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Kevci R, Lewén A, Ronne-Engström E, Velle F, Enblad P, Svedung Wettervik T. Lumbar puncture-verified subarachnoid hemorrhage: bleeding sources, need of radiological examination, and functional recovery. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05640-4. [PMID: 37227503 DOI: 10.1007/s00701-023-05640-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/15/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The primary aim was to determine the diagnostic yield of vascular work-up, the clinical course during neurointensive care (NIC), and rate of functional recovery for patients with computed tomography (CT)-negative, lumbar puncture (LP)-verified SAH. METHODS In this retrospective study, 1280 patients with spontaneous SAH, treated at our NIC unit, Uppsala University Hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiological examinations (CT angiography (CTA) and digital subtraction angiography (DSA)), treatments, and functional outcome (GOS-E) at 12 months were evaluated. RESULTS Eighty (6%) out of 1280 SAH patients were computed tomography (CT)-negative, LP-verified cases. Time between ictus and diagnosis was longer for the LP-verified SAH cohort in comparison to the CT-positive patients (median 3 vs 0 days, p < 0.001). One fifth of the LP-verified SAH patients exhibited an underlying vascular pathology (aneurysm/AVM), which was significantly less common than for the CT-verified SAH cohort (19% vs. 76%, p < 0.001). The CTA- and DSA-findings were consistent in all of the LP-verified cases. The LP-verified SAH patients exhibited a lower rate of delayed ischemic neurological deficits, but no difference in rebleeding rate, compared to the CT-verified cohort. At 1-year post-ictus, 89% of the LP-verified SAH patients had recovered favorably, but 45% of the cases did not reach good recovery. Having an underlying vascular pathology and an external ventricular drainage were associated with worse functional recovery (p = 0.02) in this cohort. CONCLUSIONS LP-verified SAH constituted a small proportion of the entire SAH population. Having an underlying vascular pathology was less frequent in this cohort, but still occurred in one out of five patients. Despite the small initial bleeding in the LP-verified cohort, many of these patients did not reach good recovery at 1 year, this calls for more attentive follow-up and rehabilitation in this cohort.
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Affiliation(s)
- Rozerin Kevci
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Fartein Velle
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden.
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Clarin M, Petersson A, Zetterberg H, Ekblom K. Detection of subarachnoid haemorrhage with spectrophotometry of cerebrospinal fluid - a comparison of two methods. Clin Chem Lab Med 2022; 60:1053-1057. [PMID: 35420000 DOI: 10.1515/cclm-2021-1320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/30/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Spectrophotometric absorption curve analysis of cerebrospinal fluid (CSF) for oxyhaemoglobin and bilirubin is necessary to accurately diagnose subarachnoid haemorrhage (SAH) in patients with typical symptoms but with negative findings on X-ray examinations. In this study, we evaluated the performance of two methods for interpreting absorption curves; one method from the United Kingdom National External Quality Assessment Service (UK-NEQAS) and the other from the national quality assurance programme in Sweden (Equalis). METHODS Consecutive absorbance curves (n=336) were interpreted with two different methods, and their performance was compared to the diagnosis as stated in the patient records. RESULTS The UK-NEQAS method displayed equal sensitivity to the Equalis method, but the specificity of the UK-NEQAS method was significantly higher than the Equalis method resulting in fewer false positive results. For UK-NEQAS, a positive predictive value (PPV) of 84.6% and a negative predictive value (NPV) of 99.7% were observed, whereas the Equalis method had a PPV of 27.5% and an NPV of 99.7%. CONCLUSIONS The semi-automated method based on the guidelines from UK-NEQAS provides an efficient and correct interpretation of absorbance curves with short turn-around times. We propose using this method for the routine interpretation of CSF spectrophotometric curves.
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Affiliation(s)
- Marcus Clarin
- Clinical Chemistry and Transfusion Medicine, Växjö Central Hospital, Växjö, Sweden
| | - Annika Petersson
- Clinical Chemistry and Transfusion Medicine, Växjö Central Hospital, Växjö, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Kim Ekblom
- Department of Research and Development, Region Kronoberg, Växjö, Sweden.,Department of Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden
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China M, Matloob SA, Grieve JP, Toma AK. The value of repeated lumbar puncture to test for xanthochromia, in patients with clinical suspicion of subarachnoid haemorrhage, with CT-negative and initial traumatic tap. Br J Neurosurg 2021; 35:476-479. [PMID: 33527849 DOI: 10.1080/02688697.2021.1875398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES For the diagnosis of subarachnoid haemorrhage (SAH), the presence of cerebrospinal fluid (CSF) xanthochromia is still considered the gold standard for patients with a thunderclap headache, in the absence of blood on brain CT scan. However, a traumatic lumbar puncture (LP) typically results in high concentrations of oxyhaemoglobin in CSF, impairing the detection of xanthochromia and preventing the reliable exclusion of SAH. In this context, the value of a repeat lumbar puncture has not yet been described. MATERIALS AND METHODS A retrospective case series of suspected SAH patients, with a negative CT scan and initial traumatic LP, managed with a repeat LP to assess for CSF xanthochromia. Clinical notes, laboratory and imaging results were reviewed. RESULTS Between August 2011 and January 2020, 31 patients with suspected SAH were referred to our neurosurgical unit following negative CT and traumatic LP. A repeat LP was performed in 7 of the 31 patients, 2.4 days (±0.79 SD) after the first traumatic LP. CSF spectrophotometry analysis from repeated LP in all 7 patients was negative for xanthochromia. No adverse clinical events were recorded on average 18 months following discharge. CONCLUSION A repeat LP performed following a traumatic tap can still yield xanthochromia-negative CSF, thereby, excluding SAH, avoiding unnecessary invasive angiography and overall promoting the safer management of these patients.
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Affiliation(s)
- Musa China
- Department of Medicine, University College London (UCL) Medical School, London, UK
| | - Samir A Matloob
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Joan P Grieve
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
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Siu WY, Thomas W, Trivedi R, Hogan A, Siddiqi U, Sarker A, Besser MW. Can CSF spectrophotometry for "Xanthochromia" be used to detect leaking subarachnoid aneurysms in patients with sickle cell anemia with negative MRI or CT angiogram despite hyperbilirubinemia? Clin Case Rep 2020; 8:894-899. [PMID: 32477541 PMCID: PMC7250967 DOI: 10.1002/ccr3.2775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/27/2020] [Accepted: 02/05/2020] [Indexed: 11/16/2022] Open
Abstract
CSF (Cerebrospinal Fluid) xanthochromia by spectroscopy should not be dismissed in the context of hyperbilirubinemia in a patient with sickle cell anemia. Xanthochromia detected by spectrophotometry offers a vital clue that further invasive diagnosis is required.
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Affiliation(s)
- Wan Yung Siu
- Department of HaematologyAddenbrooke's HospitalCambridgeUK
| | - William Thomas
- Department of HaematologyAddenbrooke's HospitalCambridgeUK
| | - Rikin Trivedi
- Department of NeurosurgeryAddenbrooke's HospitalCambridgeUK
| | - Alexandra Hogan
- Department of AnaestheticsAddenbrooke's HospitalCambridgeUK
- Cognitive Neuroscience & PsychiatryUCL Great Ormond Street Institute of Child HealthLondonUK
| | | | - Anita Sarker
- Department of BiochemistryAddenbrooke's HospitalCambridgeUK
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Rodríguez CE. New method for the determination of the net bilirubin absorbance in cerebrospinal fluid that minimizes the interference of oxyhaemoglobin and biliverdin. Scandinavian Journal of Clinical and Laboratory Investigation 2019; 80:81-86. [PMID: 31738583 DOI: 10.1080/00365513.2019.1692367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The presence of oxyhaemoglobin and biliverdin interferes with the method recommended by the UK NEQAS Specialist Advisory group for EQA of CSF Proteins and Biochemistry for estimating of the net bilirubin absorbance in CSF. This is easily demonstrated by using solutions with different concentrations of these three substances.The two secondary peaks of the oxyhaemoglobin spectrum at 540 nm and 577 nm are used as reference to minimize these interferences. Those peaks have the same absorbance as at 456 nm in the oxyhaemoglobin spectrum, independent of its concentration. This wavelength is very close to the maximum absorption of bilirubin and, therefore, is suitable for estimating the net bilirubin absorbance.A preliminary study with 48 spectrophotometric analyses of CSF from patients who were suspected of having subarachnoid haemorrhage were used to compare both net bilirubin absorbance estimation methods.The new method is practically free of oxyhaemoglobin and biliverdin interference. This allows for higher sensitivity and a more realistic estimation of the bilirubin concentration in a sample.A better estimation of the bilirubin concentration can have special relevance for diminishing the amount of equivocal or inconclusive cases and also to improve the prematurity of the diagnosis.
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Affiliation(s)
- Carlos Emilio Rodríguez
- Department of Clinical Chemistry and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Bittermann S, Schild C, Marti E, Mirkovitch J, Schweizer D, Henke D. Analysis of blood degradation products and ferritin in the cerebrospinal fluid of dogs with acute thoracolumbar intervertebral disk extrusion, a prospective pilot study. BMC Vet Res 2019; 15:148. [PMID: 31088486 PMCID: PMC6518634 DOI: 10.1186/s12917-019-1878-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/23/2019] [Indexed: 11/23/2022] Open
Abstract
Background Hemorrhage in the spinal canal leads to further damage of the spinal cord influencing outcome in dogs with intervertebral disk (IVD) extrusion. The aim of the study was to evaluate blood degradation products and ferritin in the cerebrospinal fluid (CSF) of dogs with thoracolumbar IVD extrusion, and their association to clinical parameters and MRI findings. Results In the CSF of dogs with IVD extrusion, both net oxyhemoglobin absorption (NOA) and net bilirubin absorption (NBA) were significantly higher compared to the control groups of dogs with steroid responsive meningitis arteritis (SRMA) and idiopathic epilepsy (IE) (P < 0.001), but NOA compared to the idiopathic epilepsy group contaminated artificially with blood (IEc) was not (P = 0.890). Ferritin concentration was significantly higher in dogs with IVD extrusion compared to dogs with IE (P = 0.034), but not to dogs with SRMA (P = 0.526). There was no association between NOA, NBA or ferritin concentration and severity or duration of clinical signs. In dogs with a higher ferritin concentration the outcome was better (P = 0.018). In dogs with evidence of hemorrhage on MRI, NOA and NBA were significantly higher (P = 0.016, P = 0.009), but not ferritin (P = 0.0628). Conclusion and clinical importance Quantification of blood degradation products and ferritin in the CSF of dogs to assess subarachnoidal hemorrhage is feasible; however, larger case numbers are needed to evaluate the relevance of NBA and ferritin as prognostic indicators.
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Affiliation(s)
- Sophie Bittermann
- Division of Neurological Sciences, Division of Clinical Veterinary Neurology, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland.
| | - Christof Schild
- Institute of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, INO-F3010, Bern, Switzerland
| | - Eliane Marti
- Department of Clinical Research and Veterinary Public Health, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland
| | - Jelena Mirkovitch
- Department of Clinical Research and Veterinary Public Health, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland
| | - Daniela Schweizer
- Division of Neurological Sciences, Division of Veterinary Radiology, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland
| | - Diana Henke
- Division of Neurological Sciences, Division of Clinical Veterinary Neurology, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Laenggassstrasse 128, 3012, Bern, Switzerland
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Ruptured aneurysmal subarachnoid hemorrhage in the emergency department: Clinical outcome of patients having a lumbar puncture for red blood cell count, visual and spectrophotometric xanthochromia after a negative computed tomography. Clin Biochem 2015; 48:634-9. [DOI: 10.1016/j.clinbiochem.2015.03.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 11/17/2022]
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Chu KH, Bishop RO, Brown AFT. Spectrophotometry, not visual inspection for the detection of xanthochromia in suspected subarachnoid haemorrhage: A debate. Emerg Med Australas 2015; 27:267-72. [DOI: 10.1111/1742-6723.12398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Kevin H Chu
- School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Emergency Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Roderick O Bishop
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Department of Emergency Medicine; Nepean Hospital; Sydney New South Wales Australia
| | - Anthony FT Brown
- School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Emergency Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
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Perry JJ, Alyahya B, Sivilotti MLA, Bullard MJ, Émond M, Sutherland J, Worster A, Hohl C, Lee JS, Eisenhauer MA, Pauls M, Lesiuk H, Wells GA, Stiell IG. Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study. BMJ 2015; 350:h568. [PMID: 25694274 PMCID: PMC4353280 DOI: 10.1136/bmj.h568] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture. DESIGN A substudy of a prospective multicenter cohort study. SETTING 12 Canadian academic emergency departments, from November 2000 to December 2009. PARTICIPANTS Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage. MAIN OUTCOME MEASURE Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death. RESULTS Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1 × 10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000 × 10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%). CONCLUSION No xanthochromia and red blood cell count <2000 × 10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.
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Affiliation(s)
- Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa Hospital 1053 Carling Avenue Room F647, Ottawa, ON, Canada, K1Y 4E9
| | - Bader Alyahya
- Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa Hospital 1053 Carling Avenue Room F647, Ottawa, ON, Canada, K1Y 4E9
| | | | - Michael J Bullard
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marcel Émond
- Hopital de l'Enfant-Jesus, Department of Emergency Medicine, Faculty of Medicine, Quebec City, QC, Canada G1J 1Z4
| | - Jane Sutherland
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Andrew Worster
- Department of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Corinne Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jacques S Lee
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Mary A Eisenhauer
- Division of Emergency Medicine, University of Western Ontario, London, ON, Canada
| | - Merril Pauls
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Howard Lesiuk
- Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada
| | - George A Wells
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa Hospital 1053 Carling Avenue Room F647, Ottawa, ON, Canada, K1Y 4E9
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Hann A, Chu K, Greenslade J, Williams J, Brown A. Benefit of cerebrospinal fluid spectrophotometry in the assessment of CT scan negative suspected subarachnoid haemorrhage: a diagnostic accuracy study. J Clin Neurosci 2014; 22:173-9. [PMID: 25439758 DOI: 10.1016/j.jocn.2014.07.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 07/15/2014] [Indexed: 11/19/2022]
Abstract
This study aimed to determine if performing cerebrospinal fluid spectrophotometry in addition to visual inspection detects more ruptured cerebral aneurysms than performing cerebrospinal fluid visual inspection alone in patients with a normal head CT scan but suspected of suffering an aneurysmal subarachnoid haemorrhage (SAH). We performed a single-centre retrospective study of patients presenting to the emergency department of a tertiary hospital who underwent both head CT scan and lumbar puncture to exclude SAH. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of an approach utilising both spectrophotometry and visual inspection (combined approach) was compared to visual inspection alone. A total of 409 patients (mean age 37.8 years, 56.2% female) were recruited and six (1.5%) had a cerebral aneurysm on angiography. The sensitivity of visual inspection was 50% (95% confidence interval [CI]: 12.4-82.6%), specificity was 99% (95% CI: 97.5-99.7%), PPV was 42.9% (95% CI: 10.4-81.3%) and NPV was 99.2% (95% CI: 97.8-99.8%). The combined approach had a sensitivity of 100% (95% CI: 54.1-100%), specificity of 79.7% (95% CI: 75.4-83.5%), PPV of 6.8% (95% CI: 2.6-14.3%) and a NPV of 100% (95% CI: 98.8-100%). The sensitivity of the combined approach was not significantly different to that of visual inspection alone (p=0.25). Visual inspection had a significantly higher specificity than the combined approach (p<0.01). The combined approach detected more cases of aneurysmal SAH than visual inspection alone, however the difference in sensitivity was not statistically significant. Visual xanthochromia should prompt angiography because of a superior specificity and PPV. Due to its reduced sensitivity, caution should be applied when using only visual inspection of the supernatant.
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Affiliation(s)
- Angus Hann
- School of Medicine, University of Queensland, Herston, QLD, Australia; The Prince Charles Hospital, Chermside, QLD, Australia.
| | - Kevin Chu
- School of Medicine, University of Queensland, Herston, QLD, Australia; Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jaimi Greenslade
- School of Medicine, University of Queensland, Herston, QLD, Australia; Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Julian Williams
- School of Medicine, University of Queensland, Herston, QLD, Australia; Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Anthony Brown
- School of Medicine, University of Queensland, Herston, QLD, Australia; Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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Chu K, Hann A, Greenslade J, Williams J, Brown A. Spectrophotometry or Visual Inspection to Most Reliably Detect Xanthochromia in Subarachnoid Hemorrhage: Systematic Review. Ann Emerg Med 2014; 64:256-264.e5. [DOI: 10.1016/j.annemergmed.2014.01.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 12/16/2013] [Accepted: 01/24/2014] [Indexed: 02/06/2023]
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Multi-wavelength spectrophotometric analysis for detection of xanthochromia in cerebrospinal fluid and accuracy for the diagnosis of subarachnoid hemorrhage. Clin Chim Acta 2013; 424:231-6. [PMID: 23800427 DOI: 10.1016/j.cca.2013.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 06/12/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) was examined for bilirubin, an important indicator for diagnosis of subarachnoid hemorrhage (SAH). METHODS A multi-wavelength (340, 415, and 460 nm) spectrophotometric assay was developed for the quantitative measurement of bilirubin in CSF, enabling the mathematical correction for absorbance of hemoglobin and proteins. Bilirubin and hemoglobin results were correlated to HPLC and a standard colorimetric assay, respectively. A subset of samples was sent for an absorbance reading at 450 nm following baseline correction. The multi-wavelength bilirubin assay was validated on 70 patients with confirmed SAH and 70 patients with neurologic symptoms who ruled out for SAH. RESULTS The multi-wavelength spectrophometric assay demonstrated no interferences due to proteins (albumin) up to 30 g/l or oxyhemoglobin up to 260 mg/l. The assay limit of detection was 0.2 mg/l, linear to 20 mg/l, and CVs ranged from 1 to 6% at bilirubin concentrations of 0.84 and 2.1mg/l. The spectrophotometric assay correlated to HPLC and the colorimetric assay for bilirubin and hemoglobin, respectively. Results also correlated to the absorbance method (with removal of samples with high hemoglobin and proteins). The area under the ROC curve for diagnosis of SAH was 0.971 and 0.954 for the HPLC and spectrophotometric assay, respectively. At a cutoff of 0.2mg/l, the clinical specificity was 100% for both assays, and the clinical sensitivity was 94.3% and 88.6% for SAH for the HPLC and spectrophotometric asays, respectively. CONCLUSIONS The multi-wavelength spectrophotometric assay is an objective alternative to visual inspection, HPLC, and absorbance for CSF bilirubin.
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Alons IME, Verheul RJ, Ponjee GAE, Jellema K. Optimizing blood pigment analysis in cerebrospinal fluid for the diagnosis of subarachnoid haemorrhage - a practical approach. Eur J Neurol 2012; 20:193-7. [DOI: 10.1111/j.1468-1331.2012.03834.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 07/04/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | - R. J. Verheul
- Department of Clinical Chemistry, MC Haaglanden, The Hague; The Netherlands
| | - G. A. E. Ponjee
- Department of Clinical Chemistry, MC Haaglanden, The Hague; The Netherlands
| | - K. Jellema
- Department of Neurology; MC Haaglanden; The Netherlands
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Wright BLC, Lai JTF, Sinclair AJ. Cerebrospinal fluid and lumbar puncture: a practical review. J Neurol 2012; 259:1530-45. [DOI: 10.1007/s00415-012-6413-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/19/2011] [Accepted: 01/05/2012] [Indexed: 01/07/2023]
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Affiliation(s)
- P. J. Lindsberg
- Department of Neurology, Helsinki University Central Hospital, Program of Molecular Neurology, University of Helsinki, Biomedicum Helsinki, PL 700, 00029 HUS, Finland (e‐mail: )
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Muhammed O, Teubner D, Jones DN, Slavotinek JP. Retrospective audit of the investigation of patients with suspected acute subarachnoid haemorrhage. J Med Imaging Radiat Oncol 2010; 54:339-46. [PMID: 20718914 DOI: 10.1111/j.1754-9485.2010.02180.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Recommended investigational care (RIC) of emergency department (ED) patients with suspected subarachnoid haemorrhage comprises lumbar puncture (LP) to detect xanthochromia if the preceding CT scan is negative. METHODS Retrospective audit of the investigational care of 100 consecutive ED patients presenting with possible subarachnoid haemorrhage. RESULTS Of the 100 patients, 91 had negative CT, and 36 (39.6%) of these patients had an LP performed to detect xanthochromia (i.e. RIC). Fifty-five of 91 (60.4%) patients did not receive RIC. Of the 55 patients who did not receive RIC, 25 (45.5%) had a documented senior clinical decision not to perform an LP; 15 (27.3%) had no documented reason; five (9.1%) refused consent; two (3.6%) had an LP but no xanthochromia requested, one patient did not have an LP because of technical issues, six patients underwent CT angiography (CTA), and one patient underwent magnetic resonance angiography (MRA), in the absence of a LP, following a negative CT. Two patients underwent CTA following a negative xanthochromia result. Patients admitted to the emergency extended care unit had 6.85 times the odds of receiving RIC (95% CI 2.20-21.4). CONCLUSIONS Fifty-five (55) of 91 (60%) ED patients did not receive RIC. Fifteen of the 55 did not have any documented justification for not performing an LP with xanthochromia testing. Admission to an emergency extended care unit was a predictor of receiving RIC. Inappropriate use of CTA and MRA was identified. These findings have important implications for patient safety. Multifaceted strategies are required to close this evidence-practice gap.
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Affiliation(s)
- O Muhammed
- Flinders Medical Centre, Adelaide Health Service, Adelaide, Australia
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Yap CYF, Aw TC. Revisting Cerebrospinal Fluid (CSF) Examination. PROCEEDINGS OF SINGAPORE HEALTHCARE 2010. [DOI: 10.1177/201010581001900413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Routine cerebrospinal fluid (CSF) examination bears re-visiting as the body of knowledge has expanded and numerous new analytes touted as potential markers of CNS (central nervous system) diseases have emerged. Currently, visual assessment of CSF, microscopic examination for pathologic cells, and biochemical analysis for protein and glucose form the basis for routine CSF analysis. Further investigations that may be warranted include microbiology work-ups for CNS infections and immuno-detection for oligoclonal bands for multiple sclerosis. European guidelines for CSF analyses are available. CSF testing for other neurologic disorders (e.g. Parkinson's disease, Alzheimer's disease, and amyotrophic lateral sclerosis) while promising are not ready for prime time.
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Affiliation(s)
| | - Tar Choon Aw
- Department of Lab Medicine, Changi General Hospital, Singapore
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