[Low-manifest infections with CNS damage in patients in prolonged unconscious state of non-inflammatory etiology].

AIM: Study of specter of low-manifest infections (LMI) with central nervous system (CNS) damage and their role in patients in prolonged unconscious state (PUS) of noninflammatory etiology. MATERIALS AND METHODS: 32 patients (23 male, 9 female; age 14-58) in PUS of various etiology were examined. The main group (18 patients) received therapy against all infectious diseases including LMI; control group (14 patients)--only against common and nosocomial microflora. Patients were immunologically, infectologically and neurologically examined in dynamic. The data obtained were treated by using STATISTICA for Windows (version 5.5). RESULTS: Significant differences in immune and infectologic status depending on the nature of primary CNS damage were not detected. Immunodeficiency was detected in all patients; 94% of patients had increased non-specific IgM and IgE. Among LMI agents Chlamydia spp. were predominant. Cultural and/or PCR methods detected this microorganism during the primary examination in cerebrospinal fluid samples in 56% patients and in blood samples in 56%; during the second diagnostics or autopsy--only in 13 and 25%, respectively. Detection of Bacteroides fragilis, Human Herpes Virus (HHV-6), Virus Epstein Barr (VEB), Cytomegalovirus (CMV) in cerebrospinal fluid, blood and on mucous membranes of nasopharynx and conjunctiva was grouped more frequently with the presence of Chlamydia spp. in the CNS (p < 0.05) than with other LMI agents. Sanation of CNS from LMI was significantly accompanied by regeneration of communicative activity in comparison with the control group. CONCLUSION: In patients with PUS high frequency of CNS infection by various LMI agents and primarily Chlamydia spp. should be considered. Sanation from LMI can become a "window" for effective neuro-regenerative treatment.

Cisternal MHPG level inversely correlates with Glasgow coma scale after aneurysmal subarachnoid hemorrhage.

We measured the concentrations of monoamines and amino acids in the cisternal cerebrospinal fluid obtained from 15 patients after aneurysmal subarachnoid hemorrhage. Based on the Glasgow Coma Scale (GCS), the patients were divided into two conscious (GCS always 14 or better from the third post-operative day to Day 12; n = 8) and unconscious groups (n = 7). We examined the concentrations of monoamines and amino acids between the two groups and evaluated the correlation between the concentrations and the GCS at CSF sampling. The concentration of MHPG was significantly higher in the unconscious than in the conscious group from Days 4 to 12. A significant inverse correlation was observed between the MHPG concentration and the GCS (r = approximately 0.635, p < 0.0001). Measuring the cisternal MHPG concentration may be useful for estimating convalescence after subarachnoid hemorrhage.

Cerebral malaria versus bacterial meningitis in children with impaired consciousness.

Cerebral malaria (CM) and acute bacterial meningitis (ABM) are the two common causes of impaired consciousness in children presenting to hospital in sub-Sahara Africa. Since the clinical features of the two diseases may be very similar, treatment is often guided by the initial laboratory findings. However, no detailed studies have examined the extent to which the laboratory findings in these two diseases may overlap. We reviewed data from 555 children with impaired consciousness admitted to Kilifi District Hospital, Kenya. Strictly defined groups were established based on the malaria slide, cerebrospinal fluid (CSF) leucocyte count and the results of blood and CSF culture and CSF bacterial antigen testing. Our data suggests significant overlap in the initial CSF findings between CM and ABM. The absolute minimum proportions of children with impaired consciousness and malaria parasitaemia who also had definite bacterial meningitis were 4% of all children and 14% of children under 1 year of age. The estimated maximum proportion of all children with impaired consciousness and malaria parasitaemia in whom the diagnosis was dual or unclear was at least 13%. The finding of malaria parasites in the blood of an unconscious child in sub-Saharan Africa is not sufficient to establish a diagnosis of cerebral malaria, and acute bacterial meningitis must be actively excluded in all cases.

Cerebrospinal fluid creatine kinase isoenzyme BB levels do not predict the clinical outcome in patients unconscious following cardiac resuscitation.

It has recently been claimed that an increase in creatine kinase isoenzyme BB(CK-BB) in cerebrospinal fluid (CSF) is well correlated with the cerebral outcome in patients resuscitated after cardiac arrest. Twenty-one such patients consecutively admitted from outside this hospital participated in the study. The patients were divided into two groups: 6 survivors and 15 nonsurvivors. The median CSF-CK-BB value was 5 U/L among nonsurvivors and below detection limit among survivors (NS). However, the predictive value of a positive test is limited, since only 6 of 15 nonsurvivors (40%) had an increase in CSF-CK-BB (predictive value of positive test = 67%). The predictive value of a negative test is limited, since 3 of 6 survivors (50%) showed no rise in CSF-CK-BB (predictive value of negative test = 25%). No relationship between cerebral dysfunction and CSF-CK-BB values was revealed. Thus, CSF-CK-BB does not predict the clinical outcome in patients resuscitated after cardiac arrest.

Cerebrospinal fluid creatine kinase activity and neurologic recovery after cardiac arrest.

We evaluated prospectively the relation between cerebrospinal fluid creatine kinase activity (CSF CK) and neurologic recovery after out-of-hospital cardiac arrest. Without knowledge of the enzyme results, we determined whether patients awoke, followed commands, or had comprehensible speech. CSF CK was significantly higher in never-awakening than in awakening patients. After cardiac arrest, elevation of CSF CK predicts poor neurologic recovery.

Elevated myo-inositol concentrations in cerebrospinal fluid of neonates and of patients with an impaired state of consciousness.

A simple, semiquantitative paper chromatographic method was used to identify samples of cerebrospinal fluid containing elevated concentrations of myo-inositol. All patients whose CSF inositol concentrations were greater than 70 mug/ml (as determined by S. carlsbergensis microbiological assay) showed disturbances of the state of consciousness, reported as stupor, coma or confusion in adults, or apathy and stupor in infants. An elevated level of inositol in cerebrospinal fluid appeared to be a characteristic finding in infants under one year of age. Among other age groups no common etiology was correlated with high inositol concentration.

Concentration of 3', 5' cyclic adenosine monophosphate in ventricular cerebrospinal fluid of patients with prolonged coma after head trauma or intracranial hemorrhage.

A previous study showed that cerebrospinal fluid from the lateral ventricle of patients without disturbance of sensorium or intracranial pressure contains 15 to 30 nm 3', 5' cyclic adenosine monophosphate. We measured the concentration of this cyclic nucleotide by radioimmunoassay in cerebrospinal fluid from the lateral ventricle of six patients with prolonged coma (20 days or longer) after head trauma (four), or spontaneous intracranial hemorrhage (two). Coma was graded IV to I in order of decreasing severity. Fluid was removed at intervals of six to 72 hours from a Rickham reservoir placed in the lateral ventricle. Concentration of the cyclic nucleotide (mean +/- S.E.M.) in coma of Grades IV, III, II and I was 2.1 +/- 0.3, 4.6 +/- 0.5, 6.3 +/- 1.4 and 12.5 +/- 2.4 nM respectively. After sensorium became normal, cAMP was 21.0 +/- 1.4 nM. Correlation between grade of coma and concentration was -0.89 (P less than 0.01). Thus, prolonged coma appears to be associated with a disturbance of cyclic AMP metabolism within the central nervous system.

On the nature of brain stem disorders in severe head injured patients.

In head injured patients changes were found in the CSF levels of metabolites of the dopaminergic and the serotonergic neurotransmission (HVA and 5-HIAA). After the fifth day following trauma a significant decrease of the HVA levels in the lumbar CSF after probenecid treatment was found. The intensity of this decrease was found to be related to the severity of the trauma (period of unconsciousness), but not to the state of consciousness. Also the probenecid-induced 5-HIAA levels in conscious patients were decreased after the fifth post-traumatic day. In unconscious patients, the period of unconsciousness, particularly in the period of 5-20 days after trauma. Between 21 and 60 days after trauma the 5-HIAA concentrations in unconscious patients decreased remarkably, but they were still significantly higher than in the conscious patients. It can be concluded that during unconsciousness serotonergic neurons have a high rate of turnover, but that both neurotransmitter systems are damaged by the direct or indirect consequences of the injury.

Ventricular fluid lactate, pyruvate, bicarbonate and ph in unconscious brain-injured patients subjected to controlled ventilation.

In 35 unconscious patients suffering from traumatic brain injury and subjected to controlled hyperventilation within 12 hours of the acute trauma, we measured continuously the intraventricular pressure (IVP), ventricular fluid lactate, pyruvate, L/P ratio, pH and bicarbonate during the first 4 posttraumatic days, and related the findings to the clinical course. In patients in whom the follow-up study did not reveal severe mental impairment or dementia, the ventricular fluid lactate never exceeded 4 mmol/litre. In this group, the IVP level never exceeded 40 mmHg/hour, and the mean pressure/day never exceeded 20 mmHg. In half of the patients in whom dementia, vegetative survival or death occurred, ventricular fluid lactate exceeded 4 mmol/litre; the IVP level/hour exceeded 40 mmHg in two of 23 patients, and the mean pressure/day exceeded 20 mmHg in nine of 23 patients. The prognostic value of pyruvate was of less importance, although a significant increase in patients with a poor outcome was seen. No prognostic conclusions could be drawn from ventricular fluid, L/P ratio, pH and bicarbonate.