Role of beta-2-microglobulin as a biomarker in very preterm and extremely preterm infants with CNS inflammation.

BACKGROUND: Premature infants are at risk for severe sepsis and meningitis, both infections associated with high mortality and morbidity. Cerebro-spinal fluid (CSF) culture is the gold standard method for meningitis diagnosis, but interpretation of biochemical parameters of CSF is essential at the moment of the analysis in order to start the appropriate treatment. The main objective of this study was to determine whether levels of CSF beta-2-microglobulin (B2M) were elevated in preterm infants with CNS infections or other inflammatory processes, and to establish if there were differences in B2M concentrations amongst various inflammatory settings (sepsis, meningitis, and progressive post-hemorrhagic ventricular dilatation (PHVD)). METHODS: This is a retrospective study of all very preterm and extremely preterm infants (< 32 weeks of gestation) admitted to our NICU between 2012 and 2017. All those who underwent a lumbar puncture during their stay as part of a sepsis work-up or PHVD were considered for inclusion. CSF biochemical parameters and B2M were tested in all of the patients. RESULTS: Fifty-nine patients were included in the study. In patients with CNS infections, the median value of B2M was 8.69 mg/L (3.92-18.5). B2M levels above 3.92 mg/L showed greater sensitivity and specificity than leukocyte levels in discriminating between patients with CNS infections or other inflammatory processes and those without CNS inflammation. CONCLUSIONS: In this population, CSF B2M proved to be an effective biomarker to discriminate between patients with CNS infections and other inflammatory processes and those without CNS inflammation.

Cerebral Amyloid Angiopathy-Related Microbleeds and Cerebrospinal Fluid Biomarkers in Alzheimer's Disease.

BACKGROUND: Alzheimer's disease (AD) commonly accompanies cerebral amyloid angiopathy (CAA). OBJECTIVE: We aimed to reveal associations between CAA-related brain microbleeds and cerebrospinal fluid (CSF) markers in AD patients. METHODS: Patients with probable AD (n = 88) from consecutive patients in our memory clinic were evaluated for patient demographics, vascular risk factors, neuropsychological tests, apolipoprotein E phenotype, MRI including T2*-weighted image and fluid attenuated inversion recovery sequence, and CSF amyloid and tau markers. RESULTS: The 88 patients with AD included 15 with microbleeds only in cortical/subcortical regions (cortical microbleeds) that could be CAA-related, 16 with microbleeds only in deep locations (deep microbleeds), 3 with microbleeds in both cortical and deep locations (mixed microbleeds), and 54 without microbleeds. The CSF levels of amyloid ß-protein 1-40 (Aß40) and amyloid ß-protein 1-42 (Aß42) were significantly lower in patients with cortical microbleeds than in those without microbleeds (p = 0.001 and p = 0.027, respectively). The result remained unchanged after adjustment for age, sex, apolipoprotein E E4 presence, and leukoaraiosis. CONCLUSIONS: CAA-related cortical microbleeds would be associated with lower CSF levels of Aß40 and Aß42 in AD, reflecting the deposition of both Aß40 and Aß42 in the cerebrovasculature.

Differences in Neuropeptide Y Secretion Between Intracerebral Hemorrhage and Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Neuropeptide Y (NPY) is one of the most potent endogenous vasoconstrictors, and its contribution to the multifactorial cascade of cerebral vasospasm due to nontraumatic subarachnoid hemorrhage (SAH) is not yet fully understood. This experimental study compared the hemorrhage-specific course of NPY secretion into cerebrospinal fluid (CSF) and into plasma between 2 groups: patients with SAH and patients with basal ganglia hemorrhage (BGH) or cerebellar hemorrhage (CH) over the first 10 days after hemorrhage. MATERIALS AND METHODS: Seventy-nine patients were prospectively included: SAH patients (n=66) (historic population) and intracerebral hemorrhage patients (n=13). All patients received an external ventricular drain within 24 hours of the onset of bleeding. CSF and plasma were drawn daily from day 1 to day 10. The levels of NPY were determined by means of competitive enzyme immunoassay. The CSF samples of 29 patients (historic population) who had undergone spinal anesthesia due to orthopedic surgery served as the control group. RESULTS: NPY levels in CSF were significantly higher in the 2 hemorrhage groups than in the control group. However, the 2 hemorrhage groups showed significant differences in NPY levels in CSF (SAH mean, 0.842 ng/mL vs. BGH/CH mean, 0.250 ng/mL; P<0.001) as well as in the course of NPY secretion into CSF over the 10-day period. NPY levels in plasma did not differ significantly among SAH, BGH/CH, and controls. CONCLUSIONS: Our findings support the hypothesis that excessive release of NPY into CSF but not into plasma is specific to aneurysmal SAH in the acute period of 10 days after hemorrhage. In BGH/CH, CSF levels of NPY were also increased, but the range was much lower.

Dynamic evolution of D-dimer level in cerebrospinal fluid predicts poor outcome in patients with spontaneous intracerebral hemorrhage combined with intraventricular hemorrhage.

The risk of mortality in patients with intracerebral hemorrhage (ICH) significantly increases when complicated by intraventricular hemorrhage (IVH). We hypothesize that serial measurement of cerebrospinal fluid (CSF) D-dimer levels in patients with both ICH and IVH may serve as an early marker of IVH severity. We performed a prospective study of 43 consecutive ICH patients combined with IVH and external ventricular drainage placement admitted in our institution from 2005-2006. IVH severity (Graeb score) and fibrinolytic activity were evaluated continuously for 7days using CT scans and CSF D-dimer levels. The primary outcome was 30day mortality. Overall 30day mortality was 26% (n=11), with eight deaths (72.7%) after 3days (D3). Graeb score and CSF D-dimer on admission (D0) were not significantly different between survivors and non-survivors. The temporal profiles of both parameters were distinctly different, with a downward trend in survivors and an upward trend in non-survivors. A mortality rate of 54% was observed between D0-D3 when both scores increased during this interval. In contrast, the mortality was only 4% when both measures decreased during this interval. Early phase (D0-D3) CSF D-dimer or Graeb score change demonstrated high sensitivity of 88% and specificity of 81% when predicting 30day mortality. Early phase CSF D-dimer change in patients with both ICH and IVH is accurate in predicting mortality and may be utilized as a cost-effective surrogate indicator of IVH severity. Serial monitoring of CSF D-dimer dynamic changes is useful for early identification of patients with hematoma progression and poor outcome.

The Role of Circulating Tight Junction Proteins in Evaluating Blood Brain Barrier Disruption following Intracranial Hemorrhage.

Brain injury after intracranial hemorrhage (ICH) results in significant morbidity and mortality. Blood brain barrier (BBB) disruption is a hallmark of ICH-induced brain injury; however, data mirroring BBB disruption in human ICH are scarce. The aim of this study was to assess the significance of circulating biomarkers in evaluating BBB disruption after ICH. Twenty-two patients with ICH were recruited in this study. Concentrations of the tight junction proteins (TJs) Claudin-5 (CLDN5), Occludin (OCLN), and zonula occludens 1 (ZO-1) and vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9) were measured by using enzyme-linked immunosorbent assay in serum and cerebrospinal fluid (CSF) samples obtained from patients with ICH. The white blood cell (WBC) count in blood and CSF, albumin (ALB) levels in the CSF (ALBCSF), and the BBB ratio were significantly higher in the ICH than in controls (p < 0.05). Significantly higher levels of CLDN5, OCLN, ZO-1, MMP-9, and VEGF in CSF were observed in the ICH group; these biomarkers were also positively associated with BBB ratio (p < 0.05). Our data revealed that circulating TJs could be considered the potential biomarkers reflecting the integrity of the BBB in ICH.

Remote Multiple Intraparenchymal Hemorrhages Following Aneurysmal Clipping of the Anterior Communicating Artery: A Case Report and Literature Review.

Remote intraparenchymal hemorrhage after clipping of a ruptured aneurysm is rare. The pathogenesis is variable, and the therapeutic strategies remain controversial, because the natural history is unclear. Here we report a woman with subarachnoid hemorrhage (SAH), who had an aneurysm of the anterior communicating artery identified by computed tomography angiography (CTA). A 51-year-old women, who was in a good preoperative condition without movement disorders before operation, went on to exhibit left hemiparesis after aneurysmal clipping as she recovered from anesthesia in the operating room. CT images performed immediately after surgery showed that two intraparenchymal hemorrhages were present contralateral to the site of the operation. After conservative treatment, the patient recovered, but still displayed a movement disorder in the left limb. SAH induced-vasospasm, defective vascular autoregulation, excessive drainage of the cerebrospinal fluid, a change in the intracranial pressure after craniotomy, and brain shift may contribute to the pathogenesis of remote hemorrhage after surgery.

Severe neurotoxicity following intrathecal methotrexate with nitrous oxide sedation in a child with acute lymphoblastic leukemia.

Systemic and intrathecal methotrexate is widely used in treatment protocols for childhood acute lymphoblastic leukemia. Its side effects vary in characteristics, intensity and time of onset, and depend on the administration route. Interactions with several drugs are known. Side effects of nitrous oxide sedation, often used for moderately painful procedures, typically occur after long time use and include neurological symptoms. We present a child who experienced a severe and long-lasting neurotoxicity after the third intrathecal application of methotrexate with short sedation by nitrous oxide during induction therapy for acute lymphoblastic leukemia. Symptoms completely resolved after 12 months.

[Diagnosis of cerebral hemorrhage before the era of computed tomography]. / A cerebrális állományvérzés diagnosztikája a komputertomográfia korszaka elott.

INTRODUCTION: During the past decades there has been a great progress in neuroimaging methods. Cranial computed tomography is part of the daily routine now and its use allows a fast diagnosis of parenchymal hemorrhage. However, before the availability of computed tomography the differentiation between ischemic and hemorrhagic stroke was based on patient history, physical examination, percutan angiography and cerebrospinal fluid sampling, and the clinical utility could be evaluated by autopsy of deceased patients. AIM: The authors explored the diagnostic performance of cerebrospinal fluid examination for the diagnosis of ischemic and hemorrhagic stroke. METHOD: Data of 200 deceased stroke patients were retrospectively evaluated. All patients had liquor sampling at admission and all of them had brain autopsy. RESULTS: Bloody or yellowish cerebrospinal fluid at admission had a positive predictive value of 87.5% for hemorrhagic stroke confirmed by autopsy, while clear cerebrospinal fluid had positive predictive value of 90.7% for ischemic stroke. Patients who had clear liquor, but autopsy revealed hemorrhagic stroke had higher protein level in the cerebrospinal fluid, but the difference was not statistically significant (p = 0.09). CONCLUSIONS: The results confirm the importance of pathological evaluation of the brain in cases deceased from cerebral stroke. With this article the authors wanted to salute for those who contributed to the development of the Hungarian neuropathology. In this year we remember the 110th anniversary of the birth, and the 60th anniversary of the death of professor Kálmán Sántha. Professor László Molnár would be 90 years old in 2013.

[The value of low-molecular-weight DNA of blood plasma in the diagnostic of the patological processes of different genesis].

The low-molecular-weight DNA appears in blood plasma of irradiated rats, and its content correlates directly with the irradiation dose. Cloning has shown, that enrichment of low-molecular-weight DNA with G+C content and features of its nucleotide sequences point to its ability to form rather stable nucleosomes. DNA obtained after irradiation of rats with principally different doses 8 and 100 Gy differed not only quantitatively, but also by content of the dinucleotides CpG and CpT; this suggests their origin from different sites of genome. For the first time it has been shown that exposure to low-frequency noise results in an increase of the contents of blood plasma low-molecular-weight DNA. In stroke patients blood concentrations of this DNA increased 3 days after the beginning of the acute period, and dynamics of its excretion differs in ischemic and hemorrhagic forms; in the case of ischemia low-molecular-weight DNA appears in cerebrospinal fluid. The chronic obstructive pulmonary disease in the state of remission is characterized by the decline of the level of low-molecular-weight DNA in the blood plasma unlike in the case of the chronic nonobstructive bronchitis. The clear dependence between formation and special features of the low-molecular-weight DNA fraction in blood plasma makes it possible to consider the low-molecular fraction as an universal index of apoptosis, which allows to distinguish basically different conditions of the body.

Intracranial hemorrhage after spine surgery.

OBJECT: The authors describe the largest case series of 8 patients with intracranial hemorrhage (ICH) after spinal surgery and identify associated pre-, intra-, and postoperative risk factors in relation to outcome. METHODS: The authors retrospectively reviewed the cases of 8 patients treated over 16 years at a single institution and also reviewed the existing literature and collected demographic, treatment, and outcome information from 33 unique cases of remote ICH after spinal surgery. RESULTS: The risk factors most correlated with ICH postoperatively were the presence of a CSF leak intraoperatively and the use of drains postoperatively with moderate hourly serosanguineous output in the early postoperative period. CONCLUSIONS: Intracranial hemorrhage is a rare complication of spinal surgery that is associated with CSF leakage and use of drains postoperatively, with moderate serosanguinous output. These associations do not justify a complete avoidance of drains in patients with CSF leakage but may guide the treating physician to keep in mind drain output and timing of drain removal, while noting any changes in neurological examination status in the meantime. Additionally, continued and worsening neurological symptoms after spinal surgery may warrant cranial imaging to rule out intracranial hemorrhage, usually within the first 24 hours after surgery. The presence of cerebellar hemorrhage and hydrocephalus indicated a trend toward worse outcome.

Bradykinin in blood and cerebrospinal fluid after acute cerebral lesions: correlations with cerebral edema and intracranial pressure.

Bradykinin (BK) was shown to stimulate the production of physiologically active metabolites, blood-brain barrier disruption, and brain edema. The aim of this prospective study was to measure BK concentrations in blood and cerebrospinal fluid (CSF) of patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and ischemic stroke and to correlate BK levels with the extent of cerebral edema and intracranial pressure (ICP). Blood and CSF samples of 29 patients suffering from acute cerebral lesions (TBI, 7; SAH,: 10; ICH, 8; ischemic stroke, 4) were collected for up to 8 days after insult. Seven patients with lumbar drainage were used as controls. Edema (5-point scale), ICP, and the GCS (Glasgow Coma Score) at the time of sample withdrawal were correlated with BK concentrations. Though all plasma-BK samples were not significantly elevated, CSF-BK levels of all patients were significantly elevated in overall (n=73) and early (≤72 h) measurements (n=55; 4.3±6.9 and 5.6±8.9 fmol/mL), compared to 1.2±0.7 fmol/mL of controls (p=0.05 and 0.006). Within 72 h after ictus, patients suffering from TBI (p=0.01), ICH (p=0.001), and ischemic stroke (p=0.02) showed significant increases. CSF-BK concentrations correlated with extent of edema formation (r=0.53; p<0.001) and with ICP (r=0.49; p<0.001). Our results demonstrate that acute cerebral lesions are associated with increased CSF-BK levels. Especially after TBI, subarachnoid and intracerebral hemorrhage CSF-BK levels correlate with extent of edema evolution and ICP. BK-blocking agents may turn out to be effective remedies in brain injuries.

Evaluation of 2 hematology analyzers in body fluid mode versus flow cytometry immunophenotyping of mainly neurosurgical cerebrospinal fluid samples.

BACKGROUND: For CSF analysis, exact knowledge of the type and amount of cells is essential, especially for detection of infection or bleeding. The chamber count has been the current reference method to date, yet it is problematic due to its subjectivity depending on the examiner's skill and experience. Therefore, as a reference method, we used an impulse cytophotometric measurement with Epics XL owing to its improved objectify ability and compared this method to the measurement of CSF samples performed with the ADVIA 2120 and XE-5000. MATERIAL AND METHODS: 101 CSF samples were measured with the ADVIA 2120, XE-5000, and Epics XL. For impulse cytophotometric measurement, CD235a was used for identification of erythrocytes; CD45 for the entire leukocyte population; CD56, CD16 and CD14 for monocytes; CD3, CD4 and CD19 for lymphocytes;and CD13, CD15 and CD33 for neutrophile granulocytes. RESULTS: Regarding leukocyte measurements, a strong correlation was obtained between Epics XL and XE-5000 (r = 0.990), with the correlation between Epics XL and ADVIA 2120 not as strong (r = 0.538). This finding is due to the fact that with blood-stained CSF samples (erythrocytes >1,500/µl), no valid results were produced by the ADVIA 2120. In measurements of blood-free CSF samples, correlations between Epics XL, XE-5000, and ADVIA 2120 were almost identical (r = 0.985 and r = 0.964). The same applies to the correlation between polymorphonuclear and mononuclear cells (range 0.920-0.972). In erythrocyte measurements, the correlation between XE-5000 and ADVIA 2120 was excellent (r = 0.945). Impulse cytophotometric measurement of erythrocytes with CD 238 antibodies did not appear to be functional. CONCLUSION: In the measurement of leukocytes in CSF with the ADVIA 2120, no valid results could be obtained in blood-stained CSF samples (erythrocytes >1,500/µl). In blood-free CSF samples (erythrocytes <1,500/µl), measurements of leukocytes, and polymorphonuclear and mononuclear cells performed with the ADVIA 2120 and XE-5000 produced almost identical good results. Determination of CSF cells with the XE-5000 is presently the best automated method for counting leukocytes of blood-stained CSF.

Associations between cerebrospinal fluid protein concentrations, serum albumin concentrations and intracranial pressure in neurotrauma and intracranial haemorrhage.

Recent evidence suggests that using intravenous isotonic albumin solution for haemodynamic resuscitation in neurotrauma is associated with adverse outcomes. This study assessed the correlations between cerebrospinal fluid protein concentrations, serum albumin concentrations and intracranial pressure in a cohort of neurosurgical patients. After obtaining ethics committee approval, correlations between concomitant cerebrospinal fluid protein concentrations, serum albumin concentrations and the mean daily intracranial pressure of 63 consecutive neurosurgical patients, grouped as neurotrauma or intracranial haemorrhage, admitted between 1 January and 31 December 2007, were assessed. The mean daily intracranial pressure was significantly associated with cerebrospinal fluid protein concentrations (Spearman correlation coefficient [SCC] = 0.496, P = 0.001), white cell counts (SCC = 0.359, P = 0.001), red cell counts (SCC = 0.399, P = .0O01) and serum albumin concentrations (SCC = 0.431, P = 0.001) in patients with neurotrauma (n=23). Cerebrospinal fluid protein concentrations were also significantly associated with concomitant serum albumin concentrations (SCC = 0.393, P = 0.001) in these patients. In patients with intracranial haemorrhage (n=40), the mean daily intracranial pressure was only significantly associated with cerebrospinal fluid white cell and red cell counts but not cerebrospinal fluid protein and serum albumin concentrations. In summary, intracranial pressure is correlated with cerebrospinal fluid protein and serum albumin concentrations in patients with severe neurotrauma, and these suggest that blood-brain barrier may not be completely intact after severe neurotrauma.

Cerebrospinal fluid drainage in posthaemorrhagic ventricular dilatation leads to improvement in amplitude-integrated electroencephalographic activity.

AIM: Progressive posthaemorrhagic ventricular dilatation (PHVD) may induce abnormal amplitude-integrated electroencephalographic (aEEG) activity prior to clinical deterioration or significant cerebral ultrasound changes. These abnormalities might be ameliorated with cerebrospinal fluid (CSF) drainage. The aims of this study were to investigate the occurrence of aEEG-abnormalities with progressive PHVD in relation to clinical and cerebral ultrasound changes and to evaluate whether CSF drainage results in aEEG improvement. METHODS: aEEG and cerebral ultrasound scans were performed in 12 infants with PHVD, before and after CSF drainage, until normalization of aEEG occurred. RESULTS: aEEG was abnormal with progressive PHVD in all patients. Concurrently, 60% of the patients were clinically stable without deterioration in ultrasonographic cerebral abnormalities. Post drainage, continuous pattern was restored in all but one patient, whereas the frequency of discontinuous pattern decreased in nine patients and burst-suppression pattern decreased in all but one patient. Low-voltage pattern was only observed in one patient who suffered severe grade IV IVH and died one week after EVD placement. Sleep-wake cycling matured in 75%. CONCLUSION: These findings demonstrate the impact of CSF drainage on compromised aEEG-activity associated with PHVD. aEEG changes indicative of impaired cerebral function were apparent before clinical deterioration or major ultrasound changes. These changes were reversible with CSF drainage. aEEG should therefore be used in addition to clinical observation and ultrasound when monitoring PHVD.

Diffuse leptomeningeal hyperintensity on fluid-attenuated inversion recovery MR images in neurocutaneous melanosis.

Neurocutaneous melanosis (NCM) is a rare neuroectodermal dysplasia characterized by large or multiple cutaneous congenital pigmented nevi and benign or malignant melanocytic tumors of the leptomeninges. Although the MR manifestations of this disease have been reported in a small series of cases, the usefulness of fluid-attenuated inversion recovery (FLAIR) MR findings has not been documented. We present a case of NCM that showed diffuse leptomeningeal hyperintensity on FLAIR images. This FLAIR finding may be a clue to the detection of leptomeningeal abnormalities in NCM.

Soluble Fas (CD95/Apo-1), soluble Fas ligand, and activated caspase 3 in the cerebrospinal fluid of infants with posthemorrhagic and nonhemorrhagic hydrocephalus.

Hydrocephalus may result in loss of tissue associated with neuronal degeneration, axonal damage, and reactive gliosis. The soluble form of the anti-apoptotic regulator Fas (sFas) and the pro-apoptotic factors soluble FasL (sFasL) and activated caspase 3 were studied in the cerebrospinal fluid of infants with hydrocephalus. Fifteen preterm infants with posthemorrhagic hydrocephalus undergoing serial reservoir puncture and seven term or near-term infants with nonhemorrhagic hydrocephalus and shunt surgery were included in the study. Twenty-four age-matched patients with lumbar puncture for the exclusion of meningitis served as controls. Elevated levels of sFas were observed in infants with posthemorrhagic hydrocephalus [median (range), 131 ng/mL (51-279 ng/mL)] and in nonhemorrhagic hydrocephalus [127 ng/mL (35-165 ng/mL)]. sFas concentrations were highest in a subgroup of eight patients with posthemorrhagic hydrocephalus developing periventricular leukomalacia [164 ng/mL (76-227 ng/mL)]. In contrast, in 24 control infants, sFas was low, in 15 cases below detection limit (0.5 ng/mL) and in nine cases, 24 ng/mL (20-43 ng/mL). sFasL and activated caspase 3 did not differ from control infants in all groups of patients. Increased intrathecal release of sFas in the cerebrospinal fluid of infants with hydrocephalus may serve as an indicator of brain injury from progressive ventricular dilatation.

A simple and rapid method for the determination of "free" iron in biological fluids.

We present a convenient method for determining "free" or non-protein-bound iron in biological fluids. The new method is based on the bathophenantroline method for determination of total serum iron, and comprises binding of iron by a chromogenic chelator (bathophenantroline-disulphonate, BPS), which is specific for ferrous iron. The ferrous complex of BPS absorbs strongly at 535 nm, and the detection limit is less than 1 microM in a sample size of 50 microliters. The chelator does not liberate iron from either haemoglobin or transferrin. Interference from copper or zinc in concentrations up to 50 microM does not significantly disturb measurements. The main problem when measuring in blood plasma, the high and fluctuating background in the region around 535 nm, has been overcome through filtering techniques. Data from measurements of ferrous iron in microdialysate, cerebrospinal fluid, and blood plasma in different animal models and clinical conditions are presented as illustrative examples of the usefulness of the method. The method allows the determination of ferric, as well as ferrous, iron in the same sample.