1
|
Zinganell A, Berek K, Bsteh G, Di Pauli F, Rass V, Helbok R, Walde J, Deisenhammer F, Hegen H. Subarachnoid haemorrhage or traumatic lumbar puncture. Differentiation by cerebrospinal fluid parameters in a multivariable approach. Sci Rep 2023; 13:22310. [PMID: 38102306 PMCID: PMC10724187 DOI: 10.1038/s41598-023-49693-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023] Open
Abstract
Lumbar puncture (LP) is recommended in patients with thunderclap headache and negative computed tomography to rule out spontaneous subarachnoid haemorrhage (SAH). Blood contamination of cerebrospinal fluid (CSF) due to traumatic LP poses a diagnostic dilemma. Therefore, routine CSF parameters were investigated to distinguish between SAH and a traumatic LP. CSF red blood cell (RBC), white blood cell (WBC) count, total protein, CSF colour and supernatant were used for group comparisons of patients with SAH and 'symptomatic controls'. Due to variable time intervals between bleeding onset and LP in SAH patients in contrast to patients with traumatic LP, where blood contamination of CSF occurs at the time of LP, CSF variables were adjusted for decay in time to allow comparability. Logistic regression analysis identified bloody CSF [odds ratio (OR) 32.6], xanthochromic supernatant [OR 15.5] and WBCadjusted [OR 4.5 (per increase of 100/µl)] as predictors of SAH, while age, sex and CSF total proteinadjusted were no predictors. Optimal cut-point of RBCadjusted (determined at day 1 after bleeding) was > 3667/µl to identify SAH patients with a 97% sensitivity and 94% specificity. Combination of low RBC and clear CSF supernatant was found in none of SAH patients. Combined CSF RBC count and CSF supernatant reliably distinguished traumatic LP from SAH.
Collapse
Affiliation(s)
- Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University, Linz, Austria
| | - Janette Walde
- Department of Statistics, Faculty of Economics and Statistics, University of Innsbruck, Innsbruck, Austria
| | - Florian Deisenhammer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| |
Collapse
|
2
|
Kameda-Smith M, Aref M, Jung Y, Ghayur H, Farrokhyar F. Determining the Diagnostic Utility of Lumbar Punctures in Computed Tomography Negative Suspected Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis. World Neurosurg 2020; 148:e27-e34. [PMID: 33285333 DOI: 10.1016/j.wneu.2020.11.152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND While headache is a common neurologic symptom, subarachnoid hemorrhage (SAH) is a rare and potentially catastrophic cause of sudden-onset severe headache. The utility of the imaging modalities and interventional procedures are central to the investigation of the causes of headache; however, they are not without their limitations, risks, and complications. METHODS A meta-analysis in accordance with the Preferred Reporting for Systematic Reviews and Meta-analysis guidelines was conducted searching PubMed, EMBASE, and Google Scholar. Patients investigated for suspected subarachnoid hemorrhage (SAH) with a negative computed tomography (CT) and positive lumbar puncture (LP) and final diagnosis of SAH were included. The sensitivity of LP in the context of a negative CT and vsubsequent imaging confirming the cause of SAH (computed tomography angiography, magnetic resonance angiography, digital subtraction angiography [DSA]) was quantified. The pooled data were analyzed using the DerSimonian-Laid random effects model. RESULTS Four studies with 2782 patients who presented with headache suspicious for SAH were included with an initial negative CT report and a subsequent LP to rule out SAH. All included studies had an observational prospective cohort design. A combined pooled proportion of 0.383 (0.077, 0.756); 0.086 (0.007, 0.238); and 0.22 (0.04, 0.49) for LP+, DSA+, and DSA/computed tomography angiography+ investigations were estimated with a 95% confidence interval. CONCLUSIONS The current clinical workflow of an LP after a negative CT head for a patient presenting with a sudden-onset severe headache is observed to have a high enough proportion to warrant its continued use despite the sensitivity of modern CT scanners of ≥97%.
Collapse
Affiliation(s)
- Michelle Kameda-Smith
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
| | - Mohammed Aref
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Youngkyung Jung
- Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Huphy Ghayur
- Health Research Methodology Program, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
3
|
Abstract
Diseases of the central nervous system that are caused by an underlying vascular pathology typically result in either hemorrhage or ischemia. Most prominent entities include spontaneous subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and ischemic stroke. For anatomic reasons, cerebrospinal fluid (CSF) qualifies as body fluid for the exploration of biomarkers in these disorders. Even though in subarachnoid hemorrhage a few CSF parameters have been established for routine diagnostic purposes, there is still an unmet need and broad interest in the identification of molecules that would allow further insight into disease mechanisms and supplement patients' medical care. This chapter provides an overview on what is presently known about CSF biomarkers in spontaneous subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and ischemic stroke. We recapitulate current evidence on established diagnostic tests, discuss the role of various CSF molecules in the pathophysiology of these diseases, and illuminate their potential use in future clinical practice. Furthermore, we address methodologic aspects as well as shortcomings of research in this field.
Collapse
Affiliation(s)
- Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Kolodziej MA, Proemmel P, Quint K, Strik HM. Cerebrospinal fluid ferritin—Unspecific and unsuitable for disease monitoring. Neurol Neurochir Pol 2014; 48:116-21. [DOI: 10.1016/j.pjnns.2013.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/02/2013] [Indexed: 11/28/2022]
|
6
|
Nagy K, Skagervik I, Tumani H, Petzold A, Wick M, Kühn HJ, Uhr M, Regeniter A, Brettschneider J, Otto M, Kraus J, Deisenhammer F, Lautner R, Blennow K, Shaw L, Zetterberg H, Mattsson N. Cerebrospinal fluid analyses for the diagnosis of subarachnoid haemorrhage and experience from a Swedish study. What method is preferable when diagnosing a subarachnoid haemorrhage? Clin Chem Lab Med 2013; 51:2073-86. [DOI: 10.1515/cclm-2012-0783] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 03/12/2013] [Indexed: 11/15/2022]
|
7
|
Beetham R, Egner W, Patel D. The UKNEQAS scheme for cerebrospinal fluid haem pigments: a paradigm for service improvement. Ann Clin Biochem 2011; 48:489-97. [DOI: 10.1258/acb.2011.011031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We describe the programme of an established External Quality Assurance (EQA) provider and a Specialist Advisory Group (SAG) to develop a successful EQA scheme for cerebrospinal fluid (CSF) haem pigments as an example of a professionally led, unfunded initiative with the real potential to benefit patients. Within three years, we had assured sample stability, stoichiometry, and published best practice guidelines, enabling both analytical results and interpretation to be assessed and reported with an educative summary of the desired responses. Misclassification scoring of analysis and interpretation was introduced. Following audit, guidelines were modified and republished. The outcomes were as follows: Participant numbers increased from 63 at inception to 150 10 years later; The percentage of participants using visual inspection, a poor practice indicator, decreased from 27% to less than 1%; In all, 94–100% of participants consistently detected minor increases in bilirubin over the last four years of the scheme; More than 93% of participants were able to interpret analytical results linked to straightforward clinical scenarios; Misclassification scoring demonstrated that more complex scenarios repeatedly posed problems and is the next challenge to address. Scheme success is attributed to the experience of the operator and the formation of a voluntary expert advisory group, with both concerned to advance science and patient safety and thus contribute unpaid time and effort in order to succeed. In times of fiscal constraint, such resource may not be so readily available, yet is a vital part of continuous quality improvement for the benefit of patients.
Collapse
Affiliation(s)
- Robert Beetham
- Formerly, Department of Clinical Biochemistry, North Bristol NHS Trust, Bristol BS16 1LE
| | - William Egner
- UKNEQAS Immunology, Immunochemistry and Allergy, Northern General Hospital, Sheffield S5 7YT, UK
| | - Dina Patel
- UKNEQAS Immunology, Immunochemistry and Allergy, Northern General Hospital, Sheffield S5 7YT, UK
| |
Collapse
|
8
|
Petzold A, Worthington V, Pritchard C, Appleby I, Kitchen N, Smith M. The longitudinal profile of bilirubin and ferritin in the cerebrospinal fluid following a subarachnoid hemorrhage: diagnostic implications. Neurocrit Care 2011; 11:398-402. [PMID: 19585277 DOI: 10.1007/s12028-009-9244-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) spectrophotometry for bilirubin is a highly sensitive test in the diagnostic work up of a suspected subarachnoid hemorrhage (SAH). CASES We report two cases suffering from an aneurysmal SAH in which extraventricular drainage for acute hydrocephalus was required. Longitudinal analyses of the CSF samples demonstrated that CSF bilirubin was detectable in all cases during the first week, becoming undetectable in one case in the second week. Importantly, CSF ferritin levels rose substantially (>1,000 ng/ml) after 6 days, peaking around 3,000 ng/ml after 2 weeks (normal upper reference range 12 ng/ml). In both cases blood was visible on the initial CT brain scan, disappearing on a later scan. CONCLUSION CSF ferritin levels may be an important additional laboratory test in the diagnostic work-up of patients with a suspected SAH. CSF ferritin levels may prove particularly helpful in cases with late presentation if the CT brain scan is normal and CSF bilirubin level is undetectable.
Collapse
Affiliation(s)
- A Petzold
- Department of Neuroimmunology, UCL Institute of Neurology and The Tavistock Intensive Care Unit, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
| | | | | | | | | | | |
Collapse
|
9
|
Petzold A, Worthington V, Appleby I, Kerr ME, Kitchen N, Smith M. Cerebrospinal fluid ferritin level, a sensitive diagnostic test in late-presenting subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2010; 20:489-93. [PMID: 20719531 DOI: 10.1016/j.jstrokecerebrovasdis.2010.02.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Revised: 01/15/2010] [Accepted: 02/05/2010] [Indexed: 10/19/2022] Open
Abstract
The workup of patients with suspected subarachnoid hemorrhage (SAH) presenting late is complicated by a loss of diagnostic sensitivity of computed tomography (CT) brain imaging and cerebrospinal fluid (CSF) bilirubin levels. In this prospective longitudinal study of CSF ferritin levels in SAH, serial CSF samples from 14 patients with aneurysmal SAH requiring extraventricular drainage (EVD) were collected. The control group comprised 44 patients presenting with headache suspicious of SAH. Nine patients underwent a traumatic spinal tap. CSF ferritin levels were significantly higher in the patients with SAH compared with controls (P < .0001). The upper reference range of CSF ferritin is 12 ng/mL, and there was no significant difference between the traumatic and normal spinal taps (mean, 9.0 ng/mL vs 3.9 ng/mL; P = .59). CSF ferritin levels increased after SAH, from an average of 65 ng/mL on day 1 to 1750 ng/mL on day 11 (P < .01). Both the Fisher and Columbia CT scores were significantly correlated with CSF ferritin level. The increase in CSF ferritin level after SAH and possibly may provide additional diagnostic information in patients with suspected SAH who present late to the clinic.
Collapse
Affiliation(s)
- Axel Petzold
- Department of Neuroimmunology, University College London Institute of Neurology, London, UK. .
| | | | | | | | | | | |
Collapse
|
10
|
Beetham R. CSF spectrophotometry for bilirubin – why and how? Scandinavian Journal of Clinical and Laboratory Investigation 2009; 69:1-7. [DOI: 10.1080/00365510802651866] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
11
|
Regeniter A, Kuhle J, Mehling M, Möller H, Wurster U, Freidank H, Siede WH. A modern approach to CSF analysis: pathophysiology, clinical application, proof of concept and laboratory reporting. Clin Neurol Neurosurg 2009; 111:313-8. [PMID: 19185983 DOI: 10.1016/j.clineuro.2008.12.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 12/10/2008] [Accepted: 12/19/2008] [Indexed: 11/29/2022]
Abstract
The CNS immune response often leads to characteristic interrelated biochemical changes in cerebrospinal fluid. Multiple analytes, i.e. cell count, cell differential, evaluation of barrier function and intrathecal IgG, IgA and IgM synthesis should be included in basic diagnostic workup. We describe the scientific background, laboratory investigations and characteristic patterns found with basic CSF analysis, based on the recommendations of the German cerebrospinal fluid society. The concept is substantiated by retrospectively analyzing data of 4026 paired CSF/serum samples. 53% of our samples presented with at least one or several combined abnormal findings. An intrathecal IgG, IgA or IgM immunoglobulin response (37%, n=1481) and a blood-CSF barrier dysfunction (37%; n=1473) were most frequent; followed by an elevated leukocyte cell count (25%; n=992). The immunoglobulin response showed an intrathecal production of IgG in 49% (n=731/1481), which was only detectable in isoelectric focusing in 27% (n=200/731). Intrathecal IgM (n=389) and IgA (n=361) synthesis presented with nearly equal frequency of 25% in samples with intrathecal immunoglobulin response. The immunoglobulin pattern showed a solitary one class reaction of IgG, IgA or IgM in 67%, a combined two class reaction of IgG/IgA, IgG/IgM or IgA/IgM synthesis in 16% and a combined three-class reaction of IgG, IgA and IgM in 17%. This approach generates valuable but numerous complex and interrelated biochemical data. We therefore developed a knowledge-based system combined with visual oriented laboratory output to transfer the information more effectively. This often uncovers typical patterns specific for distinct neurological diseases, is well accepted by our medical community documented by a 37% increase in external ordering.
Collapse
Affiliation(s)
- Axel Regeniter
- University Hospital Basel, Laboratory Medicine, Petersgraben 4, CH 4031 Basel, Switzerland.
| | | | | | | | | | | | | |
Collapse
|