Blood-contaminated Cerebrospinal Fluid Research Articles

A previous champagne tap reduces the probability of traumatic lumbar puncture in the following procedure

A cerebrospinal fluid (CSF) sample containing no red blood cells (RBC), colloquially known as a champagne tap, is an ideal outcome of a lumbar puncture (LP). In this pseudoprospective study of 2573 patients aged from 0 days to 95 years, we examined in four different age categories (neonates and infants, children and adolescents, adults, and older adults) whether a champagne tap in the patient’s first LP procedure and a shorter time than 1 week between the two successive procedures are independently associated with fewer blood-contaminated CSF samples (traumatic LP) in the following procedure. One out of five CSF samples from the patient’s first LP procedures were RBC-free on average, varying from about 9% in neonates and infants to about 36% in children and adolescents. The mean incidence of champagne taps was 19.5%. According to binary logistic regression, a champagne tap in the previous LP procedure significantly determined whether the following procedure was not blood-contaminated. The odds of traumatic LP were halved or even reduced tenfold after a champagne tap. Less than a week between the two successive procedures, in turn, multiplied the odds of traumatic LP in the latter even more than tenfold. A champagne tap was not significantly associated with traumatic LP in the following procedure among pediatric patients. If the patient’s condition or therapy plan permits and the blood contamination can compromise the reliability of the CSF-based analysis and consequent diagnosis, postponing the LP procedure by several days is advisable to improve the odds of receiving a high-quality CSF sample.

Incidence of traumatic lumbar punctures in adults: the impact of a patient's first procedure

Lumbar puncture (LP) is a widely used diagnostic method in patients of all ages. Blood-contaminated cerebrospinal fluid samples are frequent and may compromise diagnostic accuracy. We determined age-specific incidences of traumatic LPs (TLPs) in adults and examined factors that accounted for the incidence of TLPs. Erythrocyte count data from 15,812 LP procedures (2,404 were performed twice) were collected from hospital records of patients aged from 18 to 104 years. The incidence of TLPs in a patient's second LP procedure was evaluated with logistic regression analysis using the first LP, the time between the procedures and age as predictors. The incidence of TLP in the second procedure was at least double that in the first procedure. If the first procedure was traumatic, the odds ratio of a TLP in the second procedure was 7-40-fold. One day between the successive procedures was associated with an over 10-fold odds ratio increase of TLP, and a week was still 4-8-fold odds ratio increase. Age was also associated with the incidence of TLP. Two factors (a week or less between a patient's two LP procedures or a traumatic first LP) multiply the odds of the second procedure being traumatic and contribute to whether a patient's following LP procedure is successful.

Incidence of Traumatic Lumbar Punctures in Neonates and Infants.

The objective of this study is to examine factors accounting for the incidence of traumatic lumbar puncture (TLP) in infants younger than 1 year old. Retrospective analysis of cerebrospinal fluid (CSF) data from 1,240 neonatal (≤28 days) and 399 infant lumbar puncture (LP) procedures was conducted. Data from two successive LP procedures were obtained from 108 patients. Logistic regression analysis was used to assess factors accounting for the incidence of TLP in the second LP procedure. The following categorical variables were entered into the model: whether the first procedure was traumatic according to criteria of ≥500 and ≥10,000 erythrocytes/µL, whether the LP procedures were performed within a week, and whether the patient was neonatal at the first procedure. The incidences of TLP were 42.9% in neonates and 22.5% in infants for the criterion of ≥500 erythrocytes/µL, and 16.6 and 10.3% for the criterion of ≥10,000 erythrocytes/µL. Compared with a nontraumatic first LP procedure, if the first procedure was traumatic according to the criterion of ≥10,000 erythrocytes/µL, the odds ratio (OR) of TLP in the second procedure was 5.86 (p = 0.006). Compared with a longer time, if the successive procedures were performed within a week, the OR of TLP was 9.06 (p < 0.0001) according to the criteria of ≥500 erythrocytes/µL and 3.34 (p = 0.045) according to the criteria of ≥10,000 erythrocytes/µL. If the patient was neonatal at the first procedure, the OR of TLP at the second puncture was 0.32 (p = 0.031) according to the criterion of ≥500 erythrocytes/µL. The incidence of TLP in neonates is twice as high as that in infants. Successive LP procedures performed within a week and a highly blood-contaminated CSF sample in the first procedure each multiplied the odds of TLP in the second procedure, whereas being a neonate at the time of the first procedure reduced the odds of TLP. · Traumatic LPs increase diagnostic uncertainty.. · Traumatic LPs are twice as common in neonates as in infants.. · Two LPs performed within a week multiplied the odds of traumatic LP.. · Erythrocyte-based criteria for traumatic LP affect the incidence of TLP..

The effects of iatrogenic blood contamination on total nucleated cell counts and protein concentrations in canine cerebrospinal fluid

Cerebrospinal fluid (CSF) might be altered by iatrogenic blood contamination, precluding accurate diagnostic interpretation. Available formulas to correct for iatrogenic blood contamination are likely unreliable. Study objectives were to determine the effects of blood contamination on total nucleated cell counts (NCCs) and protein concentrations in canine CSF. Two methods were followed to evaluate the effect of blood contamination on total NCC and protein concentrations in CSF. First, records from the Colorado State University Veterinary Teaching Hospital were retrospectively searched for dogs where CSF analysis was performed. Total NCCs, RBC counts, protein concentrations, and cytologic interpretations were recorded. Second, CSF from 4 canine patients and 3 research hounds was prospectively analyzed before and after known dilutions of whole blood were added. Of the 787 clinical samples analyzed, 108 samples had a cytologic diagnosis of blood contamination. RBC counts for all clinical samples ranged from 0 to 210,000 cells/μL. No correlation between total NCCs or protein concentrations with RBC counts were found when all samples were evaluated. Total NCCs and RBCs were weakly correlated in samples with a cytologic diagnosis of blood contamination and when ≥500 RBC/μL was present. When serial dilutions of whole blood were added to normal CSF, no significant changes were observed in the total NCCsof uncontaminated aliquots and contaminated aliquots containing up to 8480 RBC/μL. Erythrocyte counts in blood-contaminated canine CSF poorly correlate with total NCCs and protein concentrations. Using formulas to correct total NCCs and protein concentrations for the number of RBCs in CSF is inappropriate.

The Diagnostic Dilemma of Traumatic Lumbar Puncture: Current Standing of Cerebrospinal Fluid Leukocyte Corrections and Our Experience With Cerebrospinal Fluid Biomarkers.

To assess the diagnostic efficiency of cerebrospinal fluid markers of procalcitonin, lactate, and cerebrospinal fluid/serum lactate ratio for detecting bacterial meningitis during traumatic lumbar puncture, and to compare these markers with routinely used uncorrected and corrected leukocyte measurements. Infants aged ≤90 days with traumatic lumbar puncture were prospectively studied. The diagnostic characteristics of cerebrospinal fluid assays of uncorrected and corrected leukocyte count, procalcitonin, lactate, and lactate ratio were described and compared. Considering the area under the curve (95% CI) analysis and standard cutoff values, the lactate-ratio (0.985 [0.964-0.989] at cutoff 1.2) had the best test indexes for identifying meningitis, followed by lactate (0.964 [0.945-0.984] at cutoff 2.2 mmol/L) and procalcitonin (0.939 [0.891-0.986] at cutoff 0.33 ng/mL) measurement, whereas the corrected total leukocyte count assay (0.906 [0.850-0.962] at cutoff 350 cells/mm3) had diagnostic properties moderately superior to uncorrected total leukocyte count measurement (0.870 [0.798-0.943] at cutoff 430 cells/mm3). Cerebrospinal fluid levels of procalcitonin, lactate, and lactate-ratio are reliable markers to diagnose bacterial meningitis in blood-contaminated cerebrospinal fluid.

Predictive value of cerebrospinal fluid lactate for the diagnosis of bacterial meningitis in patients post-neurosurgical operation with blood-contaminated cerebrospinal fluid

To evaluate the diagnostic value of cerebrospinal lactate for the diagnosis of bacterial meningitis in patients post-neurosurgical operation (PNBM) with blood-contaminated cerebrospinal fluid (CSF). A prospective observational study was conducted. 101 patients underwent neurosurgical operation and clinically suspected PNBM admitted to neurosurgical intensive care unit (NSICU) of the First Affiliated Hospital of Sun Yat-sen University from October 2015 to December 2016 were enrolled. Based on red blood cell quantitative test in CSF, the patients were divided into blood-contaminated and non blood-contaminated CSF groups. According to the PNBM diagnostic criteria of 2008 Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN), all patients were divided into PNBM group and non-PNBM group. The biochemical indexes levels in CSF were compared among the groups. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic power of CSF lactate for PNBM in blood-contaminated patients. A total of 101 suspected PNBM patients were enrolled. In 77 blood-contaminated CSF patients, 39 patients were diagnosed as PNBM (account for 50.6%); in 24 non-blood-contaminated patients, 12 patients were diagnosed as PNBM (account for 50.0%). (1) In non-PNBM patients, the lactate level in blood-contaminated CSF was significantly higher than that of non-blood-contaminated CSF (mmol/L: 3.5±1.3 vs. 2.3±1.1, P < 0.01). In PNBM patients, there was no significant difference in lactate level between blood-contaminated CSF and non blood-contaminated CSF (mmol/L: 6.8±2.1 vs. 6.9±2.5, P > 0.05). (2) In both blood-contaminated and non blood-contaminated CSF, white blood cell (WBC), protein and lactate levels in PNBM group were significantly higher than those in non-PNBM group [WBC (×106/L): 660.0 (67.5, 1 105.0) vs. 41.0 (15.0, 142.5) in blood-contaminated CSF, 168.0 (86.5, 269.5) vs. 34.5 (7.0, 83.5) in non-blood-contaminated CSF; protein (mg/L): 4 757.8 (2 995.2, 10 219.8) vs. 1 292.8 (924.2, 1 936.2) in blood-contaminated CSF, 39 247.3 (14 900.6, 62 552.2) vs. 1 441.6 (977.3, 2 963.9) in non blood-contaminated CSF; lactate (mmol/L): 6.8±2.1 vs. 3.5±1.3 in blood-contaminated CSF, 6.9±2.5 vs. 2.3±1.1 in non blood-contaminated CSF, all P < 0.05], and glucose and CSF glucose/blood glucose ratio in PNBM group were significantly lower than those in non-PNBM group [glucose (mmol/L): 2.5±1.2 vs. 4.4±1.6 in blood-contaminated CSF, 1.9±1.4 vs. 3.4±0.9 in non blood-contaminated CSF; CSF glucose/blood glucose ratio: 0.28±0.15 vs. 0.46±0.16 in blood-contaminated CSF, 0.24±0.16 vs. 0.45±0.11 in non blood-contaminated CSF, all P < 0.01]. (3) It was shown by ROC curve analysis that CSF lactate level was a good diagnostic parameter for PNBM both in blood-contaminated and non blood-contaminated CSF, and the area under ROC curve (AUC) was 0.91 and 0.97, respectively. When the cutoff value of lactate in non blood-contaminated CSF was 3.35 mmol/L, the sensitivity was 100%, and the specificity was 91.7%. When the cutoff value of lactate in blood-contaminated CSF was 4.15 mmol/L, the sensitivity was 92.3%, and the specificity was 71.1%, and the combination of CSF lactate and glucose achieved better diagnostic specificity (AUC = 0.96, sensitivity was 97.4%, specificity was 84.2%). Blood in CSF led to the elevation of CSF lactate as compared with that in non-blood-contaminated CSF of patients with PNBM. CSF lactate was still a good diagnostic parameter for PNBM both in blood-contaminated patients, and the combination of CSF lactate and glucose achieved better diagnostic specificity.

Corrections for Leukocytes and Percent of Neutrophils Do Not Match Observations in Blood-Contaminated Cerebrospinal Fluid and Have No Value Over Uncorrected Cells for Diagnosis

Corrections for Leukocytes and Percent of Neutrophils Do Not Match Observations in Blood-Contaminated Cerebrospinal Fluid and Have No Value Over Uncorrected Cells for Diagnosis

Correction of ventricular cerebrospinal fluid (CSF) samples for blood content does not increase sensitivity and specificity for the detection of CSF infection

Blood contamination is commonly observed in ventricular cerebrospinal fluid (CSF) samples from patients with extraventricular drainage systems. Because the introduction of blood may interfere with the white blood cell count as a useful marker for the diagnosis of an infection, correction for blood content would be desirable. In a retrospective study, we analysed the use of correction formulas in 724 blood-contaminated ventricular CSF samples. Using a standard correction method the white blood cell count was not normalised in most CSF samples, with pleocytosis indicating an inflammatory stimulus set by the blood itself or by the foreign body. When correcting white blood cell counts in the CSF of culture-positive patients, some samples were normalised or overcorrected. In addition, correction of the CSF white blood cell count did not increase sensitivity and specificity for the detection of culture-positive CSF samples. Correction is not necessary when using the white blood cell count as a parameter to predict CSF infection in ventricular CSF samples.

Effects of Blood Contamination of Cerebrospinal Fluid on Results of Indirect Fluorescent Antibody Tests for Detection of Antibodies againstSarcocystis NeuronaandNeospora Hughesi

The purpose of this study was to determine the effect of blood contamination of cerebrospinal fluid (CSF) on the results of indirect fluorescent antibody tests (IFATs) for Sarcocystis neurona and Neospora hughesi. The in vitro study used antibody-negative CSF collected from non-neurologic horses immediately after euthanasia and blood samples from 40 healthy horses that had a range of IFAT antibody titers against S. neurona and N. hughesi. Serial dilutions of whole blood were made in seronegative CSF to generate blood-contaminated CSF with red blood cell (RBC) concentrations ranging from 10 to 100,000 RBCs/microl. The blood-contaminated CSF samples were then tested for antibodies against both pathogens using IFAT. Blood contamination of CSF had no detectable effect on IFAT results for S. neurona or N. hughesi at any serologic titer when the RBC concentration in CSF was <10,000 RBCs/microl. At concentrations of 10,000-100,000 RBCs/microl of CSF, positive CSF results (IFAT titer >or=5) for S. neurona and N. hughesi were detected only when the corresponding serum titers were >or=160 and >or=80, respectively. The IFAT performed on CSF is reliable for testing horses for equine protozoal myeloencephalitis caused by S. neurona or N. hughesi, even when blood contamination causes the RBC concentration in CSF to be up to 10,000 RBCs/microl.

Erratum to ???Corrections for Leukocytes and Percent of Neutrophils Do Not Match Observations in Blood-Contaminated Cerebrospinal Fluid and Have No Value Over Uncorrected Cells for Diagnosis.??? B. Bonsu and M. B. Harper.

Erratum to ???Corrections for Leukocytes and Percent of Neutrophils Do Not Match Observations in Blood-Contaminated Cerebrospinal Fluid and Have No Value Over Uncorrected Cells for Diagnosis.??? B. Bonsu and M. B. Harper.

Corrections for Leukocytes and Percent of Neutrophils Do Not Match Observations in Blood-Contaminated Cerebrospinal Fluid and Have No Value Over Uncorrected Cells for Diagnosis

The utility of published adjustments for leukocytes in blood-contaminated cerebrospinal fluid (CSF) is controversial. In this study, we assess how these adjustments and a novel rule for predicting percent of neutrophils match observations in CSF. We also determine the incremental value of corrected over uncorrected cells in CSF for discriminating between bacterial and viral meningitis. We analyzed blood-contaminated CSF specimens collected from 1-month to 18-year-old children presenting to an urban academic pediatric emergency department between 1993 and 2003. Predictions of leukocytes (total) and neutrophils in CSF were derived from a standard rule and from an alternative rule based on a regression between neutrophils in peripheral blood and CSF. The match between observed and predicted cell counts was estimated by the coefficient of determination (R(2)). The value of corrected over uncorrected cells for diagnosing bacterial meningitis was evaluated by comparing the areas under respective receiver operator characteristic curves (AUC). At an R(2) of 0.11, predicted leukocytes matched observed leukocytes poorly for 682 CSF specimens that met study criteria. The percent of neutrophils in CSF predicted by the regression 7% + (0.5 x percent of neutrophils in peripheral blood) also fit observed neutrophils only modestly (R(2) 0.27). For diagnosing bacterial meningitis, there was no difference between AUC values for corrected and uncorrected leukocytes and percent of neutrophils. In blood-contaminated CSF, there is poor to modest correlation between observed and predicted counts of leukocytes and of neutrophils. Adjusted blood counts in CSF have no advantage over uncorrected counts for predicting bacterial meningitis.

Effect of cisternal drainage after early operation for ruptured intracranial aneurysms.

The effect of postoperative cisternal drainage was assessed in 132 patients who underwent early surgery for ruptured aneurysms. Although the incidence of both cerebral vasospasm and mortality was low in the patients who had cisternal drainage, the incidence of hydrocephalus was significantly higher in these patients. Drainage has been recommended as a useful procedure because it has been shown to improve the prognosis through prophylaxis and relief of vasospasm and removal of blood-contaminated cerebrospinal fluid. However, the results of this study indicate that extensive cerebrospinal fluid drainage may lead to hydrocephalus, which can be controlled by regulation of the drainage outflow and pressure.

Determination of leukocytosis in traumatic spinal tap specimens

White and red blood cell counts from peripheral blood and from the cerebrospinal fluid of all patients who had traumatic lumbar punctures over a five-year period were studied to determine the diagnostic value of using the ratio of white blood cell to red blood cells in peripheral blood to adjust the white blood cell count found in the bloody cerebrospinal fluid. In patients without meningitis, 55 percent of the cerebrospinal fluid specimens had more white blood cells than could be attributed to trauma. However, in only 10 percent was the actual white blood cell count more than 10 times greater than the number referable to trauma. In 38 percent, there were fewer white blood cells in the cerebrospinal fluid than the ratio predicted. Such underestimation was uncommon among patients with culture-positive meningitis: the ratio failed to detect leukocytosis in only 10 percent, and all but one of these patients had clinical reasons for the low cerebrospinal fluid count. It is concluded that true leukocytosis is rarely masked in blood-contaminated cerebrospinal fluid, and that the presence of more than 10 times the number of white blood cells than allowed by the adjustment is a sensitive and specific indicator of meningitis. However, a simple mechanical use of the formula is not justified, and all available clinical and laboratory data should be used when deciding whether to institute treatment in a patient with possible meningitis and bloody spinal fluid.

Lack of validity of standard corrections for white blood cell counts of blood-contaminated cerebrospinal fluid in infants.

An evaluation of the validity in infants of standard computations for the correction of white cell counts in blood-contaminated cerebrospinal fluid (traumatic lumbar puncture) was undertaken. In 39 infants with significant blood contamination (greater than 10(4) red blood cells/microL) and no evidence of bacterial meningitis, both calculated corrections based on simultaneously obtained complete blood counts and estimated corrections based on average values resulted in overcorrection in a majority of cases (33 of 39 and 25 of 39, respectively). The mechanism of this overcorrection could not be defined. In eight infants with significant blood contamination and proven bacterial meningitis, correction computations normalized or overcorrected the white cell count in one case. It appears that standard computations frequently overcorrect white cell counts in blood-contaminated cerebrospinal fluid and that the magnitude of the overcorrection may obscure pathologic states in some cases.