Predicting recovery from head injury

Outcome prediction after severe head injury remains an important issue. We investigated this problem by recording seven risk factors in 40 patients with severe head injury. By applying multivariate statistical analysis to the patients' data we selected the factors of prognostic significance: degree of initial neurological damage, severely raised intracranial pressure, and age. We compared clinical and biochemical parameters for evaluating the severity of brain lesion and proposed various simple prognostic indices allowing for correct prediction in more than 85% of patients.

"Extrapolated" creatine kinase-BB isoenzyme activity in assessment of initial brain damage after severe head injury

The severity of initial brain damage is an important risk factor in determining the prognosis of head trauma. It can be assessed by assigning neurological scores or by determining the cerebrospinal fluid (CSF) activity of the isoenzyme creatine kinase-BB (CK-BB). In 10 severely head-injured patients serial CSF samples were obtained during the first 24 hours after trauma, and exponential decay of CK-BB activity with an average half-life of 4.5 hours was demonstrated. This finding led the authors to propose an "extrapolated" CK-BB activity, which theoretically occurs immediately after injury and is calculated from a single CK-BB recording, as a new index for assessing the degree of initial brain damage. In 50 patients with severe head injury, the prognostic ability of "observed" and "extrapolated" CK-BB activity was compared with two clinical scoring systems that evaluate severity of head trauma (the Glasgow and the Glasgow-Liège Coma Scales). "Extrapolated" CK-BB activity proved to be the best prognostic factor. With a CK-BB cutoff point of 330 U/liter, a true-positive rate of 79% and a true-negative rate of 73% were obtained. These results suggest the usefulness of measuring CK-BB activity in CSF as soon as possible after hospital admission for head injury.

Cerebrospinal fluid creatine kinase isoenzyme BB levels do not predict the clinical outcome in patients unconscious following cardiac resuscitation

It has recently been claimed that an increase in creatine kinase isoenzyme BB(CK-BB) in cerebrospinal fluid (CSF) is well correlated with the cerebral outcome in patients resuscitated after cardiac arrest. Twenty-one such patients consecutively admitted from outside this hospital participated in the study. The patients were divided into two groups: 6 survivors and 15 nonsurvivors. The median CSF-CK-BB value was 5 U/L among nonsurvivors and below detection limit among survivors (NS). However, the predictive value of a positive test is limited, since only 6 of 15 nonsurvivors (40%) had an increase in CSF-CK-BB (predictive value of positive test = 67%). The predictive value of a negative test is limited, since 3 of 6 survivors (50%) showed no rise in CSF-CK-BB (predictive value of negative test = 25%). No relationship between cerebral dysfunction and CSF-CK-BB values was revealed. Thus, CSF-CK-BB does not predict the clinical outcome in patients resuscitated after cardiac arrest.

The effects of acute cerebrovascular disease on serum and cerebrospinal fluid parameters

In order to evaluate the effects due to acute cerebrovascular disease on serum and cerebrospinal fluid (CSF) parameters, biochemical data from 312 patients were studied. In serum, CK, LD and alpha 1 protein fraction showed a moderately close relationship to the severity of stroke. In CSF there could not be observed any relation between enzymatic activities (LD, ASAT, CK) and the severity of the disease. The same result was found for CSF protein and the ratio CSF albumin/serum albumin, parameters which are indicative for Blood Brain Barrier (BBB) disturbances. Substances from the intermediate metabolism in the Central Nervous System (CNS) (lactate and pyruvate) were evidently raised in CSF and there was a clear relation between the CSF concentration and the severity of stroke. No indication for IgG immunoglobulin abnormalities in CSF was found. The concentration of neurotransmitter metabolite 5HIAA in CSF was significantly higher in (in)completed stroke than in Transient Ischaemic Attack.

CSF brain creatine kinase levels and lactic acidosis in severe head injury

The posttraumatic creatine kinase-BB isoenzyme (CKBB) activity and lactate concentration in ventricular cerebrospinal fluid (CSF) have been studied in 29 patients with severe head injuries. The CKBB activity reaches its maximum a few hours after trauma, and has a monoexponential drop with a half-time of approximately 10 hours. Ventricular CSF lactate concentration continues to rise in patients with a poor outcome, and decreases only slowly and inconsistently in most of the other patients. Thus, increase of lactate in the ventricular CSF is not, like CKBB, a direct one-stage consequence of the trauma but is due to continuous production from a derangement of metabolism caused by the trauma. Since even higher ventricular CSF lactate levels can be survived when not caused by head injury, and since no significant pH changes were related to the ventricular CSF lactic acidosis in these artificially ventilated patients, it is concluded that ventricular CSF lactic acidosis is indicative of a severe, although not necessarily intractable, disturbance of brain function associated with intracellular lactate production and acidosis.

Mitochondrial and MB isoenzymes of creatine kinase in cerebrospinal fluid from patients with hypoxic-ischemic brain damage

Measurements of cerebrospinal fluid (CSF) creatine kinase (CK, EC 2.7.3.2) isoenzyme activity have been used to predict outcome in patients with acute brain injury following cardiac arrest. We identified two CK isoenzymes previously unreported in CSF from 16 patients with hypoxic-ischemic brain damage. Prior to analysis, the CK in the CSF samples was reactivated with dithiothreitol. CK isoenzymes were identified using electrophoretic and immunologic methods. Total CK activity ranged from 23 to 924 U/L (mean 452). CSF-CK-BB was the predominant isoenzyme present in all cases. In addition to CSF-CK-BB, the authors identified CSF-CK-MM in 6 cases, CSF-CK-MB in 8 cases, and CSF-mitochondrial-CK in 14 cases. The presence of CSF-CK-MM was significantly related to blood contaminating the CSF (P less than 0.02). It is proposed that CSF-CK-MB results from recombination of CK-MM and CK-BB in CSF and that mitochondrial CK is released with CK-BB into the CSF from the damaged brain tissue.

Myelin basic protein and creatine kinase BB isoenzyme as CSF markers of intracranial tumors and stroke

In patients with intracranial tumors (ICT) and acute cerebral infarctions (CI), both necrosis and reversible changes occur in central nervous system (CNS) tissue. The damaged CNS cells release specific substances into the cerebrospinal fluid (CFS). Radioimmunoassay (RIA)-determined myelin basic protein (MBP) and RIA-determined creatine kinase BB (CK-BB) are markers of damage to CNS specific structures. The elevated CSF level of MBP is considered a marker of myelin damage and the increased concentration of CSF CK-BB may be of combined neuronal and astrocytic origin. CSF was collected from 57 patients with the diagnosis of CI (n = 30) and ICT (n = 27) and the concentration of MBP and CK-BB were measured by RIA. Our study shows increased CSF levels of MBP and CK-BB in patients with CI and patients with ICT. We have also found a linear correlation between MBP and CK-BB in both CI and ICT, and for a given CK-BB level, MBP was significantly higher in patients with ICT than in patients with CI. These facts suggest that lesion markers behave differently in the different pathologic processes affecting the CNS.

Enzyme level changes in the cerebrospinal fluid of patients with acute stroke

Creatine kinase (CK), brain CK (CKBB), lactate dehydrogenase (LD), and aspartate aminotransferase (ASAT) levels were determined in cerebrospinal fluid (CSF) obtained from 35 patients with acute stroke. In patients with transient, minor neurological disturbances, only LD levels increased; in those who remained comatose and died, the levels of all the enzymes, except ASAT, increased. Patients who remained with focal motor defects had increased CK and LD levels, while CKBB and ASAT levels were variable. In most of the CSF samples, muscle CK activity was also detectable, suggestive of a leakage from blood to CSF. The pattern of the enzyme increase could be related to the causative mechanisms for the strokes. The study suggests that CSF enzyme determinations may provide supplementary information as to the extent and severity of brain damage and the recovery potentials of selected patient groups with strokes.

Pathophysiology of cerebrospinal fluid in head injury: Part 2. Biochemical markers for central nervous system trauma

Many substances are released into the cerebrospinal fluid after head injury. The study of these substances and their relationship to the severity and outcome of head trauma has lead to the search for biochemical markers to aid in the quantification of the severity of the lesion and serve as a prognostic guide. The authors review the potential usefulness of biochemical markers, qualities of an ideal marker, and several potential enzymes that may be utilized as markers in central nervous system trauma.

Quantification of cerebral infarct size by creatine kinase BB isoenzyme

Creatine Kinase BB isoenzyme (CKBB) has been shown to rise in the serum and CSF following acute cerebral injury. To test the hypothesis that brain infarct size could be estimated from the appearance and disappearance of CKBB in the serum and CSF, strokes of varying size were produced in twelve mongrel dogs by silastic emboli. The rate of disappearance, Kd of CKBB (-.00732 +/- 0.001 min-1 mean +/- SE, N = 8) was determined by injecting purified CKBB (25 IU) intravenously then measuring its disappearance. Following the embolic stroke, serum samples were taken hourly for 24 hours and then at intervals for up to 160 hours for measurement of CKBB by radioimmunoassay until the animals were sacrificed. The brains were then removed, fixed in formalin, cut in 2 mm sections and photographed. The area of the infarct was measured using high pad digitizer interfaced with an Apple computer. The infarct size was then calculated from the area and thickness. Using a one-compartment mathematical model, the infarct size was estimated from the amount of CKBB appearing in the serum, the Kd of CKBB, and the amount of CKBB depleted from tissue. The computed infarct size correlated well (r = 0.94) with the measured infarct size. This model may have value in testing therapeutic modalities in the intact animal.

Cerebrospinal fluid levels of myelin basic protein and creatin kinase BB as index of active demyelination

Radioimmunoassay-determined myelin basic protein (MBP) shed to CSF during active demyelination, has been found to be a useful but non-specific test for MS. CSF creatin kinase BB (CK-BB), as measured by radioimmunoassay, is increased in a variety of neurological diseases, and has been considered a useful indication of brain damage but not of demyelinating diseases. Taking into account that the mean concentration of CSF CK-BB should not be increased in patients during the acute phase of MS, we suggest that the CSF MBP/CK-BB ratio could be a more specific index to demyelination than CSF-MBP alone. We also defined a laboratory demyelination pattern (CSF MBP greater than mean control MBP + 2 S.D. and CK-BB less than MBP). CSF levels of MBP and CSF levels of CK-BB were determined by radioimmunoassay in 232 patients with several neurological disorders and 33 control subjects. Patients diagnosed as having MS with clinical exacerbation had significantly higher values of CSF-MBP/CSF-BB ratio than control subjects. Our study showed a significant presence of demyelination pattern in CSF of patients with MS. We conclude that the CSF MBP/CK-BB ratio and the CSF demyelination pattern may be new and reliable tests for the diagnosis of MS.

Creatine kinase and its isoenzymes in neoplastic disease

The CK-BB isoenzyme is ubiquitous in neoplastic tissue, but with low activity. Accordingly, it might be a nonspecific and insensitive tumor marker. Evaluation of BB isoenzyme in serum might indicate the extent of diseases or the response to therapy. The presence of CK-MB in patients with cancers may cause confusion with AMI. Serial determinations of both CK and lactate dehydrogenase isoenzymes are of great help in differential diagnosis. The presence of mit-CK is a poor prognostic sign in patients with malignancy. The greatest clinical significance of CK-BB and macro-CK isoenzyme lies in their effect on various assays for CK-MB. Macro-CK types 1 and 2 are much more heat stable than are CK-MB and CK-BB, and so by heating samples for 20 min at 45 degrees C the presence of thermostable macro types can be demonstrated. Macro-CK type 2 has a much higher activation energy than macro-CK type 1. If macro-CK is present, determination of the activation energy easily differentiates between types 1 and 2. CK-Bi seems to be glycosylated protein, and it is thought that glycosylation may be a general way of enzyme inactivation. If inactivation inside the cell is postulated, it has to be shown that enzymes indeed pass into the cell compartments where glycosylating enzymes are located. Another possible mechanism is within the circulation. Whether malignant cells themselves produce Ck-Bi or if inactivation occurs in the blood is still unknown. In this connection, one finding is that in plasma of cancer patients, CK-Bi can be reactivated to CK-BB by mercaptoethanol to 95%, whereas in plasma of normal persons there is no reactivation of the much lower CK-Bi concentrations.

Creatine kinase BB and beta-2-microglobulin as markers of CNS metastases in patients with small-cell lung cancer

Creatine kinase (CK) and its BB isoenzyme (CK-BB) were measured in CSF in 65 evaluable patients suspected of CNS metastases secondary to small-cell lung cancer (SCLC). In addition, CSF and plasma levels of beta-2-microglobulin (beta-2-m) were measured in a group of 73 evaluable patients. Of the 65 patients analysed for CK-BB, 17 had meningeal carcinomatosis (MC), 26 had parenchymal metastases only, and 22 had no CNS disease. Patients with MC had a significantly higher CK-BB concentration in CSF than did patients belonging to the other two groups (P less than .01). Taking 0.4 U/L (upper limit in patients without CNS disease) as a cut-off point, 15 patients (88%) with MC had elevated CSF concentrations of CK-BB. Patients without CNS metastases had no CSF levels exceeding this value, whereas five patients with multiple CNS metastases did. Receiver operating characteristic (ROC) analysis suggests that CK-BB may be useful in distinguishing MC among patients suspected of having CNS metastases, and CK-BB appears superior to total CK, CSF protein, and CSF lactic dehydrogenase (LDH). In 12 patients with MC at autopsy, CK-BB was, with the above cut-off point, elevated in six patients with a false negative cytology. Of the 73 patients examined for beta-2-m, 18 had MC, 30 had parenchymatous metastases only, and 25 patients had no CNS metastases. The CSF concentrations in the three groups were not significantly different. The median concentrations in the groups were 133 nmol/L, 125 nmol/L, and 107 nmol/L, respectively. The ratios between beta-2-m in CSF and plasma were also not significantly different between the three groups. Thus, the data on CK-BB are promising, and further studies are warranted to see if the usefulness of CK-BB can be more firmly established. By contrast, beta-2-m has no role as a marker of CNS disease secondary to SCLC.

Creatine kinaseBB-activity after head trauma related to outcome

The brain-type isoenzyme of creatine kinase was determined in serum (S) and cerebrospinal fluid (CSF) in 37 patients with severe head injury, and a correlation was made with the Glasgow coma score and Glasgow outcome score. All patients with normal S-CKBB and CSF-CKBB activities had a coma score of 15, i.e., no neurological deficits, at six hours after the trauma and a good outcome. All 15 patients with a significant increase in the enzyme in serum and CSF had a coma score less than 15. The outcome was still good for five of these patients, while six were moderately disabled, two were severely disabled, and two died. There was no correlation between the individual CKBB-values and the outcome.

Highly sensitive enzyme immunoassay for human creatine kinase BB isozyme

A sensitive sandwich-type enzyme immunoassay method for measurement of brain-type isozyme of human creatine kinase (CK-BB) was developed using purified antibodies specific to the B subunit. The assay system consisted of polystyrene balls with immobilized antibody F(ab')2 fragments and the same antibody Fab' fragments labelled with beta-D-galactosidase from Escherichia coli. The assay was highly sensitive and 1 pg of CK-BB was measurable. The assay was specific to the B subunit of creatine kinase (CK-B), and it cross-reacted about 25% with CK-MB, the heart-type isozyme. However, the assay showed no cross-reactivity with CK-MM, the muscle type-isozyme or with neuron-specific gamma gamma enolase. Coefficients of variation in within-run and between-run precision studies for serum CK-B were less than 8%. Serum CK-B levels in healthy adults of various ages (16-59 yr old) ranged from 0.25-1.44 ng/ml, whereas the CK-B concentrations in children (less than 10 yr old) were relatively high, ranging from 1.3-7.4 ng/ml. The CK-B levels in the cerebrospinal fluids (CSF) could be determined by the present method, and they ranged from 0.10-0.76 ng/ml in the samples from patients with non-neuronal disorders. Determination of immunoreactive CK-B in the extracts of various human tissues confirmed previous reports that CK-B was distributed at high concentrations in the central nervous tissue, prostate, uterus, bladder, gastrointestinal tract and heart muscle.

Creatine kinase brain isoenzyme: relationship of cerebrospinal fluid concentration to the neurologic condition of newborns and cellular localization in the human brain

Immunocytochemical study of human brain showed creatine kinase brain isoenzyme (CKBB) present in both neurons and astrocytes. Because creatine kinase brain isoenzyme is an intracellular enzyme that might be released with brain injury, its concentration in the CSF of newborns was measured using a radioimmunoassay. Infants who suffered a documented neurologic insult (a cerebroventricular hemorrhage or a CNS infection) were found to have a greater mean CSF creatine kinase brain isoenzyme concentration than those without a history of neurologic insult. Infants with a high concentration had a poor short-term outcome (death or neurologic abnormality when discharged) more frequently than did those with a lower concentration. Infants with a grade 3 or 4 cerebroventricular hemorrhage had a higher mean concentration than did those with a grade 1 or 2 hemorrhage. These data are consistent with the hypothesis that CSF creatine kinase brain isoenzyme is a metabolic indicator of brain damage in newborns.

Derivation of a bioclinical prognostic index in severe head injury

We investigated the problem of outcome prediction from seven risk factors in 40 severely head injured patients - 13 favorable and 27 unfavorable outcomes. By applying stepwise logistic discriminant analysis to the patients' data, we selected three significant risk variables: cerebrospinal fluid (CSF) CK-BB isoenzyme activity recorded on admission, severely raised intracranial pressure (more than 40 mmHg) and age, respectively. CSF CK-BB activity, which quantifies the initial neurological damage, proved to be the best prognostic factor. The presence of severe intracranial hypertension was always associated with a bad outcome, whereas its absence was not necessarily indicative of good prognosis. Finally, we combined the three selected variables into a single risk index, which allowed correct predictions in 92% of patients with favorable outcome and in 85% of patients with unfavorable outcome (total predictive efficiency 88%).

[Changes in some cerebrospinal fluid enzyme activities in patients with various neurological diseases]

The authors have examined the activities of the enzymes GOT, CPT, CK, LDH, gamma-GT, PCHE and ALP in the cerebrospinal fluid of 50 patients with various neurological diseases. The results obtained show that many activities constantly and remarkably increase in few diseases of the nervous system. Particularly, GOT, GPT, LDH and ALP demonstrated raised values in the meningitis; LDH, CK, GOT, GPT in the brain tumors; CK and LDH in the hydrocephalus. A comparison between the results of the protein and enzyme determinations in the cerebrospinal fluid of the same patients, revealed in the enzymologic reactions a more precocious and sensitive indicator of initial brain lesions.