Imaging in Bacterial Meningitis: Overview, Radiography, Computed Tomography

Imaging in Bacterial Meningitis: Overview, Radiography, Computed Tomography 1/31/18, 5:41 PM
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Imaging in Bacterial Meningitis

Updated: Nov 28, 2015
Author: Lutfi Incesu, MD; Chief Editor: James G Smirniotopoulos, MD more...
OVERVIEW
Overview
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, 2] 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).
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https://emedicine.medscape.com/article/341971-overview#a20 Page 1 of 36
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.
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Ventriculitis in a patient with bacterial meningitis. This contrast-enhanced computed tomography scan shows
ependymal enhancement.
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The diagnosis of acute bacterial meningitis is not made on the basis of imaging studies. Rather,
it is established by the affected patient’s history, physical examination findings, and laboratory
results. [1, 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 articles Meningitis 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, 2] 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. [5]
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. [6, 7, 8] See the image below.
Acute bacterial meningitis. This contrast-enhanced, axial T1-weighted magnetic resonance image shows
leptomeningeal enhancement (arrows).
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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.
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Acute bacterial meningitis. This axial T2-weighted magnetic resonance image shows only mild
ventriculomegaly.
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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 matter–white 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.
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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.
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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.
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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. [9] 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. [6, 7, 8]
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).
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ventriculomegaly.
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Pachymeningitis and cerebritis in a patient with bacterial meningitis. This T2-weighted axial magnetic
resonance image shows parenchymal focal edema (cerebritis).
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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.
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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.
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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.
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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.
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axial magnetic resonance image shows a developing abscess formation with mass effect and bilateral
subdural fluid collections (empyema).
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Enhancement may be prominent. See the image below.
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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.
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enhancement.
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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.
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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 matter–white 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
enhancement.
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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.
ventriculomegaly.
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Obstructive hydrocephalus can occur with chronic inflammatory changes in the subarachnoid
space or ventricular obstruction.
Gadolinium Warning
Gadolinium-based contrast agents 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 influenzae meningitis.
Subdural empyemas are uncommon findings and result when the effusions become infected;
US features may help differentiate effusions from empyemas. [10]
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. [11] 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. [12] 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.
References
1. Akhvlediani T, Shakarishvili R, Tsertsvadze T. THE ROLE OF IMAGING STUDIES IN CNS

INFECTIONS. Georgian Med News. 2008 Dec. 94-98. [Medline].
2. Hofinger D, Davis LE. Bacterial meningitis in older adults. Curr Treat Options Neurol. 2013
Aug. 15(4):477-91. [Medline].
3. Minonzio G, Colico MP, Ghezzi A, Zarcone D. Imaging of cranio-meningeal infectious and

inflammatory involvement. Neurol Sci. 2008 Sep. 29 Suppl 2:S279-82. [Medline].
4. Glimåker M, Johansson B, Bell M, Ericsson M, Bläckberg J, Brink M, et al. Early lumbar

puncture in adult bacterial meningitis--rationale for revised guidelines. Scand J Infect Dis.
2013 Sep. 45(9):657-63. [Medline].
5. Khan EA, Choudhry S, Roohullah M, Hashmi I, Nazir R. Recurrent meningitis in children. J

Pak Med Assoc. 2013 Feb. 63(2):274-6. [Medline].
6. Lummel N, Koch M, Klein M, Pfister HW, Brückmann H, Linn J. Spectrum and Prevalence
of Pathological Intracranial Magnetic Resonance Imaging Findings in Acute Bacterial
Meningitis. Clin Neuroradiol. 2014 Sep 23. [Medline].
7. Oliveira CR, Morriss MC, Mistrot JG, Cantey JB, Doern CD, Sánchez PJ. Brain magnetic
resonance imaging of infants with bacterial meningitis. J Pediatr. 2014 Jul. 165 (1):134-9.
[Medline].
8. Hazany S, Go JL, Law M. Magnetic resonance imaging of infectious meningitis and

ventriculitis in adults. Top Magn Reson Imaging. 2014 Oct. 23 (5):315-25. [Medline].
9. Runge VM, Wells JW, Williams NM, et al. Detectability of early brain meningitis with
magnetic resonance imaging. Invest Radiol. 1995 Aug. 30(8):484-95. [Medline].
10. Chen CY, Huang CC, Chang YC, et al. Subdural empyema in 10 infants: US
characteristics and clinical correlates. Radiology. 1998 Jun. 207(3):609-17. [Medline].
11. 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. J Neurol. 1998 Feb. 245(2):87-92. [Medline].
12. Haring H, Kampfl A, Grubwieser G, et al. Cerebral blood flow velocity and perfusion in
purulent meningitis: a comparative TCD and 99M-TC-HMPAO-SPECT study. Eur J Neurol.
1998 Jan. 5(1):75-81. [Medline].
13. Chang YC, Huang CC, Wang ST, Chio CC. Risk factor of complications requiring
neurosurgical intervention in infants with bacterial meningitis. Pediatr Neurol. 1997 Sep.
17(2):144-9. [Medline].
Media Gallery
Chronic mastoiditis and epidural empyema in a patient with bacterial meningitis. This axial
computed tomography scan shows sclerosis of the temporal bone (chronic mastoiditis), an
adjacent epidural empyema with marked dural enhancement (arrow), and the absence of
left mastoid air.
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).
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).
This T2-weighted axial magnetic resonance image shows a developing abscess formation
with mass effect and bilateral subdural fluid collections (empyema).
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).
contrast-enhanced axial computed tomography scan shows leptomeningitis and
parenchymal enhancement (cerebritis) with a low-attenuating area (edema) in the left

basal ganglia.
contrast-enhanced axial computed tomography scan shows a ring-enhancing, lobulated,
hypoattenuating mass (abscess) in the left basal ganglia.
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
axial computed tomography scan shows bilateral subdural effusion (empyema) and
parenchymal low-attenuating areas.
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.
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.
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).
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.
Pachymeningitis and cerebritis in a patient with bacterial meningitis. This T2-weighted
axial magnetic resonance image shows parenchymal focal edema (cerebritis).
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.
Ventriculitis in a patient with bacterial meningitis. This contrast-enhanced computed
tomography scan shows ependymal enhancement.
Lacunar infarct in a patient with bacterial meningitis. This axial computed tomography scan
shows the distribution of the perforating vessels in the brainstem, basal ganglia, and white
matter.
Bilateral subdural empyema in a patient with bacterial meningitis. This computed
tomography scan demonstrates the important diagnostic features of meningitis: prominent
enhancement of the margin and increased attenuation of the empyema.
Abscess formation in a patient with bacterial meningitis. This contrast-enhanced, T1-
weighted, axial magnetic resonance image shows an abscess formation in the right frontal
lobe (arrows) and a right parasagittal subdural empyema (arrowhead).
Pachymeningitis in a patient with bacterial meningitis. This contrast-enhanced, T1-
weighted, coronal magnetic resonance image also shows subdural empyemas on the left
side.
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Contributor Information and Disclosures
Author
Lutfi Incesu, MD Professor, Department of Radiology, Ondokuz Mayis University School of

Medicine; Chief, Neuroradiology, Department of Radiology, Ondokuz Mayis University Hospital,
Turkey
Disclosure: Nothing to disclose.
Coauthor(s)
Anil Khosla, MBBS, MD Assistant Professor, Department of Radiology, St Louis University

School of Medicine, Veterans Affairs Medical Center of St Louis
Anil Khosla, MBBS, MD is a member of the following medical societies: American College of
Radiology, American Roentgen Ray Society, American Society of Neuroradiology, North
American Spine Society, Radiological Society of North America
Specialty Editor Board
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation
Services, Hutt Valley District Health Board, New Zealand
C Douglas Phillips, MD, FACR Director of Head and Neck Imaging, Division of Neuroradiology,
New York-Presbyterian Hospital; Professor of Radiology, Weill Cornell Medical College
C Douglas Phillips, MD, FACR is a member of the following medical societies: American College
of Radiology, American Medical Association, American Society of Head and Neck Radiology,
American Society of Neuroradiology, Association of University Radiologists, Radiological
Society of North America
Chief Editor
James G Smirniotopoulos, MD Chief Editor, MedPix®, Lister Hill National Center for
Biomedical Communications, US National Library of Medicine; Professorial Lecturer,
Department of Radiology, George Washington University School of Medicine and Health
Sciences
James G Smirniotopoulos, MD is a member of the following medical societies: American

College of Radiology, American Society of Neuroradiology, Radiological Society of North
America
Additional Contributors
Lucien M Levy, MD, PhD
Lucien M Levy, MD, PhD is a member of the following medical societies: American Cancer
Society, American College of Radiology, American Heart Association, American Medical
Association, American Roentgen Ray Society, American Society of Neuroradiology,
Radiological Society of North America

Imaging in Bacterial Meningitis: Overview, Radiography, Computed Tomography

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Imaging in Bacterial Meningitis: Overview, Radiography, Computed Tomography 1/31/18, 5:41 PM

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Imaging in Bacterial Meningitis

Preferred Radiologic Examination

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Enhancement of the meninges is seen on contrast-enhanced CT scans and MRIs in cases of

Sequelae from meningitis may be depicted on CT scans as periventricular and meningeal

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Magnetic Resonance Imaging

of meningeal inflammation. Gadolinium-enhanced MRI studies can demonstrate abnormal

Enhancement may be prominent. See the image below.

Occasionally, a portion of the medial subjacent cerebral surface of an effusion demonstrates

Paratentorial and subtemporal extension is well demonstrated on coronal MRIs.

Prominent enhancement of the margin of an empyema is an important diagnostic feature on

Subdural empyema may be differentiated from subacute/chronic subdural hematoma. On MRI,

Magnetic resonance venography (2-dimensional time-of-flight or phase-contrast) can aid the

Venous and Arterial Infarcts

Abnormal Parenchymal Echogenicity

1. Akhvlediani T, Shakarishvili R, Tsertsvadze T. THE ROLE OF IMAGING STUDIES IN CNS

3. Minonzio G, Colico MP, Ghezzi A, Zarcone D. Imaging of cranio-meningeal infectious and

4. Glimåker M, Johansson B, Bell M, Ericsson M, Bläckberg J, Brink M, et al. Early lumbar

5. Khan EA, Choudhry S, Roohullah M, Hashmi I, Nazir R. Recurrent meningitis in children. J

Meningitis. Clin Neuroradiol. 2014 Sep 23. [Medline].

8. Hazany S, Go JL, Law M. Magnetic resonance imaging of infectious meningitis and

11. Müller M, Merkelbach S, Hermes M, König J, Schimrigk K. Relationship between short-

parenchymal enhancement (cerebritis) with a low-attenuating area (edema) in the left

Contributor Information and Disclosures

Lutfi Incesu, MD Professor, Department of Radiology, Ondokuz Mayis University School of

Disclosure: Nothing to disclose.

Anil Khosla, MBBS, MD Assistant Professor, Department of Radiology, St Louis University

Disclosure: Nothing to disclose.

Specialty Editor Board

Disclosure: Nothing to disclose.

Disclosure: Nothing to disclose.

James G Smirniotopoulos, MD is a member of the following medical societies: American

Disclosure: Nothing to disclose.

Lucien M Levy, MD, PhD

Disclosure: Nothing to disclose.

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