This study had several limitations. First, there is spectrum bias because brain MRI is more likely to be performed in severe cases than mild ones. However, though such a bias would lead to a higher prevalence of hearing loss in this study, it should not affect the interpretation of the data, since the correlation between cochlear enhancement and hearing status should remain independent of meningitis severity (ie, the test characteristics of sensitivity and specificity are independent of disease prevalence, in this case, hearing loss), and in fact all levels of hearing outcome were well represented. Second, our study may have overlooked a few cases of mild hearing loss, since it included 6 patients who underwent only ear-specific screening ABR but no further testing. Because such screens are conducted at 30 to 35 dB, it is conceivable that 1 or more of them had undetected mild hearing loss in the 20- to 30-dB range. If so, this would have caused a slight upward bias of the apparent sensitivity of GdMRI but would not have affected its specificity. Finally, the images were brain MRIs with relatively large slice thicknesses. While this did not allow resolution of fine inner ear detail, an assessment of its MRI enhancement was in fact possible in nearly all ears. Only 1 patient was excluded owing to inadequate visualization of both inner ears. This did not bias our results, since even in the worst case of a false-positive MRI result (the patient had normal hearing), specificity would only drop to 97% and PPV to 93%, and sensitivity and NPV would remain unchanged. Nevertheless, these limitations highlight several modifications that should be incorporated in any future, prospective evaluation of GdMRI: dedicated temporal bone high-resolution MRI sequences, standardized ear-specific audiometric testing, and a strict regimen of follow-up audiometry.