Why did we perform a lumbar puncture in a young patient with ischemic stroke?

Pleocytosis in cerebrospinal fluid attributed to ischemic stroke: A review of the literature

INTRODUCTION

Lumbar puncture is generally performed in stroke settings when infectious or inflammatory diseases are suspected to be the etiology. This review aimed to assess the prevalence of pleocytosis in the cerebrospinal fluid following ischemic stroke without inflammatory or infectious etiology.

METHODS

We searched PubMed for studies with mentions of "[ischemic stroke] AND [cerebrospinal fluid]". We included only studies written in English, including patients with a primary diagnosis of either ischemic stroke or transient ischemic attack (TIA), and where white blood cell count in the spinal fluid was presented. Studies investigating common etiologies for pleocytosis, was excluded. Study and patient characteristics, white blood cell count and time to lumbar puncture were presented in tables, and the prevalence of pleocytosis were reported and plotted graphically.

RESULTS

We included 15 studies with 1607 patients, 1522 with ischemic stroke and 85 with TIA. The prevalence of pleocytosis was between 0% to 28,6% and a mean of 11.8%. The highest white blood cell count found with common etiologies for pleocytosis ruled out was 56 cells/mm3. A mean white blood cell count of 4.0 was based on the three studies where this was available.

DISCUSSION

The included studies were methodologically heterogenous and few had pleocytosis as primary outcome. Pleocytosis following ischemic stroke is uncommon and should prompt further investigations.

Low Diagnostic Yield of Routine Cerebrospinal Fluid Analysis in Juvenile Stroke

Background: The diagnostic value of cerebrospinal fluid (CSF) analysis in juvenile stroke, i.e., stroke in young adult patients, is not well studied. We sought to determine the therapeutic impact of routine CSF-analysis in young adults with acute ischemic stroke or transient ischemic attack (TIA).

Methods: We abstracted data from patients with acute cerebral ischemia aged 18–45 years who were consecutively admitted to our stroke center between 01/2008 and 12/2015. We routinely performed CSF-analysis in patients with hitherto unknown stroke etiology after complete diagnostic work up. We assessed the frequency and underlying causes of abnormal CSF-findings and their impact on secondary stroke prevention therapy.

Results: Among 379 patients (median [IQR:IQR3-IQR1] age 39 [10:43-33] years, 48% female) with acute ischemic stroke (n = 306) or TIA (n = 73), CSF analysis was performed in 201 patients (53%). Of these, 25 patients (12.4 %) had CSF pleocytosis (leucocyte cell count ≥ 5 Mpt/L), that was rated as non-specific (e.g., traumatic lumbar puncture, reactive pleocytosis) in 22 patients. Only 3 patients (1.5% of all patients who underwent CSF-analysis) with CSF-pleocytosis had specific CSF-findings that were related to stroke etiology and affected secondary stroke prevention therapy. Imaging findings had already suggested cerebral vasculitis in two of these patients.

Conclusions: The diagnostic yield of routine CSF-analysis in juvenile stroke was remarkably low in our study. Our data suggest that CSF-analysis should only be performed if further findings raise the suspicion of cerebral vasculitis.