Diagnostic Lumbar Puncture Research Articles

Serum total cholesterol correlates positively to central serotonergic turnover in male but not in female subjects

Reduced central serotonergic activity and low total serum cholesterol have been related to increased aggression, violent behavior, and suicidality. Searching for a correlation between them, we estimated serum total cholesterol and CSF levels of the main serotonin metabolite 5-HIAA in medication free male and female subjects for whom diagnostic lumbar puncture was performed. To eliminate age influence, we included in the study subjects in the age range 26 to 45 years. In a group of 62 subjects (30 males), found negative after diagnostic neurological examination, the correlation was not significant for the whole group, but after sex stratification, a significant positive correlation was revealed for males but not for females. These results were replicated in a second group of 76 subjects (31 males) with clinical and laboratory findings suggestive of multiple sclerosis (clinically isolated syndrome). The results link low cholesterol to low serotonergic activity only in males, predisposing them for violent and risky behaviors. This phenomenon could be seen as an evolutionary trait, possibly a result of the distinct role of males in a hunter–gatherer environment of evolutionary adaptedness, and may contribute to the understanding of the higher incidence of violent behavior observed in males.

Carcinomatous infiltration of cerebrospinal fluid with reactive lymphocytosis and granulocytosis

Hematologists are frequently involved with morphological analysis of centrifuged cerebrospinal fluid (CSF) for the diagnosis of malignant infiltration of the central nervous system (CNS). Although malignant cells in the CSF are most often due to underlying hematological cancers, leptomeningeal carcinomatous infiltration from a solid tumor is not uncommon. A 46-year-old lady presented with focal neurological signs suggestive of cauda equina compression. She was on adjuvant therapy for invasive ductal carcinoma of breast with expression of human epidermal growth factor receptor-2 (HER-2). MRI scan confirmed a metastatic deposit in the conus medullaris with tumor nodules in the cauda equina and diffuse meningeal enhancement. Clear CSF was obtained from a diagnostic lumbar puncture and microscopy showed the presence of 50/mm3 white cells and 10/mm3 red cells, with no evidence of infection. A centrifuged cytospin preparation of CSF stained with May-Grunwald-Giemsa (MGG) showed numerous small lymphocytes, neutrophils, metamyelocytes, and metastatic breast carcinoma cells (Image 1). The latter cells were much larger than the hematological cells, with homogeneous nuclei containing open chromatin and abundant cytoplasm with prominent blebs from the cell surface (Image 1). Six large metastatic carcinoma cells on a background of hematological cells including two neutrophils (bottom left), a metamyelocyte (top right), and numerous small lymphocytes (MGG stained CSF cytospin; ×40). HER-2 positive breast cancers are known to carry a higher risk for CNS metastasis [1]. The presence of lymphocytosis and granulocytosis in this nonhemorrhagic CSF is a likely localized inflammatory response to metastasis from the breast carcinoma.

Central nervous system involvement at the time of presentation in acute promyelocytic leukemia

Central nervous system (CNS) involvement is rarely observed in acute promyelocytic leukemia (APML). Most cases of CNS involvement occur at relapse rather than at presentation. Because of the extremely low incidence of CNS disease, diagnostic lumbar puncture is not routinely required and prophylactic intrathecal chemotherapy is not routinely administered. Here, we describe a teenage patient with newly diagnosed APML, chloromas, and symptomatic CNS involvement confirmed by MRI and cerebrospinal fluid (CSF) findings.

CSF phospho-tau is independent of age, cognitive status and gender of neurological patients

CSF phospho-tau (p-tau(181)) levels have shown good diagnostic utility in differential diagnosis of Alzheimer disease (AD). Unlike total-tau (t-tau), age related changes of this promising biomarker are sparsely studied. The aim of the study was to determine whether p-tau(181) is dependent on age, cognitive status or gender in patients with different neurological diseases who underwent diagnostic lumbar puncture and who had no clinical evidence of neurodegenerative diseases. CSF levels of p-tau(181) and total-tau (t-tau) of 46 neurologic patients (age range 22-89 years; 22 male, 24 female) were analyzed. Clinical diagnoses were cerebral ischaemia (n = 6), multiple sclerosis (n = 13), epileptic seizures (n = 3), polyneuropathy (n = 9) and other neurological diagnoses (n = 15). Cognitive performance was assessed by the German version of the CERAD battery. The mean level of p-tau(181) was in accordance with previous findings in neurological patients (42.8 +/- 15.3 pg/ml) and did not differ between neurological diseases. In contrast to t-tau (r = 0.38; P = 0.009), p-tau(181) did not correlate significantly to age (r = 0.15; P = 0.308). No influence of cognitive status or gender on p-tau(181) levels could be detected. The study corroborates the independence of p-tau(181) from age, cognitive status, gender and a wide spectrum of neurological diseases. The findings suggest that neither age related neurodegenerative processes nor ischaemic or inflammatory processes are accompanied by tau protein phosphorylation. In contrast, the data support the view that p-tau(181) seems to be a sign of the highly AD-specific pattern of tau phosphorylation during formation of neurofibrillary tangles.

UNUSUAL LEPTOMENINGEAL DISSEMINATION IN A CHILD WITH EXTRACRANIAL METASTATIC ALVEOLAR RHABDOMYOSARCOMA

The authors describe a 6-year-old boy diagnosed with alveolar rhabdomyosarcoma located in the thigh, with distal metastases to lungs, bones, and bone marrow. A very good partial response to first-line chemotherapy was obtained, but the child developed fatal leptomeningeal dissemination immediately after complete resection of the primary tumor. This case demonstrates the rapidity with which leptomeningeal spread of extracranial metastatic alveolar rhabdomyosarcoma can occur and underscores the importance of diagnostic lumbar puncture and brain radiological investigations at diagnosis, even when the tumors are not in the parameningeal location.

Cranial subdural haematoma: a rare complication of spinal anaesthesia

Cranial subdural haematoma: a rare complication of spinal anaesthesia

234: Comparison of Blunt Versus Sharp Spinal Needles Used in the Emergency Department in Rates of Post-Lumbar Puncture Headache

To compare rates of post-lumbar puncture headache (PLPHA) in patients undergoing a diagnostic lumbar puncture (LP) in the emergency department (ED) with blunt versus sharp spinal needles of the similar size.

Neuraxial Techniques in Obstetric and Non-Obstetric Patients with Common Bleeding Diatheses

There are few data in the literature regarding the safety of neuraxial techniques in patients with the most common bleeding diatheses, including hemophilia, von Willebrand's disease (vWD), and idiopathic thrombocytopenic purpura (ITP). Neuraxial techniques are not widely used in these populations because of concerns of potential hemorrhagic and/or subsequent neurologic complications. In this article, we review the available literature describing neuraxial techniques in patients with hemophilia, vWD, or ITP with the aim to assist anesthesiologists considering neuraxial techniques in these populations. After a systematic Pubmed, MEDLINE, and EMBASE search, we reviewed 30 articles published between January 1, 1975 and October 1, 2008 in which neuraxial techniques were performed in patients with hemophilia, vWD, or ITP to determine the perioperative management and evaluate the frequency of hemorrhagic complications. We identified 507 neuraxial techniques (482 patients) performed in patients with hemophilia (107 neuraxial techniques, 85 patients), vWD (74 neuraxial techniques, 72 patients), or ITP (326 neuraxial techniques, 325 patients). Among the 507 neuraxial techniques performed, there were 371 lumbar epidural anesthetics, 78 spinal anesthetics, 53 lumbar punctures, 2 combined spinal epidural analgesia, 2 paravertebral blocks, and 1 thoracic epidural anesthetic. Four hundred six neuraxial techniques were placed in the obstetric population, 53 were performed in the emergency room for diagnostic lumbar puncture, 46 were performed for lower limb orthopedic surgery, 1 was performed for postoperative analgesia, and 1 was performed for an obstetric patient undergoing non-obstetric surgery. Factor replacement to normal levels (>0.5 IU mL(-1)) was initiated before block performance, though treatment was not standardized, in 105 of 107 patients with hemophilia and 10 of 74 with vWD. Sixty-four of the 74 patients with vWD had spontaneous normalization of factor levels before block performance. No hemorrhagic complications were reported when the diagnosis of hemophilia or vWD was known before the neuraxial technique. A single case of spinal hematoma (resulting in permanent paraplegia) was identified when the presence of hemophilia was not known before needle insertion and factor replacement had not been given. In all 326 cases of ITP, with or without systemic treatment of platelet transfusion, there were no reports of hemorrhagic complications associated with neuraxial techniques. Among the 326 neuraxial techniques placed in the setting of ITP, 9 patients had platelet counts of <50 x 10(9) L(-1), 19 had a platelet counts of 50-75 x 10(9) L(-1), 204 had a platelet counts of 75-100 x 10(9) L(-1), and 94 had a platelet count more than 100 x 10(9) L(-1) before needle insertion. There is a paucity of published data regarding the provision and safety of neuraxial techniques in patients with common bleeding diatheses. The minimum "safe" factor levels and platelet count for neuraxial techniques remain undefined in both the obstetric and general populations, and evidence-based recommendations in the setting of hemophilia, vWD, or ITP cannot be offered.

Epidural Cerebrospinal Fluid Collection After Lumbar Puncture

Lumbar puncture is a common procedure in the emergency department. Cerebrospinal fluid (CSF) leak through a dural tear can cause transient side effects including headache and backache, although more severe symptoms may occur. These CSF collections can be managed nonoperatively without any neurologic sequelae. We report a patient with a symptomatic epidural CSF collection after diagnostic lumbar puncture, followed by a brief review of the literature including discussion of techniques that can reduce CSF leak.

Decreased cerebrospinal fluid hypocretin‐1 (orexin A) in patients after repetitive generalized tonic–clonic seizures

The effects of seizures on the hypocretin/orexin system have not yet been investigated in epileptic patients. The present study aimed to assay hypocretin-1 in the cerebrospinal fluid (CSF) of patients after generalized tonic-clonic (GTC) seizures. Study groups consisted of 21 patients after GTC seizures and 19 controls. Diagnostic lumbar puncture was performed in control and epileptic patients within 48 h after the GTC seizures. Hypocretin-1 levels were measured in unextracted CSF samples, using a standardized commercial radioimmunoassay. There was a significant overall difference in median CSF hypocretin-1 concentrations between controls and patients with GTC patients (p < 0.001). The lowest concentrations were noted in a subgroup of patients with repetitive GTC seizures (RS) compared to those with a single GTC seizure (SS) (p > 0.05) or controls (p < 0.001). The current results suggest that the hypocretin-1 system deficiency contributes to the complex pathophysiology of repetitive GTC seizures and status epilepticus (SE) and could be associated with typical somnolence after seizure attacks.

Sequential analysis of biomarkers in cerebrospinal fluid and serum during invasive meningococcal disease

The aim of the present study was to determine the profile of different inflammatory molecules in serum and cerebrospinal fluid (CSF) during invasive meningococcal disease (IMD). Their relationship with IMD severity was also assessed. A cohort of 12 patients with IMD was investigated. Paired serum and CSF samples were obtained at the time of diagnostic and follow-up lumbar puncture and were examined using Luminex® analysis. IMD severity correlated with serum interleukin-6 (IL-6) and interleukin-1 receptor antagonist (IL-1ra) on admission. Furthermore, the CSF levels of IL-1β, IL-1ra, IL-6, IL-8, macrophage inflammatory protein-1β (MIP-1β), and monocyte chemoattractant protein-1 (MCP-1) were significantly higher than their respective serum levels. The strongest correlations were found between serum concentrations of IL-1β and IL-1ra, IL-6, IL-8, and MIP-1β, whereas the strongest correlations in CSF were found between endotoxin and IL-8, IL-17, MIP-1β, and MCP-1. As was expected, the concentrations of inflammatory molecules in both serum and CSF significantly decreased after antibiotic treatment. With regard to kinetics, a severe course of IMD correlated positively with rapid declines of CSF IL-6 and cortisol levels. Sequential multiple analyses revealed patterns of inflammatory responses that were associated with the severity of IMD, as well as with the compartmentalization and kinetics of the immune reaction.

Clinical Prediction Rules for Meningitis in Children Pretreated With Antibiotics: In Reply

We appreciate the thoughtful comments and careful review of our manuscript by Drs Devlin and Devlin. As we described in our recent article,1 before performance of a diagnostic lumbar puncture, many children with meningitis receive antibiotics, which may render bacterial culture results falsely negative. Clinicians then have difficulty determining the appropriate duration of antibiotic treatment for these children with pretreated culture-negative …

Extensive Tension Pneumocephalus Caused by Spinal Tapping in a Patient with Basal Skull Fracture and Pneumothorax

Tension pneumocephalus may follow a cerebrospinal fluid (CSF) leak communicating with extensive extradural air. However, it rarely occurs after diagnostic lumbar puncture, and its treatment and pathophysiology are uncertain. Tension pneumocephalus can develop even after diagnostic lumbar puncture in a special condition. This extremely rare condition and underlying pathophysiology will be presented and discussed. The authors report the case of a 44-year-old man with a basal skull fracture accompanied by pneumothorax necessitating chest tube suction drainage, who underwent an uneventful lumbar tapping that was complicated by postprocedural tension pneumocephalus resulting in an altered mental status. The patient was managed by burr hole trephination and saline infusion following chest tube disengagement. He recovered well with no neurologic deficits after the operation, and a follow-up computed tomography (CT) scan demonstrated that the pneumocephalus had completely resolved. Tension pneumocephalus is a rare but serious complication of lumbar puncture in patients with basal skull fractures accompanied by pneumothorax, which requires continuous chest tube drainage. Thus, when there is a need for lumbar tapping in these patients, it should be performed after the negative pressure is disengaged.

Complicación espinal hemorrágica secundaria a una punción lumbar diagnóstica

Spinal cord hematoma is a serious and feared complication of lumbar puncture. We here describe two patients who developed a spinal cord hematoma following diagnostic lumbar punctures.CASE 1: a 22-year-old male with a syndrome of cerebrospinal fluid hypotension, with normal coagulation parameters, underwent a traumatic, diagnostic lumbar puncture followed, a few hours later, by back pain irradiated to the legs. MRI showed the presence of a subdural hematoma from the lower dorsal region to the sacral region. A conservative approach, without surgery, was decided and he showed a complete recovery. CASE 2: a 69-year-old woman underwent a diagnostic lumbar puncture for the study of recent-onset headache with tinnitus and unstable gait. Puncture was traumatic and cerebrospinal fluid was normal. A few hours later, she complained of back pain and sciatica, and examination revealed a bilateral Lassegue sign. She required urinary catheterization. MRI showed an epidural hematoma from the T10 vertebra to the sacral area. Her outcome with a conservative approach was also excellent.Spinal cord hematomas can occur after a traumatic lumbar puncture in people without coagulation disorders or any other predisposing factor. Although surgery has been traditionally advocated in these cases, a conservative approach is an option when symptoms are mild and a close follow-up is possible.

Three Current Controversies in Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH), or pseudotumour cerebri, is a condition of increased intracranial pressure without space-occupying lesion, cerebrospinal fluid abnormalities or venous sinus thrombosis. This manuscript will discuss three controversies in IIH: (1) its nomenclature; (2) existence without papilloedema; and (3) therapeutic venous stenting. The name pseudotumour cerebri is controversial; idiopathic intracranial hypertension, idiopathic intracranial pressure or primary and secondary intracranial hypertension are preferred terms. Some do not believe the condition exists without papilloedema. Our evaluation found idiopathic intracranial hypertension without papilloedema (IIHWOP) in ∼6% of cases. IIHWOP patients had more diagnostic lumbar punctures and non-physiological visual field constriction; 93% of IIH patients had venous sinus stenosis. Others suggest treating venous sinus narrowing with stenting, which may be viable in rare cases but should not be first-line treatment.

Atraumatic Lumbar Puncture Needles

Cutting needles remain the most commonly used needle design for lumbar puncture in the neurology community, although atraumatic (noncutting) needles have become common and popular for anesthesiologists performing spinal anesthesia. The use of atraumatic spinal needles for lumbar puncture has been shown to significantly reduce the incidence of postdural puncture headache compared with cutting needles, without loss of efficacy or ease of use. The use of noncutting or pencil-point spinal needles should become the standard for performing diagnostic lumbar puncture.

Intrathecal synthesis of IgE in children with eosinophilic meningoencephalitis caused by Angiostrongylus cantonensis

BackgroundEosinophilic meningoencephalitis caused by the helminth Angiostrongylus cantonensis, is an emerging infectious disease in America. The objective of this paper was to determine if the intrathecal synthesis of immunoglobulin E is produced during the acute phase of the disease.MethodsThirteen patients, mean age 4.5 years were studied; a diagnostic lumbar puncture was performed and serum samples taken. Immunoglobulin E (IgE) in serum and in cerebrospinal fluid (CSF) was quantified by nephelometry. Control patients had other infections or other neurological diseases.ResultsThe mean cell count in the CSF was 500 × 10-6 cells/L and of these 23% were eosinophils. In blood the eosinophils were 13%. The chief symptoms of the patients were migraine, vomiting and fever and 50% presented some meningeal signs. IgE intrathecal synthesis analyzed by the corresponding quotient diagram (Reibergram) was observed in all patients. No intrathecal IgE synthesis was seen in control patients.ConclusionIntrathecal synthesis of IgE demonstrates the participation of this immunoglobulin in the destruction of the third stage larvae of the parasite in the CSF. The test should be considered in our environment as a tool to aid diagnosis.

MS and autoimmune disorders

The paper in this issue from Hemminki courageously takes on the thorny question of the co-association of multiple sclerosis (MS) with other diseases, a query which has had more than a few prior attempts at resolution. A priori, this is not an easy question to answer since MS is not all that common, and many of the diseases which have been sought for co-association are even less so. Among ways to attenuate the problems, the most important are ensuring adequate sample size and controlling for ascertainment. Scandinavian registries are to be envied as on their own they make a strong case for national health delivery. These in particular have been systematically available for study. Hemminki et al. provide a large sample for scrutiny and employ it to conclude that MS is associated with autoimmune and “related” disorders. The dataset is large, the approach is sound, and the investigators are experienced and reliable. The direction of ascertainment, i.e., coming from the autoimmune side, and case-finding for MS is novel and attractive and is complementary to existing studies. There are, however, reasons for misgivings despite my admiration for the authors and their methodology, and this has to do with interpretation of the results. Ascertainment on the basis of hospital admission may select for more severe cases depending on local custom for diagnostic lumbar puncture with geographic variation. It might be that even these may have changed from the previous generation to the present, but both are included in the study. Pooling MS and “related” disorders raises two issues. The first is that adding in cases of familial MS perhaps should not be used to support the argument of co-association as the authors have done. This will surely seem to some a circular argument—increased frequency of MS in the relatives of MS patients is being used to support the thesis that MS is related to autoimmune diseases. Familiality of MS has long been known. The authors, having made a distinction between MS and “related” disorders, perhaps unwittingly merged both into autoimmunity in their discussion. They are so counted in a claimed relative risk of 1.21 for autoimmune disease among the relatives of those with these conditions. Removing MS and amyotrophic lateral sclerosis (ALS) from the numbers subtracts 139 cases or 12.7% of the total of 1,087 cases identified, eliminating the proposed 1.21× excess of “autoimmunity.” Taking out the asthma inclusion from the ranks of the “autoimmune and related” as well leaves a reduction—not the increase proposed. The inclusion of ALS and asthma does strain the limits of orthodox contemporary concepts of these disorders. It would help to be reassured these inclusions were not made post hoc when the data were found not to fit a prior hypothesis. There is very little evidence that ALS is autoimmune in nature, and asthma seems primarily more in the allergy line with tenuous connections to autoimmunity. It is possible that the ALS findings result from the inclusion of cases of chronic myelopathy (many of whom had MS) from a previous generation especially when upper extremity atrophy was present or spondylosis coexisted. On the other hand, the one thing that MS and ALS do share is progressive central axonal degeneration.

45-Year-Old Woman With Recurrent Headache and Photophobia

45-Year-Old Woman With Recurrent Headache and Photophobia

BK virus encephalitis in an allogeneic hematopoietic stem cell recipient

The shedding of BK virus into the urinary system andhemorrhagic cystitis has also been described in otherpatients, forexample, afterhematopoietic stem celltransplantation. Here, we report a patient who hadundergone allogeneic hematopoietic stem cell transplanta-tion because of relapsed common acute lymphocyticleukemia and was transplanted from a matched unrelateddonorafterconditioning with 12Gy TBI, rituximab andcyclophosphamide. Post transplantation immunosuppres-sion consisted of CYA and a short-course methotrexateand was discontinued at day þ68. He developed grade IVacute GvHD afterdonorlymphocyte infusion that wasrefractory to steroid treatment but responded toa combination of steroids, rapamycin and CYA. Duringthe course of immunosuppression, hemorrhagic cystitisoccurred and the patient showed a bilateral ureteralobstruction that had to be treated with indwelling ureteralstents. On day þ123 aftertransplantation, diagnosticlumbar puncture and cranial magnetic resonance imagingwere performed because of seizures. BK virus DNA couldbe amplified from urine and cerebrospinal fluid samples.Primers had been designed to amplify the large T-antigenof the BK virus by light cycler PCR. Sequenceswere,forward5