Jolt accentuation of headache as a test for acute meningitis in emergency settings

Why is the diagnosis of acute meningitis by physical examination important?

Meningitis is inflammation of the tissue that protects the brain and spinal cord (the meninges). Acute meningitis, especially bacterial and tubercular meningitis, is potentially life-threatening, and requires prompt diagnosis and early treatment.

Diagnosis usually needs an analysis of cerebrospinal fluid collected by lumbar puncture. Lumbar puncture involves the insertion of a needle between the bones of the lumbar spine. Lumbar puncture is an invasive test that can cause headache.

If physical examination can accurately exclude the possibility of acute meningitis, patients may be able to avoid having to undergo a lumbar puncture. However, traditional physical examinations of people with suspected meningitis, such as inability to flex the neck forward (nuchal rigidity), does not exclude acute meningitis.

What is the aim of this review?

We aimed to estimate how accurate jolt accentuation of headache is for diagnosis of acute meningitis in emergency settings. Jolt accentuation of headache is a more recent (1991) and less well-recognised physical examination compared to other tests. Jolt accentuation involves making the headache worse by rotating the head horizontally two or three times per second.

What was studied in this review?

We studied jolt accentuation of headache in people who presented with potential acute meningitis in emergency settings.

What are the main results of this review?

We included nine studies involving 1161 participants who presented with potential acute meningitis. Five studies included only adults, and four studies included both adults and children. Due to lack of data, we could not perform separate analyses for adults and children.

How confident are we in the results of the review?

It appears that jolt accentuation of headache is not sensitive enough to exclude a diagnosis of acute meningitis.

To whom do the review's results apply?

People who present with potential acute meningitis. Most studies targeted emergency settings, therefore it is uncertain whether the test would work in primary care settings. Most studies included adults or adolescents; the youngest participant was aged 13 years. There is no evidence that this test is applicable for children.

What are the implications of this review?

Even where jolt accentuation of headache is negative, there is still the possibility of acute meningitis.

How up-to-date is this review?

We searched for studies published up to 27 April 2020.

Authors' conclusions: 

Jolt accentuation for headache may exclude diagnoses of meningitis in emergency settings, but high-quality evidence to support use of this test is lacking. Even where jolt accentuation of headache is negative, there is still the possibility of acute meningitis. This review identified the possibility of heterogeneity. However, factors that contribute to heterogeneity are incompletely understood, and should be considered in future research.

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Background: 

Meningitis is inflammation of the meninges, the layers that protect the brain and spinal cord. Acute meningitis is an emergent disease that develops over the course of hours to several days. Delay in treatment can lead to serious outcomes.

Inflammation of the meninges is assessed by analysing cerebrospinal fluid. Identifying the pathogen in cerebrospinal fluid is another way to diagnose meningitis. Cerebrospinal fluid is collected by doing a lumbar puncture, which is an invasive test, and can be avoided if a physical examination excludes the diagnosis of meningitis. However, most physical examinations, such as nuchal rigidity, Kernig's test, and Brudzinski's test, are not sufficiently sensitive to exclude meningitis completely.

Jolt accentuation of headache is a new and less well-recognised physical examination, which assesses meningeal irritation. It is judged as positive if the headache is exacerbated by rotating the head horizontally two or three times per second. A 1991 observational study initially reported high sensitivity of this examination to predict pleocytosis. Pleocytosis, an abnormally high cerebrospinal fluid sample white cell count, is an accepted indicator of nervous system infection or inflammation. Jolt accentuation of headache may therefore accurately rule out meningitis without the use of lumbar puncture. However, more recent cross-sectional studies have reported variable diagnostic accuracy.

Objectives: 

To estimate the diagnostic accuracy of jolt accentuation of headache for detecting acute meningitis in emergency settings. Secondary objectives: to investigate the sources of heterogeneity, including study population, patient condition, and types of meningitis.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), and Embase (Elsevier) to 27 April 2020. We searched ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and Ichushi-Web Version 5.0 to 28 April 2020.

Selection criteria: 

We included cross-sectional studies that assessed the diagnostic accuracy of jolt accentuation of headache for people with suspected meningitis in emergency settings. We included participants of any age and any severity of illness. Meningitis should be diagnosed with any reference standard, such as cerebrospinal fluid pleocytosis, proof of causative agents, or autopsy.

Data collection and analysis: 

Two review authors independently collated study data. We assessed methodological quality of studies using QUADAS-2 criteria. We used a bivariate random-effects model to determine summary estimates of sensitivity and specificity where meta-analysis was possible. We performed sensitivity analyses to validate the robustness of outcomes. We assessed the certainty of the evidence using the GRADE approach.

Main results: 

We included nine studies (1161 participants). Five studies included only adults. Four studies included both adults and children; however, the proportion was not reported in three of these studies. The youngest child reported in the studies was aged 13 years. There was no study including only children.

The reference standard was pleocytosis in eight studies, and the combination of pleocytosis and increased protein in the cerebrospinal fluid in one study. Two studies also used smear or positive culture of cerebrospinal fluid.

Risk of bias and concern about applicability was high in the participant selection domain for all included studies and the consciousness subgroup.

Overall, pooled sensitivity was 65.3% (95% confidence interval (CI) 37.3 to 85.6), and pooled specificity was 70.4% (95% CI 47.7 to 86.1) (very low-certainty evidence). We established the possibility of heterogeneity from visual inspection of forest plots. However, we were unable to conduct further analysis for study population, types of meningitis, and participants' condition, other than disturbance of consciousness (a secondary outcome).

Amongst participants whose consciousness was undisturbed (8 studies, 921 participants), pooled sensitivity and specificity were 75.2% (95% CI 54.3 to 88.6) and 60.8% (95% CI 43.4 to 75.9), respectively (very low-certainty evidence).

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