[CNS tumors with the clinical picture of meningitis]

Incidentally CNS tumours may simulate acute bacterial or viral meningitis, cerebral abscess, and tuberculous or luetic basal meningitis. 64 cases from the literature are analysed together with 2 personal observations. This form of presentation is found most frequently in high-grade malignancy, i.e. in glioblastoma, medulloblastoma and ependymoma. In the group of benign CNS neoplasms dermoid and epidermoid cysts are most often associated with the meningeal syndrome. The only criterion facilitating a differentiation between acute bacterial meningitis and CNS malignancy is CSF culture. In individual cases an afebrile course, a normal sedimentation rate, and a normal WBC count may help to differentiate. In the presence of basal meningitic or diencephalic symptoms related to a prolonged course discrimination between brain tumour an tuberculous or luetic meningitis may become extremely difficult. In these cases the determination of creatine kinase BB isoenzyme and carcinoembryonic antigen in CSF may overcome the difficulty.

The significance of total creatine kinase activity and isozyme determinations in cerebrospinal fluid of neurological patients

Total CK activity is often increased in cerebrospinal fluid samples in neurological diseases (35%). These increased levels are frequently caused by CK M-chain activity and appear to have no diagnostic relevance. Furthermore, an obvious concentration gradient for total CK activity was often observed in two subsequent tubes from the same lumbar puncture. In this study, CK non-M activity is measured, being the sum of all CK activity not caused by the M-chain. A bioluminescence technique using anti-M-inhibiting antibodies was used for this purpose. In two subsequent tubes from the same lumbar puncture a difference of 8% in CK non-M activity was found. A similar gradient could be observed for total protein. Retrospectively, the correlation between CK non-M levels and the amount of brain tissue damage was studied in 81 neurological patients and in 19 healthy subjects. There was an obvious relation between the extent of brain tissue damage and the CSF CK non-M levels. The clinical results in this study are promising and justify a prospective study of the diagnostic relevance of this parameter in CSF in various patient groups.

Creatine kinase isoenzymes in human cerebrospinal fluid and brain

Extracts of normal brains obtained at autopsy and cerebrospinal fluid (CSF) from patients with global brain ischemia were analyzed for creatine kinase (CK; EC 2.7.3.2) isoenzymes. We used both qualitative and quantitative assays (electrophoresis and immunoinhibition). Brain extracts contained CK-BB isoenzyme and mitochondrial CK. In 54 CSF samples free of blood contamination and with total activities ranging from 7 to 2010 U/L (mean 202 U/L), virtually all of the CK activity was due to CK-BB, and none to CK-MM or CK-MB. We conclude that brain contains CK-BB and mitochondrial CK, but lacks CK-MM and CK-MB. After cardiac arrest, CK-BB is released into the CSF. Any CK-MM in the CSF is probably from blood contamination, in which case immunoinhibition with anti-CK-M antibodies accurately quantifies CK-BB.

The prognosis of patients with concussion and increased creatine kinase BB in the cerebrospinal fluid

In a series of 93 emergency patients, 58 were classified as concussions on a clinical basis. Thirteen of the patients with concussion had increased levels of creatine kinase isoenzyme BB (CK-BB) in their cerebrospinal fluid (CSF). We performed a prospective, follow-up investigation comparing 10 patients with a CK-BB increase and 10 patients without a CK-BB increase after concussion. Within 24 hours, at 6 months and 3 years after concussion, each patient was subject to a special interview to obtain pre-concussional baseline data and post-concussional follow-up data concerning their complaints and capacity for daily activities. We found a definite change towards increasing disability in 8 of the 10 patients with a raised CK-BB, and in only 1 of the 10 patients with normal levels of CK-BB. A careful neuropsychological examination confirmed inferior performance in tests especially sensitive to brain injury in patients with a CK-BB increase. Our results suggest that increased levels of CK-BB after concussion signify a more severe injury which is not found in the clinical examination during the first days after the accident, and that these patients are a high-risk group for the development of post-concussional problems and symptoms.

Cerebrospinal fluid creatine kinase activity and neurologic recovery after cardiac arrest

We evaluated prospectively the relation between cerebrospinal fluid creatine kinase activity (CSF CK) and neurologic recovery after out-of-hospital cardiac arrest. Without knowledge of the enzyme results, we determined whether patients awoke, followed commands, or had comprehensible speech. CSF CK was significantly higher in never-awakening than in awakening patients. After cardiac arrest, elevation of CSF CK predicts poor neurologic recovery.

Changes in cerebrospinal fluid enzyme activity after severe head injury. Diagnostic and prognostic values

We studied CSF CK and LDH isoenzyme activities in 27 patients with severe head injury and in 10 patients with chronic hydrocephalus not related to trauma. CSF enzymes showed an increased activity immediately after trauma, contrasting with the low values measured in the patients with hydrocephalus. In severe head injury, we found a correlation between enzyme release and brain dysfunction assessed according to two methods: the Glasgow coma scale (GCS), and the Liège coma scale (LCS) which uses elements of the GCS and the study of 5 brain stem reflexes. The correlation between enzyme activity and the Liège coma scores is better than that observed with the Glasgow coma scores. High enzyme activity is associated with a bad outcome at six months. It has a prognostic value on so far as it reflects the severity of traumatic structural brain damage.

The effect of methylprednisolone pre-treatment on brain damage in dogs during cardiopulmonary bypass. A double blind study

Brain damage remains a significant cause of post-operative morbidity following open-heart surgical procedures. Though cerebral ischaemia and micro-embolic damage are considered the main causative factors, further understanding of this particular clinical problem has been hampered by the lack of an acceptably sensitive experimental model. Recent development of a biochemical marker model using cerebrospinal fluid levels of creatine kinase enzyme and its B brain specific isoenzyme have been used in the present study designed to investigate the effect of corticosteroid pre-treatment of dogs submitted to 60 minutes of normothermic cardiopulmonary bypass. Identical vials containing methylprednisolone 30 mg/kg body weight or placebo were administered intravenously to the dog before the period of bypass was begun. The cisterna magna was cannulated in order to obtain appropriate cerebrospinal fluid samples. The results indicate a rise in the enzyme and isoenzyme levels in cerebrospinal fluid during the period of perfusion for both total creatine kinase enzyme and its B isoenzyme. Analysis of the results following completion of the study indicated that the levels of enzyme and isoenzyme rise in the steroid treated group were always lower than the levels obtained in the group receiving placebo. Though this difference was consistent it did not achieve statistical significance. Analysis of the distribution of the rise in enzyme levels in the individual dogs in the two groups suggested, however, that the group of dogs receiving methylprednisolone were possibly protected from excessive degrees of enzyme release indicating a possible protective effect of steroid pre-treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

First clinical trial with iohexol in myelography

This is a report of the first clinical trial with iohexol in lumbar myelography. The investigation was carried out as an open, non-comparative study in 30 patients and was part of a multicentre trial. Iohexol doses of 10 to 15 ml (180 mg I/ml) were used and clinical and laboratory tests were performed before and during 48 h after myelography. Spinal repuncture 6 or 24 h after myelography was done in all patients. Only minor side effects of temporary duration were recorded in 8 patients. No seizures or spikes on EEG were seen. There was no significant increase in CSF parameters such as white cell counts, protein or IgG.

Creatine kinase isoenzyme BB in cerebrospinal fluid from patients with meningitis and encephalitis

High CK BB isoenzyme activity has been demonstrated in the CSF of many patients with various neurologic disorders and is considered to reflect brain tissue damage [1, 2]. Increased CK BB activity in the CSF has been described in a patient with fatal pneumonococcal meningitis [3] and also in two patients with viral encephalitis [1]. Since routine laboratory tests are of limited value for assessing the prognosis of patients with CNS infections, the present investigation was undertaken to study the possibility of early detection of brain tissue damage in such patients by determining the CK BB activity in the CSF. The CK BB activity in the control subjects was less than or equal to 10 nkat/liter, which is in accordance with a previous study based on bioluminescence assay [2]. Six of the seven patients with neurologic complications in the present study had marked increases of the CK BB activity. In the patient with brain death due to HSV infection, serial measurements of the CK BB activity in the CSF have shown a maximal fourfold increase from the value of 45 nkat/liter found on admission. In one of the patients with purulent meningitis who developed a slight hydrocephalus, the CK BB activity was normal, but no focal brain damage was found by computed tomography in this case. The results indicate that increased CK BB activity in the CSF is related to the clinical outcome of patients with infections of the CNS. Thus, the determination of the CK BB activity seems to be useful for assessing the prognosis of patients with bacterial and viral meningitis and encephalitis.

Creatine kinase isoenzymes in severe head injury

Brain-type creatine kinase (CK) isoenzyme (CK-BB) was found in the ventricular cerebrospinal fluid (CSF) and the serum in a series of 35 patients within 13 hours following severe head injury. There was a good correlation between total CK and CK-BB activities in CSF only. The values found in the CSF appear to be a quantitative index of brain dysfunction at admission, and did not correlate with intracranial pressure activity. High levels of CK-BB in the CSF correlated with a poor outcome, and thus offer a reliable criterion for the assessment of the severity of head injury.

Creatine kinase BB isoenzyme in CSF in neurologic diseases. Measurement by radioimmunoassay

The concentration of creatine kinase BB isoenzyme (CK BB) was measured by radioimmunoassay in CSF from 306 patients with various neurologic disorders. Levels above 2.0 ng/mL were not found in patients without neurologic disease. Whereas mean CSF CK BB level was less than 2.0 ng/mL in groups of patients with systemic malignant neoplasms, latent syphilis, peripheral neuropathy, disk disease, polyradiculopathy, myelopathy, multiple sclerosis, neurodegenerative disease, encephalopathy, and hydrocephalus, it was elevated in groups of patients with convulsive disorder, CNS neoplasm, cerebrovascular disease, vasculitis, and meningoencephalitis.

CSF enzymes in lacunar and cortical stroke

Cerebrospinal fluid enzyme levels of creatine kinase (CK), lactate dehydrogenase (LDH), glutamate oxaloacetate transaminase (GOT) and angiotensin converting enzyme (ACE) were studied in 40 acute stroke patients comprising 20 lacunar strokes and 20 cortical strokes. A marked elevation of at least one of the enzymes CK, GOT or LDH was seen in 80% of cases of cortical strokes. No elevation was seen in lacunar stroke with CK, GOT or ACE and only a slight elevation with LDH. Within the cortical group, there was a correlation between the site, size of infarction seen on CT scan and enzyme level. These findings may help to explain the previously noted unpredictability of rises in CSF enzymes in stroke patients. In certain instances, a study of CSF enzymes may be of use to distinguish cortical from lacunar stroke. A precise diagnosis of lacunar infarction is important for management purposes, entry into stroke treatment trials or description of new syndrome types.

Cerebral damage following open-heart surgery in deep hypothermia and circulatory arrest

Six patients undergoing aortic arch replacement during deep hypothermia and circulatory arrest were subjected to studies including serial determinations of total creatine kinase (CK) activity in the cerebrospinal fluid (CSF), monitoring of the intracranial epidural pressure and the cerebral perfusion pressure and clinical neurological evaluation. In two of four patients with postoperative pressure monitoring, a marked increase in pressure was seen. In one case this pressure rise terminated in brain tamponade six days postoperatively, despite aggressive treatment with steroids, mannitol and barbiturate. In comparison with patients undergoing surgery for valve replacement or aorto-coronary by-pass, some of the patients with aortic arch replacement clearly sustained more severe cerebral damage, as judged by clinical examination and autopsy findings as well as by assessment of the degree or extent of the neuronal damage from CK activity in CSF. Patients of this type are obvious candidates for postoperative neuro-intensive monitoring and care. Repeated pulsed Doppler flow velocity determinations in precerebral arteries, performed bedside, combined with monitoring of the cerebral perfusion pressure, provide a useful indication of the cerebral circulatory state in such situations.

Total creatine kinase activity in cerebrospinal fluid as an indicator of brain damage during open-heart surgery

In a selected series of 33 patients undergoing open-heart surgery, the creatine kinase (CK) activity in cerebrospinal fluid (CSF) was compared with the clinical results in regard to the central nervous system. The level of CK activity in CSF showed correlation with the degree of irreversible neuronal damage. Determination of CK in CSF may thus be of prognostic value in these patients. Caution is essential, however, in the setting of strict limits above which return to normal or acceptable quality of life is not to be expected.

Cerebrospinal fluid prognostic indices in experimental pneumococcal meningitis

The prognostic value of initial and sequential determinations of quantitative bacterial concentrations, leukocytes, glucose, lactate, lactic acid dehydrogenase, and creatine phosphokinase in CSF was examined in rabbits with experimental pneumococcal meningitis while they were receiving equivalent, rapidly bactericidal antibiotic therapy. The following mean CSF variables correlated with death due to meningitis: (1) an early (day 1) high bacterial titer and lactate concentration with simultaneous low leukocyte count and glucose level and (2) late (day 3) elevated lactate and lactic acid dehydrogenase levels and leukocyte count. A high concentration of bacteria inoculated into the CSF and a high plasma glucose level also adversely influenced prognosis. Careful analysis of these variables may identify high-risk patients with pneumococcal meningitis and ultimately may be useful in gauging the therapeutic response.

Bioluminescent assay of total and brain-specific creatine kinase activity in cerebrospinal fluid

A bioluminescent assay based on the firefly luciferase reaction has been used for determination of creatine kinase activity in CSF. Activities as low as 0.1 U/L can be measured. The coefficient of variation at an activity level of 0.3-0.4 U/L was between 5 and 6%. The assay conditions optimized for serum specimens can be used for CSF. The adenylate kinase activity is almost completely inhibited, which simplifies the procedure. The creatine kinase/(CK) isoenzyme distribution was obtained using the bioluminescent assay in combination with immunoinhibition or ion exchange chromatography. All specimens contained both MM and BB activity, but no MB was found. The study indicates that the bioluminescent assay is useful in the determination of CK isoenzymes in CSF. The clinical importance of the observed CK levels will be reported in a separate communication.

Biochemical constituents of cerebrospinal fluid in premature and full term foals

Total protein content and a variety of enzyme activities and electrolyte values were determined in 73 cerebrospinal fluid (CSF) samples from 66 horses and ponies. The foals (48) were divided into 3 categories-spontaneously delivered normal foals (Group A), full term induced normal foals (Group B) and premature induced non-surviving foals (Group C). CSF samples from a group of 18 normal adults (Group D) were included for comparison. Paired serum and CSF samples were collected on 32 occasions and subjected to similar analyses. CSF sodium and chloride were always higher than serum sodium and chloride; the reverse occurred with potassium. The CSF protein and enzyme levels were always lower than corresponding serum values. The foals had higher total protein and creatine kinase in CSF than the adults, except for Group C (non-survivors) which had significantly lower creatine kinase than either of the other 2 foal groups. Creatine kinase values tended to fall towards adult levels over 40 h post partum. It was also noted that foals with both high total protein and creatine kinase in CSF, compared with adult values, had a better chance of survival than those with high total protein but low creatine kinase.

Optimized bioluminescence assay of creatine kinase and creatine kinase B-subunit activity

Spectrophotometry of CK-B subunit activity based on immunoinhibition is rapid and convenient. However, the low sensitivity limits clinical applications to serum samples with CK-B activities considerably above normal. A sensitive, but not optimized, bioluminescent assay of CK-B, also based on immunoinhibition, has been described. We improved this method by the use of an ADP concentration saturating the CK reaction and by the combined use of AMP and diadenosine pentaphosphate for inhibition of adenylate kinase. The optimized bioluminescent method is similar to the corresponding spectrophotometric method (reaction conditions, analytical procedure, numerical results, etc.) and results by the two methods correlate well. However, the measuring time is shorter and, more important, the sensitivity of the bioluminescent method allows accurate determinations of CK-B, even in serum from healthy individuals (CV approximately 3%). Kits and instrumentation (manual and automatic) for determination of CK and CK-B are now commercially available.

The diagnostic value of measuring creatine kinase BB activity in cerebrospinal fluid following acute head injury

During a period of 2 months the activity of creatine kinase BB (CK-BB) was measured in the cerebrospinal fluid (CSF) from 93 consecutive patients admitted as emergencies to the Neurosurgical Department. Fourteen of the 15 patients with verified brain contusion showed an increased activity of CK-BB in the CSF whereas all patients with various other acute neurological disorders, such as epilepsy and acute headache, had a normal CK-BB activity. Two of 5 patients with subarachnoidal haemorrhage and 13 of 58 patients classified as concussion also showed an increased CK-BB activity. Spinal fluid pressure, number of red cells and activity of CK (total) were less useful than CK-BB in diagnosing acute brain damage. Even diagnostic ventricular puncture with a Fisher cannula, producing a tiny (diameter = 2.8 mm) brain lesion, gave rise to an increased CK-BB activity. CSF sampled repeatedly from 10 other patients with brain contusion showed CK-BB activities that suggest the optimum period for sampling to be between one and 15 hours after head injury. The results obtained suggest that CK-BB is a reliable indicator of brain damage following head injury.

Levels of enolase and other enzymes in the cerebrospinal fluid as indices of pathological change

The activities of enolase, aldolase, pyruvate kinase, lactate dehydrogenase and creatine phosphokinase were measured in cerebrospinal fluid of 121 patients presenting with a range of disorders of the central nervous system. The results from 41 patients undergoing myelography were used as controls. An assessment was made of the relative merits of these five enzymes as markers of brain damage with special reference to brain tumours. Enolase was the most sensitive marker of pathological change and was the only enzyme raised in the CSF of patients with low grade astrocytomas.