MR and cerebrospinal fluid enzymes as sensitive indicators of subclinical cerebral injury after open-heart valve replacement surgery

PURPOSE

To evaluate MR imaging and lumbar cerebrospinal fluid enzymes as potential sensitive indicators of cerebral injury after open-heart valve replacement surgery.

METHODS

Thirty-four patients with cardiac valvular disease were prospectively entered into this study and then underwent valve replacement or repair under cardiopulmonary bypass using a membrane oxygenator. In 26 patients, MR head images were obtained 12 to 24 hours before surgery; repeat MR images were obtained between 1 and 2 weeks after surgery. In 18 patients, lumbar puncture cerebrospinal fluid was analyzed 24 to 48 hours after surgery; the analyses included measurement of lactic dehydrogenase, creatine phosphokinase, adenylate kinase, and neuron-specific enolase.

RESULTS

After surgery, MR imaging showed new ischemic lesions in 15 (58%) of 26 patients: 7 with deep white matter hyperintense lesions; 5 with brain stem, caudate, cerebellar, or thalamic/basal ganglia infarcts; 1 with intraparenchymal hemorrhage; 1 with a subdural hematoma and cortical infarct; and 1 with a corpus callosum lesion consistent with calcium or air. These new ischemic lesions seen on MR images were associated with a focal neurologic deficit in only 4 (27%) of the 15 patients. Neuron-specific enolase and lactic dehydrogenase were abnormally elevated after surgery in 5 (28%) of 18 patients. Adenylate kinase and creatine phosphokinase (brain isozymes) were elevated in one (67%) of the patients. Two (40%) of the five patients with abnormally high neuron-specific enolase or lactic dehydrogenase after surgery also showed a new focal neurologic deficit.

CONCLUSIONS

MR imaging is a sensitive measure of subclinical cerebral ischemia after cardiac valve replacement under cardiopulmonary bypass. Cerebrospinal fluid neuron-specific enolase and lactic dehydrogenase are less sensitive than MR imaging for detecting subclinical cerebral ischemia, but these values were elevated after surgery more frequently than was adenylate kinase in our patients.

[Creatine phosphokinase activity in cerebrospinal fluid in purulent meningitis]

32 patients with purulent meningitis were examined. Depending on clinical course and CSF cytosis they were divided into three groups: 1-7 patients with mild course and cytosis, mean = 290.76/1 mm3; 2-15 patients with moderate course and cytosis mean = 2361.0/1 mm3; 3-10 patients with severe course and cytosis mean = 15466/1 mm3. Control group consisted of 28 patients without symptoms of meningitis. The investigation showed significant increase of CPK in CSF, the highest in group 3 which maintain after treatment despite normalization of CSF parameters. The presence of correlation between CPK activity and protein concentration (not with cytosis and glucose concentration) was stated. In serum of these patients CPK concentration was significantly higher in comparison with control. There was no correlation between CPK activity in CSF and serum. Indication between CPK in CSF among patients with purulent meningitis can be used in prognosis of the course of the disease and to estimate the efficacy of treatment.

Creatine kinase isoenzyme BB concentrations in cerebrospinal fluid in asphyxiated preterm neonates

Creatine kinase isoenzyme BB was determined in cerebrospinal fluid (CSF) in 79 preterm neonates using an original enzyme-linked immunosorbent assay. The criterion for inclusion was an Apgar score of 7 or less at 5 min of life. Neurological examination was performed on day 2 and day 5 of life. CSF was obtained on the same days. Lumbar puncture was performed on 41 of these babies on day 2 and in 39 on day 5 of life (one baby underwent lumbar puncture twice). All babies had clinical features of hypoxic-ischemic encephalopathy (HIF) which was classified according to Sarnat and Sarnat. The control group consisted of 90 asphyxiated term babies and 30 adults without CNS pathology. The concentration of CK-BB in cerebrospinal fluid (mean +/- SD) was significantly higher (p < 0.0005) in preterm (168.0 +/- 2) than in term babies (29.0 +/- 3.1) and healthy adults (5.3 +/- 1.2). Our results demonstrate the possibility of using the classification system of Sarnat and Sarnat for assessment of the severity of brain damage not only in term, but also in preterm babies. Neonates with HIE stages II and III showed markedly higher CK-BB values than those with HIE I on day 2 (p < 0.025) and day 5 (p < 0.05) of life. CK-BB values were markedly higher in preterm babies with none of some primitive responses (head turning, Babkin's reflex, palmar grasp). The mean concentration of CK-BB was higher in neonates with retarded psychomotor development compared with those with normal development (p < 0.05) on day 3, and after 6 and 9 months. At 12 months of age no significant difference in median CK-BB concentration was detected between neonates with normal and developmental disturbances.

[Clinical chemical investigation of selected laboratory parameters of cerebrospinal fluid and blood of health cattle]

Selected Parameters in cerebrospinal fluid of adult, healthy cattle of different breeds were analyzed. Group size amounted to 68. Liquor samples were taken by lumbosacral punction. At the same time blood was taken from the Vena jugularis for analysis of the same parameters as in cerebrospinal fluid. Classification into 3 groups based on the macroscopic aspect of the cerebrospinal fluid: clear-colourless, flaky-colourless, bloody-flaky. In the first group all parameters were analyzed in order to fix standard distribution. A range of standard values of every parameter in cerebrospinal fluid was defined after finding of runaways and narrowing of random sample to 95%. Standard values for the parameters were: TP 0.83-1.40 g/l, GLU 1.18-3.20 mmol/l, LAC 1.4-1.9 mmol/l, CK 0.2-18.7 U/l, GLDH 0.7-3.7 U/l, AST 3.2-12.8 U/l. Possibilities to integrate results from the other two groups into these standard values were shown. A linear correlation between cerebrospinal fluid and blood serum values was found to exist for GLU (r = 0.91), LAC (r = 0.55) and GLDH (r = 0.48).

[A possible risk for geriatric risk patients caused by intraoperative disorder of cerebral energy utilization?]

OBJECTIVE

This study was carried out on cerebrospinal fluid (CSF) to investigate the perioperative course of certain ischaemic markers, namely neurone-specific enolase (NSE), creatine kinase (CK-BB), hypoxanthine, and lactate in order to identify a disturbed cerebral energy utilisation which could be responsible for the development of temporary mental dysfunctions. Those dysfunctions are characterised by preserved memory content and perception, but the coordination and association of these functions are disturbed. Typical clinical signs are motor restlessness, disordered emotions, and symptoms of dementia. Little is known about the aetiology of those symptoms, but they are most likely due to various events, such as direct drug effects, the extent of surgical trauma, sensorial deprivation, and disturbed perfusion.

METHODS

Eight orthopaedic patients (ASA III or IV) scheduled for removal of their total hip replacement were anaesthetised by catheter-spinal anaesthesia (CSA) for pain relief in combination with standardised, modified neuroleptanalgesia (NLA). At six defined times (15 hours preoperatively, immediately before and after surgery and 6, 24, and 36 hours postoperatively) CSF samples were drawn and the ischaemic markers were determined by means of radioimmunoassay (NSE), electrophoresis (CK-BB), photometry (lactate), and high-pressure liquid chromatography (hypoxanthine). The release of ischaemic markers into CSF correlates linear with the extent of ischaemic brain damage.

RESULTS

Mean concentrations of the following ischaemic markers increased in all patients intraoperatively: NSE from 12.3 ng/ml to 13.4 ng/ml, hypoxanthine from 1.86 mumol/l to 3.73 mumol/l, and lactate from 1.4 mmol/l to 2.0 mmol/l respectively, all of which returned to normal within 36 hours. The CK-BB concentrations were all within normal values and not affected by the operation during this investigation.

CONCLUSION

Although no clinical signs of temporary mental dysfunction have been observed, the results indicate that in CSF ischaemic markers temporarily undergo certain changes in their concentrations during the removal of total hip replacements in elderly patients. These changes are reason for assuming that risk patients may suffer a temporary disturbed cerebral energy utilisation intraoperatively, even if stable clinical and cardiovascular conditions prevail under anaesthesia. Such a temporary ischaemic penumbra might be responsible for the postoperative development of temporary mental dysfunctions.

The use of cytosolic enzyme increase in cerebrospinal fluid of patients resuscitated after cardiac arrest. Brain Resuscitation Clinical Trial I Study Group

Levels of brain creatine phosphokinase (CPK), glutamic oxalic transaminase, lactate dehydrogenase, and lactate in lumbar cerebrospinal fluid (CSF) were analyzed as an adjunctive study in a randomized clinical trial evaluating the effects of thiopental loading intravenously in comatose survivors of cardiac arrest. Three hospitals participated and a total of 62 cases of enzyme changes were studied. Enzyme levels but not lactate were higher at 48 hours than at 24 hours after restoration of spontaneous circulation. All enzymes were highly correlated with one another at 24 and 48 hours (P < .001). There was a significant negative correlation between cerebral recovery and increased CPK levels at 24 hours (P < .05), and a highly significant correlation with all three enzyme levels at 48 hours (P < .0001). The increase of cytosolic enzyme activity in lumbar CSF reflects permanent brain damage, and there is a relationship between activity levels and cerebral outcome.

Enzymatic changes in the cerebrospinal fluid in patients with infections of the central nervous system

Enzymatic determinations in cerebrospinal fluid (CSF) of aspartate aminotransferase (AST), lactic dehydrogenase (LDH), gammaglutamyl transpeptidase (GGT), creatine phosphokinase (CPK) and creatine kinase BB (CK-BB) were performed in 16 patients with aseptic meningitis (AM), in 25 children with bacterial meningitis (BM) and in 15 patients with meningism. The activity of AST and GGT was significantly higher in patients with BM on admission compared with those with AM and meningism (p < 0.05 and p < 0.005, respectively) and decreased with therapy. The highest concentration of AST and LDH appeared in patients with poor outcome as well as in those with ventriculomegaly on neurosonography (p < 0.05). The concentration of CK-BB increased in all patient groups on admission and remained higher on termination of therapy. The present study confirms the high activity of AST and GGT in BM patients in the CSF whereas the increased activity of AST and LDH reflects the extent of brain injury. Nevertheless, the prognosis for individual patients cannot be established on the basis of enzyme activity alone, but depends on several factors.

Composition of cerebrospinal fluid in healthy adult llamas

Cerebrospinal fluid and serum were obtained from 17 adult, healthy llamas (9 males, 1 castrated male, and 7 females). Osmolality; activities of lactate dehydrogenase and creatine kinase; and concentrations of glucose, sodium, chloride, potassium, total protein, and albumin were determined in serum and CSF. Total and differential cell counts were determined in CSF, and electrophoresis of CSF proteins was performed. Total nucleated cell count was low, 0 to 3/microliters, which is lower than that reported for other domestic species and is similar to values in healthy people. Differential leukocyte percentages were disparate depending on the degree of blood contamination. Blood contamination influenced the percentage of neutrophils and eosinophils in CSF. Samples with few erythrocytes had differential leukocyte distribution similar to that of other species: mostly lymphocytes, fewer monocytoid cells, and scant neutrophils. Older llamas had a few eosinophils in the CSF. Total protein, albumin, and gamma-globulin concentrations in llamas were similar to values in cattle and were higher than values in most domestic species. Glucose concentration in CSF was approximately 40% of the value in serum (nonruminant animals and peoply typically have CSF glucose concentration that is approximately 60 to 80% of the serum glucose concentration). Sodium and Cl concentrations in CSF were higher than those in serum, whereas K concentration was lower in CSF, compared with serum. Activities of creatine kinase and lactate dehydrogenase in CSF were markedly lower than those in serum, and the ranges of values in this group of healthy llamas were narrow.

Neural tissue-related proteins (NSE, G0 alpha, 28-kDa calbindin-D, S100b and CK-BB) in serum and cerebrospinal fluid after cardiac arrest

To estimate brain damage after cardiac arrest, the concentrations of neuron specific enolase (NSE), GTP-binding protein (G0 alpha), 28 kDa calbindin-D, S100b protein, and creatine kinase BB (CK-BB) in serum and cerebrospinal fluid (CSF) were determined by enzyme immunoassays. Ten mongrel dogs were subjected to 30 min of circulatory arrest at normal body temperature and serial CSF and blood samples were taken during the first 18 h after reperfusion. The NSE concentration in CSF increased significantly after reperfusion, reaching a 15-fold increase (243 +/- 107 ng/ml, p < 0.01) 18 h later, however, it did not increased significantly in serum (8.1 +/- 3.3 ng/ml vs. 23.5 +/- 7.0 ng/ml). G0 alpha concentration in CSF increased sharply between the 2nd and 4th h after reperfusion and peaked 18 h after reperfusion (428 +/- 195 pg/ml, p < 0.01), however, it did not increase significantly in serum. Calbindin-D concentration in CSF increased between the 1st and 6th h after reperfusion, and reached a plateau thereafter (621 +/- 235 ng/ml, a 23-fold increase, p < 0.05) and also increased significantly in serum (p < 0.05). The S100b concentration in CSF also increased dramatically after the 4th h of reperfusion and reached a plateau at the 8th h after reperfusion (16.0 +/- 9.3 ng/ml, a 50-fold increase, p < 0.01), however, it in serum was below the detection threshold. The CK-BB concentration in CSF peaked 4 h after reperfusion (113 +/- 69 ng/ml, a 19-fold increase, p < 0.01) and it in serum increased 4-fold (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical, cerebrospinal fluid, and histological data from thirty-four cats with primary noninflammatory disease of the central nervous system

The purpose of this study was to report the clinical, cerebrospinal fluid (CSF), and histological data derived from a study of 34 cats with noninflammatory central nervous system (CNS) disease, and to report the activities of the enzymes lactate-dehydrogenase (LDH), aspartate transferase (AST), and creatine kinase (CK) in the CSF from 15 cats with a variety of CNS diseases. The cats were part of a study of 61 cats that were admitted to two university clinics because of signs of CNS disease. The most frequent noninflammatory diseases were neoplasia (n = 12) and ischemic encephalopathy (n = 4). The majority of cats with CNS neoplasia had a mild increase in CSF protein concentration (less than 1 g/L [100 mg/dL]), an increased percentage of neutrophils or lymphocytes, and a normal total white cell count. Cats with ischemic encephalopathy (IE) had a mild to moderate increase in CSF protein concentration (< or = 2 g/L [200 mg/dL]) and a mild increase in white cell count (< or = 10 cells/microL) with an increased percentage of lymphocytes. The enzymes LDH, AST, and CK in the CSF were not sensitive indicators of chronic CNS disease. The CSF differential cell count was frequently abnormal when the total white cell count was normal, and blood contamination in the CSF samples was a frequent problem that had to be considered in the interpretation of the results. The history, signalment, and clinical signs, when combined with the CSF findings, were valuable in the diagnosis of noninflammatory CNS disease.

Diagnostic value of cerebrospinal fluid cytology in comparison with tumor marker activity in central nervous system metastases secondary to breast cancer

BACKGROUND

Central nervous system (CNS) metastases occur in approximately 35% of patients with breast cancer. Parenchymal brain metastases (MET) remain undetected in a large proportion of patients, and only 50% of patients with leptomeningeal carcinomatosis (MC) are diagnosed in vivo.

METHODS

Cytology and activity of the tumor markers tissue polypeptide antigen (TPA) and creatine kinase-BB isoenzyme (CK-BB) were evaluated in the cerebrospinal fluid (CSF) in 71 consecutive patients with breast cancer suspected for CNS metastases.

RESULTS

Forty-three patients had no CNS metastases, 12 patients had MET, 5 patients had both MET and MC, and 11 patients had MC alone. Seven of the patients with MC had an intracerebroventricular (ICV) reservoir inserted, and an additional 70 ICV CSF samples from these patients were obtained. In CSF obtained by lumbar puncture, 11% of the samples were classified as "suspicious for malignancy," but a very limited interobserver variability was demonstrated (Kappa test value, 0.81; 95% confidence limits, 0.67-0.95%). Fifty-one percent of the ICV CSF samples were classified as "suspicious for malignancy" (Kappa test value, 0.58; 95% confidence limits, 0.34-0.82%). TPA and CK-BB were both measured in 101 CSF specimens (61 from lumbar puncture and 40 ICV samples). The differences between patients with and without CNS metastases were significantly different according to TPA (P < 0.00001) and CK-BB (P < 0.00003; Mann-Whitney test). The sensitivity and predictive value of a negative test for having any CNS metastases (in case of elevated values of either TPA or CK-BB or both) were 85% (95% confidence limits, 65-96%) and 90% (95% confidence limits, 76-97%), respectively. In addition, a significant correlation between TPA and CK-BB was demonstrated in CSF from lumbar puncture (Spearmans-Rho, 0.49; P < 0.0001) and ICV (Spearmans-Rho, 0.37; P < 0.02).

CONCLUSIONS

Cytologic evaluation of CSF obtained by lumbar punctures is a reliable procedure. In CSF from ICV reservoirs, cytologic evaluation is of limited use, but CK-BB and TPA is of potential value.

CSF and serum brain-specific creatine kinase isoenzyme (CK-BB), neuron-specific enolase (NSE) and neural cell adhesion molecule (NCAM) as prognostic markers for hypoxic brain injury after cardiac arrest in man

Creatine kinase (CK) and its brain-specific isoenzyme (CK-BB), neuron-specific enolase (NSE), neural cell adhesion molecule (NCAM) and the ions sodium, potassium, chloride and calcium were measured both in CSF and serum and inorganic phosphate in CSF in order to assess their prognostic value in total brain ischemia due to cardiac arrest. The samples were collected at 4, 28 and 76 h after resuscitation. Twenty consecutive patients resuscitated from ventricular fibrillation or asystole were included in the study. Nine of the patients recovered consciousness (recovered) but eleven remained comatose (disabled). The follow-up period was 2 years after which only one patient was still alive. The earliest statistically significant differences between neurologically recovered and disabled patient groups were seen in CSF inorganic phosphate (P = 0.030) already at 4 h and CK-BB (P = 0.046) and NSE (P = 0.020) activity at 28 h. Later, at 76 h after the resuscitation CSF NSE differentiated the groups most clearly (P = 0.014). The values were higher in the disabled patients. A negative correlation between CSF parameters and Glasgow Coma scores was also seen at these timepoints. Statistically significant differences between the groups were seen in both CSF and blood pCO2, pO2, base excess (BE) and actual bicarbonate (HCO3-). CSF or serum NCAM has no prognostic value in anoxic-ischemic coma. The results suggest that in CSF CK-BB and NSE are useful prognostic indicators of hypoxic brain injury when measured 28-76 h after cardiac arrest whereas blood samples have no prognostic value.

Critical evaluation of postmortem changes in human autopsy cisternal fluid. Enzymes, electrolytes, acid-base balance, glucose and glycolysis, free amino acids and ammonia. Correlation to total brain ischemia

By studying early postmortem changes in cerebrospinal fluid (CSF) it is possible to draw conclusions as to premortem focal brain cell injury and terminal brain ischemia. Cisternal fluid (CF) from 40 different adult cadavers with no known neurological disorder was analyzed and compared with known in vivo values. They were divided into four groups (n = 10 in each group), CF samples taken 2, 4, 10, and 24 h after death. The enzyme activity of CK and CK-BB (EC 2.7.3.2) increased linearly and statistically significantly 4-24 h postmortem (P < 0.001) the 2 h values being already 10 to 20 times higher than in vivo, LD and its isoenzymes 1 to 3 (EC 1.1.1.27) distinctly 10 to 24 h after death. Glucose and pyruvate concentrations in the CF declined, as did Na+ and Cl-. Lactate and K+ increased over time. The earliest statistically significant changes between different timepoints were seen in lactate, pyruvate and K+ concentrations. The GABA concentration was already more than 170 times at 2 h postmortem, and glutamate more than 20 times higher than in vivo. The concentrations of alanine, glycine, lysine, histidine, isoleucine, phenylalanine, and tyrosine were 2 to 3 times higher at 2 h postmortem than during life. The concentrations of all amino acids and ammonia increased linearly and statistically significantly (P < 0.001) in the CF 4 to 24 h postmortem.

Ferritin, creatine kinase, and neopterin in subacute sclerosing panencephalitis

To study the disease process in the brain in subacute sclerosing panencephalitis (SSPE), sequential changes in ferritin, creatine kinase (CK), and neopterin in the cerebrospinal fluid (CSF) of two patients with SSPE were compared with the changes in the clinical signs and symptoms and the findings by magnetic resonance imaging (MRI). On the basis of changes in various substances in the CSF, especially ferritin, CK and neopterin, we concluded that the high-intensity area in MRI might be evidence of local inflammation and the resulting cell damage. Ferritin, CK and neopterin seemed to be biochemical markers in patients with SSPE for detection of the extent of lesions, and their measurement may provide information useful for evaluation of the therapeutic response.

High levels of nervous system-specific proteins in cerebrospinal fluid in patients with early stage Creutzfeldt-Jakob disease

Concentrations of several proteins that are characteristic of the nervous system were time-sequentially analyzed by radio- and enzyme-immunoassay in the cerebrospinal fluid (CSF) of patients with Creutzfeldt-Jakob disease (CJD). We found abnormally high levels of several proteins, such as neuron-specific enolase (NSE), S-100b protein, brain-type isozyme of creatine kinase (CK-BB) and alpha subunit of GTP binding protein G0 (G0 alpha) in the early stage of the disease. Generally, these protein levels were far higher in CJD patients than in normal controls and other neurological patients in the early stage before the typical clinical manifestations were evident. These levels increased to maxima when the disease activity was most prominent and returned to normal or mildly elevated levels in the terminal stage. The results imply that these protein levels can serve as biochemical markers for the presence of an active destructive process in CJD brain and provide us with a useful indicator for early diagnosis of CJD.

[Central nervous system disorders in myotonic dystrophy--with special reference to neuron-specific enolase, S-100b protein and creatine kinase BB isoenzyme levels in CSF]

In order to evaluate central nervous system disorders in myotonic dystrophy (MyD), neuron-specific enolase (NSE), S-100b protein and creatine kinase BB (CK-BB) isoenzyme were measured using enzyme immunoassay in MyD. Intelligence quotient (IQ) test (WAIS, 17 cases), electro-encephalography (17 cases) and brain computed tomography (18 cases) were examined. In patients with MyD, NSE level was significantly elevated in comparison with 25 age-sex matched control subjects. In some cases of MyD levels of S-100b protein and CK-BB in CSF were elevated. IQ test disclosed intellectual impairment in 70.6% of the patients examined and EEG study demonstrated slowing of basic rhythm in the majority of the cases. On brain CT both enlarged ventricles and dilated sulci were commonly found. The results of the present study suggest that in MyD the CNS is involved not only functionally but structurally as well. Since NSE, S-100b and CK-BB are localized in neuronal and glia cells, their elevated levels in CSF indicate existence of organic lesions in the central nervous tissue in patients with MyD.

Neuroprotective effects of phencyclidine on acute cerebral ischemia and reperfusion injury of rabbits

Acute cerebral ischemia and reperfusion injury of rabbits was produced by permanently occluding the vertebral arteries and temporarily clamping the common carotid arteries for 30 min. Phencyclidine [1-(phenylcyclohexyl)piperidine, PCP] 40-80 micrograms.kg-1 icv 30 min before ischemia significantly attenuated the decrease of the total power of electroencephalogram (EEG) within 30 min of ischemia and improved the recovery of brain electric activity following reperfusion. PCP 20-80 micrograms.kg-1 dose-dependently suppressed the creatine kinase (CK) release during cerebral ischemia and reperfusion, and PCP 40-80 micrograms.kg-1 reduced brain ischemic damage. These improvements indicated that PCP has protective effects on acute cerebral ischemia and reperfusion injury.

Evaluation of hypoxic brain injury with spinal fluid enzymes, lactate, and pyruvate

OBJECTIVE

To investigate the prognostic importance in neurologic recovery of the lumbar cerebrospinal fluid (CSF) variables creatine kinase (CK) and brain-type creatine kinase isoenzyme (CK-BB), lactate dehydrogenase (LDH) and its isoenzymes (LDH 1-5), CSF acid phosphatase, beta-D-N-acetylglucosaminidase activity, and CSF lactate, pyruvate, sodium, potassium, and calcium concentrations in patients who experienced cardiac arrest.

DESIGN

Prospective clinical study with blood and CSF samples collected 4, 28, 76, and 172 hrs after resuscitation.

SETTING

Medical ICU in a university hospital.

PATIENTS

Twenty consecutive victims of out-of-hospital cardiac arrest. Eight patients recovered neurologically and 12 patients remained comatose or neurologically disabled until death.

MEASUREMENTS AND MAIN RESULTS

CSF CK, CK-BB, LDH, and LDH isoenzyme 1-3 concentrations in all disabled patients were markedly increased at 76 hrs after the resuscitation. However, these variables were not changed in the recovered subjects. Patients (n = 7) with a mean CSF CK level of 25 +/- 33 (SD) U/L, CK-BB 23 +/- 33 U/L, and CSF lactate 3.8 +/- 0.9 mmol/L at 28 hrs after cardiac arrest remained unconscious and died. In the recovered patients, the mean CSF CK concentration was 2.0 +/- 1.5 U/L (p less than .001) and CSF lactate concentration 2.5 +/- 0.5 mmol/L (p less than .002). The lactate concentration was highest at 4 hrs after resuscitation, declining thereafter. Patients with a mean CSF total LDH level of 609 +/- 515 U/L and acid phosphatase 2.4 +/- 1.2 U/L 76 hrs after resuscitation died without regaining consciousness. In the recovered patients, the mean total CSF LDH activity was 82 +/- 58 U/L (p = .003) and CSF acid phosphatase was 0.8 +/- 0.5 U/L (p = .01) 76 hrs after resuscitation.

CONCLUSIONS

CSF CK, CK-BB, and CSF lactate concentrations reflect a patient's outcome most reliably when measured within 28 to 76 hrs of the cardiac arrest. Similarly, CSF LDH, its isoenzymes 1-3, and CSF acid phosphatase concentrations, when measured at 76 hrs, can be used to monitor the patient's outcome after cardiac arrest. When correlated with Glasgow Coma Scale scores, the closest negative correlation was again seen in CSF CK and CK-BB at 28 and 76 hrs, as well as in LDH, LDH1-3, and acid phosphatase values at 76 hrs. The negative correlation between CSF lactate and Glasgow Coma Scale scores was most distinct at 28 hrs.

Efficacy of cerebro-spinal fluid biochemistry in the diagnosis of brain insult

Postmortem biochemical indices may provide a useful adjunct to morphological studies in the identification of antemortem brain insult. We studied 34 routine medico-legal cases categorising them into one of four diagnostic groups. There were 11 cases of head trauma, 7 of 'hypoxia' (3 hangings and 4 carbon monoxide or drug poisonings), 7 sudden cardiac deaths and 9 miscellaneous cases. Survival time and postmortem interval was known for each case. The degree of cranio-cerebral trauma was graded. Cerebro-spinal fluid (CSF) and vitreous humour were analysed for calcium, glucose, total proteins, aldolase, aspartate transaminase (AST), alanine transaminase (ALT), gamma glutamyltransferase (GGT), lactate dehydrogenase (LDH), creatine kinase (CK) and creatine kinase BB isoenzyme (CK-BB). CK-BB was also measured in superior vena cava serum. In CSF there was a significant correlation between the severity of cranio-cerebral trauma and levels of aldolase, CK-BB, AST, ALT and total proteins. CSF CK-BB, median units/l (range), for the groupings of head trauma, hypoxia, sudden cardiac death and miscellaneous were respectively 823 (2-3431); 96 (2-187); 4 (2-25); 5 (1-69). Corresponding serum CK-BB levels were 240 (28-322); 390 (26-411); 180 (20-482); 79 (18-530).

Creatine kinase isoenzyme BB concentrations in the cerebrospinal fluid of newborns: relationship to short-term outcome

Creatine kinase brain isoenzyme (CK-BB) was determined in cerebrospinal fluid of 150 neonates by a newly developed immunoenzymatic assay. Newborns with a documented neurologic disorder (intraventricular hemorrhage, postasphyxial encephalopathy, central nervous system infection, or persistent periventricular intraparenchymal echodensities) showed markedly higher concentrations of immunoreactive CK-BB than did the normal newborns or those with subarachnoid hemorrhage. In neonates with seizures the data suggest that the underlying neurologic disorder accounts for the higher CK-BB values and not the seizures per se. High concentrations of CK-BB in the neonatal period were followed by poor short-term outcome.

Increases of neuron-specific enolase, S-100 protein, creatine kinase and creatine kinase BB isoenzyme in CSF following intraventricular catheter implantation

In 15 patients without acute brain injury the concentrations of Neuron-specific Enolase (NSE), S-100 Protein (S-100), Creatine Kinase (CK), and Creatine Kinase BB isoenzyme (CK-BB) in ventricular cerebrospinal fluid (CSF) were measured immediately after lateral ventricle cannulation for diagnostic or treatment purposes. From patients who were treated with a shunt another CSF sample was obtained one week after shunt implantation by puncture of the antechamber of the valve. The CSF concentrations of NSE, S-100, CK and CK-BB after cannulation were found to be of the same order as found in patients with severe head injury, stroke or subarachnoid haemorrhage. One week after shunt implantation the concentrations of S-100, CK and CK-BB had returned to normal levels in almost all patients, while the NSE concentrations remained elevated. These findings indicate that the sampling procedure may result in contamination of CSF with NSE, S-100, CK and CK-BB and they should be taken into account in the prognostic evaluation of enzyme concentrations after brain injury.

Predicting outcome in hypoxic-ischemic coma. A prospective clinical and electrophysiologic study

A prospective analysis of 40 patients with hypoxic-ischemic coma lasting at least 6 h following sudden cardiac arrest was undertaken. The patients, all of whom had preserved brain-stem function, were studied electrophysiologically with electroencephalography (EEG), and median nerve somatosensory evoked potentials (SEPs) within 48 h to establish prognostic indices. Our results indicate that preserved brain-stem function does not necessarily predict favorable outcome following cardiac arrest as 26 of 40 (65%) patients died without awakening. The bilateral absence of cortical evoked potentials predicted death without awakening in 19 of 26 patients (73%) while malignant EEG change was similarly predictive in 11 patients (42%). Bilateral absence of cortical evoked potentials and/or malignant EEG change reliably predicted unfavorable outcome in 21/26 patients (81%). Patients with normal or delayed central conduction time (CCT) as well as 'benign' or 'uncertain' EEG findings had an uncertain prognosis as some entered a persistent vegetative state (PVS) or died without awakening. Fourteen patients (35%) awakened of whom 5 (13%) recovered completely while another 9 (23%) had varying degrees of motor or cognitive impairment. SEP and EEG findings did not distinguish between these outcomes.

Mass concentration measurements of creatine kinase BB isoenzyme as an index of brain tissue damage

A new two-site immunoenzymometric method using monoclonal antibodies was developed for measuring CK-BB mass concentrations in cerebrospinal fluid (CSF). Within- and between-assay coefficient of variation values for the method varied between 6 and 9%. Assay results are not affected by presence of sulfate and sialic acid groups on the enzyme. In comparison to catalytic activity measurements, a steady decline in the enzyme's specific activity was observed after acute head trauma. Repetitive measurements of CK-BB mass concentration in cerebrospinal fluid during the first 24 h after trauma enabled the estimation of brain lesion size. Clinical outcome of acute head trauma patients evaluated by Glasglow Outcome Scale, correlated well with cumulative CK-BB release after trauma. Also in neonates, CK-BB determinations in CSF correlated well with clinical findings.