Bloody Cerebrospinal Fluid Research Articles

Spontaneous spinal subarachnoid hemorrhage after severe coughing: a case report

IntroductionSpinal subarachnoid hemorrhage has many causes including trauma, vascular malformations, aneurysms, spinal cord tumors, coagulation abnormalities, use of anticoagulants, systemic lupus erythematosus, or Behçet’s disease. We report on a rare case of a spontaneous spinal subarachnoid hemorrhage after severe coughing of unknown origin. To the best of our knowledge, this is the first report of spontaneous spinal subarachnoid hemorrhage after severe coughing.Case presentationA 66-year-old Japanese woman initially complained of headache with severe back pain after severe coughing. She was referred to our neurology department 6 days after her first visit to our hospital. No neurological deficits were revealed except for meningism. Computed tomography of her head revealed no abnormality. A lumbar puncture showed bloody cerebrospinal fluid with xanthochromia. Cerebral angiography revealed no abnormality. Magnetic resonance imaging of her lumbar spine revealed subarachnoid hemorrhage. Spinal angiography revealed no abnormality. The diagnosis of spontaneous spinal subarachnoid hemorrhage was made. She recovered with conservative treatment and her neurological status was normal 2 years after the onset.ConclusionsSpontaneous spinal subarachnoid hemorrhage could be caused by rapid changes in intrathoracic and intra-abdominal pressure. Spontaneous subarachnoid hemorrhage should be considered when sudden back pain associated with severe headache develops. Even though emergent surgical decompression is necessary when the neurological state progressively deteriorates, conservative treatment with close monitoring of the symptoms can be recommended for patients with a stable neurological status.

Diagnosis of cerebral hemorrhage before the era of computed tomography

During the past decades there has been a great progress in neuroimaging methods. Cranial computed tomography is part of the daily routine now and its use allows a fast diagnosis of parenchymal hemorrhage. However, before the availability of computed tomography the differentiation between ischemic and hemorrhagic stroke was based on patient history, physical examination, percutan angiography and cerebrospinal fluid sampling, and the clinical utility could be evaluated by autopsy of deceased patients. The authors explored the diagnostic performance of cerebrospinal fluid examination for the diagnosis of ischemic and hemorrhagic stroke. Data of 200 deceased stroke patients were retrospectively evaluated. All patients had liquor sampling at admission and all of them had brain autopsy. Bloody or yellowish cerebrospinal fluid at admission had a positive predictive value of 87.5% for hemorrhagic stroke confirmed by autopsy, while clear cerebrospinal fluid had positive predictive value of 90.7% for ischemic stroke. Patients who had clear liquor, but autopsy revealed hemorrhagic stroke had higher protein level in the cerebrospinal fluid, but the difference was not statistically significant (p = 0.09). The results confirm the importance of pathological evaluation of the brain in cases deceased from cerebral stroke. With this article the authors wanted to salute for those who contributed to the development of the Hungarian neuropathology. In this year we remember the 110th anniversary of the birth, and the 60th anniversary of the death of professor Kálmán Sántha. Professor László Molnár would be 90 years old in 2013.

Superparamagnetic beads for estimation of spinal subarachnoid space permeability in rats

BackgroundHuman spinal pathological processes have been linked to a loss of spinal subarachnoid space (SSAS) permeability, which has therefore become a target for therapy. Hence, it has become important to measure SSAS patency in rat models of these human disorders. New methodThe estimation of in vivo rat SSAS patency is described by quantifying passage of streptavidin-covered superparamagnetic beads (SPMB) in cerebrospinal fluid (CSF). Beads are injected into the cisterna magna and recovered at spinal level L2. They are then coated with biotynilated horseradish peroxidase for enzymatically based colorimetric measurement, after removal of bloody CSF to avoid interference with the colorimetric readings. The procedure was tested in intact rats and in rats 24h after T9 laminectomy. Residual beads in SSAS were viewed by histology. ResultsAverage bead recovery from intact rats was 6.4% of amount initially administered, in a mean CSF volume of 126μL; in laminectomized rats, it was 1%, in a mean CSF volume of 39.2μL. Comparison with existing method(s)Unlike in vivo imaging techniques, such as myelography (used here to validate our method) and near infrared fluorescence technology for qualitative rat SSAS patency viewing, our SPMB-based method allows for an in vivo quantitative estimation of the permeability of this space. ConclusionsA novel method has been established to reliably determine SSAS permeability in rats. The method is reproducible and has the required sensitivity to detect an 84.4% reduction in bead recovery, as seen in laminectomized rats compared to intact animals.

Clearing bloody cerebrospinal fluid

Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments. Intraventricular fibrinolysis (IVF) for accelerated IVH-resolution has been clinically tested since the early 1990s. The lately summarized evidence from smaller studies indicates that IVF may result in a benefit in mortality and outcome. Recent investigations have elucidated different aspects of IVF, mainly related to safety. Neuroendoscopy has also emerged as a minimally invasive technique allowing fast removal of IVH. The capability of lumbar drainage to reduce vasospasm after SAH has been tested in a large trial. IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.

The Mechanisms of Energy Crisis in Human Astrocytes After Subarachnoid Hemorrhage

Calcium (Ca2+) is a cofactor of multiple cellular processes. The mechanisms that lead to elevated cytosolic Ca2+ concentration are unclear. To illuminate how bloody cerebrospinal fluid (bCSF) from patients with intraventricular hemorrhage causes cell death of cultured human astrocytes. Cultured astrocytes were incubated with bCSF. In control experiments, native CSF was used. Cytosolic Ca2+ concentration was measured by fura-2 fluorescence. Apoptosis and necrosis were evaluated by staining with Hoechst-3342 and propidium iodide. Incubation of astrocytes with bCSF provoked a steep Ca2+ concentration peak that was followed by a slow Ca2+ rise during the observation period of 50 minutes. Necrosis, but not apoptosis, was induced. Blockade of ATP-sensitive P2 receptors with suramin inhibited the bCSF-induced initial Ca2+ peak and necrosis. Blockade of P1 receptors with 8-phenyltheophylline or of N-methyl-D-aspartate receptors with D(-)-2-amino-5-phosphopentanoic acid had no significant effect. Preincubation with xestospongin D, a blocker of inositol 1,4,5-trisphosphate receptors, prevented the initial Ca2+ rise and reduced the rate of necrosis. Preemptying of the endoplasmic reticulum with thapsigargin protected astrocytes from the bCSF-induced Ca2+ peak. Inhibition of mitochondrial permeability transition pores opening with cyclosporin A reduced the rate of astrocytic necrosis significantly, although it did not influence the initial Ca peak. bCSF elicits a steep, transient Ca rise when administered to human astrocytes by activation of ATP-sensitive P2 receptors and subsequent inositol 1,4,5-trisphosphate-dependent Ca release from endoplasmic reticulum. This massive Ca overload leads to subsequent mitochondrial permeability transition pores opening and necrosis of the cells.

止血剤の点滴および内服加療で改善をみとめた脳表ヘモジデリン沈着症の1例

A 39-year-old man suffering from progressive dysarthria, gait disturbance, and sensorineural deafness for 2 years was admitted to our hospital. He scored 28 points on the mini-mental state examination. He had previously undergone surgery at 24 years and 39 years of age for a cerebellar tumor (pilocytic astrocytoma). Superficial siderosis (SS) was diagnosed based on bloody cerebrospinal fluid (CSF) and the findings of T2-weighted head MRI that revealed marginal hypointensity of the surface of the cerebellum, brainstem, and cerebral cortex. After intravenous infusion and the oral use of hemostatic drugs (carbazochrome, tranexamic acid), the CSF became watery clear and his condition improved. Hemostatic drug therapy should be considered for SS.

Abstract 472: Calcium Current by Somatostatin Leads to Vasoconstriction in Rabbit Cerebral Artery

Somatostatin-containing neurons have a widespread distribution in the central nervous system. Moreover, the level of somatostatin in bloody cerebrospinal fluid and plasma is elevated patients with stroke. However, there is little evidence to support that somatostatin is a possible factor of vasopasm after stroke. This experiment was to undertaken to evaluate the effects of somatostatin on Ca 2+ currents using the whole-cell voltage-clamp techniques and on Ca 2+ transients using whole-cell fluorescence in cerebral arteries of the rabbit. During rectangular pulses, both peak and steady-state Ca 2+ currents were significantly increased by the application of somatostatin. Somatostatin had little effect on the steady-state activation kinetics, however, significant effect on the time constants for current decay. τ increased monotonically with voltage and was slightly slower in somatostatin-treated cells between 0 and +30 mV. The half maximal concentration of somatostatin was 8.5±1.3 pM in dose-response relation. Moreover, Ca 2+ transients by somatostatin were significantly increased in cells. From these results, the activation of Ca 2+ currents by somatostatin could be involved in pathogenesis of vasospasm after stroke.

Endovascular embolization of cerebral arteriovenous malformations( AVMs) with Onyx: preliminary analysis of hemorrhagic complications

Objective The purpose of this study was to analyze the factors associated with acute complications of AVM treated with Onyx embolization and to manage these complications.Methods 15 consecutive patients with cerebral AVMs treated with Onyx embolization led bleeding complications were retrospectively reviewed from September 2003 to December 2010.Results 7 patients bleeding during operations.(5 cases were treated with conservative symptomatic treatment,another 2 cases had given bloody cerebrospinal fluid drainage treatment).8 cases bleeding after the operation. (5 cases were treated with conservative symptomatic treatment,3 patients had given craniotomy to remove the hematoma).Postoperative mRS ( modified Rankin Scale) score was 2.53 in average,and 2 patients died.Conclusions Endovascular treatment of cerebral arteriovenous malformation is an effective way to treat the AVM.a variety of factors can Iead to hemorrhagic complications associated with the embolization.Avoiding the blind pursuit of the whole embilization and using different treatment strategies can achieve satisfactory results. Key words: Cerebral arteriovenous malformations; Endovascular embolization; Onyx; Complication

Early management of intracranial ruptured vertebral dissecting aneurysms

To evaluate the early management of intracranial ruptured vertebral dissecting aneurysms. Twenty-two patients with ruptured vertebral dissecting aneurysms were managed by various treatment modalities according to their conditions. One aneurysm was treated by proximal vertebral artery coiling, 15 aneurysms by aneurysm and parent artery coiling, and 5 aneurysms by stent-assisted coiling (4 of 5 by stent-within-a-stent technique), one by single double-stent. Bloody cerebrospinal fluid was drained by postoperative lumbar subarachnoid drainage in order to prevent cerebral vasospasm. All 22 cases were successful without bleeding complication during the operation.There was 1 case of early postoperative non-aneurysmal hemorrhage, 2 cases of posterial group cranial nerves palsies, 1 case harbored Hunt & Hess IV who gave up treatment. After follow-up for 3-18 months, there was no rebleeding and infarction. Twenty patients recovered well, except 1 having posterial group cranial nerves palsies. Fourteen cases were followed up by angiography. In 3 patients treated by stent-assisted coiling, DSA showed that aneurysms disappeared and loading vessel passed freely.DSA of 11 cases with aneurysm and parent artery coiling demonstrated complete obliteration of the dissection without aneurysm imaging. Early endovascular treatment of ruptured vertebral dissecting aneurysms is essential. The selective method of endovascular management according to the characteristics of aneurysm is safe and effective. Double stent-assisted coiling should be the first choice.

The clinical study of preoperative external lumbar drainage in patients with aneurysmal subarachnoid hemorrhage in Hunt and Hess grades I～III undergoing early surgery

Objective To explore the therapeutic effect of preoperative external hunbar drainage in Hunt and Hess grade Ⅰ～Ⅲ patients with subarachnoid hemorrhage ( SAH ) undergoing early surgery for intracranial aneurysms. Method The 101 cases of grade Ⅰ～Ⅲ patients according to the classification of Hunt and Hess with early surgical treatment were devided into preoperative external lumbar drainage group(47 cases) and postoperative external lumbar drainage group(54 cases).Outcome of patients with different external drainage of cerebrospinal fluid was analyzed. Results There was no case of aneurysm rebleeding could be associated with preoperative spinal drain placement. Tne incidences of intraoperative aneurysm rapture in preoperative external lumbar drainage group was 8. 5%,which was lower than 11. 1% in postoperative external lumbar drainage group. The incidences of symptomatic cerebral vasospasm and chronic hydrocephalus in preoperative external lumbar drainage group were 12. 8% and 12.8% ,which were lower than 20. 4% and 14. 8% in postoperative external lumbar drainage group. There all were not significant differences between the two groups. Conclusions Preoperative external lumbar drainage wont increase a risk of rebleeding for grade Ⅰ～Ⅲ patients with aneurysmal SAH undergoing early surg ery. Furthermore, it can decrease the incidences of symptomatic cerebral vasospasm and chronic hydrocephalus,which is a safe and useful method of removing bloody cerebrospinal fluid. Key words: Intracranial aneurysm; Subarachnoid hemorrhage; External lumbar drainage

Arachnoid cell involvement in the mechanism of coagulation-initiated inflammation in the subarachnoid space after subarachnoid hemorrhage

To assess if arachnoid cells have the capability to present antigen and activate T-lymphocytes after stimulation by bloody cerebrospinal fluid (CSF), and to illuminate the mechanism of coagulation-initiated inflammation in the subarachnoid space after subarachnoid hemorrhage (SAH). Arachnoid cells were cultured, characterized, and examined by immunofluorescence for the basal expression of human leukocyte antigen-DR (HLA-DR). Expression of HLA-DR, after co-culturing arachnoid cells in vitro with bloody CSF, was investigated by immunofluorescence and flow cytometry (FCM). The variation of arachnoid cells' ultrastructure was observed by transmission electron microscope (TEM). Arachnoid cells were co-cultured with peripheral blood mononuclear cells (PBMCs). The content of soluble interleukin-2 receptor (sIL-2r) in culture medium was detected by enzyme-linked immunosorbent assay (ELISA). (1) Arachnoid cells were successfully cultured for many passages. The immunofluorescent staining was positive for HLA-DR in over 95% of the human arachnoid cells. The punctate HLA-DR was distributed in cytoplasm and not in the karyon. (2) After co-culturing arachnoid cells in vitro with bloody CSF, numerous particles with strong fluorescence appeared in the cytoplasm on Day 6. On Day 8, the quantity of particles and fluorescent intensity were maximal. FCM showed that the percentage of HLA-DR expressing cells was (2.5+/-0.4)% at the first 5 d, increasing to (60.8+/-3.6)% on Day 7. (3) After co-culturing arachnoid cells in vitro with bloody CSF, many lysosome and secondary lysosome particles were present in the cytoplasm. Hyperplasia of rough endoplasmic reticulum and enlarged cysts were observed, with numerous phagocytizing vesicles also observed at the edge of the arachnoid cells. (4) Arachnoid cells stimulated by bloody CSF were co-cultured in vitro with PBMCs. The content of sIL-2r in the culture medium, having been maintained at around 1.30 ng/ml during the first 3 d, had increased by Day 4. The content of sIL-2r peaked 7.53 ng/ml on Day 7 and then reduced gradually. (1) Basic HLA-DR expression is present in arachnoid cells. (2) After stimulation by bloody CSF, arachnoid cells have the potential to serve as antigen presenting cells (APCs) and the ability to activate T-lymphocytes, indicating that arachnoid cells are involved in the mechanism of coagulation-initiated inflammation in the subarachnoid space after SAH.

Early management of ruptured intracranial vertebral dissecting aneurysms

Objective To evaluate the early management of intracranial vertebral dissecting anourysms. Method The raptured intracrunial verterbral dissecting aneurysms have been treated early since August 2005 according to their specific configuration by three endovascular techniques. 6 aneurysms were treated by stent-assisted coiling;4 aneurysras were treated by double stents technique;4 anourysms were treated by anemysm and parent artery coiling. Bloody cerebrospinal fluid was drained as early as possible after endovascular treatment, together with calcium channel blockers to prevent cerebral vasospasm. Results There was no embolic or bleeding complication during the operations. 13 patients recovered well, except that one patient who harbored Hunt&Hess Ⅴ died due to initiated severe brain damage. Follow-up 16 months, there is no rebleeding. Angiographic follow-up,6 anerysms treated by stent-assisted coiling except one who had partial recanahzation did not recur. In 4 aneurysms treated by double stents technique, the fusiform ectasia portion of two aneurysms disappeared and remarkably diminished in another two aneurysms. 3 aneurysms treated by aneurysm and parent artery coiling have no recanalization. Conclusions Early endovascular treatment of ruptured vertebral dissecing uneurysms is safe and effective. According to morphologic characteristics of aneurysm,it is better to choose a suitable technique such as stent-assisted coiling. Key words: Vertebral artery; Dissecting aneurysm; Endovascular treatment

Bloody cerebrospinal fluid during replacement of descending thoracic aorta -A case report-

Cerebrospinal fluid (CSF) drainage is a routinely used adjunct to thoracoabdominal aortic surgery which may reduce the incidence of preoperative paraplegia by improving spinal cord perfusion. However, this procedure infrequently causes complications. Bloody or bloody-tinged CSF may be associated with intracranial or spinal hematoma. We present herein a case of bloody CSF during the replacement of the descending thoracic aorta.

破裂前交通動脈瘤クリッピング術３日後にアプローチと反対側にｓｙｌｖｉａｎ ｈｅｍａｔｏｍａが増大した１例

We report a case of sylvian hematoma enlarging 3 days after neck clipping for a ruptured anterior communicating artery aneurysm, in the contralateral sylvian fissure to the operative approach. This 65-year-old man was admitted with sudden loss of consciousness by ambulance. Angiography revealed a saccular aneurysm at the anterior communicating artery complex, measuring 2.3×2.4 mm and pointing inferiorly. The aneurysmal neck was successfully clipped by using the right pterional approach. To minimize predictable vasospasm, the hematoma in the left sylvian stem was removed. Postoperative CT scan showed a considerable decrease in hematoma in the basal cistern, but a slight decrease in the vertical portion of the left sylvian fissure. The patient’s consciousness gradually recovered, but deteriorated again 3 days after the operation. CT scan showed a large high-density area in the sylvian fissure suggesting unexpected enlargement of sylvian hematoma. A left fronto-temporal craniotomy was performed. When the subpial hematoma around the sylvial fissure was removed, a large amount of bloody cerebrospinal fluid (CSF) flowed out. The cavity containing bloody fluid was located in the temporal lobe. Postoperative course was uneventful. He recovered well, but moderate sensory aphasia remained. Sylvian hematoma is rarely associated with ruptured anterior communicating artery aneurysms. Furthermore, there has been no report describing delayed onset sylvian hematoma as far as we are aware. The following mechanism was considered to explain this very rare condition. Removal of subarachnoid hematoma in the left sylvian fissure made a recovery of CSF flow up to the limen insulae, but CSF appeared to be blocked from entering the distal sylvian fissure by the thick subpial sylvian hematoma. Instead of normal CSF flow route, CSF may enter into the weakened subpial space to allow accumulation of bloody CSF in the temporal lobe. Subpial hematoma may act as a one-way valve.

Subarachnoid bleeding into the superior cerebellopontine cistern after radiofrequency trigeminal rhizotomy: case report

Sir, We would like to report an unusual case of a patient suffering from trigeminal neuralgia, who underwent percutaneous radiofrequency trigeminal rhizotomy (RF-TR), and complicated with subarachnoidal bleeding in the superior cerebellopontine cistern. A 68-year-old woman had been suffering from medically intractable trigeminal neuralgia. She had a 6-year history of trigeminal neuralgia at the ophthalmic and maxillary branches of the left trigeminal nerve. Cranial magnetic resonance imaging scans revealed no structural or vascular abnormality. Routine preoperative analyses, including coagulation studies, were normal. The patient underwent RF-TR under intravenously administered sedation and analgesia. The localization was confirmed within the nerve by electrical stimulation at 0.5 V (100 Hz, 0.2 m); and a lesion was made at a temperature of 70°C for 60 s. After the procedure, the patient’s pain resolved completely. However, 12 h after the procedure, sudden onset of severe headache, vomiting and neck stiffness occurred. The initial cranial computed tomography (CT) scan was normal. Lumbar puncture examination revealed bloody cerebrospinal fluid (CSF); the lymphocyte and monocyte proportions were normal. The control cranial CT scan showed subarachnoidal bleeding in the left superior cerebellopontine cistern (Fig. 1). The patient underwent conservative treatment, and neck stiffness and headache improved. She was discharged 7 days after the procedure. Trigeminal RF-TR is an effective and commonly performed procedure for control of medically refractory pain. Surgical procedures, such RF-TR, microvascular decompression, etc, may lead to serious complications. Anesthesia dolorosa, painful dysesthesia, absence of corneal reflex, corneal keratitis, masseter paralysis, septic-aseptic meningitis, cranial nerve palsy (cranial nerves III, IV, VI, VII, and VIII), blindness, carotid puncture, and carotidcavernous fistulae are all potential complications of the RFTR procedure [2]. Thus, all surgeons should be aware of these risks and not consider any of these methods as easy and safe. Meckel’s cave and root entry zone, which are the focus of these intervention methods, are at the same time the areas where multiple anatomic variations and vital structures are located [3]. Meckel’s cave opens through a porus into the cerebellopontine cistern. Meckel’s segment of the trigeminal nerve, which begins at the porus and extends to the trigeminal ganglion, is differentiated from the cavernous segment in the wall of the cavernous sinus. Meckel’s segment is narrower adjacent to the porus and fans out as it approaches the posterior edge of the gasserian ganglion, which is embedded in the dura just anterior to the anterior edge of Meckel’s cave. The superior petrosal sinus extends medially through the upper edge of the porus of Meckel’s cave and above the trigeminal nerve to join the cavernous sinus [1]. Some superior petrosal veins may join the sinus on the medial side of the trigeminal nerve. The SCA A. Savas Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey

Cerebral Vasospasm: New Strategies in Research and Treatment

Cerebral Vasospasm: New Strategies in Research and Treatment

Examination of body fluids: evaluating gross appearance; performing cell counts.

1. Leilani Collins, MS MT(ASCP)SH CLS(NCA)[⇑][1] 1. is associate professor, Clinical Laboratory Science Program, University of Tennessee Health Sciences Center, Memphis TN 1. Address for correspondence: Leilani Collins MS MT(ASCP)SH CLS(NCA), associate professor, Clinical Laboratory Science Program, University of Tennessee Health Sciences Center, 930 Madison Avenue, Suite 670, Memphis TN 38163.. (901) 448-6299. lcollins{at}utmem.edu. 1. Describe the normal appearance of cerebrospinal fluid, serous fluids, and synovial fluid. 2. Define gross findings that distinguish a traumatic tap from a pathologic bleed when a bloody CSF is encountered. 3. Name laboratory findings that aid in identifying a serous fluid as a transudate or exudate. 4. Describe how the appearance of a fluid can be used to determine the correct dilution for accurate cell counts. Evaluating gross appearance: CSF Spinal fluid is the only fluid that is normally available in quantities sufficient to sample. Adults have 90-150 mL of cerebrospinal fluid (CSF) and neonates 60-90 mL.1 The spinal fluid bathes the brain and spinal column providing nutrients to, removing waste products from, and acting as a protective cushion for the central nervous system (CNS). Since this fluid circulates around the brain and spinal column, it is an excellent source of information for the condition of the CNS. CSF is collected by lumbar puncture and, ideally, is placed into three or four sterile tubes labeled 1, 2, 3, and 4 in the order in which it is collected. If multiple tubes are received and multiple tests are ordered, tube #1 should be used for chemistry and immunology testing, tube #2 for microbiology, tube #3 for cell counts and differential, and tube #4 for any other tests.1 The normal appearance of CSF is colorless and crystal clear, resembling water. A cloudy or turbid fluid indicates increased WBCs or protein. A bloody fluid can indicate a traumatic tap in which a blood vessel is inadvertently punctured in the process of collection or blood can mean an intracranial hemorrhage or pathologic bleed. If multiple tubes are collected, there is clearing of the blood from the first tube to the last tube collected in the case of a traumatic tap but a consistent amount of blood in all tubes in the case of a pathologic bleed. If only one tube… ABBREVIATIONS: CNS = central nervous system; CSF = cerebrospinal fluid; RBC = red blood cell; WBC = white blood cell. 1. Describe the normal appearance of cerebrospinal fluid, serous fluids, and synovial fluid. 2. Define gross findings that distinguish a traumatic tap from a pathologic bleed when a bloody CSF is encountered. 3. Name laboratory findings that aid in identifying a serous fluid as a transudate or exudate. 4. Describe how the appearance of a fluid can be used to determine the correct dilution for accurate cell counts. [1]: #corresp-1

Platelet count has no influence on traumatic and bloody lumbar puncture in children undergoing intrathecal chemotherapy

British Committee for Standards in Haematology, Blood Transfusion Task Force (2003) produced guidelines suggesting a platelet count of ≥50 × 109/l to safely proceed with lumbar puncture (LP). This has led us to review our institute's policy of a platelet count of ≥30 × 109/l as a safety cutoff for LP procedures and administration of intrathecal chemotherapy. There is obvious concern because a low platelet count may be associated with devastating neurological complications due to spinal bleeding. Furthermore, on presentation if a traumatic tap occurs, leukaemic cells circulating in the blood may be introduced into the cerebrospinal fluid (CSF), thereby possibly worsening the patient's prognosis (Gajjar et al, 2000). Howard et al (2000) reported a large retrospective analysis of 4309 LPs performed in 959 children, including 941 procedures with platelet count of <50 × 109/l with no neurological haemorrhagic complications. This article recommended that a platelet count of 10 × 109/l or higher would be adequate to perform routine LP. The authors (Howard et al, 2002), found that platelet counts of below 100 × 109/l were associated with increased risk of traumatic or bloody tap, but this risk was not different across platelet categories once the platelet count reduced below this threshold. Our aim in this retrospective cohort study was to review the available literature, ensure the safety of our practice and determine if the platelet count had any influence on the rate of traumatic LP performed. We report a review of 54 consecutive paediatric patients, 29 male and 25 female, age range 3 months to 17 years (median 7 years), with haematological malignancy who underwent a total of 738 LP procedures at Royal Manchester Children's Hospital between March 2001 and June 2005. All patients underwent LP and intrathecal chemotherapy under general anaesthetic conditions and procedures were performed by experienced clinicians (Consultant or Specialist registrar) according to the national guidelines. Patients underwent between 1 and 25 (median 11) procedures LPs from diagnosis. For each LP, the platelet count and number of red blood cells (RBCs) within CSF was recorded. Traumatic LP was defined as an LP in which cerebral fluid contained at least 10 RBCs/μl and bloody LP which the CSF contained at least 500 RBCs/μl. Of the 738 LPs performed, 65 (9%) were traumatic and 30 (4%) were bloody. No bleeding or neurological complications observed in any of the patients. Regression curve analysis showed no correlation with platelet count and red cell count in the CSF (R2 = 0.004). There appeared to be no increase in the incidence of traumatic or bloody taps in patients with a lower pre-procedure platelet count (Fig 1). Incidence of traumatic and bloody taps dependant on platelet count (×109/l). Within this cohort of patients with platelet count <50 × 109/l we observed no bleeding complications, and no increase in traumatic or bloody CSF. These findings support previous published data. These results indicate a significantly less traumatic rate than previously reported (Howard et al, 2000). At our institute we attribute the low rate of red cell contamination to experienced clinicians, dedicated general anaesthetic lists, and specific LP 24-guage needles. This study and existing evidence in the literature would support the safety of performing LPs with platelet counts ≥30 × 109/l. This policy enabled 27 of 738 patients (3.6%) to avoid a platelet transfusion, and thus reduced donor exposure, platelet-associated infections, delay in procedure, as well as reducing costs and making better use of platelet resources.

Continuous Suction Method in Superficial Temporal Artery-Middle Cerebral Artery Anastomosis Surgery-Technical Note-

A new method was developed to maintain a bloodless microscopic operative field for superficial temporal artery-middle cerebral artery (MCA) anastomosis surgery. A silicone suction tube with multiple holes is placed circumferentially under the reflected dural flaps around the craniotomy. Blood and irrigated saline are continuously aspirated by the tube. Use of this method in nine patients significantly reduced the mean MCA trapping time (24.0 +/- 2.8 min) compared with nine patients treated using the conventional method (30.1 +/- 4.6 min). MCA trapping time is shortened because the surgery is not interrupted for manual suctioning of bloody cerebrospinal fluid.

Postoperative Rupture of an Untreated Aneurysm on the 3rd Day After Subarachnoid Hemorrhage Surgery-Case Report-

A 58-year-old male presented with severe consciousness disturbance and left hemiparesis. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) and acute subdural hematoma caused by a ruptured right middle cerebral artery aneurysm. The aneurysm was clipped and the hematoma was evacuated. The patient had almost recovered without new neurological deficits on the next day. Arterial systolic blood pressure was postoperatively controlled within 120 to 150 mmHg. Continuous ventricular and cisternal drainage from the level 10 cm above the external auditory meatus was performed to drain bloody cerebrospinal fluid and prevent vasospasm. Three days after surgery, the patient suddenly lapsed into a coma. CT demonstrated diffuse SAH and bilateral intraventricular hemorrhage caused by rupture of an anterior communicating artery aneurysm. Neck clipping was performed immediately. Unfortunately, the patient died of primary damage due to SAH 3 days after the second surgery. In this case, cisternal drainage was probably important in the aneurysm rupture because of decreased intracranial pressure and change in the perianeurysm environment. Postoperative management of patients with residual untreated aneurysms must consider the possibility that cisternal drainage may result in higher transmural pressure, leading to rupture of the untreated aneurysms.