Cerebrospinal Fluid Red Blood Cell Research Articles

Pro-inflammatory cerebrospinal fluid profile of neonates with intraventricular hemorrhage: clinical relevance and contrast with CNS infection.

Interpretation of cerebrospinal fluid (CSF) studies can be challenging in preterm infants. We hypothesized that intraventricular hemorrhage (IVH), post-hemorrhagic hydrocephalus (PHH), and infection (meningitis) promote pro-inflammatory CSF conditions reflected in CSF parameters. Biochemical and cytological profiles of lumbar CSF and peripheral blood samples were analyzed for 81 control, 29 IVH grade 1/2 (IVH1/2), 13 IVH grade 3/4 (IVH3/4), 15 PHH, 20 culture-confirmed bacterial meningitis (BM), and 27 viral meningitis (VM) infants at 36.5 ± 4weeks estimated gestational age. PHH infants had higher (p < 0.02) CSF total cell and red blood cell (RBC) counts compared to control, IVH1/2, BM, and VM infants. No differences in white blood cell (WBC) count were found between IVH3/4, PHH, BM, and VM infants. CSF neutrophil counts increased (p ≤ 0.03) for all groups compared to controls except IVH1/2. CSF protein levels were higher (p ≤ 0.02) and CSF glucose levels were lower (p ≤ 0.003) for PHH infants compared to all other groups. In peripheral blood, PHH infants had higher (p ≤ 0.001) WBC counts and lower (p ≤ 0.03) hemoglobin and hematocrit than all groups except for IVH3/4. Similarities in CSF parameters may reflect common pathological processes in the inflammatory response and show the complexity associated with interpreting CSF profiles, especially in PHH and meningitis/ventriculitis.

Subarachnoid haemorrhage or traumatic lumbar puncture. Differentiation by cerebrospinal fluid parameters in a multivariable approach

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.

Lower initial red blood cell count in cerebrospinal fluid predicts good functional outcome in patients with spontaneous subarachnoid haemorrhage.

Red blood cell (RBC) degradation after subarachnoid haemorrhage (SAH) negatively affects functional outcome. Although the detection of RBCs in the cerebrospinal fluid (CSF) is a widely available part of neurological routine diagnostics, the prognostic value as a biomarker remains unclear. This study was undertaken to investigate whether CSF RBC count correlates with established radiological markers of SAH volume and whether the CSF RBC count can predict functional outcome in SAH patients. A total of 121 consecutive spontaneous SAH patients were retrospectively analyzed. CSF was collected from external ventricular drain as part of routine diagnostic procedures. We used multivariable binary logistic regression to investigate associations between CSF RBC counts and functional outcome 3 months after SAH or hospital survival. Good functional outcome was defined as modified Rankin Scale ≤ 2. Patients' age was 60 ± 14 years, and the median admission Hunt & Hess grade (H&H) was 4. CSF samples were collected 2 days after intensive care unit admission. High CSF RBC counts positively correlated with radiological measurements for SAH volume, for example, modified Fisher score (p = 0.002) and Hijdra ventricle score (p = 0.016). Multivariable regression analysis adjusted for age, H&H grade, modified Fisher and Hijdra scores showed that low CSF RBC counts predicted hospital survival (per 100,000 CSF RBCs: adjusted odds ratio [adjOR] = 0.74, 95% confidence interval [CI] = 0.61-0.89, p = 0.001) and good functional outcome after 3 months (per 100,000 CSF RBC: adjOR = 0.76, 95% CI = 0.60-0.96, p = 0.020). CSF RBC counts correlate with radiographic scores quantifying SAH volume and may serve as an early independent biomarker for hospital survival and good functional 3-month outcome in patients requiring ventriculostomy after SAH.

Reference range for cerebrospinal fluid values in neonates: 5-year retrospective study

Background Cerebro spinal fluid (CSF) parameters (white blood cell count, protein, glucose) in the diagnosis of neonatal bacterial meningitis Objectives To report the reference range of CSF parameters (white blood cell count, protein, glucose) in both term and preterm infants. Methods This was a single center retrospective study over a period of 5 years (2015–2020). We included infants aged 0–3 months admitted to the neonatal unit and infants ≤28 days attending pediatric acute care and who underwent Lumbar Puncture. We excluded infants with evidence of CSF bacteremia, viral infection and traumatic lumbar puncture defined as CSF Red Blood Cell >500 cells/µL. Clinical, demographic, and microbiological data were collected from the hospital database. The study was approved by ethics committee. Results We identified a total of 518 CSF samples, with 232 CSF samples available for final analysis. 54% of excluded samples were traumatic. Median birth gestation and birth weight of the study cohort were 38 (IQR 35–40) weeks and 3030 (IQR 1965–3565) grams respectively. Median RBC, WBC count, protein and glucose were 15 (IQR 3–85)/µL, 3(IQR 0–8.5)/µL, 0.72 (0.53–1.06) g/L and 2.8 (2.4–3.3) mmol/L respectively. There was no difference in CSF WBC cell count between preterm and term infants. Higher CSF protein content was noted in preterm infants and infants in the first 7 days of life. Use of antibiotics prior to LP was associated with higher CSF protein. Presence of any CSF RBC (including <500 cells/µL) influenced the CSF WBC count and protein content. Conclusion We have provided a reference range of CSF parameters in neonates without meningitis. CSF WBC count between preterm and term infants were similar with higher CSF protein content in preterm infants and for infants in the first seven days of life. Presence of any CSF RBC influenced CSF parameters.

Interpretation of white blood cell counts in the cerebrospinal fluid of neonates with traumatic lumbar puncture: a retrospective cohort study

BackgroundDifficulty in interpreting white blood cell (WBC) counts in cerebrospinal fluid (CSF) complicates the diagnosis of neonatal meningitis in traumatic lumbar punctures (LP). The aim of our study was to determine the correction factor for WBC counts in traumatic LP that offers the greatest diagnostic efficacy in meningitis.MethodsWe conducted a retrospective observational study of LP in neonates between January 2014 and December 2020. Traumatic LP was defined as a red blood cell (RBC) count ≥ 1,000 cells/mm3 CSF and pleocytosis as WBCs ≥ 20 cells/mm3 CSF. The CSF RBC:WBC ratio was analyzed by linear regression to determine a new correction factor. Cell count adjustments were also studied using the 500:1, the 1,000:1 ratio method, and the peripheral blood RBC:WBC ratio, using ROC curves and studies of accuracy (sensitivity and specificity).ResultsOverall, 41.0% of the 1,053 LPs included in the study were traumatic. The best results for effective WBC correction were the method based on the peripheral blood ratio (sensitivity = 1.0 and specificity = 0.9 for bacterial meningitis and sensitivity = 0.8 and specificity = 0.9 for viral meningitis) and the 400:1 ratio (sensitivity = 1.0 and specificity = 0.8 for bacterial meningitis and sensitivity = 0.8 and specificity = 0.8 for viral meningitis) obtained from linear regression (95% CI 381.7–427.4; R2 = 0.7).ConclusionBoth the peripheral blood correction and the 400:1 correction reduce the number of neonates classified with pleocytosis who were not eventually diagnosed with meningitis. Both methods might be a useful tool to clarify the neonatal meningitis diagnosis, offering neonatologists the possibility to assess the WBC count in traumatic LP.

The Champagne Tap: Time to Pop the Cork?

A "champagne tap" is a lumbar puncture with no cerebrospinal fluid (CSF) red blood cells (RBCs). Clinicians disagree whether the absence of CSF white blood cells (WBCs) is also required. As supervising providers frequently reward trainees after a champagne tap, we investigated how varying the definition impacted the frequency of trainee accolades. We performed a secondary analysis of a retrospective cross-sectional study of infants ≤60days of age who had a CSF culture performed in the emergency department (ED) at one of 20 centers participating in a Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) endorsed study. Our primary outcomes were a champagne tap defined by either a CSF RBC count of 0cells/mm3 regardless of CSF WBC count or both CSF RBC and WBC counts of 0cells/mm3 . Of the 23,618 eligible encounters, 20,358 (86.2%) had both a CSF RBC and WBC count obtained. Overall, 3,147 (13.3%) had a CSF RBC count of 0cells/mm3 and 377 (1.6%) had both CSF WBC and RBC counts of 0cells/mm3 (relative rate 8.35, 95% confidence interval 7.51 to 9.27). In infants, a lumbar puncture with a CSF RBC count of 0cells/mm3 regardless of the CSF WBC count occurred eight-times more frequently than one with both CSF WBC and RBC counts of 0cells/mm3 . A broader champagne tap definition would allow more frequent recognition of procedural success, with the potential to foster a supportive community during medical training, potentially protecting against burnout.

Cerebrospinal fluid immunoglobulins are increased in neonates exposed to Zika virus during foetal life

ObjectiveTo compare immunoglobulin levels in cerebrospinal fluid (CSF) of neonates exposed to Zika virus (ZIKV) during foetal life (cases) with levels in CSF of control neonates. MethodsWe identified 16 neonates who underwent lumbar puncture (LP), during the ZIKV epidemic (December/2015 to March/2016) whose mothers reported ZIKV clinical symptoms during gestation (cases). Congenital microcephaly was defined as head circumference ≤31.9 cm (boys) and ≤31.5 cm (girls) for term neonates, or ≤2 standard deviations below the mean for premature (<37 weeks) neonates. Subsequently, we identified neonates who underwent LP in the same lab and fulfilled criteria to be controls: age ≤4 days, CSF white blood cell count ≤8/mm3, CSF protein ≤132 mg/dL, CSF red blood cell count ≤1,000/mm3, neither central nervous system illness, nor congenital infection, nor microcephaly. CSF immunoglobulin concentrations were measured by mass spectrometry. Results13 controls were included. IgM, IgA, IgG, IgK, and IgL were significantly higher among cases (p < 0.001). Eight (50%) ZIKV exposed infants had congenital microcephaly. These showed the strongest immunoglobulin elevation of the IgM and IgA classes. ConclusionNeonates exposed to ZIKV infection during gestation present with elevated distinct immunoglobulins in CSF, both in cases that developed microcephaly and in cases that did not.

Elevated Cerebrospinal Fluid Protein Is Associated with Unfavorable Functional Outcome in Spontaneous Subarachnoid Hemorrhage

Background/objective: Subarachnoid hemorrhage (SAH) is a devastating neurologic event for which markers to assess poor outcome are needed. Elevated cerebrospinal fluid (CSF) protein may result from inflammation and blood-brain barrier (BBB) disruption that occurs during SAH. We sought to determine if CSF protein level is associated with functional outcome after SAH. Methods: We prospectively collected single-center demographic and clinical data for consecutive patients admitted with spontaneous SAH. Inclusion required an external ventricular drain and daily CSF protein and cellular counts starting within 48 hours of symptom onset and extending through 7 days after onset. Seven-day average CSF protein was determined from daily measured values after correcting for contemporaneous CSF red blood cell (RBC) count. Three-month functional outcome was assessed by telephone interview with good outcome defined as modified Rankin score 0-3. Variables univariately associated with outcome at P less than .25 and measures of hemorrhage volume were included for binary logistic regression model development. Results: The study included 130 patients (88% aneurysmal SAH, 69% female, 54.8 ± 14.8 years, Glasgow Coma Scale [GCS] 14 [7-15]). Three-month outcome assessment was complete in 112 (86%) patients with good functional outcome in 74 (66%). CSF protein was lower in good outcome (35.3 [20.4-49.7] versus 80.5 [40.5-115.5] mg/dL; P < .001). CSF protein was not associated with cerebral vasospasm, but delayed radiographic infarction on 3 to 12-month neuroimaging was associated with higher CSF protein (46.3 [32.0-75.0] versus 30.2 [20.4-47.8] mg/dL; P = .023). Good 3-month outcome was independently associated with lower CSF protein (odds ratios [OR] .39 [.23-.70] for 75th versus 25th percentile of protein; P = .001) and higher admission GCS (OR 1.23 [1.10-1.37] for good outcome per GCS point increase; P < .001). Parenchymal hematoma predicted worse outcome (OR 6.31 [1.58-25.25]; P = .009). Results were similar after excluding nonaneurysmal SAH and after including CSF RBC count, CT score, and intraventricular hemorrhage volume in models. Conclusions: Elevated average CSF protein is associated with poor outcome after spontaneous SAH. Further research should investigate if elevated CSF protein identifies patients in whom mechanisms such as BBB disruption contribute to poor outcome.

Cerebrospinal Fluid Profiles of Infants ≤60 Days of Age With Bacterial Meningitis.

We aimed to describe the cerebrospinal fluid (CSF) profiles of infants ≤60 days old with bacterial meningitis and the characteristics of infants with bacterial meningitis who did not have CSF abnormalities. We included infants ≤60 days old with culture-positive bacterial meningitis who were evaluated in the emergency departments of 11 children's hospitals between July 1, 2011, and June 30, 2016. From medical records, we abstracted clinical and laboratory data. For infants with traumatic lumbar punctures (CSF red blood cell count of ≥10 000 cells per mm3), we used a red blood cell count/white blood cell (WBC) count correction factor of 1000:1 to determine the corrected CSF WBC count. We calculated the sensitivity for bacterial meningitis of a CSF Gram-stain and corrected CSF pleocytosis (≥16 WBCs per mm3 for infants ≤28 days old and ≥10 WBCs per mm3 for infants 29-60 days old). Among 66 infants with bacterial meningitis, the sensitivity of a CSF Gram-stain was 71.9% (95% confidence interval [CI]: 59.2-82.4), and the sensitivity of corrected CSF pleocytosis was 80.3% (95% CI: 68.7-89.1). The sensitivity of combining positive Gram-stain results with corrected CSF pleocytosis was 86.4% (95% CI: 75.7-93.6). Of 9 infants with meningitis who had a negative Gram-stain result and no corrected CSF pleocytosis, 8 (88.9%) had either an abnormal peripheral WBC count (>15 000 or <5000 cells per μL) or bandemia >10%. Most infants ≤60 days old with bacterial meningitis have CSF pleocytosis or a positive Gram-stain result. Infants with no CSF pleocytosis and a negative Gram-stain result are unlikely to have bacterial meningitis in the absence of other laboratory abnormalities.

Assessment of Diagnostic Yield of Nonculture Infection Testing on Cerebrospinal Fluid in Immune-Competent Children

Nonculture infection tests of cerebrospinal fluid (CSF) samples using polymerase chain reaction and antigen or antibody assays are frequently ordered on lumbar puncture specimens concurrently with routine CSF cell counts, but the value of CSF infection testing in otherwise healthy children is unknown. To determine the value of nonculture CSF infection testing in immune-competent children with normal CSF cell counts. This cross-sectional study reviewed screening and diagnostic tests in the electronic medical record system of a large academic tertiary care children's hospital. Records of children aged 0.5 to 18.9 years (n = 4083) who underwent lumbar puncture (n = 4811 procedures) in an inpatient or outpatient facility of Children's Hospital of Philadelphia between July 1, 2007, and December 31, 2016, were reviewed. Those with indwelling CSF shunts or catheters; those with active or past oncologic, immunologic, or rheumatologic conditions; or those taking immune-suppressing medications were excluded from analysis. This study was conducted from July 20, 2017, to March 13, 2019. Outcome variables included frequency of nonculture CSF infection testing and frequency of positive results in the entire cohort, and among those with normal cell counts. Normal cell counts were defined as CSF white blood cell counts lower than 5 cells/μL and CSF red blood cell counts lower than 500 cells/μL. In total, 4811 lumbar puncture procedures were performed on 4083 unique children, with a median (range) age of 7.4 (0.5-18.9) years, 2537 boys (52.7%), and 3331 (69.2%) with normal CSF cell counts. At least 1 nonculture CSF infection test was performed on 1270 lumbar puncture specimens with normal cell counts (38.1%; 95% CI, 36%-40%), and more tests were performed in the summer months. Only 18 (1.4%; 95% CI, 0.9%-2.2%) of 1270 lumbar puncture specimens with normal cell counts had at least 1 nonculture infection test with a positive result; 2 of these 18 children required clinical intervention for their positive results, but each also had other clear clinical signs of infection. Nonculture CSF infection testing appeared to be common in immune-competent children with normal CSF cell counts, but positive results were uncommon and were not independently associated with clinical care; delaying the decision to send nonculture infection tests until CSF cell counts are available could reduce unnecessary diagnostic testing and medical costs, which may improve value-based care.

Abstract WMP107: Cerebrospinal Fluid Leukocyte Subtypes After Intraventricular Hemorrhage: An Analysis of the CLEAR-III Trial

Background: Intracerebral hemorrhage (ICH) results in significant mortality and morbidity and initiates a cascade of inflammatory cell activation. Leukocyte subtypes have different effects, with monocytes contributing to increased hematoma expansion and mortality and neutrophils decreasing hematoma expansion. However, the response of cerebrospinal fluid (CSF) leukocytes to ICH with IVH has not been investigated. Methods: We retrospectively analyzed CSF and serum leukocyte counts from patients enrolled in CLEAR-III. After correction for CSF red blood cell (RBC) counts, data were plotted chronologically. Linear mixed-effects models were used to assess the differences in leukocyte subtypes after intraventricular saline or alteplase. Generalized linear models are being created to assess the relationship between CSF leukocyte subtypes and IVH volumes and 30, 60, 90, and 180-day outcomes. Results: Data were available for 237 and 228 patients in the saline and alteplase groups, respectively. Serum total white blood cell (WBC) and neutrophil counts increased after ICH, peaking at two days. Significant increases occurred in serum monocyte and lymphocyte counts, peaking at 6 and 10 days, respectively. Intraventricular alteplase had no effect on serum leukocyte counts. Peak CSF leukocyte counts occurred on day 1 after IVH (pretreatment) in the saline group. However, intraventricular alteplase resulted in a significant increase in WBC ( P =0.0001), neutrophil ( P =0.0003), monocyte ( P =0.0064), and lymphocyte counts ( P= 0.0339), peaking two days after starting treatment. No significant associations between peak serum or CSF cell counts and 30, 180, and 365 day modified Rankin Scale were found. Conclusions: ICH drives an increase in serum leukocyte counts. Intraventricular alteplase results in an increase in all CSF leukocyte subtypes. Further work will be presented on the complex interactions between leukocyte counts, ICH severity, and outcomes.

Validation of Mycobacterium tuberculosis real-time polymerase chain reaction for diagnosis of tuberculous meningitis using cerebrospinal fluid samples: a pilot study

Background Timely diagnosis of tuberculous meningitis (TBM) remains challenging. Molecular diagnostic tools are necessary, particularly in low- and middle-income countries. There is no approved commercial polymerase chain reaction (PCR) assay that can be used to detect Mycobacterium tuberculosis in non-respiratory samples, such as the cerebrospinal fluid (CSF). We aimed to validate the threshold cycle (Ct) cut-off points; calculate the operational characteristics of real-time PCR for detection of M. tuberculosis (MTb qPCR) in the CSF; and the inhibitory affect of CSF red blood cells (RBC) and total proteins on MTb qPCR. Methods A total of 334 consecutive participants were enrolled. Based on clinical, laboratory and imaging data, cases of suspected TBM were categorized as definite, probable, possible or not TBM cases. Receiver operating characteristic curve analysis was used to select the best discriminating Ct value. Results For TBM cases categorized as definite or probable (n=21), the Ct validated for CSF (≤39.5) improved the diagnostic performance of MTb qPCR on CSF samples. The sensitivity was 29%, specificity was 95%, positive predictive value was 26%, negative predictive value was 95%, efficiency was 90% and positive likelihood was 5.3. The CSF RBC and total protein did not affect the positivity of the MTb qPCR. Conclusions These data support the validation of a highly specific but low sensitive MTb qPCR assay for the TBM diagnosis using CSF samples. MTb qPCR contributes significantly to the diagnosis, mainly when associated with conventional microbiology tests and clinical algorithms.

Cerebrospinal fluid:serum glucose ratio in the ventricular and lumbar compartments: implications for clinical practice.

Calculation of the cerebrospinal fluid:serum glucose (CSF:SGlu ) ratio is part of the routine cerebrospinal fluid (CSF) work-up. Reference values have been defined for lumbar CSF, but are lacking for ventricular CSF. The objective of this study was to investigate whether the CSF:SGlu ratio is similar in lumbar and ventricular compartments, and to determine cut-off values for CSF:SGlu ratio in ventricular CSF. We included CSF samples that were collected by either lumbar puncture or ventricular drainage, with a red blood cell count <500/μL, normal white blood cell count and age-related normal total protein content, with simultaneously withdrawn serum sample and time to laboratory processing of ≤2 h. This resulted in 1808 sample pairs. Glucose concentrations in CSF and serum were measured by enzymatic spectrophotometry. The CSF:SGlu ratio was similar in ventricular and lumbar compartments after controlling for age, sex, time between sample withdrawal and laboratory processing, CSF white blood cell and red blood cell count, CSF total protein and serum glucose concentration using a multiple linear regression model. Lower limits for CSF:SGlu ratio in the ventricular compartment, defined as 5th percentile, were 0.51 for patients with serum glucose concentration < 100 mg/dL, 0.45 for those with serum glucose concentration ≥ 100 mg/dL and <150 mg/dL, and 0.36 for those with serum glucose concentration ≥150 mg/dL. The CSF:SGlu ratio was similar in the ventricular and lumbar compartments, and depended mainly on time to laboratory processing and absolute serum glucose levels. Previously established lower limits for CSF:SGlu ratio in lumbar CSF can be also applied for ventricular CSF.

Prevalence of Concomitant Acute Bacterial Meningitis in Neonates with Febrile Urinary Tract Infection: A Retrospective Cross-Sectional Study

To describe the frequency of concomitant acute bacterial meningitis (ABM) in neonates with febrile urinary tract infection (UTI). This was a retrospective cross-sectional study from 2005 to 2013 of infants ≤30 days old evaluated in the emergency department of a quaternary care children's hospital with fever and laboratory-confirmed UTI. Definite ABM was defined as cerebrospinal fluid (CSF) culture with growth of pathogenic bacteria and probable ABM if pleocytosis with ≥ 20 white blood cell was present in an antibiotic-pretreated patient. The timing of lumbar puncture and first antibiotic dose was recorded to assess for antibiotic pretreatment. A total of 236 neonates with UTI were included. Mean age was 18.6 days (SD 6.2); 79% were male infants. Twenty-three (9.7%) had bacteremia. Fourteen (6%) were pretreated. No neonate (0%; 95% CI 0%-1.6%) had definite ABM and 2 (0.8%; 95% CI 0.1%-3.0%) neonates with bloody CSF had probable ABM. CSF white blood cell count was 25 and 183 for these 2 infants, and CSF red blood cell count was 3100 and 61 932, respectively. Another neonate had herpes simplex virus meningoencephalitis. The frequency of ABM in neonates with febrile UTI is low. Further prospective studies are needed to evaluate the safety of a tiered approach to evaluate for serious bacterial infection, in which lumbar puncture potentially could be avoided in well-appearing febrile neonates with suspected UTI.

Red blood cells in cerebrospinal fluid as possible inhibitory factor for enterovirus RT-PCR.

The presence of hemoglobin in samples are considered an important inhibitory factor for polymerase chain reaction (PCR). The aim of this study was to examine the influence of red blood cells (RBC)s in cerebrospinal fluid (CSF) as an inhibitory factor to reverse transcription polymerase chain reaction (RT-PCR) for enteroviruses (EV). Forty-four CSF samples from patients showing characteristics of viral meningitis were assessed for EV by RT-PCR. Viral RNA extracted with guanidine isothyocianate buffer and virus detection was performed by in-house nested PCR. Positivity for EV RT-PCR was higher in CSF samples without RBCs than in samples with RBCs: 13(26%) and 36(9.2%), p = 0.001. In the group with positive EV RT-PCR, the mean + SD CSF RBC was 37 ± 183 cell/mm3; the group with negative results had 580 + 2,890 cell/mm3 (p = 0.007). The acceptable upper limit for CSF RBCs that could not influence RT-PCR was 108 cells/mm3. CSF samples with negative results for EV RT-PCR have more erythrocytes.

Validation of cerebrospinal fluid findings in aneurysmal subarachnoid hemorrhage

BackgroundRecently proposed cutoff criteria for cerebrospinal fluid (CSF) analyses might safely exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). ObjectiveThe objective of this study was to examine the sensitivity of a CSF red blood cell (RBC) count greater than 2000 × 106/L (ie, 2000 RBCs per microliter) or the presence of visible CSF xanthochromia in identifying patients with aSAH. MethodsWe identified a retrospective case series of patients diagnosed with aSAH after lumbar puncture (LP) in an integrated health delivery system between January 2000 and June 2013 by chart review. All identified patients had at least 1 cerebral aneurysm that was treated with a neurosurgical or endovascular intervention during the index hospitalization. The lowest CSF RBC count was used for validation analysis. Cerebrospinal fluid color was determined by visual inspection. Xanthochromia was defined as pink, orange, or yellow pigmentation of CSF supernatant. ResultsSixty-four patients met study inclusion criteria. Of these, 17 (33%) of 52 underwent LP within 12 hours of headache onset, and 49 (84%) of 58 exhibited CSF xanthochromia. The median CSF RBC count was 63250 × 106/L. The sensitivity of a CSF RBC count of greater than 2000 × 106/L in identifying aSAH was 96.9% (95% confidence interval, 89.3%-99.1%). Additional consideration of CSF xanthochromia resulted in a sensitivity of 100% (95% confidence interval, 94.3%-100%). ConclusionsAll patients in this case series of patients with aSAH had either a CSF RBC count greater than 2000 × 106/L or visible CSF xanthochromia, increasing the likelihood that this proposed cutoff strategy may safely identify patients who warrant further investigation for an aneurysmal cause of subarachnoid hemorrhage.

The Effect of Traumatic Lumbar Puncture on Hospitalization Rate for Febrile Infants 28 to 60 Days of Age

The authors measured the effect of a traumatic or unsuccessful lumbar puncture (LP) on the management of febrile infants. This was a 10-year retrospective cross-sectional study of low-risk infants by the "Boston" criteria 28 to 60days of age presenting to the emergency department for evaluation of fever. "Normal LP" infants had cerebrospinal fluid (CSF) WBC < 10×10(6) cells/L. "Traumatic" or "unsuccessful LP" infants had CSF red blood cell count ≥ 10×10(9) cells/L or no CSF cell counts obtained, respectively. A serious bacterial infection (SBI) was defined as growth of a bacterial pathogen from culture. The hospitalization and SBI rates were compared between infants with normal versus traumatic or unsuccessful LPs. Of the 929 study infants, 756 (81.4%) had normal LPs, and 173 (18.6%) had traumatic or unsuccessful LPs. Infants with traumatic or unsuccessful LPs had a higher hospitalization rate (72.3% traumatic or unsuccessful LP vs. 18.1% normal LP; difference= 54.1%; 95% confidence interval [CI] = 46.4% to 60.8%), but a similar SBI rate (2.9% vs. 4.1%; difference= 1.2%; 95% CI = -2.7% to 3.6%). No infant had proven bacterial meningitis (0% risk, 95% CI = 0 to 0.3%). Low-risk infants aged 28 to 60days with traumatic or unsuccessful LPs are more frequently hospitalized, although SBI rates were similar to those of infants with normal LPs.

Analysis of infant lumbar puncture success rates: sitting flexed versus lateral flexed positions.

The primary objective was to determine whether the sitting flexed position yields higher success rates of obtaining cerebrospinal fluid (CSF) for culture. The secondary objectives were to determine whether the sitting flexed position yields higher success rates of obtaining the following: CSF for cell count, non-traumatic CSF, and CSF on the first attempt. The study investigator performed a retrospective chart review of infants 0 to 365 days of age who had a lumbar puncture (LP) performed from January 1 to December 31 of 2010. Data on the LP position and the number of attempts were abstracted from procedure notes. Twenty-one LPs were excluded because of incomplete data on LP position and/or number of attempts. Spinal fluid count results were obtained from electronic medical records. Non-traumatic LPs were defined in 2 categories: CSF red blood cell counts of 500 cells per cubic millimeter or less and 10,000 cells per cubic millimeter or less. One hundred thirty-two LPs were included: 30 sitting flexed and 102 lateral flexed. There were no differences in success rates between positions for the primary objective of obtaining CSF for culture and the secondary study objectives of obtaining CSF for cell count and non-traumatic CSF. A significant secondary objective was that operators who performed the LP in the sitting flexed position were more likely to obtain CSF on the first attempt (odds ratio, 2.74; confidence interval, 1.17-6.45). The sitting flexed position was as successful as the lateral flexed position in the primary objective of obtaining CSF for culture and the secondary objectives of obtaining CSF for cell count and non-traumatic CSF. For the secondary objective of obtaining CSF on the first attempt, the sitting flexed position was associated with a higher rate of obtaining CSF on the first attempt in infants younger than 12 months.

Impact of Herpes simplex virus load and red blood cells in cerebrospinal fluid upon herpes simplex meningo-encephalitis outcome.

BackgroundHerpes simplex encephalitis (HSE) often leads to severe disability or death. Factors usually associated with outcome include Simplified Acute Physiology Score, age and delay of initiation of acyclovir treatment.Our aim was to determine the impact of Herpes simplex virus (HSV) load in cerebrospinal fluid (CSF) upon HSE outcome.MethodsWe retrospectively determined HSV load in the CSF of 43 patients with confirmed HSE, hospitalized in northern France from 1998 to 2005, using CSF samples collected the day of hospital admission and stored at −20°C. We analyzed the association between HSV load and mortality/morbidity by the Glasgow Outcome Scale. Fisher’s exact test and Wilcoxon’s test were used for statistical analysis.ResultsThe M/F sex ratio was 1.7 and median patient age was 61 years. Median HSV load in CSF was 2.0 log copies/μL (IQR 25-75=1.2-2.6). The mortality rate was 32.6% six months after HSE diagnosis. Higher age was associated with mortality (p=0.03). Longer delay in acyclovir initiation tended to be associated with higher mortality but did not reach statistical significance (p=0.08). Severe disability and death due to HSV were associated with a higher Knaus score (p=0.004), later acyclovir initiation (p=0.006), older age (p=0.04) and presence of red blood cells in CSF (p=0.05). HSV load in CSF was neither associated with mortality (p=1.00) nor with morbidity (p=0.90).ConclusionIn this study, HSV load in CSF was not found to be associated with poor outcome in patients with HSE. These data do not support measurement of HSV load at admission in patients with HSE.

564 Autoimmune Encephalopathy Nine Year Old Boy with No History of Interest

Background and AimsNine year old boy admitted with meningeal syndrome. six days ago began with fever being treated with azithromycin. three days before entering a high fever, bilious vomiting, no...