Advertisement

CSF and EEG in Neurological Emergency

  • Mamta Bhushan Singh
  • Rohit Bhatia
  • Deepti Vibha
Chapter

Abstract

Performing a lumbar puncture and examining the cerebrospinal fluid (CSF) provide a unique opportunity to explore the internal milieu in which the brain and spinal cord are bathed. Analysis of the CSF is the cornerstone of diagnosis and management of many neurological emergencies. It also plays an important role in the diagnosis and sometimes prognostication of non-infectious diseases. Evaluation of the CSF is critical in establishing a diagnosis of infectious meningitis and in guiding antimicrobial therapy. Less commonly, a lumbar puncture (LP) is used as a part of the diagnostic workup of patients with suspected subarachnoid haemorrhage, demyelinating disease and leptomeningeal metastasis (LM) [1], all of which may present as neurological emergencies. The two major issues that may interfere with appropriate and timely CSF analysis (either by LP or shunt tap) are concerns about uncal or cerebellar tonsillar herniation and the need to initiate empirical antibiotics emergently [2]. Once the clinical indication for CSF analysis is understood, the amount to be tapped, investigations to be sent and an algorithm of action to be taken should be clearly drawn by the clinician. Doing an LP without a clear-cut question in mind is likely to cause a delay in sending samples for the most appropriate investigations.

References

  1. 1.
    Report of the quality standards subcommittee of the American Academy of Neurology. Practice parameters: Lumbar puncture. Neurology. 1993;43:625–7.Google Scholar
  2. 2.
    Ziai WC, Lewin JJ III. Update in the diagnosis and management of central nervous system infections. Neurol Clin. 2008;26:427–68.CrossRefGoogle Scholar
  3. 3.
    Chamberlain MC. Neoplastic meningitis. Oncologist. 2008;13:967–77.CrossRefGoogle Scholar
  4. 4.
    Steigbigel NH. Computed tomography of the head before a lumbar puncture in suspected meningitis—is it helpful? N Engl J Med. 2001;345:1768–70.CrossRefGoogle Scholar
  5. 5.
    Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001;345:1727–33.CrossRefGoogle Scholar
  6. 6.
    Roos KL. Lumbar puncture. Semin Neurol. 2003;23:105–14.CrossRefGoogle Scholar
  7. 7.
    Yasuda T, Tomita T, McLone DG, et al. Measurement of cerebrospinal fluid output through external ventricular drainage in one hundred infants and children: correlation with cerebrospinal fluid production. Pediatr Neurosurg. 2002;36:22–8.CrossRefGoogle Scholar
  8. 8.
    Thwaites G, Fisher M, Hemingway C, et al. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect. 2009;59:167–87.CrossRefGoogle Scholar
  9. 9.
    Somand D, Meurer W. Central nervous system infections. Emerg Med Clin North Am. 2009;27:89–100.CrossRefGoogle Scholar
  10. 10.
    Bonadio WA. The cerebrospinal fluid: physiologic aspects and alterations associated with bacterial meningitis. Pediatr Infect Dis J. 1992;11:423–32.CrossRefGoogle Scholar
  11. 11.
    Dougherty JM, Roth RM. Cerebral spinal fluid. Emerg Med Clin North Am. 1986;4:281–97.PubMedGoogle Scholar
  12. 12.
    Conley JM, Ronald AR. Cerebrospinal fluid as a diagnostic body fluid. Am J Med. 1983;75:102–6.CrossRefGoogle Scholar
  13. 13.
    Fishman RA. Composition of the cerebrospinal fluid. In: Fishman RA, editor. Cerebrospinal fluid in diseases of the nervous system. Philadelphia: W.B. Saunders; 1992. p. 183–252.Google Scholar
  14. 14.
    Roos KL. What I have learned about infectious diseases with my sleeves rolled up. Semin Neurol. 2002;22:9–15.CrossRefGoogle Scholar
  15. 15.
    Chaudhuri A, Martin PM, Kennedy PGE, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS task force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008;15:649–59.CrossRefGoogle Scholar
  16. 16.
    Glimåker M, Johansson B, Grindborg Ö, et al. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60:1162.CrossRefGoogle Scholar
  17. 17.
    Sharon E. Mace. Acute bacterial meningitis. Emerg Med Clin North Am. 2008;38:281–317.Google Scholar
  18. 18.
    Roos K, Tunkel A, et al. Acute bacterial meningitis in children and adults. In: Scheld W, Whitley R, Durack D, editors. Infections of the central nervous system. 2nd ed. Philadelphia: Lippincott-Raven; 1997. p. 335–402.Google Scholar
  19. 19.
    Aminpour S, Tinling SP, Brodie HA. Role of tumor necrosis factor-alpha in sensorineural hearing loss after bacterial meningitis. Otol Neurotol. 2005;26:602–9.CrossRefGoogle Scholar
  20. 20.
    Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39:1267–84.CrossRefGoogle Scholar
  21. 21.
    Coyle PK. Overview of acute and chronic meningitis. Neurol Clin. 1999;17:691–710.CrossRefGoogle Scholar
  22. 22.
    Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in paediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics. 2001;108:1169–74.PubMedGoogle Scholar
  23. 23.
    Marra CM, Maxwell CL, Collier AC, et al. Interpreting cerebrospinal fluid pleocytosis in HIV in the era of potent antiretroviral therapy. BMC Infect Dis. 2007;7:37.CrossRefGoogle Scholar
  24. 24.
    Wong M, Schlaggar BL, Landt M. Postictal cerebrospinal fluid abnormalities in children. J Pediatr. 2001;138:373–7.CrossRefGoogle Scholar
  25. 25.
    Garges HP, Moody MA, Cotten CM, et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters? Pediatrics. 2006;117:1094–100.CrossRefGoogle Scholar
  26. 26.
    Aksamit AJ. Cerebrospinal fluid in the diagnosis of central nervous system infections. In: Roos KL, editor. Central nervous system infectious diseases and therapy. New York: Marcel Dekker; 1997. p. 731–45.Google Scholar
  27. 27.
    Davies NWS, Brown LJ, Gonde J, et al. Factors influencing PCR detection of viruses in cerebrospinal fluid of patients with suspected CNS infections. J Neurol Neurosurg Psychiatry. 2005;76:82–7.CrossRefGoogle Scholar
  28. 28.
    Ogawa S, Shrestha MP, Rai SK, et al. Serological and virological studies of Japanese encephalitis in the Terai region of Nepal. Southeast Asian J Trop Med Public Health. 1992;23:37–43.PubMedGoogle Scholar
  29. 29.
    Sakushima K, Hayashino Y, Kawaguchi T, et al. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. J Infect. 2011;62:255.CrossRefGoogle Scholar
  30. 30.
    Beaty HN, Oppenheimer S. Cerebrospinal fluid lactic dehydrogenase and its isoenzymes in infections of the central nervous system. N Engl J Med. 1968;279:1197–2002.CrossRefGoogle Scholar
  31. 31.
    Leib SL, Boscacci R, Gratzl O, et al. Predictive value of cerebrospinal fluid (CSF) lactate level versus CSF/blood glucose ratio for the diagnosis of bacterial meningitis following neurosurgery. Clin Infect Dis. 1999;29:69–74.CrossRefGoogle Scholar
  32. 32.
    Corral I, Quereda C, Navas E, et al. Adenosine deaminase activity in cerebrospinal fluid of HIV-infected patients: limited value for diagnosis of tuberculous meningitis. Eur J Clin Microbiol Infect Dis. 2004;23:471e6.CrossRefGoogle Scholar
  33. 33.
    Sanchez-Juan P, Green A, Ladogana A, et al. CSF tests in the differential diagnosis of Creutzfeldt–Jakob disease. Neurology. 2006;67:637–43.CrossRefGoogle Scholar
  34. 34.
    Twijnstra A, Ongerboer de Visser BW, van Zanten AP, et al. Serial lumbar and ventricular cerebrospinal fluid biochemical marker measurements in patients with leptomeningeal metastases from solid and hematological tumors. J Neuro-Oncol. 1989;7:57–63.CrossRefGoogle Scholar
  35. 35.
    Damek DM. Cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastasis and paraneoplastic syndrome. Emerg Med Clin North Am. 2009;27:209–29.CrossRefGoogle Scholar
  36. 36.
    Dupont SA, Wijdicks EFM, Manno EM, et al. Thunderclap headache and normal computed tomographic results: value of cerebrospinal fluid analysis. Mayo Clin Proc. 2008;83:1326–31.CrossRefGoogle Scholar
  37. 37.
    Petzold A, Brettschneider J, Jin K, et al. CSF protein biomarkers for proximal axonal damage improve prognostic accuracy in the acute phase of Guillain–Barré syndrome. Muscle Nerve. 2009;40:42–9.CrossRefGoogle Scholar
  38. 38.
    Leitinger M, Trinka E, Gardella E, Rohracher A, Kalss G, Qerama E, Höfler J, Hess A, Zimmermann G, Kuchukhidze G, Dobesberger J. Diagnostic accuracy of the Salzburg EEG criteria for non-convulsive status epilepticus: a retrospective study. The Lancet Neurology. 2016;15(10):1054–62.CrossRefGoogle Scholar
  39. 39.
    Leitinger M, Beniczky S, Rohracher A, Gardella E, Kalss G, Qerama E, Höfler J, Lindberg-Larsen AH, Kuchukhidze G, Dobesberger J, Langthaler PB. Salzburg consensus criteria for non-convulsive status Epilepticus–approach to clinical application. Epilepsy Behav. 2015;49:158–63.CrossRefGoogle Scholar
  40. 40.
    Gururangan K, Razavi B, Parvizi J. Utility of electroencephalography: experience from a US tertiary care medical center. Clin Neurophysiol. 2016;127(10):3335–40.CrossRefGoogle Scholar
  41. 41.
    Privitera MD, Strawsburg RH. Electroencephalographic monitoring in the emergency department. Emerg Med Clin North Am. 1994;12:1089–100.PubMedGoogle Scholar
  42. 42.
    Praline J, Grujic J, Corcia P, et al. Emergent EEG in clinical practice. Clin Neurophysiol. 2007;118:2149–55.CrossRefGoogle Scholar
  43. 43.
    Bauer G, Trinka E. Nonconvulsive status epilepticus and coma. Epilepsia. 2010;51:177–90.CrossRefGoogle Scholar
  44. 44.
    Claassen J, Mayer SA, Kowalski RG, et al. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology. 2004;62:1743–8.CrossRefGoogle Scholar
  45. 45.
    Dworetzky BA, Mortati KA, Rossetti AO, et al. Clinical characteristics of psychogenic nonepileptic seizure status in the long-term monitoring unit. Epilepsy Behav. 2006;9:335–8.CrossRefGoogle Scholar
  46. 46.
    Chaudhuri A, Kennedy PGE. Diagnosis and treatment of viral encephalitis. Postgrad Med J. 2002;78:575–83.CrossRefGoogle Scholar
  47. 47.
    Silverman D, Saunders MG, Schwab RS, et al. Cerebral death and the electroencephalogram. Report of the ad hoc committee of the American electroencephalographic society on EEG criteria for determination of cerebral death. JAMA. 1969;209:1505–10.CrossRefGoogle Scholar
  48. 48.
    Firosh Khan S, Ashalatha R, Thomas SV, et al. Emergent EEG is helpful in neurology critical care practice. Clin Neurophysiol. 2005;116:2454–9.CrossRefGoogle Scholar
  49. 49.
    Varelas PN, Spanaki MV, Hacein-Bey L, et al. Emergent EEG: indications and diagnostic yield. Neurology. 2003;61:702–4.CrossRefGoogle Scholar
  50. 50.
    Mani R, Arif H, Hirsch LJ, Gerard EE, LaRoche SM. Interrater reliability of ICU EEG research terminology. J Clin Neurophysiol. 2012;29(3):203–12.CrossRefGoogle Scholar
  51. 51.
    Hirsch LJ, LaRoche SM, Gaspard N, Gerard E, Svoronos A, Herman ST, Mani R, Arif H, Jette N, Minazad Y, Kerrigan JF. American clinical neurophysiology society’s standardized critical care EEG terminology: 2012 version. J Clin Neurophysiol. 2013;30(1):1–27.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2019

Authors and Affiliations

  • Mamta Bhushan Singh
    • 1
  • Rohit Bhatia
    • 1
  • Deepti Vibha
    • 1
  1. 1.Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia

Personalised recommendations