43 The utility of neuroimaging in neonates and infants with bacterial meningitis

In order to reduce the chance of mortality or permanent neurologic sequelae, neonates and infants with suspected meningitis must be recognized and treated in a timely manner, including recognition of complications such as ventriculitis, hydrocephalus, stroke and intracranial abscess. Anecdotally, there is wide variation in the management of Canadian neonates and infants diagnosed with bacterial meningitis regarding the timing, modality, and indications for neuroimaging. Magnetic Resonance Imaging (MRI) imaging has become widely available in tertiary centres, but not in smaller hospitals. To review current literature regarding neuroimaging in neonates and infants with bacterial meningitis and summarize the utility of neuroimaging in this population in Canada. We conducted a PubMed search for English language case series describing term or preterm neonates and infants with confirmed bacterial meningitis and corresponding neuroimaging results, reported from countries where meningitis epidemiology would likely be similar to Canada. Out of 7 case series included in a final review, 4 focused on Group B Streptococcusmeningitis, 1 on Escherichia coliand 2 included various pathogens. Cranial ultrasound was frequently used in the acute setting (within 3 days of diagnosis). MRI was utilized for acute and/or follow-up imaging (3 days- 2 weeks after diagnosis). The most common indications for MRI imaging were failure of cerebrospinal fluid sterilization, seizures, or abnormal findings on neurologic examination. The most common ultrasound finding was increased echogenicity localized in various brain regions. 22/50 patients had normal ultrasound images, but 7 of these patients were found to have intracranial abnormalities on subsequent MRI. In GBS meningitis, multiple or diffuse ischemic infarcts were commonly seen on MRI. Abnormal imaging results led to a change in management in 47% of infants, regardless of causative pathogen. Changes in management included prolongation of antimicrobial therapy, addition of anticoagulant therapy, and neurosurgical intervention. Current literature suggests that cranial ultrasound may underestimate the presence of intracranial complications in neonates and infants with bacterial meningitis. Brain MRI may be a preferred modality in infants with bacterial meningitis who have persistently positive CSF cultures or abnormal neurological findings. As ischemic strokes appear to be more common in GBS meningitis, a lower threshold for MRI imaging, including vascular imaging, may be warranted to detect strokes early and treat to prevent new strokes from occurring.

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