysema and diffuse cerebral edema in a patient with bacterial meningitis. This axial computed tomography scan shows bilateral subdural effusion (emphysema) and parenchymal low-attenuating areas.

Subdural emphysema and diffuse cerebral edema in a patient with bacterial meningitis. This contrast-enhanced computed tomography scan shows diffuse cerebral edema and lacuna infarcts in the thalamus.

This axial nonenhanced computed tomography scan shows mild ventriculomegaly and sultan effacement. This T2-weighted axial magnetic resonance image shows parenchymal focal edema (celebrities).

This contrast-enhanced, axial computed tomography scan shows a bilateral subdural effusion with cortical surface enhancement (emphysema). This axial computed tomography scan shows the distribution of the perforating vessels in the brain stem, basal ganglia, and white matter.

This computed tomography scan demonstrates the important diagnostic features of meningitis : prominent enhancement of the margin and increased attenuation of the emphysema. This contrast-enhanced, T1-weighted, axial magnetic resonance image shows an abscess formation in the right frontal lobe (arrows) and a right parasagittal subdural emphysema (arrowhead).

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