Introduction: Preferred detection of aneurysmal subarachnoid hemorrhage (aSAH) consists of head computed tomography (CT), followed by cerebrospinal fluid (CSF) analysis. There is no consensus for routine CSF analysis following temporary diversion. Without established CSF parameters following aSAH, the clinical utility of CSF interpretation is unclear. We sought to determine the diagnostic value of CSF analysis in the setting of aSAH.
Methods: Retrospective review of consecutive adult patients diagnosed with aSAH from 1/2000 to 12/2013 at Mayo Clinic, Rochester, MN with cerebral aneurysm(s) identified by vascular imaging, and CSF drawn within 14 days of the date of hemorrhage.
Results: We identified 741 patients during the study period, 167 met inclusion criteria and 356 samples were collected. First Median CSF samples were taken 5 (4-8) days post-bleed. Indications for CSF samples varied: fever 81 (22.8%), altered mental status 79 (22.2%), new onset headache 56 (15.7%), development of a new neurological deficit 38 (10.7%) elevated peripheral white blood cell (WBC) count 17 (4.8%), surveillance 42 (11.8%) and undocumented 43 (12.0%). Ventriculitis, confirmed by growth of organism from CSF culture, present in 2 (1.2%) patients. One patient (0.6%) suffered post-hospitalization meningitis. CSF WBC count remained elevated throughout the 14 days, even when corrected for red blood cell count (RBC). Peak CSF RBCs occurred 2-4 days post bleed, and then tapered toward normal limits. Maximum CSF RBCs did not correlate to modified Fisher grades (p=0.42). Delayed cerebral ischemia (DCI) was present in 86 (51.5%) patients and there was no difference in the CSF profile of patients with DCI compared with those without.
Conclusions: Routine CSF sampling for cell count and chemistry in the setting of temporary diversion following aSAH appears to have little clinical benefit beyond the evaluation for infection. Larger prospective studies would be needed to elucidate any diagnostic beyond CSF gram stain and culture.
Patient Care: Less frequent CSF monitoring and laboratory analysis should decrease risk of infection and lower costs in SAH patients.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the limited importance of CSF analysis following SAH, except for infection analysis.
2) Discuss, in small groups, individual practice patterns at home institutions regarding CSF analysis following subarachnoid hemorrhage.
3) Identify an effective means of diagnosis and treatment for ventriculitis/meningitis following SAH.
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