Abstract
BackgroundWe investigate the frequency and diagnostic yield of cerebrospinal fluid (CSF) analysis in adult patients with status epilepticus (SE) and its impact on the outcome.MethodsFrom 2011 to 2018, adult patients treated at the University Hospital Basel were included. Primary outcomes were defined as the frequency of lumbar puncture and results from chemical, cellular, and microbiologic CSF analyses. Secondary outcomes were differences between patients receiving and not receiving lumbar puncture in the context of SE.ResultsIn 18% of 408 patients, a lumbar puncture was performed. Of those, infectious pathogens were identified in 21% with 15% detected ± 24 h around SE diagnosis. 74% of CSF analyses revealed abnormal chemical or cellular components without infectious pathogens. Screening for autoimmune diseases was only performed in 22%. In 8%, no or late (i.e., > 24 after SE diagnosis) lumbar puncture was performed despite persistent unknown SE etiology in all, transformation into refractory SE in 78%, and no recovery to premorbid neurologic function in 66%. Withholding lumbar puncture was associated with no return to premorbid neurologic function during hospital stay independent of potential confounders. Not receiving a lumbar puncture was associated with presumed known etiology and signs of systemic infectious complications.ConclusionsWithholding lumbar puncture in SE patients is associated with increased odds for no return to premorbid neurologic function, and CSF analyses in SE detect infectious pathogens frequently. These results and pathologic chemical and cellular CSF findings in the absence of infections call for rigorous screening to confirm or exclude infectious or autoimmune encephalitis in this context which should not be withheld.
Highlights
We investigate the frequency and diagnostic yield of cerebrospinal fluid (CSF) analysis in adult patients with status epilepticus (SE) and its impact on the outcome
Of the remaining 408 adult patients with SE, lumbar puncture was performed during their hospital stay in 72 patients (17.6%) within a median of 0 days [interquartile range (IQR) 0–1] from SE diagnosis
**Hosmer–Lemeshow goodness of fit test C hi2 6.33; p = 0.611 indicating adequate model fit the importance of CSF analyses, our results suggest that CSF analyses should be performed more frequently, since many patients have a persistent undetermined etiology of SE and lumbar puncture is safe if neuroimaging reveals no signs of increased intracranial pressure
Summary
We investigate the frequency and diagnostic yield of cerebrospinal fluid (CSF) analysis in adult patients with status epilepticus (SE) and its impact on the outcome. Conclusions Withholding lumbar puncture in SE patients is associated with increased odds for no return to premorbid neu‐ rologic function, and CSF analyses in SE detect infectious pathogens frequently These results and pathologic chemical and cellular CSF findings in the absence of infections call for rigorous screening to confirm or exclude infectious or autoimmune encephalitis in this context which should not be withheld. As infec‐ tious (meningo-)encephalitis encompasses many different viral and bacterial infections of the central nervous system (CNS) [6] and accounts for up to 10% of SE etiologies (not accounting for missed or underdiagnosed cases) [28, 35], the question arises whether or not CSF analyses should be labeled as mandatory with persistent unknown etiology, as already recommended for the diagnosis of new-onset refrac‐ tory SE (NORSE) or cryptogenic NORSE [13, 34] This comes with uncertainty once CSF is analysed regarding the extent to which chemical and cellular changes may be caused by SE per se and not by underlying infectious or autoimmune diseases. Despite these worrisome facts and uncertainties, studies in this context are lacking
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