Cerebrospinal Fluid Analysis, (etc)



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Cerebrospinal Fluid Analysis, (etc)

Alan J. Hunter, MD








Glucose







Normal

Low

(Arachnoid leak)



WBC’s

100’s

(> 5-999)



Infectious

  • Early bacterial

  • Partially Tx’d bacterial

  • Early granulomatous

  • Viral/aseptic

  • Parameningeal Inflammation

    • Brain absc, sinus, orbit, etc

  • Meningovascular syphilis or Lyme’s

  • Uncomplicarted zoster

Non-Infectious

  • Paraneoplastic (L. encephalitis)

  • Heavy metals

    • e.g. Lead poisoning in children

  • Vasculitis/autoimmune

    • e.g. SLE, MCTD

  • CVA with cortical necrosis

  • Medications:

    • TMP/SMZ, cipro, NSAID, OKT3, araC, IGG, etc..

  • Granulomatous

    • Tuberculosis

    • Fungal

      • Cryptococcus

      • Histoplasmosis

      • Coccidioides

    • Listeriosis

    • Brucellosis

    • Parasitic

    • Sarcoidosis (~10%)

    • Other…

  • Meningovascular syphilis

  • Subarachnoid hemorrhage

  • Neoplastic meningitis (~10%)

  • Viral (RARE!)

    • LCV - Lymphocytic choriomeningitis (Cats!)

    • Mumps

    • HSV

  • Partially treated bacterial meningitis




1000’s

  • Aseptic Meningitis

    • Viral/Drug/chemical

  • Early or partially TX’d Bacterial

  • Acute Bacterial

  • RARELY granulomatous

Personal communication: T Ward, R Bryant…and a little.. me
Diagnostic Yield (Bacterial Menigngits)




Cut-Off

LR+

LR-

P

CSF/Bld Glucose Ratio

0.4

18

0.31

DOES not R/O

CSF leukocytes

500/µL

15

0.30

DOES not R/O

CSF lactate

31 mg/dL

21

0.12




CSF Gram Stain

Positive

> 500

0.14-0.44




Straus SE, RCE: Tests for Meningitis. JAMA 2006:296;2012-22.
Reduction of Adverse Effects Lumbar Puncture

4 Trials of 717 pts

Trials

(Pts)

% HA

ARR

(CI)

NNT

P

Background

  • Headache can occur in up to 60% of pts

  • Backache can occur in up to 40% of pts

  • Other Rare C/O: cerebral herniation; subdural hemorrhage, spinal epidural hemorrhage; infection.

Reduction of Headache




Atraumatic needle

(blunted, side fill)



5

(587)


17%

12.3 %

(-1.72% to 26.2%)



~ 8

NS

Re-insertion of stylet pre needle removal

1

(115)

NG

11.3 %

(6.5%-16.2%)

~ 9

Signif

immediate mobilization post LP vs 4 hr bed rest

4

(717)


40%

2.9%

(-3.4%-9.3%)



~ 34

NS

Straus SE, RCE: Tests for Meningitis. JAMA 2006:296;2012-22.

Other Physical Exam Findings;



+++

John Attia JAMA. 1999;282:175-181



Karen E. Thomas Clinical Infectious Diseases 2002; 35:46–52

(see below for more contemporary & conflicting assessments)
Acute bacterial meningitis & subarachnoid hemorrhage

Finding__Freq_(%)__Sens_(%)'>Finding

Freq (%)

Sens (%)

Spec (%)

LR+

LR-




Acute Bacterial Meningitis



















Meningismus

57-92
















Fever

66-100
















Altered sensorium

44-96
















HA

50
















Jolt acceleration HA




100

54

2.2

0




ANY: Fever, HA, MS 




99.5







+++




Bredzinskis sign




97

65

2.8

0.05

??

Kernig’s




57

88

4.8

0.49




Kernig’s or Bredzinski’s signs

61
















Focal neurologic deficit

9-37
















Seizures

9-23
















Petechial rash

3-52





































Sub-Arachnoid hemorrhage

Freq (%)

Sens (%)

Spec (%)

LR+

LR-




Meningismus

21-86

59

94

10.3

0.4




Seizures

32

32

86

2.2

NS




Altered sensorium

29

64

89

5.9

0.4




Focal neurologic deficit

13-36
















Fever

8
















Pre-retinal hemorrhages

2
















Age ≤ 60 years




86

52

1.8

0.3




Adapted from above [Attia J (JAMA 1999) & Thomas KE (CID 2002)] & Table 23-1 & Table 23-2; p 305;

McGee S, Evidence Based Physical Diagnosis, Saunders Inc, 2001



(see below for more contemporary & conflicting assessments)
More (newer explorations) on Jolt Acceleration Headache


Sensitivity / Specificity of Jolt, Kernig’s, Brudzinski, & Meningismus for CSF pleocytosis in an observational (convenience sample) eval of 240 adults with suspected meningitis in 2 urban NYC ED’s

Finding

Sens (%)

Spec (%)

LR+

LR-

Jolt Acceleration

21%

85%

1.36

0.93

Kernig’s

2%

97%

.77

1.01

Brudzinski

2%

98%

0.97

1.00

Nuchal Rigidity

13%

80%

0.63

1.09

MD Suspicion of “Bacterial”

45%

40%

0.75

1.37

American Journal of Emergency Medicine 32 (2014) 24–28


Jolt Acceleration Headache Utility: from a retrospective trial of 531 pt with suspected meningitis

(139 patients with [86% viral] and 392 without)




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