Early Lumbar Puncture Research Articles

Intra‐ and post‐procedural lumbar puncture symptoms in a sample of Black/African American, American Indian/Alaska Native, and White middle age older adults

AbstractBackgroundCerebral spinal fluid (CSF) as a biomarker of Alzheimer’s disease (AD) is a helpful tool in diagnosing preclinical disease. While blood‐based biomarkers are becoming increasingly used for early detection, CSF collection is still necessary for validation of AD blood‐based biomarkers and for identification of biomarkers for other types of dementias, including those that commonly co‐occur with AD. Attitudes and beliefs surrounding lumbar punctures (LPs) vary, and differing techniques as well as side effect rates might dissuade both clinicians and participants from considering LPs as a viable biomarker option. The aim of this analysis was to examine intra‐ and post‐procedural symptoms of a specific technique for collecting CSF from adult volunteers enrolled in the Wisconsin Alzheimer’s Disease Research Center.MethodLPs were performed on 587 volunteers using a standardized LP technique with atraumatic needle. Up to 22 milliliters of cerebral spinal fluid was obtained using gentle syringe aspiration of fluid. Clinician notes documenting the procedure were used to assess intra‐procedural symptoms. A follow‐up phone call the next day was used to evaluate any post‐procedural symptoms. The association between participant characteristics and LP intra‐procedural symptoms, post‐procedural symptoms, and LP success were tested using linear regression.ResultThe majority of participants did not report any intra‐procedural (59%) or post‐procedural (77%) symptoms. Being female was associated with experiencing increased intra‐procedural symptoms among Black / African American and White participants; younger age and lower waist‐to‐hip ratio were associated with higher rates of intra‐procedural symptoms among White participants. Participant characteristics were not associated with post‐procedural symptoms. LP success was high for all groups (67% to 90%). Among White participants, pain and vasovagal responses were associated with terminating the LP before sufficient fluid was collected. Among Black / African American participants, pain was associated with terminating the LP procedure before sufficient fluid was collected. Among American Indian / Alaska Native participants, no intra‐procedural symptoms were associated with early LP termination.ConclusionWe provide rates of LP intra‐procedural and post‐procedural symptoms in a diverse sample of middle‐aged and older adults. These data suggest that LPs are safe and well tolerated across a diverse group of participants.

Acute bacterial meningitis.

Purpose of reviewCommunity-acquired bacterial meningitis is a continually changing disease. This review summarises both dynamic epidemiology and emerging data on pathogenesis. Updated clinical guidelines are discussed, new agents undergoing clinical trials intended to reduce secondary brain damage are presented.Recent findingsConjugate vaccines are effective against serotype/serogroup-specific meningitis but vaccine escape variants are rising in prevalence. Meningitis occurs when bacteria evade mucosal and circulating immune responses and invade the brain: directly, or across the blood–brain barrier. Tissue damage is caused when host genetic susceptibility is exploited by bacterial virulence. The classical clinical triad of fever, neck stiffness and headache has poor diagnostic sensitivity, all guidelines reflect the necessity for a low index of suspicion and early Lumbar puncture. Unnecessary cranial imaging causes diagnostic delays. cerebrospinal fluid (CSF) culture and PCR are diagnostic, direct next-generation sequencing of CSF may revolutionise diagnostics. Administration of early antibiotics is essential to improve survival. Dexamethasone partially mitigates central nervous system inflammation in high-income settings. New agents in clinical trials include C5 inhibitors and daptomycin, data are expected in 2025.SummaryClinicians must remain vigilant for bacterial meningitis. Constantly changing epidemiology and emerging pathogenesis data are increasing the understanding of meningitis. Prospects for better treatments are forthcoming.

Delays in lumbar puncture are independently associated with mortality in cryptococcal meningitis: a nationwide study

Background Cryptococcal meningitis (CM) is the most serious presentation of invasive cryptococcosis. Seen in patients with and without HIV infection, CM is associated with significant morbidity and mortality. Early lumbar puncture is a cornerstone of treatment in cryptococcal meningitis. We present findings from a nationwide analysis of patients admitted with CM in the United States between 2007 and 2016, with the aim of determining the impact of delays in lumbar puncture on inpatient outcomes. Methods The national inpatient sample (NIS) database was queried for all inpatient visits for cryptococcal meningitis between January 2007 and December 2016. Logistic regression models were used to determine risk factors for inpatient mortality, prolonged admissions, and delays in obtaining an initial lumbar puncture. Results The annual number of admissions for CM decreased during the study interval, from 3590 in 2007 to 2830 in 2016. Mortality did not change over this period (9.9%); however, length of stay and inpatient cost significantly increased. The proportion of patients with HIV declined from 70.7% to 54.0%. Delay in lumbar puncture beyond the first 24 h was independently associated with mortality (OR = 1.55, CI = 1.31–1.82, p-value <.001). Patients admitted on a weekend, those of African–American ethnicity, and those without a known history of HIV were more likely to have delays in obtaining an early LP. HIV patients had a lower risk of mortality (OR = 0.77, CI = 0.68–0.86, p-value <.001). Conclusion We found an independent association of delay in early lumbar puncture with worsened patient outcomes. Inpatient mortality for patients with CM continues to remain high, with an increasing proportion of patients without underlying HIV infection. There were significant deviations in management of CM from Infectious Diseases Society of America (IDSA) guidelines.

SOP: emergency workup in patients with suspected acute bacterial meningitis

IntroductionDespite antibiotic therapy, adjunctive treatment with dexamethasone, and care on modern intensive care units, bacterial meningitis remains a life-threatening disease with a high mortality and morbidity. One of most critical factors that influences outcome is a targeted quick but profound workup and early initiation of therapy in the Emergency Department. This standardized operating procedure was designed to guide physicians through the workup of patients with suspected acute bacterial meningitis.First stepsIn patients with suspected community-acquired bacterial meningitis, the first steps aim at establishing a diagnosis and at starting empiric therapy without delay. Therefore, physicians need to seek for an early lumbar puncture that can be done safely without prior imaging if clinical signs that point at contraindications of a lumbar puncture are absent. Immediately after lumbar puncture, empiric therapy with ceftriaxone, ampicillin and dexamethasone should be started. In regions with a critical resistance rate of pneumococci against third generation cephalosporines, vancomycin or rifampicin need to be added.CommentsClinical signs that are associated with intracranial conditions that are a contraindication for a lumbar puncture are severely decreased consciousness, new onset focal neurological signs, and epileptic seizures. If any of these clinical signs are present, cerebral imaging is recommended before lumbar puncture. Whenever lumbar puncture is delayed, empiric therapy needs to be begun before cerebrospinal fluid is obtained.ConclusionSuspected acute bacterial meningitis is an emergency and requires attention with high priority in the emergency department to ensure a quick workup and early start of therapy.

52. A Nationwide Analysis of the Trends and Outcomes of Cryptococcal Meningitis in the United States

BackgroundCryptococcal Meningitis (CM) is the most common presentation of invasive cryptococcosis. Seen in patients with and without HIV, CM is associated with significant morbidity and mortality. We present findings from a nationwide analysis of patients admitted with CM in the United States between 2007 and 2016.MethodsThe national inpatient sample (NIS) database was queried for all inpatient visits for Cryptococcal Meningitis between January 2007 and December 2016. Logistic regression models were used to determine risk factors for mortality, prolonged admissions, and delays in obtaining an initial lumbar puncture.ResultsThe number of admissions for CM decreased during the study interval, from 3590 in 2007 to 2830 in 2016. Mortality did not change over this period (9.9%), however length of stay and inpatient cost significantly increased (P = 0.003 and P < 0.001 respectively). The proportion of patients with HIV declined from 70.7% to 54.0% (P < 0.001). HIV patients had a lower risk of mortality (OR = 0.77, CI 0.68–0.86, P < 0.001), whereas Africa-American, Hispanic and Native American ethnicities had a significantly increased association with mortality. Delay in lumbar puncture beyond the first 24 hours was independently associated with mortality, with an OR of 1.55 (CI 1.31–1.82, P < 0.001). . Patients admitted on a weekend, those of African-American ethnicity, and those without a known history of HIV were more likely to have delays in obtaining an early LP.ConclusionInpatient mortality for patients with CM continues to remain high, with an increasing proportion of patients without underlying HIV infection. We found significant deviations in management of CM from IDSA guidelines, and an independent association of delay in early lumbar puncture with worsened patient outcomes.Disclosures All Authors: No reported disclosures

Clinical analysis of 69 cases of non-HIV-related cryptococcal meningitis

The clinical data of 69 patients with non-HIV-related cryptococcal meningitis admitted in the Second Hospital of Hebei Medical University from January 2013 to May 2019 were analyzed retrospectively.The main presentations of 69 patients are headache,fever,nausea,vomiting, visual impairment, hearing damage.Among them, 36 cases (52%) had underlying diseases, 30 cases (43%) were misdiagnosed, and 38 cases (55%) were complicated with high intracranial pressure. Cerebrospinal fluid examination showed that leukocytes increased in 47 cases, protein increased in 55 cases, chloride decreased in 41 cases, glucose decreased in 34 cases. The imaging findings were cerebral ischemia, hydrocephalus, meningeal or cerebral parenchyma enhancement. During the induction period, 63 cases were treated with combined antifungal drugs and 6 cases were treated with single antifungal drugs. The clinical symptoms were improved in 54 cases, 9 cases were discharged automatically and 6 cases died. The clinical manifestations, routine and biochemical examination of cerebrospinal fluid, imaging findings are not specific for patients with non-HIV-related cryptococcal meningitis.So early and multiple lumbar puncture should be performed to find etiological evidence to reduce misdiagnosis. The combination of antifungal drugs during the induction period is safe and effective. Key words: Meningitis,cryptococcal; Antifungal agents; Intracranial pressure; Neurosurgical procedures

Evaluation of cerebrospinal fluid and blood parameters finding in early diagnosis and drug therapy of suspected bacterial meningitis in neonates.

Background:Whether early lumbar puncture (LP) and blood indicators are suitable as diagnostic criteria and helpful to treatment strategies for newborns remains to be solved. The study was to evaluate the value of cerebrospinal fluid (CSF) at the first LP and blood indicators at the similar time in the early diagnosis and the drug therapy of neonatal bacterial meningitis.Materials and Methods:We conducted a retrospective observational study of 997 infants with suspected bacterial meningitis between June 2012 and June 2018. CSF and blood parameters were evaluated by three stepwise logistic models to assess their ability: to distinguish bacterial meningitis from nonbacterial meningitis, to distinguish positive CSF culture from negative, and to distinguish Gram-positive bacteria from negative.Results:Of the 997 neonates, 236 (23.67%) were later diagnosed as bacterial meningitis. Of the neonates with meningitis, 54 (22.88%) had positive CSF culture results. And of neonates with positive CSF culture, 27 (50%) had Gram-positive results. One or more CSF indicators were added to the three models. Only blood hypersensitive C-reactive protein and blood lactate dehydrogenase were added to the first model, while no blood parameters was added to the other two models. The areas under the effect-time curves of the three models were 0.91 (95% confidence interval [CI]: 0.89–0.92, P < 0.001), 0.69 (95% CI: 0.63–0.75, P < 0.001), and 0.86 (95% CI: 0.74–0.94, P < 0.001), respectively.Conclusion:LP was irreplaceable predictor of bacterial meningitis, and comprehensive analysis of CSF indicators can predict the offending organism, which enables refinement of therapy.

Analysis of 18 cases of toxic encephalopathy caused by occupational acute 1, 2-dichloroethane poisoning

Retrospective analysis of 18 cases of occupational acute 1, 2-dichloroethane (1, 2-DCE) poisoning. The results showed that all patients have the main manifestations such as dizziness, headache, unresponsiveness and other symptoms of nervous system damage; Brain CT showed varying degrees of diffuse white matter lesions. Brain MRI showed extensive involvement of white matter in both cerebral hemispheres. Affected white matter area presented low intensity on T1WI, hyperintensity on T2WI and T2-Flair; Lumbar puncture examination of cerebrospinal fluid (CSF) pressure (262.5±48.39) mm H(2)O; After treatment, the required time for CSF pressure to restore was (161.56±75.27) days (50-280) days. Summary, Occupational acute 1, 2-DCE poisoning caused by toxic encephalopathy can be manifested as persistent abnormalities in CSF pressure, and the CSF pressure drops slowly during treatment; Early head CT and lumbar puncture examination will be helpful for early detection of intracranial pressure in toxic encephalopathy caused by acute 1, 2-DCE poisoning. Dynamic monitoring of CSF provides guidance for acute 1, 2-DCE poisoning with a long time of treatment and various types of dehydrating agents.

Clinical characteristics of enteroviral meningitis without pleocytosis in children: a retrospective single center observational study in the Republic of Korea

BackgroundWe aimed to study the prevalence of enterovirus (EV) meningitis without the presence of cerebrospinal fluid (CSF) pleocytosis and identify patient factors and clinical features associated with it.MethodsThis was a retrospective analysis of patients aged < 18 years old who were diagnosed with EV meningitis by CSF reverse-transcriptase polymerase chain reaction (RT-PCR) testing between January 2015 and December 2016. Clinical variables were compared with regard to the presence of CSF pleocytosis.ResultsA total of 305 patients were enrolled in study; 169 (55.4%) had no pleocytosis. Patients without pleocytosis were younger (median age 2 months vs. 67.0 months, p < 0.01) and had lower white blood cell (WBC) count (median, 8600/mm3 vs. 10,300/mm3, p < 0.01). Also absolute neutrophil (ANC) count were lower than pleocytosis group (median, 4674/mm3 vs. 7600/mm3, p < 0.01). Comparing three age groups, CSF apleocytosis was present in 106 of 128 patients (82.8%) aged ≤3 months, 7 of 13 patients (53.8%) aged 3 months–3 years and 56 of 164 patients (34.1%) aged > 3 years. Younger age groups had higher prevalence of CSF apleocytosis (p < 0.01). In patients aged ≤3 months, 94.5% underwent lumbar puncture within 24 h of symptom onset. The frequency of not having pleocytosis was higher than the frequency of having pleocytosis during peak EV infection prevalent months (summer and fall) (p < 0.01).ConclusionThis study shows that EV meningitis in young infants, with early lumbar puncture, or occurring during peak EV meningitis prevalent seasons cannot be solely excluded by pleocytosis. Also, a confirmation test for EV meningitis should be performed using RT-PCR.

Early lumbar puncture and risk of intraventricular hemorrhage in very low birth weight infants

BackgroundLumbar puncture (LP) is the gold standard for diagnosing meningitis; however it is unknown whether early LP (≤3days of life) is associated with increased risk of intraventricular hemorrhage (IVH) in very low birth weight (VLBW) infants. ObjectiveTo determine whether early LP in VLBW infants is associated with severe IVH. MethodsVLBW infants from a cohort of 1,158,789 infants discharged from 382 neonatal intensive care units (1997–2015) were enrolled. Exclusion criteria: infants with major congenital anomalies, outborns, died/transferred prior to day of life 3, and those who had an LP performed only after day of life 3. Logistic regression was used to determine the association between early LP and the incidence of severe IVH (IVH grades 3/4) by 28days of life for each day of life from day 0 (birth) to day 3, adjusting for clinical covariates. Results106,461 infants were included: 754 received an LP on Day-0, 640 on Day-1, 559 on Day-2 and 483 on Day-3. Severe IVH occurred in 4% (4130/104,025) of the infants in the no LP group and 9% (217/2436) of the LP group. Severe IVH was higher for infants with early LP: adjusted OR (95% confidence interval)=2.64 (1.96–3.54) on Day-0; 2.21 (1.61–3.04) on Day-1; 1.55 (1.03–2.34) on Day-2; and 2.25 (1.50–3.38) on Day-3. ConclusionsEarly LP was associated with severe IVH in VLBW infants by 28days of life. LP is either a surrogate for an unrecognized factor or is itself associated with an increased risk of IVH.

Reduced Slow-Wave Sleep Is Associated with High Cerebrospinal Fluid Aβ42 Levels in Cognitively Normal Elderly.

Emerging evidence suggests a role for sleep in contributing to the progression of Alzheimer disease (AD). Slow wave sleep (SWS) is the stage during which synaptic activity is minimal and clearance of neuronal metabolites is high, making it an ideal state to regulate levels of amyloid beta (Aβ). We thus aimed to examine relationships between concentrations of Aβ42 in the cerebrospinal fluid (CSF) and measures of SWS in cognitively normal elderly subjects. Thirty-six subjects underwent a clinical and cognitive assessment, a structural MRI, a morning to early afternoon lumbar puncture, and nocturnal polysomnography. Correlations and linear regression analyses were used to assess for associations between CSF Aβ42 levels and measures of SWS controlling for potential confounders. Resulting models were compared to each other using ordinary least squared linear regression analysis. Additionally, the participant sample was dichotomized into "high" and "low" Aβ42 groups to compare SWS bout length using survival analyses. A significant inverse correlation was found between CSF Aβ42 levels, SWS duration and other SWS characteristics. Collectively, total SWA in the frontal lead was the best predictor of reduced CSF Aβ42 levels when controlling for age and ApoE status. Total sleep time, time spent in NREM1, NREM2, or REM sleep were not correlated with CSF Aβ42. In cognitively normal elderly, reduced and fragmented SWS is associated with increases in CSF Aβ42, suggesting that disturbed sleep might drive an increase in soluble brain Aβ levels prior to amyloid deposition.

Analysis of influential factors of postoperative secondary hydrocephalus in patients with severe and most severe craniocerebral injury

Objective To investigate the risk factors for postoperative secondary hydrocephalus in patients with severe and most severe craniocerebral injury. Methods The clinical data of 144 patients with severe and most severe craniocerebral injury admitted to the Department of Neurosurgery, General Hospital of Ningxia Medical University from June 2010 to December 2013 were analyzed retrospectively. Univariate analysis was used to examine the relationship between the patients’ age, gender, pre/postoperative Glasgow Coma Scale(GCS), site of injury, pre/postoperative intraventricular hematocele, pre/postoperative aqueduct of midbrain and ambient cisterna structure, postoperative large area cerebral infarction, postoperative intracranial infection, postoperative intracranial pressure, as well as the postoperative lumbar puncture and the secondary hydrocephalus, and multivariate logistic analysis was further conducted to investigate the influencing factors of hydrocephalus after procedure. Results The patients with low GCS during the perioperative period(before procedure: P=0.041; after procedure: P=0.039), intraventricular hematocele(before procedure: 0.027; after procedure: 0.039), injury site near skull base(P=0.042), structures of ambient cisterna and aqueduct of midbrain not clear(before procedure: P<0.001; after procedure: P<0.001), postoperative massive cerebral infarction(P=0.031), and postoperative intracranial infection(P=0.027)were the risk factors for secondary hydrocephalus after procedure, and postoperative reduction of intracranial pressure(P=0.001)and early lumbar puncture(P<0.001)were its protective factors. Compared with the patients of the non-lumbar puncture group, postoperative early lumbar puncture could reduce the incidences of acute hydrocephalus(P=0.026)and chronic hydrocephalus(P=0.033)of this kind of craniocerebral injury after the procedure, and there was significant difference in the incidence of hydrocephalus between the patients of both groups. Conclusions The patients with severe and most severe craniocerebral injury who have the low GCS during the perioperative period, preoperative and postoperative intraventricular hematocele, injury site near skull base, structures of the ambient cisterna and aqueduct of midbrain unclear, massive cerebral infarction after procedure, and postoperative intracranial infection are prone to hydrocephalus after procedure. While timely and effectively reducing intracranial pressure and releasing the bloody cerebrospinal fluid after procedure may reduce the occurrence of postoperative hydrocephalus. Key words: Craniocerebral trauma; Hydrocephalus; Neurosurgical procedures; Risk factors

Cerebrospinal fluid white cell count: discriminatory or otherwise for enteroviral meningitis in infants and young children?

Non-polio enteroviruses (EV) are the most common viruses causing aseptic meningitis in children. We aim to evaluate the cerebrospinal fluid (CSF) characteristics of neonates and children with EV meningitis with a view to determine whether it could be discriminatory or otherwise in making a positive diagnosis. We performed a 3-year (July 2008-July 2011) retrospective study of children ≤16 years, treated at a tertiary children's hospital, with positive CSF EV polymerase chain reaction (PCR) and negative blood and CSF bacterial cultures. A total of 206 children were studied. The median CSF white cell count was 79 cells/mm(3) (range 0-4608 cells/mm(3)). CSF pleocytosis was observed in 99/150 (66%) aged ≤90 days, 3/4 (75%) aged 90 days-1 year, and 49/52 (94%) children ≥3 years. There was a huge variability in CSF pleocytosis in infants ≤90 days, where 34% of them had no pleocytosis, while in 66%, a wide range of pleocytosis that might even suggest bacterial meningitis was noted. CSF red cells were low, and protein or sugar values were not discriminatory. CSF pleocytosis in relation to increasing age was found to be statistically significant (p < 0.001). Early lumbar puncture within 48 h of symptoms and absence of CSF pleocytosis was also statistically significant (p = 0.039). CSF pleocytosis in EV meningitis is commoner in older children. As there was a huge variability in CSF pleocytosis in infants ≤90 days particularly, CSF analysis including EV PCR could avoid unnecessary antibiotic therapy.

Multiplicity and prevention for patients with hydrocephalus secondary to severe traumatic brain injury after surgery

To investigate the factors for hydrocephalus secondary to severe traumatic brain injury after surgery, and to explore a new theory and guideline for clinical early prevention and treatment for hydrocephalus. The clinical data regarding 107 patients with severe traumatic brain injury, who were admitted to our hospital from June 2010 to June 2013, were analyzed. Logistic multi-factor regression was used to analyze the different factors including ages, gender, the Glasgow coma scale (GCS) score before or after surgery, the situation of ventricular system bleeding secondary to surgery, the situation of midbrain aqueduct and ambient cistern before or after surgery, the relationship between early lumbar puncture and the hydrocephalus. The risk and protective factors for postoperative hydrocephalus were discussed. The results showed that patients with low GCS score in pre/postoperative (OR=0.099, 95%CI: 0.028-0.350)/(OR=0.088, 95%CI: 0.012-0.649), ventricular system bleeding in postoperative (OR=0.168, 95%CI: 0.029-0.979) and dim CT image for midbrain aqueduct and ambient cistern (OR=0.134, 95%CI: 0.038-0.473)/(OR=0.221, 95%CI: 0.055-0.882) are risk factors. Whereas lumbar puncture (OR=75.885, 95%CI: 9.612-599.122) is a protective factor for postoperative hydrocephalus in STBI patients. The secondary hydrocephalus was mainly occurred in 2 weeks and 2 weeks to 3 months after operation. The incidence of the control group that occurred secondary hydrocephalus is higher than that of the lumbar puncture group (P<0.05). The secondary hydrocephalus were mainly occurred in 2 weeks and 2 weeks to 3 months after operation, with no statistical significance between the 2 groups after 3 months of operation (P>0.05). For patients with stable vital signs, early lumbar puncture could significantly reduce the incidence of secondary hydrocephalus in acute and subacute stage after severe traumatic brain injury.

Complications of endoscopic third ventriculostomy for hydrocephalus

To explore the complications of endoscopic third ventriculostomy (ETV) for hydrocephalus and examine their preventions. From September 2008 to September 2013, ETV was offered for obstructive hydrocephalus (n=15) and communicating hydrocephalus (n=5). And the prevention and treatment of common complications were analyzed. All had achieved satisfactory outcomes. For 16 cases, their symptoms and signs disappeared, ventricle returned to normal and interstitial edema resolved; for another 4 cases, there were improvements of symptoms and (or) signs, ventricular shrinking and/or interstitial edema lessening. And the postoperative complications included fever (n=5), poor healing of incision (n=2), scalp hydrops (n=2) and intracranial infection (n=1). The indications of ETV should be selected strictly according to the specific anatomical characteristics of bottom of third ventricle. And individualized methods of stoma are necessary. And early postoperative lumbar puncture and drainage may obviously reduce complications and improve surgical outcomes.

Lues-assoziierte zerebrale Vaskulitis mit delirantem Syndrom

In a 40-year-old man with delirium, right-sided facial palsy and anisocoria (right > left) were noticed. He had been suffering from headaches for four weeks prior to admission. The patient's HI-virus status was positive and he used illicit drugs regularly. Therefore, the symptoms were initially thought to be drug-induced. EXAMINATION AND DIAGNOSIS: Laboratory tests showed a pleocytosis of the cerebrospinal fluid (CSF) with 929 cells/µl. The MRI of the brain revealed several ischemic strokes in the territories of the middle cerebral artery and posterior cerebral artery in the left hemisphere. A highly positive IgG CSF/serum index confirmed the diagnosis of neurosyphilis. An antibiotic regime with penicillin was administered, during which the clinical symptoms remitted and the liquor pleocytosis nearly normalized. The intracranial stenoses persisted for three months even after therapy with nimodipine, atorvastatin, and antibiotics. Therefore they are presumed to be a result of the lues-associated vasculitis. In patients with delirium the initially suspected underlying condition needs to be challenged. Early cerebral MRI, lumbar puncture and ultrasound of the cerebral arteries are mandatory to exclude menigoencephalitis.

Early lumbar puncture in adult bacterial meningitis—rationale for revised guidelines

Current international guidelines recommend cerebral computerized tomography (CT) before lumbar puncture (LP) in many adults with suspected acute bacterial meningitis (ABM), due to concern about LP-induced cerebral herniation. Despite guideline emphasis on early treatment based on symptoms, performing CT prior to LP implies a risk of delayed ABM treatment, which may be associated with a fatal outcome. Firm evidence for LP-induced herniation in adult ABM is absent and brain CT cannot discard herniation. Thus, the recommendation to perform CT before LP may contribute to an avoidable delay of LP and ABM treatment. The inappropriate use of the diagnostic treatment sequence of brain CT scan, followed by LP, followed by antibiotics and corticosteroids should be avoided in adults with suspected ABM by omitting needless contraindications for LP, thus eliminating an unnecessary fear of immediate LP. Revised Swedish guidelines regarding early LP are presented, and the background documentation and reasons for omitting impaired consciousness, new onset seizures, and immunocompromised state as contraindications to LP are discussed.

Intraventricular hemorrhage in premature infants

Dr. Stonestreet presented a case of an infant who was born 25 weeks gestation by spontaneous vaginal delivery with Apgar scores of 11 and 55. The infant was intubated because of decreased respiratory effort. He developed a pneumothorax on day 2 of life and bilateral grade 4 intraventricular hemorrhages. This case was used as a clinical example of infants that develop intraventricular hemorrhage. There is a large increase in brain maturation that occurs over the interval when infants develop intraventricular hemorrhage. From 23–32 weeks of gestation, important processes such as branching synaptagenesis, programmed cell death and reorganization of synapses are occurring in premature infants. The grading scale of LuAnn Papile has long been used to categorize grade of intraventricular hemorrhage. Fortunately, the incidence of intraventricular hemorrhage has decreased from the 1980's until 2006. In 2006, the incidence of all types of intraventricular hemorrhage were at 36 percent with severe types (Grades 3 and 4) representing 14 percent of infants <1000 gm. Many clinical prenatal and postnatal factors predispose infants to intraventricular hemorrhage. Factors that can be protective against the neonatal development of intraventricular hemorrhage include maternal transport, optimal delivery, decreased use of ventilation where possible, limitation of intravenous volume boluses, limitation of the use of Dopamine, limitation of treatment with bicarbonate, avoiding pneumothorax and gentle handling. Hemorrhagic hydrocephalus occurs 1–3 weeks after intraventricular hemorrhage. In sixty-five percent of infants that develop post-hemorrhagic, it hydrocephalus resolves within 4 weeks. Fifteen to twenty percent of these infants require a shunt for post-hemorrhagic hydrocephalus. Serial lumbar punctures do not prevent the need for a shunt or improve neurologic outcomes. However, serial lumbar punctures and ventricular taps may be necessary as a temporizing effort. Futile therapies for post-hemorrhagic hydrocephalus include early lumbar punctures, the use of diuretics and fibrinolytic therapy to prevent shunt dependence. An intraventricular shunt may be necessary for infants with post-hemorrhagic hydrocephalus. However, the timing of the shunt placement is based largely upon clinical judgment and the size of the ventricles. When the ventricular dilation is 4 ml higher than the 97th percentile for ventricular width at a given, a shunt is most likely indicated. Recent data suggests that infants that require shunting for post-hemorrhagic hydrocephalus have poorer neurodevelopmental outcomes than infants with severe hydrocephalus that do not require a shunt. Nonetheless, at age 5 the infant that was presented by Dr. Stonestreet is doing quite well and is mainstreaming in a normal school environment. Early intervention therapies can help with the neurologic development even in infants that develop post-hemorrhagic hydrocephalus. from 52nd Annual Meeting of the Society for Research into Hydrocephalus and Spina Bifida Providence, RI, USA. 11–14 June 2008

Hemorragia intraventricular del prematuro e hidrocefalia post-hemorrágica. Propuesta de un protocolo de manejo basado en la derivación ventrículo-peritoneal precoz

About 50% of the preterm neonates with a ventricular haemorrhage will develop posthaemorrhagic hydrocephalus. Medical treatment is not effective neither safe, does not reduce shunt's dependence and therefore can not be recommended; early and repetitive ventricular or lumbar punctures and the use of intraventricular fibrynolitic treatment have showed no effect on reducing patient's disability, shunt's necessity or mortality of these patients and furthermore, they can have several and important side effects. The ventriculo-peritoneal shunt can be in many cases the only option for definitive treatment, despite well-known infective and obstructive complications and there is an ongoing debate about the ideal moment for the intervention. To present a diagnostic and treatment protocol for post-haemorrhagic hydrocephalus of the preterm and describe our initial experience with its application on the Paediatric Neurosurgical Department at the Hospital Materno-Infantil Carlos Haya of Málaga. A total of 21 patients with diagnosis of preterm post-haemorrhagic hydrocephalus were surgically treated at our hospital with ventriculoperitoneal shunt between January 2003 and September 2006 following the designed protocol. All the cases were Papile's grade III or IV with severe ventricular dilation (Thalamus-Caudate index over 1.5 cm) and subacute or chronic presentation. We used medium pressure valves and antibiotic impregnated catheters. We considered 1500 g as the minimum weight permitted for the intervention. We report the early and late postoperative complications and the patients functional state at the ambulatory follow up classifying them in 4 grades (Excellent or Grade 1; Good or Grade 2; Regular or Grade 3; Poor or Grade 4) according to the presence of neurological focal signs, relation with the surrounding environment, response to stimuli and presence of seizures. The most frequent complications were escaphocephalic cranium in 5 patients, persistent subgaleal collections in 2 patients, symptomatic slit ventricles in 2 patients and surgical wound dehiscence with shunt infection in 1 patient. One patient presented a systemic fungical infection with non-diagnosed meningeal compromise previous to the shunt. 7 patients required shunt replacement (14 procedures); in 2 cases of tabicated hydrocephalus an endoscopical septostomy (associated with an ETV that did not function) was done, and in a third case ETV and shunt removal was performed after shunt malfunction, with delayed failure of ETV. For the functional results 9 patients were classified as Grade 1, 5 patients as Grade 2, 3 patients as Grade 3 and 4 patients as Grade 4. This means a 67% of good or excellent results. We propose a diagnostic and treatment protocol for preterm neonates with haemorrhagic hydrocephalus that we have been using since 2003 at our department. In our experience it is possible to shunt patients starting at 1500 g with low morbidity. The use of protocols can help in reducing complications and improving functional results in these patients.

Posthaemorrhagic ventricular dilatation: new mechanisms and new treatment.

Post haemorrhagic ventricular dilatation is associated with a high rate of disability, multiple impairments and adverse effects of shunt surgery for hydrocephalus. Post haemorrhagic ventricular dilatation results initially from multiple small blood clots throughout the cerebrospinal fluid channels impeding circulation and re-absorption. Transforming growth factor beta is released into the cerebrospinal fluid and there is evidence that this cytokine stimulates the laying down of extracellular matrix proteins which produce permanent obstruction to the cerebrospinal fluid pathways. Prolonged raised pressure, pro-inflammatory cytokines and free radical damage from iron may contribute to periventricular white matter damage and subsequent disability. Interventions such as early lumbar punctures, diuretic drugs to reduce cerebrospinal fluid production and intraventricular fibrinolytic therapy have been tested and, not only fail to prevent shunt dependence, death or disability, but have significant adverse effects. Surgical interventions such as subcutaneous reservoir, external drain, choroid plexus coagulation and third ventriculostomy have not been subject to controlled trial. Ventriculoperitoneal shunt is not feasible in the early phase after intraventricular haemorrhage but, despite the problems with blockages and infections, remains the only option for infants with excessive head expansion over periods of weeks. We have piloted drainage, irrigation and fibrinolytic therapy as a way of removing blood early enough to stop the progressive deposition of matrix proteins, permanent hydrocephalus and shunt dependence.