Incesu L. Meningitis, Bakterial.

Ondokuz Mayis University School of Medicine; Department

of Radiology, Ondokuz Mayis University Hospital, Turkey Updated: Mar 13, 2009.
Available at.http://emedicine.medscape.com/article/341971.

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, empyema, and infarction and to exclude
parenchymal abscess and ventriculitis. Identifying cerebral complications early is
important, as some complications, such as symptomatic hydrocephalus, subdural
empyema, and cerebral abscess, require prompt neurosurgical intervention.
[1]
See
the images below.
Frontal sinusitis, empyema, 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 empyema (arrows).
Watershed and lacunar infarcts in a patient with
bacterial meningitis. This axial computed tomography scan shows a left
frontoparietal watershed infarct, a right basal ganglia lacunar infarct, and a bilateral
subdural effusion. Ventriculitis in a patient with bacterial
meningitis. This contrast-enhanced computed tomography scan shows ependymal
enhancement.
The diagnosis of acute bacterial meningitis is not made on the basis of imaging
studies. Rather, it is established by the affected patients history, physical
examination findings, and laboratory results.
[2, 3]
Lumbar puncture is the single most
important diagnostic study.
Imaging studies performed in patients with acute meningitis may provide normal
findings. The results of an imaging study do not exclude or prove the presence of
acute meningitis.
For excellent patient education resources, visit eMedicineHealth's Brain and Nervous
System Center. Also, see eMedicineHealth's patient education articlesMeningitis in
Adults, Meningitis in Children, and Brain Infection.
Preferred Radiologic Examination
Computed tomography (CT) scanning is often performed first to exclude
contraindications for lumbar puncture.
[4, 5]
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.
[6]

Currently, 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. See the image below.
Acute bacterial meningitis. This contrast-enhanced, axial
T1-weighted magnetic resonance image shows leptomeningeal enhancement
(arrows).
Effusion, hydrocephalus, cerebritis, 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. Chest radiographs may be obtained
to look for signs of pneumonia or fluid in the lungs, especially in children.
In uncomplicated cases of purulent meningitis, early CT scans and MRIs usually
demonstrate normal findings or small ventricles and effacement of sulci. The value of
CT scanning in the early diagnosis of subdural empyema is limited because of the
presence of bone artifact.
Acute bacterial meningitis. This axial nonenhanced
computed tomography scan shows mild ventriculomegaly and sulcal effacement.
Acute bacterial meningitis. This axial T2-weighted
magnetic resonance image shows only mild ventriculomegaly.
Acute bacterial meningitis. This contrast-enhanced, axial
T1-weighted magnetic resonance image shows leptomeningeal enhancement
(arrows).
Enhancement of the meninges is seen on contrast-enhanced CT scans and MRIs in
cases of bacterial meningitis. However, meningeal enhancement is nonspecific and
may also be caused by the following 5 different etiologic subgroups:
Infectious
Carcinomatous meningitis
Reactive (eg, surgery, shunt, trauma)
Chemical (eg, ruptured dermoid and cysticercoid cysts, intrathecal chemotherapy)
Inflammatory (eg, sarcoidosis, collagen vascular disease
Radiography
Plain radiographs do not have diagnostic importance in bacterial meningitis. Chest
radiography may be obtained to look for signs of pneumonia or fluid in the lungs. As
many as 50% of patients with pneumococcal meningitis also have evidence of
pneumonia on initial chest images.
Computed Tomography
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 empyema,
and cerebral abscess. Contrast-enhanced CT scans may also help in detecting
complications such as venous thrombosis, infarction, and ventriculitis. Ventriculitis is
a complication of bacterial meningitis that is seen commonly in neonates. Ependymal
enhancement can be seen on contrast-enhanced CT scans.
The value of CT scanning in the early diagnosis of subdural empyema and effusion
has been controversial, as this modality may not detect meningitis, especially
nonenhanced CT scans in the early stage of the disease. Normal results on CT
imaging do not exclude the presence of acute meningitis.
CT scans may reveal the cause of meningeal infection. Obstructive hydrocephalus
can occur with chronic inflammatory changes in the subarachnoid space or in cases
of ventricular obstruction. Otorhinologic structures and congenital and posttraumatic
calvarial defects can be evaluated (see image below).
Cerebritis and developing abscess formation in a patient
with bacterial meningitis. This contrast-enhanced, axial computed tomography scan
was obtained 1 month after surgery and shows a small, ring-enhanced,
hypoattenuating mass (recurrence of abscess) in the left basal ganglia and a left
lentiform-shaped subdural fluid collection with enhanced meninges (arrowhead).
Coronal thin-section CT scanning is useful for evaluating patients with recurrent
bacterial meningitis; CT cisternography may depict CSF leaks, which may be the
source of infection in cases of recurrent meningitis.
Sequelae from meningitis may be depicted on CT scans as periventricular and
meningeal calcifications, localized areas of encephalomalacia, porencephaly, and
ventricular dilatation secondary to brain atrophy.
Nonenhanced CT scan findings may be normal (>50% of patients), or the studies
may demonstrate mildventricular dilatation and effacement of sulci, cerebral edema,
and focal low-attenuating lesions. See image below.
Acute bacterial meningitis. This axial nonenhanced
computed tomography scan shows mild ventriculomegaly and sulcal effacement.
Obliteration of the basal cisterns may result from increased attenuation, perhaps
owing to 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 iodinated
contrast material. Diffuse enhancement of the subarachnoid space is characteristic.
See the image below.
Cerebritis and developing abscess formation in a patient
with bacterial meningitis. This contrast-enhanced axial computed tomography scan
shows leptomeningitis and parenchymal enhancement (cerebritis) with a low-
attenuating area (edema) in the left basal ganglia.
Curvilinear meningeal enhancement over convexities, interhemispheric and sylvian
fissures, and obliteration of basal cisterns are usually seen on contrast-enhanced CT
scans. Dural enhancement also may occur. However, meningeal enhancement is
nonspecific and may be caused not only by bacterial meningitis but also by
neoplasm, hemorrhage, sarcoidosis, and other noninfectious inflammatory disorders.
Subdural Effusion
Subdural effusion is a common complication of meningitis, especially in young
children. CT scans have shown that as many as 25-40% of children develop this
complication during or after treatment for meningitis. Some subdural effusions
resolve spontaneously, whereas others may require aspiration or drainage.
Important diagnostic features on CT scans are high-attenuating effusions from the
CSF and prominent enhancement of the margin of an empyema. The marked degree
of enhancement of an empyema 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. See images below.
Cerebritis and developing abscess formation in a patient
with bacterial meningitis. This contrast-enhanced, axial computed tomography scan
was obtained 1 month after surgery and shows a small, ring-enhanced,
hypoattenuating mass (recurrence of abscess) in the left basal ganglia and a left
lentiform-shaped subdural fluid collection with enhanced meninges (arrowhead).
Subdural empyema and arterial infarct in a patient with
bacterial meningitis. This contrast-enhanced axial computed tomography scan
shows left-sided parenchymal hypoattenuation in the middle cerebral artery territory,
with marked herniation and a prominent subdural empyema.
Subdural empyema and diffuse cerebral edema in a
patient with bacterial meningitis. This axial computed tomography scan shows
bilateral subdural effusion (empyema) and parenchymal low-attenuating areas.
Subdural empyema with strand in a patient with
bacterial meningitis. This contrast-enhanced, axial computed tomography scan
shows a bilateral subdural effusion with cortical surface enhancement (empyema).
Note that the attenuation of the effusion is higher than that of the cerebrospinal fluid.
Sinus Thrombosis
Sinus thrombosis can be demonstrated on CT scans. In the acute phase (when the
clot is dense), a hyperattenuating thrombus can be seen in the sagittal sinus on a
nonenhanced scan. 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
Infarcts can be reliably diagnosed with CT scanning. Infarcts tend to be sharply
marginated and confined to a specific arterial vascular territory. Commonly, multiple
lacunar infarcts are seen in the distribution of perforating vessels in the brainstem,
basal ganglia, and white matter. See the images below.
Subdural empyema and arterial infarct in a patient with
bacterial meningitis. This contrast-enhanced axial computed tomography scan
shows left-sided parenchymal hypoattenuation in the middle cerebral artery territory,
with marked herniation and a prominent subdural empyema.
Watershed and lacunar infarcts in a patient with
bacterial meningitis. This axial computed tomography scan shows a left
frontoparietal watershed infarct, a right basal ganglia lacunar infarct, and a bilateral
subdural effusion. Subdural empyema and diffuse
cerebral edema in a patient with bacterial meningitis. This contrast-enhanced
computed tomography scan shows diffuse cerebral edema and lacunar infarcts in
the thalamus.
Cerebritis
In cerebritis, CT scans can show ill-defined areas of low attenuation, which are
evidence of edema in the affected brain. On nonenhanced CT scans, abscesses,
which are most commonly located near the gray matterwhite matter junction, can
appear as areas of low attenuation with a thin wall of slightly increased attenuation.
After the administration of contrast material, the abscess wall and surrounding
inflammatory tissue enhancement are ring shaped. See the images below.
Cerebritis and developing abscess formation in a patient
with bacterial meningitis. This contrast-enhanced, axial computed tomography scan
was obtained 1 month after surgery and shows a small, ring-enhanced,
hypoattenuating mass (recurrence of abscess) in the left basal ganglia and a left
lentiform-shaped subdural fluid collection with enhanced meninges (arrowhead).
Cerebritis and developing abscess formation in a patient
with bacterial meningitis. This contrast-enhanced axial computed tomography scan
shows a ring-enhancing, lobulated, hypoattenuating mass (abscess) in the left basal
ganglia. Abscess in a patient with bacterial meningitis.
This contrast-enhanced computed tomography scan shows a ring-enhancing,
hypoattenuating mass (abscess) with peripheral edema and mass effect.
Magnetic Resonance Imaging
Routine contrast-enhanced brain MRI is the most sensitive modality for the diagnosis
of bacterial meningitis because it helps to detect the presence and extent of
inflammatory changes in the meninges as well as complications. The increased
sensitivity and specificity of MRI results from direct multiplanar imaging, increased
contrast resolution, and the absence of artifact caused by bone.
Nonenhanced MRI studies performed in patients with uncomplicated acute bacterial
meningitis may demonstrate unremarkable findings; however, such results do not
exclude acute meningitis.
Some authors suggest performing MRI with a high dose of contrast material (0.3
mmol/kg), which is the most important factor.
[7]
They also recommend imaging
immediately after the injection and then performing magnetization transfer imaging,
which can help to depict abnormal meningeal enhancement and which facilitates the
diagnosis of early brain meningitis. Meningeal enhancement is nonspecific, however,
and may be caused not only by bacterial meningitis but also by neoplasm,
hemorrhage, sarcoidosis, and other noninfectious inflammatory disorders.
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. Diffuse enhancement of the
subarachnoid space is characteristic. See the images below.
Frontal sinusitis, empyema, 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 (empyema).
Acute bacterial meningitis. This axial T2-weighted
magnetic resonance image shows only mild ventriculomegaly.
Pachymeningitis and cerebritis in a patient with bacterial
meningitis. This T2-weighted axial magnetic resonance image shows parenchymal
focal edema (cerebritis).
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. See the images below.
Frontal sinusitis, empyema, 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 empyema (arrows).
Acute bacterial meningitis. This contrast-enhanced, axial
T1-weighted magnetic resonance image shows leptomeningeal enhancement
(arrows).
Dural enhancement may occur, and extension of enhancing subarachnoid exudate
deep into the sulci can be seen in severe cases. See the images below.
Pachymeningitis in a patient with bacterial meningitis. This
contrast-enhanced, axial T1-weighted magnetic resonance image shows diffuse
dural enhancement. Pachymeningitis and cerebritis in a
patient with bacterial meningitis. This contrast-enhanced, T1-weighted axial
magnetic resonance image shows left-sided dural enhancement (pachymeningitis)
and focal pial enhancement.
Revealing the cause of meningeal infection is best accomplished with MRI. MRI can
help to 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. See the images below.
Frontal sinusitis, empyema, 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 (empyema).
Frontal sinusitis, empyema, 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 (empyema).
Enhancement may be prominent. See the image below.
Frontal sinusitis, empyema, 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 empyema (arrows).
MRI also can help to exclude congenital and posttraumatic calvarial defects.
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.
Plain and contrast-enhanced MRIs help to depict the complications of meningitis
better than other images. Such complications include empyema/effusion,
cerebritis/abscess, venous thrombosis, venous and arterial infarcts, ventriculitis,
hydrocephalus, and edema (with or without cerebral herniation). See the images
below.
Frontal sinusitis, empyema, 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 (empyema). Pachymeningitis and cerebritis in
a patient with bacterial meningitis. This contrast-enhanced, T1-weighted axial
magnetic resonance image shows left-sided dural enhancement (pachymeningitis)
and focal pial enhancement. Pachymeningitis and
cerebritis in a patient with bacterial meningitis. This T2-weighted axial magnetic
resonance image shows parenchymal focal edema (cerebritis).
Subdural Empyema/Effusion
Sterile fluid collections may develop within the subdural space in patients with
meningitis. Effusions may be slightly hyperintense relative to CSF on MRIs and are
most commonly located in cerebral convexities and interhemispheric fissures. See
the images below.
Frontal sinusitis, empyema, 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 empyema (arrows).
Frontal sinusitis, empyema, 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 (empyema).
Frontal sinusitis, empyema, 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 (empyema).
Occasionally, a portion of the medial subjacent cerebral surface of an effusion
demonstrates mild enhancement, presumably from an inflammatory surrounding
membrane. These effusions are not empyemas and typically resolve spontaneously.
In the early stages of subdural empyema, T2-weighted images can demonstrate a
thin hyperintense convexity and interhemispheric collection usually not visible on CT
scans.
Paratentorial and subtemporal extension is well demonstrated on coronal MRIs.
Prominent enhancement of the margin of an empyema is an important diagnostic
feature on MRI and results from the formation of a membrane of granulomatous
tissue on the leptomeninges and from inflammation in the subjacent cerebral cortex.
Subdural empyema may be differentiated from subacute/chronic subdural
hematoma. On MRI, even a noninfected subdural hematoma enhances markedly on
gadolinium-enhanced T1- and T2-weighted images because of the presence of
extracellular methemoglobin and other forms of iron.
Cerebritis/Abscesses
Cerebritis is the earliest stage of a purulent brain infection. If bacterial cerebritis 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 matterwhite matter) junction is the most
commonly affected location, and the frontal and parietal lobes are the most frequent
sites. Less than 15% of intracranial abscesses occur in the posterior fossa. Multiple
abscesses are uncommon except in patients who are immunocompromised. MRI
findings of pyogenic brain abscesses are characteristic.
On MRIs, stage I cerebritis appears as an ill-defined edematous area on both T1-
and T2-weighted images. See the images below
Pachymeningitis and cerebritis in a patient with bacterial
meningitis. This contrast-enhanced, T1-weighted axial magnetic resonance image
shows left-sided dural enhancement (pachymeningitis) and focal pial enhancement.
Pachymeningitis and cerebritis in a patient with bacterial
meningitis. This T2-weighted axial magnetic resonance image shows parenchymal
focal edema (cerebritis).
In late stage II cerebritis/early abscess, the abscess wall is hyperintense on T1-
weighted images and slightly hypointense on T2-weighted images. In stage III
(subacute abscess), the abscess wall is hyperintense on both T1- and T2-weighted
images. In stage IV (chronic phase), the abscess wall is isointense on T1-weighted
MRIs and markedly hypointense on T2-weighted MRIs. Although abscesses in
stages II-IV all exhibit ring-type enhancement after the infusion of a paramagnetic
contrast agent, better edge definition is seen in the enhancing wall of stage II lesions
than in stages III and IV.
Abscesses may imitate brain tumors and can be differentiated with use of proton
magnetic resonance spectroscopy. Brain tumors usually demonstrate elevated
choline and possibly decreased creatine peaks, as well as N -acetyl-aspartate
peaks. Abscesses do not demonstrate these abnormal peaks; instead, they have
lactate peaks and the lipid peaks of amino acids.
Venous Thrombosis
Thrombosis of the deep veins, cortical veins, and venous sinuses is an uncommon
complication of meningitis; however, thrombosis more often develops in the
presence of superimposed dehydration.
Gradient-echo and spin-echo MRIs can demonstrate cortical vein and/or dural sinus
thrombosis, as well as the characteristic signal-intensity properties of acute and
subacute hemorrhagic infarctions.
MRI-aided diagnosis for acute and chronic sinus thrombosis may be complex;
however, sinus thrombosis is readily diagnosed when the thrombus is subacute
because they are hyperintense on T1-weighted images.
Magnetic resonance venography (2-dimensional time-of-flight or phase-contrast) can
aid the diagnosis of venous sinus thrombosis.
Cavernous sinus thrombosis is an uncommon sequela of meningitis. The signal
intensity of this condition varies depending on the state of infection, inflammation,
and clot evolution. The sinus may be enlarged with a narrowed or occluded
cavernous carotid artery. T2-signal prolongation may occur in the adjacent clivus or
petrous apex.
Venous and Arterial Infarcts
Venous infarcts are diagnosed on the basis of their characteristic location and
appearance. Typically, infarcts from a sagittal sinus thrombosis involve the parietal
lobes; those from the straight sinus/vein of Galen thrombosis involve the thalami;
and infarcts from the transverse sinus or sigmoid sinus thrombosis involve the
temporal lobe.
Arterial infarctions in bacterial meningitis are usually the result of arteritis caused by
involvement of the vascular spaces and the arterial walls. When major cerebral
arteries are involved, large cortical infarctions result. Frequently, multiple lacunar
infarcts are seen in the distribution of the perforating vessels in the brainstem, basal
ganglia, and white matter.
Ventriculitis
In ventriculitis associated with meningitis, the infecting organisms enter the ventricles
via the choroid plexuses. On MRIs, as on CT scans, proteinaceous debris in the
trigone or occipital horn of the lateral ventricle and intense enhancement of the
ependyma are seen.
Hydrocephalus
Ventriculomegaly can occur in the course of meningitis and is usually mild to
moderate in severity. See the image below.
Acute bacterial meningitis. This axial T2-weighted
magnetic resonance image shows only mild ventriculomegaly.
Obstructive hydrocephalus can occur with chronic inflammatory changes in the
subarachnoid space or ventricular obstruction.
Gadolinium Warning
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist],
gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide
[OptiMARK], gadoteridol [ProHance]) have been linked to the development of
nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD).
The disease has occurred in patients with moderate to end-stage renal disease after
being given a gadolinium-based contrast agent to enhance MRI or MRA scans.
NSF/NFD is a debilitating and sometimes fatal disease. 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.
Ultrasonography
The role of ultrasonography in patients with bacterial meningitis is limited to the
evaluation of complications or deterioration in the patient's clinical situation.
Commercially available equipment is used with a 3- to 7.5-MHz transducer,
depending on the size of the patient's head. Transducers of 5-7.5 MHz are used for
newborns, whereas transducers of 3-5 MHz are used for older infants. US is a
heavily operator-dependent technique. Experience is needed to demonstrate the
meningeal and parenchymal findings of bacterial meningitis.
In newborns and older infants, complications of meningitis that are depicted on
cranial CT scans and MRIs can also be demonstrated on cranial sonograms
obtained with a transfontanel approach.
Important US findings in infants with bacterial meningitis have been described.
These findings include echogenic sulci, ventriculomegaly and obstructive
hydrocephalus, ventriculitis, prominent leptomeninges, subdural effusions,
empyema, parenchymal echogenicity, and abscess formation. US can help to
identify these complications, but the findings are usually not specific.
Echogenic sulci 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.
Ventriculomegaly
Mild to moderate ventriculomegaly, which is usually reversible, can occur in the
course of meningitis. Exudates may produce CSF loculations and pathway
obstruction, resulting in a communicating hydrocephalus, whereas obstructive
hydrocephalus may occur with ventricular obstruction or chronic inflammatory
changes in the subarachnoid space. Intraventricular septa formation may result in
ventricular compartmentalization. Progressive ventriculomegaly can be excluded
with the use of serial sonograms.
Ventriculitis
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
septa occur over the 2 weeks following bacterial meningitis; US is best for identifying
septa, compared with CT scanning or MRI.
Subdural Effusion
Subdural effusion is a common US finding in infants with Haemophilus
influenzaemeningitis. Subdural empyemas are uncommon findings and result when
the effusions become infected; US features may help differentiate effusions from
empyemas.
[8]

Abnormal Parenchymal Echogenicity
Areas of abnormal parenchymal echogenicity are a significant finding. The lesions
represent cerebritis, infarction, encephalomalacia, or, rarely, abscess formation.
Abscesses appear as homogeneous echogenic masses with a hypoechoic center
that is surrounded by a thin hyperechoic rim.
Doppler Ultrasonography
Doppler US can easily demonstrate the major intracranial vessels via the anterior
transfontanel approach; in older children, these vessels can be demonstrated via the
transtemporal approach. The cerebral blood flow can be evaluated qualitatively.
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.
[9]
Transcranial
Doppler US can potentially be used to identify high-risk patients who may benefit
from adjuvant therapeutic interventions.
Nuclear Imaging
Although CT scanning and MRI are the most common imaging modalities used to
evaluate patients with a possible abscess, distinguishing brain abscesses with these
2 modalities is occasionally difficult. Technetium-99 (
99m
Tc)
hexamethylpropyleneamine oxime, which is a radionuclide imaging label for
leukocytes, and radiolabeled polyclonal immunoglobulin antibodies may be helpful in
select patients.
99m
Tc hexamethylpropyleneamine oxime may also be used in the
evaluation of the cerebral blood flow velocity and perfusion in bacterial
meningitis.
[10]
In addition, radionuclide cisternography may depict CSF leaks, which
may be the source in cases of recurrent meningitis.
Angiography
Arterial angiography may demonstrate arterial spasm or may show focal areas of
inflammation that have manifested by hypervascularity.
If magnetic resonance venography is not available, a reliable and cost-effective
method for detecting venous sinus thrombosis is intravenous digital-subtraction
angiography.