Cerebrospinal fluid creatine kinase activity in horses with central nervous system disease: 69 cases (1984-1989)

The CSF creatine kinase (CK) activity was determined in 70 CSF samples from 69 horses with CNS disease. Abnormal values (greater than or equal to 1 IU/L) were determined from 32 CSF samples, and normal values (less than 1 IU/L) were found in 38 samples. Increased CK activity was most frequently associated with a diagnosis of equine protozoal myelitis; CK activity was not increased in 11 horses with cervical compressive myelopathy. Other diagnoses, in which CSF CK activity was increased included trauma (n = 1), idiopathic epilepsy (n = 2), botulism (n = 2), articular facet fracture (n = 1), intervertebral disk protrusion (n = 1), and toxemia (n = 1).

Reference intervals for feline cerebrospinal fluid: biochemical and serologic variables, IgG concentration, and electrophoretic fractionation

Reference intervals are reported for feline CSF biochemical and serologic variables, IgG concentration, and electrophoretic fractionation, derived from 58 clinically normal adult cats that did not have histologic lesions of the CNS. There was no apparent effect of age on any variable. The CSF total protein concentration was significantly (P = 0.012) greater in males than in females, but all other variables were unaffected by gender. The only variable that had a statistically significant correlation with its corresponding blood concentration was IgG. Blood contamination of the CSF affected the following CSF variables: total protein concentration, activities of lactate dehydrogenase and creatine kinase, IgG ratio, and gamma-globulin percentage. The reference intervals proposed for feline CSF were derived from 33 cats with CSF RBC count less than 31 cells/microliters. Reference limits for CSF with 31 to 1,700 RBC/microliters also are reported.

Creatine kinase isoenzyme BB in the cerebrospinal fluid of patients with acute neurological diseases

In order to predict the outcome of patients with acute neurological symptoms at discharge, the concentration of creatine kinase isoenzyme BB (CK-BB) was determined by radioimmunoassay in the cerebrospinal fluid (CSF) of 115 consecutive patients. On admission and over the next 3 days the concentration of CK-BB was significantly increased in patients with brain death and other neurological sequelae compared with those with favourable outcome. There was a variation in time in concentrations of CK-BB between diseases causing neurological sequelae. Thus, cerebrovascular haemorrhages caused highest concentrations on admission, but cerebral ischaemia due to cardiac arrest caused highest concentrations 3 days after admission. On admission the CK-BB measurements were highly specific with high predictive value of positive result when distinguishing patients with brain death and other neurological sequelae from those without complications at discharge. However, when distinguishing patients with brain death from those with other neurological sequelae, the test was most specific and had highest predictive value of a positive result 3 days after admission.

Creatine kinase-BB in the cerebrospinal fluid as a marker of CNS metastases and leptomeningeal carcinomatosis in patients with breast cancer

To determine whether creatine kinase-BB isoenzyme would be useful in detecting central nervous system metastases secondary to breast cancer, we measured the cerebrospinal fluid (CSF) activity of creatine kinase (CK) and its BB isoenzyme (CK-BB) in 65 consecutive patients suspected of having CNS involvement. All patients underwent neurological evaluation, computer tomography (CT) scan and/or radionuclide scintigraphy and lumbar puncture with CSF examination. Thirty patients had CNS metastases, of whom 18 had parenchymal brain metastases (MET). Twelve had leptomeningeal carcinomatosis (MC), of whom four also had parenchymal brain metastases. Thirty-four patients were concluded not to have CNS involvement, whereas one was considered equivocal. CK-BB activity was significantly higher in patients with CNS metastases than in those without (P less than 0.05). This difference was primarily related to the fact that patients with MC had a significantly higher CK-BB activity than patients without CNS metastases or patients with parenchymal brain metastases only (P less than 0.01 and P less than 0.05, respectively). Taking 0.20 U/l as a tentative cut-off value (the upper limit range of patients without CNS metastases being 0.19 U/l), 10 out of 12 patients with MC had activities above this level. The sensitivity and specificity for having MC were 83% and 87%, and the positive and negative predictive values 60% and 96%, respectively. The sensitivity and negative predictive value for having any CNS metastases were 57% and 72%. Specificity and positive predictive value: 100%. The CSF activity of CK-BB appears to be a contribution in the diagnosis of MC secondary to breast cancer and seems superior to protein and LDH.

Relationship between CT attenuation changes and post-traumatic CSF-CKBB-activity after severe head injury in man

In order to evaluate if it is practically possible to assess the volume of contused brain tissue from the CT pictures, a comparison has been carried out between the size of the cerebral contusion(s)--as estimated from the CT scans--and the post-traumatic CSF-CKBB activity, in a series of 29 patients with severe head injury. A clearance curve for the elimination of CKBB from the CSF was constructed. The relation between contusion volume and CSF-CKBB-activity was not statistically significant, while the relationships between contusion volume and outcome, and between CSF-CKBB, as estimated at 6 hours after from the clearance curve, and outcome, were.

Neurological outcome after out-of-hospital cardiac arrest. Prediction by cerebrospinal fluid enzyme analysis

The prognostic value of cerebrospinal fluid (CSF) and serum neuron-specific enolase and brain-type creatine kinase isozyme (CK-BB) measurements was studied in 75 consecutive victims of out-of-hospital cardiac arrest. All patients with a CSF neuron-specific enolase level of more than 24 ng/mL 24 hours after cardiac arrest remained unconscious and died. The CSF CK-BB level was as reliable as an index of brain injury. Cerebrospinal fluid neuron-specific enolase, CSF CK-BB and serum neuron-specific enolase levels correlated with the neurological outcome at 3 months. Thus, the analysis of these enzymes in CSF seems to be useful in the early prognostic assessment of cardiac arrest victims.

[Creatine phosphokinase in the cerebrospinal fluid of patients with acute meningitis]

A study is presented of the general activity and isoenzymatic spectrum of creatine phosphokinase (CPK) in the cerebrospinal fluid (CSF) in patients with acute meningitis of different etiology. The enzymatic activity proved to be increased due to the cerebral (CPK-BB) isoform. Liberation of CPK-BB from the brain tissue and its penetration into the intercellular fluid and then into the CSF was related to the functional-structural changes in the cellular membranes of the brain in meningitis.

[Cerebrospinal fluid level of aldolase C in patients with various neurological disorders: comparison with neuron-specific enolase, S-100b protein and creatine kinase BB isoenzyme]

By employing a highly sensitive immunoassay method, concentration of aldolase C (Ald C) was determined in cerebrospinal fluid (CSF) of 180 patients with various neurological disorders and 46 age-and-sex matched control subjects. The results were compared with CSF levels of neuron-specific enolase (NSE), S-100b proteins (S-100b) and creatine kinase BB isoenzyme (CK-BB) in the same samples. Normal level of Ald C was 7.95 +/- 2.52 (mean +/- SD) ng/ml. CSF level of Ald C was elevated not only in patients with acute disorders, but also those of degenerative diseases. It increased significantly in purulent meningitis, encephalitis, cerebral infarction, and cervical spondylosis as compared with control subjects. The levels of Ald C were reached the peak levels later than those of NSE, S-100b and CK-BB. Concentration of Ald C in CSF correlated well with that of NSE but poorly with that of S-100b or CK-BB. These results suggested that Ald C in CSF was one of the useful marker in neurological disorders. Since these proteins have different distributions in the central nervous system and have different molecular weights, simultaneous determination of Ald C, NSE, S-100b and CK-BB levels in CSF might provide valuable information about pathologic nature of the underlying neurological disorders.

Enzymatic changes in the cerebrospinal fluid as indices of pathological change

Enzymatic determinations in cerebrospinal fluid (CSF) of lactic dehydrogenase (LDH), creatine phosphokinase (CPK) and creatine kinase BB (CK-BB) were performed on 94 patients presenting with a range of disorders of the central nervous system. Enzyme results from 37 patients undergoing myelography were used as controls. The highest concentration of these enzymes appeared in patients with the most severe brain injury. In head-injured patients with a Glasgow Coma Score (GCS) of 3 to 7, only the CK-BB correlated with the degree of injury and with the ultimate outcome. Within the subgroup of spinal cord injuries none of the enzymes correlated with the severity of neurological injury. However, patients with acute spinal cord trauma who demonstrated CSF CK-BB values greater than 10 U/litre had never recovered. The present study confirms that CSF CK-BB seems to be a sensitive index of acute brain damage, but it reflects best the extent of CNS tissue disruption rather than the severity of neurological deficits.

Serum and cerebrospinal fluid enzymes in subarachnoid haemorrhage

Serum levels of creatine kinase (CK) and its isoenzyme CK-MB, lactate dehydrogenase (LDH), hydroxybutyric dehydrogenase (HBDH), glutamic oxalacetic transaminase (GOT) and glutamic pyruvic transaminase (GPT) were studied in 50 patients with subarachnoid haemorrhage. In 18 cases the cerebrospinal fluid (CSF) was also examined for total concentration of CK and CK-MB. The results were correlated with the degree of neurological deterioration, the angiographic spasm and prognosis. Concurrent increase of CK-MB, LDH and HBDH serum levels indicates a poor prognosis, whereas increase of GOT and GPT does not have clinical significance. High CK-MB levels in CSF were associated with the worst clinical evolution. However, increase of serum enzymes coincided in most cases with the appearance of the spasm. Monitoring of CK-MB, LDH and HBDH serum levels can be useful for following the evolution of the spasm and in predicting the outcome for patients with subarachnoid haemorrhage.

Creatine phosphokinase in serum and cerebrospinal fluid, and microscopic findings in brain and heart in hypothermic rabbits

Signs of hypothermia injury were studied in rabbits cooled to a core temperature of 30 degrees C by immersion in ice water and thereafter rewarmed to 35 degrees C. Anaesthetized control rabbits were kept normothermic (37 degrees C) for a corresponding time (4 h). Creatine phosphokinase (CPK) activity increased 24 h after hypothermia to 20-fold in serum. In cerebrospinal fluid the activity was already significantly (5-fold) increased after hypothermia and was still as high at 24 h. Smaller increase was also found in the control normothermic rabbits both in serum (10-fold) and cerebrospinal fluid (2-fold). The values had returned to the initial level after 1 week. Small haemorrhages were observed in the brain at 24 h and slight scarring was seen in the myocardium of some rabbits which had lived 4 weeks following hypothermia. The results indicate that CPK can be a useful marker in the diagnostics of hypothermia death, especially in cerebrospinal fluid, which is less affected than blood by autolysis.

Brain enzyme levels in CSF after cardiac arrest and resuscitation in dogs: markers of damage and predictors of outcome

Levels of brain creatine kinase (CK), aspartate aminotransferase (ASAT), and lactate dehydrogenase (LD) in CSF after cardiac arrest were studied in dog models. Ventricular fibrillation cardiac arrest lasting 10 min or asphyxiation cardiac arrest lasting 0-10 min was followed by cardiopulmonary resuscitation and 96-h intensive care. Outcome was scored as neurologic deficit (0% = normal, 100% = brain death) and overall performance category (1 = normal, 5 = death). Both measures correlated with EEG return time after asphyxiation cardiac arrest, but not after ventricular fibrillation cardiac arrest. Peak activity of enzymes in CSF at 48-72 h post arrest correlated with outcome, and CK was the best predictor. Brain histopathologic damage score at autopsy 96 h post arrest correlated with CK level in CSF (r = 0.79, n = 39) and neurologic deficit (r = 0.70, n = 50). Ischemic neuronal changes occurred after ventricular fibrillation cardiac arrest of 10 min, and neuronal changes plus microinfarcts occurred after asphyxiation cardiac arrest of 1.5-10 min. Brain enzymes were decreased at 6 h post arrest in regions with worst histologic damage (gray matter of neocortex, hippocampus, caudate nucleus, cerebellum). Brain CK decreased further, ASAT remained low, and LD increased at 72 h after arrest. The temporal changes in CK level paralleled the temporal ischemic neuronal changes in the brain, and time to peak activity was unaffected by the severity of the ischemic insult. Peak activity of individual enzymes in CSF was determined predominantly by the brain concentration, but was also influenced by rate of decomposition. This "chemical brain biopsy method" represents a useful adjunctive tool to predict permanent, severe brain damage during comatose states after cardiac arrest and resuscitation.

Creatine kinase (CK-BB) determination in cerebrospinal fluid after acute experimental head injury

Early changes of the activity of enzymes such as creatine kinase in the cerebrospinal fluid (CSF) or serum are often investigated after head injuries to assess the extent of brain damage and establish a reliable prognosis. The purpose of the present study was to determine levels of creatine kinase isoenzyme CK-BB in the CSF of rats after experimental head injuries. External head injuries of different severity were inflicted on rats, immediately after which CSF was collected for isoenzyme activity determination. It was found that the levels of CK-BB were significantly elevated immediately after the head injury and that the greater the degree of external cranial injury inflicted, the higher the isoenzyme activity was. The results seem to provide evidence that CK-BB activity is an early indicator of brain damage and that its level may reflect the extent of cerebral damage involved.

Creatine kinase BB release into cerebrospinal fluid after lateral ventricle cannulation

Creatine kinase (CK) and creatine kinase BB isoenzyme (CK-BB) activities were measured in ventricular CSF obtained by lateral ventricle cannulation in patients suspected of normal pressure hydrocephalus. Lateral ventricle cannulation resulted in highly and variably elevated CK and CK-BB levels. The results emphasise the interference of these CK and CK-BB elevations in studies on the prognostic value of CSF CK and CK-BB levels in head trauma patients with respect to outcome.

Nitrous oxide and cerebrospinal fluid markers of ischaemia following cardiopulmonary bypass

Twenty patients with good ventricular function undergoing coronary artery bypass surgery were studied to determine whether the pre-bypass use of nitrous oxide resulted in any differences in cerebrospinal fluid markers indicative of cerebral ischaemia. All patients were anaesthetised with diazepam, fentanyl and pancuronium, after which ten patients received 50-60% nitrous oxide in oxygen until commencement of bypass, and the remaining patients 100% oxygen. Because of the known effect of nitrous oxide in expanding gaseous bubbles, any neurological dysfunction of gaseous microembolic origin may be worsened in the presence of nitrous oxide. Patients were lumbar punctured 24 hours after cardiopulmonary bypass and cerebrospinal fluid analysed for the following markers of central nervous system ischaemia: creatine kinase, lactate, total protein, noradrenaline, adrenaline and adenylate kinase. There was a statistically significant difference in cerebrospinal fluid lactate between the two groups. There were no statistically significant differences in the other cerebrospinal fluid markers of ischaemia.

Temporal pattern of enzyme changes in cerebrospinal fluid in patients with neurologic complications after open heart surgery

We serially measured creatine kinase (CK), lactate dehydrogenase, aspartate aminotransferase (AST) and lactate from the lumbar cerebrospinal fluid in 14 patients with neurologic complications after open heart surgery with cardiopulmonary bypass (CPB). These analyses revealed a correlation between worsening neurologic deficit and the peak CK (r = .87, p less than .001), AST (r = .75, p less than .01), and lactate (r = .93, p less than .001) levels. Lactate increased before enzymes did. In 12 patients without complications, only lactate was significantly (p less than .005) elevated; however, within this group, CK but not lactate could be used to differentiate patients who later developed subtle mental changes. Although CPB appeared to induce metabolic changes in the brain that could possibly disturb function, severe cerebral damage appeared to require additional global or focal anoxic-ischemic factors. Short hypothermia during bypass did not influence CK, but it was falsely elevated after prolonged hypothermic periods. The testing of these enzymes may be a reliable indicator of the degree of brain damage and the prognosis.

The neurologic sequelae of cardiac arrest

This discussion was selected from the weekly Grand Rounds in the Department of Medicine, University of Washington School of Medicine, Seattle. Taken from a transcription, it has been edited by Drs Paul G. Ramsey, Associate Professor of Medicine, and Philip J. Fialkow, Professor and Chair of the Department of Medicine.