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Original Investigation
December 13/27, 1999

Cranial Computed Tomography Before Lumbar Puncture: A Prospective Clinical Evaluation

Author Affiliations

From the Department of Medicine, Duke University (Drs Gopal, Whitehouse, Simel, and Corey), and the Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center (Dr Simel), Durham, NC. Dr Gopal is now with the Division of Medical Oncology, University of Washington Medical Center, Seattle.

Arch Intern Med. 1999;159(22):2681-2685. doi:10.1001/archinte.159.22.2681

Objective  To prospectively identify which patients can safely undergo lumbar puncture (LP) without screening cranial computed tomography (CT).

Methods  Emergency department physicians examined patients before CT. Examiners recorded the presence or absence of 10 clinical findings and answered 8 additional questions. The criterion standard was noncontrast cranial CT interpreted by staff radiologists. Clinical findings were prospectively compared with those of CT.

Results  One hundred thirteen consecutive adults with the urgent need for LP (median age, 42 years) were studied. Fifteen percent of patients meeting entrance criteria had new CT-documented lesions, with 2.7% having lesions that contraindicated LP. Sensitivity, specificity, and likelihood ratios (LRs) were measured for the clinical findings. Three statistically significant predictors of new intracranial lesions were identified: altered mentation (positive LR, 2.2; 95% confidence interval [CI], 1.5-3.2), focal neurologic examination (positive LR, 4.3; 95% CI, 1.9-10), and papilledema (positive LR, 11.1; 95% CI, 1.1-115). No single item adequately predicted the absence of CT abnormalities, but the clinical screening items in aggregate significantly predicted the results (negative LR, 0; upper 95% confidence limit, 0.6). The overall clinical impression had the highest predictive value in identifying patients with CT-defined contraindications to LP (positive LR, 18.8; 95% CI, 4.8-43).

Conclusions  Because of the low prevalence of lesions that contraindicate LP, screening cranial CT solely to establish the safety of performing an LP typically provides limited additional information. Physicians can use their overall clinical impression and 3 clinical predictors to identify patients with the greatest risk of having intracranial lesions that may contraindicate LP.