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 contrastenhanced, 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 contrastenhanced, 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