Lumbar Puncture Testing Research Articles

Analysis of the clinical characteristics of 25 cases with parenchymal neuro-Behcet's disease

Objective: To retrospectively investigate the clinical data, radiological characteristics, treatment, and outcome of patients with parenchymal neuro-Behcet's disease (P-NBD) with particular emphasis on dizziness. Methods: This was a cross-sectional study of clinical data from 25 patients with a confirmed diagnosis of P-NBD who were admitted to the Department of Neurology of the First Medical Center of Chinese People's Liberation Army General Hospital between 2010 and 2022. The median age of the population was 37 years (range: 17-85 years). Clinical data were retrospectively analyzed, including gender, age of onset, disease duration, clinical manifestations, serum immune indicators, cerebrospinal fluid (CSF) routine biochemical and cytokine levels, cranial and spinal magnetic resonance imaging (MRI) findings, treatment, and outcome. Results: The majority of patients were male (16 cases; 64.0%), the mean age of onset was (28±14) (range: 4-58 years), and the disease course was acute or subacute. Fever was the most common clinical presentation, and the complaint of dizziness was not uncommon (8/25 patients). Analysis of serum immune indices, including complement (C3 and C4), erythrocyte sedimentation rate, interleukin-1 (IL-1), IL-6, IL-8 and tumor necrotic factor-alpha were abnormal in 80.0% of patients (20/25). Most of the 16/25 patients who underwent lumbar puncture tests had normal intracranial pressure and increased CSF white cell count and protein [median values were 44 (15-380) ×106/L and 0.73 (0.49-2.81) g/L, respectively]. Of the five patients who underwent CSF cytokine tests, four patients had abnormal results; of these, an elevated level of IL-6 was most common, followed by IL-1 and IL-8. The most common site of involvement in cranial MRI was the brainstem and basal ganglia (60.0% respectively), followed by white matter (48.0%) and the cortex (44.0%). Nine cases (36.0%) showed lesions with enhancement and six cases (24.0%) showed mass-like lesions. Three patients (12.0%) patients had lesions in the spinal cord, most frequently in the thoracic cord. All patients received immunological intervention therapy; during follow up, the majority had a favorable outcome. Conclusions: P-NBD is an autoimmune disease with multiple system involvement and diverse clinical manifestations. The symptom of dizziness is not uncommon and can be easily ignored. Early treatment with immunotherapy is important and can improve the outcome of these patients.

Impact of IVIG in the Management of Guillain-Barre Syndrome: A Case Series from South India

In Guillain-Barré syndrome, the body's immune system attacks part of the peripheral nervous system. We present a case series of four cases with different variants. Three cases have been diagnosed with nerve conduction studies, one case with positive lumbar puncture test with albumino-cytological dissociation. Each patient was treated with Intravenous Immunoglobulin (IVIG) and improved clinically. This series is being delivered in order to clinically inform individuals on the early diagnosis of GBS and its management.
 Keywords: GBS, IVIG, Lower limb, Lumbar puncture test, Nerve conduction studies, Radiating pain.

A Reversible Lesion of the Corpus Callosum Associated With Bacterial Meningitis

We report the rare case of a 22-year-old female admitted for headaches, nausea, and an isolated lesion of the splenium of the corpus callosum (SCC) found on brain magnetic resonance imaging (MRI). A lumbar puncture test was performed, and Pseudomonas aeruginosa meningitis was found. Twenty days before the symptoms, she had spinal anesthesia for a cesarean section.As soon as the diagnosis was made, antibiotic therapy was initiated. Nonetheless, no signs or symptoms were related to this lesion, which spontaneously disappeared within one month on the control MRI.Pseudomonas aeruginosa is a gram-negative bacillus and may cause rare and severe meningitis. Therefore, a history of a neurosurgical procedure or spinal anesthesia should be sought in the anamnesis.

Keeping It Simple With Febrile Seizures

Keeping It Simple With Febrile Seizures

Trends in ED Resource Use for Infants 0 to 60 Days Evaluated for Serious Bacterial Infection.

We examined trends in resource use for infants undergoing emergency department evaluation for serious bacterial infection, including lumbar puncture (LP), antibiotic administration, hospitalization, and procalcitonin testing, as well as the association between procalcitonin testing and LP, administration of parenteral antibiotics, and hospitalization. We performed a cross-sectional study of infants aged 0 to 60 days who underwent emergency department evaluation for serious bacterial infection with blood and urine cultures from 2010 to 2019 in 27 hospitals in the Pediatric Health Information System. We examined temporal trends in LP, antibiotic administration, hospitalization, and procalcitonin testing from 2010 to 2019. We also estimated multivariable logistic regression models for 2017-2019, adjusted for demographic factors and stratified by age (<28 and 29-60 days), with LP, antibiotic administration, and hospitalization as dependent variables and hospital-level procalcitonin testing as the independent variable. We studied 106 547 index visits. From 2010 to 2019, rates of LP, antibiotic administration, and hospitalization decreased more for infants aged 29 to 60 days compared with infants aged 0 to 28 days (annual decrease in odds of LP, antibiotics administration, and hospitalization: 0 to 28 days: 5%, 5%, and 3%, respectively; 29-60 days: 15%, 12%, and 7%, respectively). Procalcitonin testing increased significantly each calendar year (odds ratio per calendar year 2.19; 95% confidence interval 1.82-2.62), with the majority (91.1%) performed during 2017-2019. From 2017 to 2019, there was no association between hospital-level procalcitonin testing and any outcome studied (all P values > .05). Rates of LP, antibiotic administration, and hospitalization decreased significantly for infants 29 to 60 days during 2010-2019. Although procalcitonin testing increased during 2017-2019, we found no association with hospital-level procalcitonin testing and patterns of resource use.

Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians.

Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examinedtheirpractice pattern variation by observing their diagnostic approaches andtheir adherence to the ACEP Clinical Policy. We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs. Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects > 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006). Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

Finger tapping and verbal fluency post-tap test improvement in INPH: its value in differential diagnosis and shunt-treatment outcomes prognosis.

Idiopathic normal pressure hydrocephalus (INPH) diagnosis is challenging as it can be mimicked by other neurological conditions, such as neurodegenerative dementia and motor syndromes. Additionally, outcomes after lumbar puncture (LP) tap test and shunt treatment may vary due to the lack of a common protocol in INPH assessment. The present study aimed to assess whether a post-LP test amelioration of frontal cognitive dysfunctions, characterizing this syndrome, can differentiate INPH from similar neurological conditions and whether this improvement can predict INPH post-shunt outcomes. Seventy-one consecutive patients referred for INPH suspicion and LP testing, were enrolled. According to the consensus guidelines criteria, 29 patients were diagnosed as INPH and 42 were assigned an alternative diagnosis (INPH-like group) after reviewing clinical, neuropsychological and imaging data, and before LP results. A comprehensive neuropsychological assessment for frontal executive, upper extremity fine motor functions, aphasias, apraxias, agnosias and gait evaluation were administered at baseline. Executive, fine motor functions and gait were re-examined post-LP test in all patients and post-shunt placement in INPH patients. Of the INPH patients, 86.2% showed cognitive amelioration in the post-LP test; in addition, all but one (97%) presented with neurocognitive and gait improvement post-shunt. Verbal phonological fluency and finger tapping task post-LP improvement predicted positive clinical outcome post-shunt. None of the INPH-like group presented with neurocognitive improvement post-LP. Post-LP amelioration of verbal fluency and finger tapping deficits can differentiate INPH from similar disorders and predict positive post-shunt clinical outcome in INPH. This becomes of great importance when gait assessment is difficult to perform in clinical practice.

Lumbar Puncture Test in Normal Pressure Hydrocephalus: Does the Volume of CSF Removed Affect the Response to Tap?

There is limited evidence to support the use of high-volume lumbar taps over lower-volume taps in the diagnosis of normal pressure hydrocephalus. The purpose of this study is to detect whether the volume of CSF removed from patients undergoing high-volume diagnostic lumbar tap test for normal pressure hydrocephalus is significantly associated with post-lumbar tap gait performance. This retrospective study included 249 consecutive patients who underwent evaluation for normal pressure hydrocephalus. The patients were analyzed both in their entirety and as subgroups that showed robust response to the lumbar tap test. The volume of CSF removed was treated as both a continuous variable and a discrete variable. Statistical tests were repeated with log-normalized volumes. This study found no evidence of a relationship between the volume of CSF removed during the lumbar tap test and subsequent gait test performance in the patient population (Pearson coefficient r = 0.049-0.129). Log normalization of the volume of CSF removed and controlling for age and sex failed to yield a significant relationship. Subgroup analyses focusing on patients who showed greater than 20% improvement in any of the gait end points or who were deemed sufficiently responsive clinically to warrant surgery also yielded no significant relationships between the volume of CSF removed and gait outcomes, but there were preliminary findings that patients who underwent tap with larger-gauge needles had better postprocedure ambulation among patients who showed greater than 20% improvement in immediate time score (P = .04, n = 62). We found no evidence to support that a higher volume of CSF removal impacts gait testing, suggesting that a high volume of CSF removal may not be necessary in a diagnostic lumbar tap test.

Effects of Supportive Educational Program on Anxiety of Mothers of Children Undergoing the Lumbar Puncture (LP)

Background: Lumbar Puncture test is one of the most stressful diagnostic procedures in pediatric ward that its prescription put mothers under extreme pressure. There are limited interventions in this regard. Aim: determining the impact of supportive educational program on the anxiety of mothers whose children are undergoing lumbar puncture (LP). Method: the present study is a randomized controlled clinical trial carried out in 2015. Sixty mothers of children undergoing lumbar puncture and hospitalized 3educational hospitals of Mashhad, Iran, were randomly divided to control group (n=30) and intervention group (n=30). The intervention group received supportive program during a session of 60 min. Spielberger State-Trait Anxiety Inventory (STAI) was selected as the research tool. Finally, data were analyzed by Chi-square test, independent t-test using SPSS v.16 software. Results: The mean age of the mothers was 27.3±5.3 and 26.0±3.1, respectively. The mean pre-interventions maternal manifest anxiety was 51.9±6.2 and 53.4±4.3 out of 80, respectively, in the intervention and control groups. The mean post-interventions maternal manifest anxiety was 44.9±5.1 and 52.7±4.2, respectively, in the intervention and control groups. According to the results of independent t-test, significant difference was observed statistically for the mean maternal manifest anxiety between the two groups (p> 0.001). Implications for Practice: Regarding the reduction of maternal anxiety in the intervention group, which is possible because of the attention to the emotional needs of mothers, in addition to proper training; this program can be considered as an effective method to reduce maternal anxiety before the LP test.

Emergency Department Evaluation and Management of Children With Simple Febrile Seizures.

Workup of simple febrile seizures (SFS) has changed as the American Academy of Pediatrics made revisions to practice guidelines. In 2011, revisions were made regarding need for lumbar puncture (LP) as part of the SFS workup. This study surveyed more than 100 emergency departments regarding workup of children with SFS and performed a medical record review of workup that was performed. The survey shows that laboratory workup is done routinely and LP is done infrequently. The majority documents a complete exam. The medical record review demonstrates documentation of the examination, frequent laboratory and infrequent LP evaluation. Consistent with the American Academy of Pediatrics' revisions, survey and record reviews demonstrate that LP testing is infrequent. Contrary to the guideline, laboratory studies are routinely performed. This study suggests there is an opportunity to improve management of SFS by directing efforts toward finding the source of the fever and away from laboratory workup.

Analysis of Lumbar Puncture Test in 5 Patients with Good Prognosis of Shunt Operation for Normal Pressure Hydrocephalus

Five patients with favorable outcomes after a shunt operation in normal pressure hydrocephalus were analyzed with the aim of identifying consistent findings in a lumbar puncture (LP) test. The cases commonly showed improvement in at least one cognition and two gait LP parameters. We suggest that when judging the effects of LP on a shunt operation, the gait parameters need to be tailored to the gait status and the analyzed LP parameters should be evaluated at least twice at different times. J Korean Neurol Assoc 33(1):29-32, 2015

Myelitis Caused by Infection of Angiostrongylus cantonensis

A 32-year-old man presented to our hospital on July 5, 2006, after the onset of headache, paresthesias of the left upper limb for 10 days, and weakness for 7 days before admission. He had eaten an inadequately cooked Pomacea canaliculata 20 days previously. Laboratory testing indicated a normal white blood cell count of 6,700/mm3 with mild eosinophilia of 7.8% (523/mm3). A lumbar puncture test showed an opening pressure of 220 mm H2O and 160 cells with 23% eosinophils, and cerebrospinal fluid (CSF) cultures were negative. We detected the circulating antigens (CAg) of Angiostrongylus cantonensis by double antibody sandwich enzyme-linked immunosorbent assay (ELISA), and they tested positive. This method had a high sensitivity (86.4%), and no cross-reactions with sera from patients with many other parasites were observed.1 Therefore, the result was helpful for diagnosis. Spinal magnetic resonance imaging (MRI) showed a lesion with high signal intensity in the cervical spinal cord on both sagittal and transverse T2-weighted imaging (T2WI) (Figures 1 and ​and2)2) at 9 days after admission. Figure 1. A lesion in the cervical spinal cord presented as hyperintense on a sagittal T2WI. Figure 2. A lesion in the cervical spinal cord presented as hyperintense on a transverse T2WI. On the basis of history, clinical presentation, and examinations, a diagnosis of angiostrongyliasis was made,2 and the patient was treated with a combination of albendazole and dexamethasone. Symptoms of headache and paresthesia resolved within 14 days, and spinal-cord lesions completely resolved by a 1-month follow-up (Figures 3 and ​and44). Figure 3. The abnormally high signal on a sagittal T2WI completely disappeared. Figure 4. The abnormally high signal on a sagittal T2WI completely disappeared.

Pediatric Residents' Ability to Perform a Lumbar Puncture

To assess the baseline ability of pediatric residents to successfully perform a lumbar puncture (LP) and to evaluate the impact of an educational intervention on this skill in both a simulated and clinical environment. An experimental group of first-year residents and a control group of second-year residents were enrolled in a prospective nonrandomized intervention study. Knowledge and skill at performing LPs were assessed using a written and a simulated LP test. The experimental group was tested at the start of their residency and then received the educational intervention. They were retested 6 months later. The control group did not receive the educational intervention and were tested at the start of their second year. The outcomes of clinical LPs performed by the 2 groups were also recorded. The experimental group showed significant improvement on both the written and the simulated LP test after the educational intervention. When compared with the control group, they performed the simulated LP significantly better as measured by the number of correctly performed steps. Both groups performed a low number of clinical LPs. After an educational intervention, pediatric first-year residents performed a simulated LP better than a group of second-year residents who had greater clinical LP experience. The low number of clinical LPs performed limits our ability to determine the educational intervention's impact in the clinical setting and reinforces the concern that recent changes to pediatric residencies may negatively impact residents' procedural experience.

Yield of Lumbar Puncture Among Children Who Present With Their First Complex Febrile Seizure

To assess the rate of acute bacterial meningitis (ABM) among children who present with their first complex febrile seizure (CFS). This study was a retrospective, cohort review of patients aged 6 to 60 months who were evaluated in a pediatric emergency department (ED) between 1995 and 2008 for their first CFS. Cases were identified by using a computerized text search followed by a manual chart review. Exclusion criteria included prior history of nonfebrile seizures, an immunocompromised state, an underlying illness associated with seizures or altered mental status, or trauma. Data extracted included age, gender, seizure features, the number of previous simple febrile seizures, temperature, a family history of seizures, findings on physical examination, laboratory and imaging study results, and ED diagnosis and disposition. We identified 526 patients. The median age was 17 months (interquartile range: 13-24), and 44% were female. Ninety patients (17%) had a previous history of simple febrile seizures. Of the patients, 340 (64%) had a lumbar puncture (LP). The patients' median white blood cell count during a CFS was 1 cell per microL (interquartile range: 1-2), and 14 patients had CSF pleocytosis (2.7% [95% confidence interval [CI]: 1.5-4.5]). Three patients had ABM (0.9% [95% CI: 0.2-2.8]). Two had Streptococcus pneumoniae in a culture of their cerebrospinal fluid. Among these 2 patients, 1 was nonresponsive during presentation, and the other had a bulging fontanel and apnea. The third child appeared well; however, her blood culture grew S pneumoniae and failed the LP test. None of the patients for whom an LP was not attempted subsequently returned to the hospital with a diagnosis of ABM (0% [95% CI: 0, 0.9]). Few patients who experienced a CFS had ABM in the absence of other signs or symptoms.

Rifabutin Related Uveitis in AIDS: A Case Report

Purpose: To describe a case of symptomatic rifabutin-related uveitis with hypopyon and vitreous opacity in apatient with acquired immunodeficiency syndrome infected with Mycobacterium tuberculosis. Case summary: A 33-year-old male patient with acquired immunodeficiency syndrome was referred to our clinic for abruptly decreased vision in his right eye. Multi-drug therapy with rifabutin was administered for 5 weeks to treat tuberculosis enteritis and pulmonary tuberculosis. Visual acuity of the right eye was hand motion and hypopyon as well as vitreous opacity was found in ocular examinations. Other serologic tests, anterior chamber paracentesis and lumbar puncture test were normal. Rifabutin was immediately stopped and topical steroid and cycloplegics were administered, which resulted in resolution of the hypopyon, vitreous opacity and visual acuity. Four weeks after the initial episode, rifabutin was restarted to treat the pulmonary tuberculosis and rifabutin-related uveitis relapsed in the opposite eye. Conclusions: Rifabutin-related uveitis should be considered in cases of uveitis in immunosuppressive patients, especially in acquired immunodeficiency syndrome patients. Underling disease and medication history should be carefully assessed.

Evaluation of autonomic malfunction in idiopathic normal pressure hydrocephalus

The autonomic nervous system plays an important role in urinary disturbance which is one of the main symptoms of idiopathic normal pressure hydrocephalus (iNPH); thus, the focus of the present study was to identify the autonomic function parameters that would be useful as clinical indicators of iNPH. The subjects consisted of 18 iNPH patients (group N) and 31 normal controls (group C). Before and after a lumbar puncture test, they were examined for CVR-R and total heart rate. A power spectral analysis of R-R interval variability of their 24-hour Holter ECGs was also done. High frequency (HF) was an indicator of parasympathetic activity, while the low to high frequency ratio (L/H) was used as an indicator of sympathetic activity. Urinary incontinence was evaluated using the overactive bladder symptom score (OABSS) questionnaire and bladder capacity. Correlations between the above indicators and clinical indicators of iNPH, such as the mini-mental state examination and the Evans index, were examined. The HF values (ms(2)) were 190.3 in group C and 237.2 in group N; the difference was statistically significant. In group N, the HF value after the lumbar puncture test was lower (160.3) than the value before the lumbar puncture test, confirming that the increased parasympathetic state returned to a near normal level after CSF drainage. A significant positive correlation was noted only between the pre-lumbar puncture HF value and the OABSS. iNPH is associated with increased parasympathetic activity, and the lumbar puncture test and shunt surgery may correct this autonomic imbalance to near normal levels.

761 THE IMPACT OF CLINICAL APPEARANCE ON MEDICAL DECISION MAKING

In an effort to understand how clinical appearance is utilized when making medical decisions, we presented 30 physicians with written histories and videotapes of febrile infants. The videotapes and the history were rated to be either highly predictive (HP) or weakly predictive (WP) of bacteremia. Each subject was presented with a set of 4 problems. A between subjects design was utilized to test the following combinations. For each problem, subjects estimated the probability (P) of bacteremia and how likely they were to perform a lumbar puncture (LP), treat and/or hospitalize, seek consultation, arrange for a follow-up (F/U) visit in six hours, and obtain additional lab tests. Results showed: (1) no significant difference between combinations a. and c. for (P) bacteremia or obtaining LP, consultaitons, F/U, or additional lab tests, (2) significantly higher values for b. compared to d. for (P) bacteremia,(p=.002), and obtaining LP (p=.002), consultations, (p=.02), F/U (p=.008), and lab tests (p=.0001). This study demonstrated that (1) a sick appearing patient may cause clinicians to disregard the predictivity of the history and (2) when the patient appears well, the predictivity of the history has a significant effect on the physician decision making.

INTRACRANIAL HEMORRHAGE IN THE NEW-BORN

Two years ago at the meeting of this section, a preliminary report 1 of lumbar puncture tests on 100 consecutive new-born babies within from twelve to twenty-four hours after birth was presented. It was so surprising to find bloody and blood-tinged cerebrospinal fluid in many of these cases that similar tests to confirm or disprove the findings of the first series were performed on a second series of 100 new-born babies, and these observations have been continued until the total series consists of 500 new-born babies on whom a lumbar puncture was performed within from twelve to forty-eight hours after birth; bloody and blood-tinged cerebrospinal fluid was present in forty-five babies, that is, 9 per cent. This frequency of intracranial hemorrhage of varying degree in the new-born of this series suggests the importance of recognizing the clinical signs, if any, of its presence and of the early treatment of the