Comparison of international guidelines for CT prior to lumbar puncture in patients with suspected meningitis

PURPOSE

To compare the performance of multiple international guidelines in selecting patients for head CT prior to lumbar puncture (LP) in suspected meningitis, focusing on identification of potential contraindications to immediate LP.

METHODS

Retrospective study of 196 patients with suspected meningitis presenting to an emergency department between March 2013 and March 2023 and undergoing head CT prior to LP. UK Joint Specialist Society Guidelines (UK), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Infectious Diseases Society of America (IDSA) guidelines were evaluated by cross-referencing imaging criteria with clinical characteristics present at time of presentation. Sensitivity of each guideline for recommending neuroimaging in cases with brain shift on CT was evaluated, along with the number of normal studies and incidental or spurious findings.

RESULTS

2/196 (1%) patients had abnormal CTs with evidence of brain shift, while 14/196 (7%) had other abnormalities on CT without brain shift. UK, ESCMID and IDSA guidelines recommended imaging in 10%, 14% and 33% of cases respectively. All three guidelines recommended imaging pre-LP in 2/2 (100%) cases with brain shift. IDSA guidelines recommended more CT studies with normal findings (59 vs 16 and 24 for UK and ESCMID guidelines respectively) and CT abnormalities without brain shift (4 vs 1 and 2 respectively) than the other guidelines.

CONCLUSION

UK, ESCMID and IDSA guidelines are all effective at identifying the small cohort of patients who benefit from a head CT prior to LP. Following the more selective UK/ESCMID guidelines limits the number of normal studies and incidental or spurious CT findings.

Persistent Elevation of Opening Pressure Despite Treatment and Symptom Resolution in Pediatric Intracranial Hypertension

BACKGROUND

Currently no guidelines for repeating a lumbar puncture to guide management in primary intracranial hypertension (PIH) exist.

METHODS

An institutional database of patients 18 years and younger followed in the institution's pediatric intracranial hypertension clinic was examined for opening pressure changes in PIH at diagnosis, before medication wean, and following medication wean, as well as to examine whether measurements at the time of diagnosis differed between those with and without disease recurrence.

RESULTS

Forty-two patients were included in this study; 36% were male and the mean age at diagnosis was 11.01 years. Treatment duration averaged 9.68 months in those without recurrence and 8.5 months in those with recurrence. Average body mass index percentile of patients with disease recurrence was 83.7 and 72.1 in those without recurrence (P = 0.16). Average opening pressure values of all patients at diagnosis, prewean, and postwean was 36.53 cm H2O, 30.7 cm H2O, and 31.1 cm H2O, respectively. There was no statistically significant difference in opening pressures across these time points (P = 0.14). The change in opening pressure from diagnosis to postwean was statistically significant with a reduction of 5.18 cm H2O (P = 0.04). There was no statistical difference between change in opening pressure at diagnosis versus postwean between those with and without recurrence (P = 0.17).

CONCLUSIONS

This clinical observational study suggests that mean opening pressure measurements in patients with PIH remain elevated both before and after medication wean despite papilledema resolution and patient-reported PIH symptoms. Clinically, this suggests that other features such as signs of optic disc edema and symptoms should be used to inform a clinical determination of disease recurrence and treatment course.

Quantitative anatomical analysis of lumbar interspaces based on 3D CT imaging: optimized segment selection for lumbar puncture in different age groups

BACKGROUND

Optimal lumbar puncture segment selection remains controversial. This study aims to analyze anatomical differences among L3-4, L4-5, and L5-S1 segments across age groups and provide quantitative evidence for optimized selection.

METHODS

80 cases of CT images were collected with patients aged 10-80 years old. Threedimensional models containing L3-S1 vertebrae, dural sac, and nerve roots were reconstructed. Computer simulation determined the optimal puncture angles for the L3-4, L4-5, and L5-S1 segments. The effective dural sac area (ALDS), traversing nerve root area (ATNR), and area of the lumbar inter-laminar space (ALILS) were measured. Puncture efficacy ratio (ALDS/ALILS) and nerve injury risk ratio (ATNR/ALILS) were calculated. Cases were divided into four groups: A (10-20 years), B (21-40 years), C (41-60 years), and D (61-80 years). Statistical analysis was performed using SPSS.

RESULTS

1) ALDS was similar among segments; 2) ATNR was greatest at L5-S1; 3) ALILS was greatest at L5-S1; 4) Puncture efficacy ratio was highest at L3-4 and lowest at L5-S1; 5) Nerve injury risk was highest at L5-S1. In group D, L5-S1 ALDS was larger than L3-4 and L4-5. ALDS decreased after age 40. Age variations were minimal across parameters.

CONCLUSION

The comprehensive analysis demonstrated L3-4 as the optimal first-choice segment for ages 10-60 years, conferring maximal efficacy and safety. L5-S1 can serve as an alternative option for ages 61-80 years when upper interspaces narrow. This study provides quantitative imaging evidence supporting age-specific, optimized lumbar puncture segment selection.

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

Physician's conceptions of the decision-making process when managing febrile infants ≤ 60 days old: a phenomenographic qualitative study

BACKGROUND

The management of febrile infants aged ≤ 60 days and adherence to guidelines vary greatly. Our objective was to describe the process of decision-making when managing febrile infants aged ≤ 60 days and to describe the factors that influenced this decision.

METHODS

We conducted 6 focus group discussions with 19 clinically active physicians in the pediatric emergency departments of 2 university hospitals in Skåne region, Sweden. We followed an inductive qualitative design, using a phenomenological approach. A second-order perspective was used, focusing on how physicians perceived the phenomenon (managing fever in infants) rather than the phenomenon itself. The transcribed interviews were analyzed using a 7-step approach.

RESULTS

Performing a lumbar puncture (LP) was conceived as a complex, emotionally and mentally laden procedure and dominated the group discussions. Three central categories emerged as factors that influenced the decision-making process on whether to perform an LP: 1) a possible focus of infection that could explain the origin of the fever, 2) questioning whether the temperature at home reported by the parents was a fever, especially if it was ≤ 38.2°C, and 3) the infant's general condition and questioning the need for LP in case of well-appearing infants. Around these 3 central categories evolved 6 secondary categories that influenced the decision-making process of whether to perform an LP or not: 1) the physicians' desire to be able to trust their judgement, 2) fearing the risk of failure, 3) avoiding burdensome work, 4) taking others into account, 5) balancing guidelines and resources, and 6) seeing a need to practice and learn to perform LP.

CONCLUSIONS

The difficulty and emotional load of performing an LP were important factors that influenced the decision-making process regarding whether to perform an LP. Physicians highlighted the importance of being able to rely on their clinical judgment and make independent decisions. Guidelines may consider allowing a degree of flexibility and independent thinking to take into account patients' characteristics and needs.

Simple detecting of elevated ICP through liquor flow after lumbar puncture

Elevated intracranial pressure (ICP) is defined as a cerebrospinal fluid (CSF) opening pressure (OP) greater than 25 cmH2O. When a diagnostic lumbar puncture is performed it is useful to estimate also intracranial pressure. To do this it is required a presence of pressure gauges, which are currently the gold standard, not available in most resource-constrained contexts. We decided to evaluate whether it is possible to estimate it simply by counting the drops of cerebrospinal liquor, which are collected after lumbar puncture, according to Poiseuille's law. Was examined a sample of 52 patients, aged between 18 and 85 years, belonging to the emergency room of "Santa Maria delle Grazie" Hospital in Pozzuoli (Naples) who needed a diagnostic lumbar puncture (LP). The ICP was initially measured using a standard narrow-gauge manometer by attaching it to the spinal needle. After removing the pressure gauge, the number of drops of cerebrospinal fluid flowing from the spinal needle in 30  seconds was counted. A statistical analysis was made with linear regression and ROC analysis. OP as measured by standard manometry was raised on 17 occasions with CSF drop rate median of 47 drops/30 seconds and range 30-74 drops/30 seconds. OP was normal on 35 occasions with CSF drop rate median of 23 drops/30 seconds  with range of 14-34 drops/30 seconds. A linear regression analysis was performed which resulted in a Pearson correlation of 0.936 an adjusted R square of 0.874 (see Fig. 1). Analysis through ANOVA documented an F of 355.301 with p < 0.01 and Dubin Watson of 1.642. The analysis through ROC showed an AUC of 0.980, with a sensitivity of 100% and a specificity of 91% if chosen as a limit, 29 drops in 30 seconds  (Youden Index of 0.9140). Therefore, we have concluded, that although there are several precautions, like patient's position, it is technically feasible to indirectly estimate cerebrospinal fluid pressure with good accuracy by counting the drops of cerebrospinal fluid flowing from a 22 G spinal needle.

Meningitis in critically ill patients admitted to intensive care unit for severe community-acquired pneumococcal pneumonia

BACKGROUND

Although it has been reported that patients with pneumococcal pneumonia may develop meningitis, lumbar puncture is not systematically recommended in these patients, even in patients with associated bacteremia or invasive pneumococcal disease. The aim of this study was to determine the characteristics and outcomes of patients admitted to intensive care unit (ICU) for pneumococcal community-acquired pneumonia who developed meningitis.

METHODS

We retrospectively included all consecutive patients admitted to our ICU from January 2006 to December 2020 for severe pneumococcal community-acquired pneumonia according to American Thoracic Society criteria. Meningitis was defined as pleocytosis > 5 cells/mm3 or a positive culture of cerebrospinal fluid for Streptococcus pneumoniae in lumbar puncture. The primary endpoint was the proportion of patients with meningitis during their ICU stay.

RESULTS

Overall, 262 patients [64(52-75) years old] were included: 154(59%) were male, 80(30%) had chronic respiratory disease, 105(39%) were immunocompromised and 6(2%) were vaccinated against S. pneumoniae. A lumbar puncture was performed in 88(34%) patients with a delay from ICU admission to puncture lumbar of 10.5 (2.8-24.1) h and after the initiation of pneumococcal antibiotherapy in 81(92%) patients. Meningitis was diagnosed in 14 patients: 16% of patients with lumbar puncture and 5% of patients in the whole population. Patients with meningitis had more frequently human immunodeficiency virus positive status (29 vs. 5%, p = 0.02), neurological deficits on ICU admission (43 vs. 16%, p = 0.03) and pneumococcal bacteremia (71 vs. 30%, p < 0.01) than those without. The ICU mortality rate (14 vs. 13%, p = 0.73) and the mortality rate at Day-90 (21 vs. 15%, p = 0.83) did not differ between patients with and without meningitis. The proportion of patients with neurological disorders at ICU discharge was higher in patients with meningitis (64 vs. 23%, p < 0.001) than in those without. The other outcomes did not differ at ICU discharge, Day-30 and Day-90 between the two groups of patients.

CONCLUSION

Meningitis was diagnosed in 16% of patients with severe pneumococcal community-acquired pneumonia in whom a lumbar puncture was performed, was more frequent in patients with pneumococcal bacteremia and was associated with more frequent neurological disorders at ICU discharge. Further studies are needed to confirm these results.

Ultrasound-assisted lumbar puncture with a horizontal and perpendicular paramedian approach based on positioning in patients with abnormal spinal anatomy: a case report and technical description

BACKGROUND

The use of ultrasound has been reported to be beneficial in challenging neuraxial procedures. The angled probe is responsible for the main limitations of previous ultrasound-assisted techniques. We developed a novel technique for challenging lumbar puncture, aiming to locate the needle entry point which allowed for a horizontal and perpendicular needle trajectory and thereby addressed the drawbacks of earlier ultrasound-assisted techniques.

CASE PRESENTATION

Patient 1 was an adult patient with severe scoliosis who underwent a series of intrathecal injections of nusinersen. The preprocedural ultrasound scan revealed a cephalad probe's angulation (relative to the edge of the bed) in the paramedian sagittal oblique view, and then the probe was rotated 90° into a transverse plane and we noted that a rocking maneuver was required to obtain normalized views. Then the shoulders were moved forward to eliminate the need for cephalad angulation of the probe. The degree of rocking was translated to a lateral offset from the midline of the spine through an imaginary lumbar puncture's triangle model, and a needle entry point was marked. The spinal needle was advanced through this marking-point without craniocaudal and lateromedial angulation, and first-pass success was achieved in all eight lumbar punctures. Patient 2 was an elderly patient with ankylosing spondylitis who underwent spinal anesthesia for transurethral resection of the prostate. The patient was positioned anteriorly obliquely to create a vertebral rotation that eliminated medial angulation in the paramedian approach. The procedure succeeded on the first pass.

CONCLUSIONS

This ultrasound-assisted paramedian approach with a horizontal and perpendicular needle trajectory may be a promising technique that can help circumvent challenging anatomy. Larger case series and prospective studies are warranted to define its superiority to alternative approaches of lumbar puncture for patients with difficulties.

Securing direct stakeholder feedback to inform clinical research in serious mental illness: Results of a patient and family perspectives survey

Mental illness research routinely includes unfamiliar or potentially frightening procedures like lumbar puncture (LP), contributing to low enrollment and retention. Previous studies related to LP acceptance have focused on older individuals, and little information on participant preferences for educational materials is available. We developed an online survey assessing existing knowledge, comfort and concerns, and preferences for educational materials in the context of our clinical study on schizophrenia spectrum conditions (SSCs). We found that participants were generally knowledgeable and interested in engaging with clinical SSC research. Frequency of engagement with research publications differed significantly by participant groups and age. Comfort levels were consistently highest for study procedures other than LP, though surprisingly the average number of informational needs per procedure was not significantly different for LP compared to other procedures. Preferences for format and source of educational materials varied across participant groups and age. Our results suggest that younger individuals with an SSC diagnosis are likely to have limited exposure to information, and proactively providing accessible and accurate educational materials may improve positive perceptions of LP. Providing content in a range of formats and sources will ensure that participants and their support networks have access to their preferred resources.

Using a novel virtual-reality simulator to assess performance in lumbar puncture: a validation study

BACKGROUND

A lumbar puncture procedure's success depends on a competent physician minimizing the risk of failing to get a sample and avoiding complications such as post-dural headache. A new virtual-reality simulator might be helpful in deciding when a physician is competent to perform lumbar puncture. We aimed to investigate validity evidence for a simulator-based test in lumbar puncture and establish a pass/fail standard to allow a mastery learning training program.

METHODS

Validity evidence was investigated using Messick's framework by including participants who were novices, intermediates, or experienced in lumbar puncture. Each participant performed two lumbar puncture procedures on the simulator, and fifty-nine predefined simulator metrics were automatically recorded. Cronbach's alpha was used to explore internal consistency reliability. Intergroup comparisons were made using independent sample t-tests with Tukey's correction for multiple comparisons. The learning effect was explored using paired sample t-test analysis, and a pass/fail standard was established using the contrasting groups' method.

RESULTS

73 novices, 18 intermediates, and 19 physicians performed the test resulting in a total of 220 procedures. 25 metrics (42.4%) had good discriminatory ability, and the reliability of these metrics was good, Cronbach's α = 0.81. The experienced physicians were significantly better than the novices (18.3 vs. 13.3, p < 0.001), and the pass/fail standard was established at 16 points. This standard resulted in 22 (30.1%) novices passing (i.e., false positives) and 5 (26.3%) physicians failing (i.e., false negatives).

CONCLUSION

This study provides validity evidence for a simulator-based test of lumbar puncture competence. The test can help ensure basic competence at the end of a simulation-based training program for trainees, i.e., a mastery learning training program.

Lumbar puncture position in infants-a systematic review and meta-analysis

To analyze the optimal lumbar puncture position in infants. A systematic review and meta-analysis. Infants (age < 1 year). December 2022 in PubMed, Scopus, and Web of Science. Randomized controlled trials focusing on lumbar puncture positions were included. Other lumbar puncture position than standard lateral decubitus position. First puncture success and overall success rate. Secondary outcome was desaturation during puncture and procedure-related harms. Risk of bias 2.0 assessment was performed. Outcomes are reported as risk ratios (RR) with 95% confidence intervals (CI). We screened 225 abstracts, and six studies were included. Four studies compared sitting position, one study head elevated lateral position, and one study prone position to lateral position. Risk of bias was high in two studies. First puncture success rate in sitting position (RR 1.00, CI: 0.78-1.18; 2 studies) and overall success rate in sitting position were similar to lateral position (RR 0.97, CI: 0.87-1.17; 3 studies). First attempt success rate was higher in elevated lateral position (RR 1.48, CI: 1.14-1.92; 1 study) and in prone position (RR 1.09, CI: 1.00-1.17; 1 study).  Conclusion: Sitting position seems to be equally effective in terms of first attempt and overall success in lumbar puncture than standard lateral position. Elevated lateral position and prone positions had better first attempt success than standard lateral position, but these were assessed only in one study each and thus further studies in these positions are needed.  Trial registration: This review was registered in PROSPERO. ID: CRD42022382953. What is Known: •  Success rate in lumbar puncture has been poor and first attempt success rate has varied between 50 to 80% in literature. •  Optimal lumbar puncture positions for infants have been debated between sitting and lateral decubitus position mostly. What is New: •  This is the first meta-analysis focused on lumbar puncture positions in infants, and it found that sitting position was equal to standard lateral position. • Prone position and head elevated lateral positions had higher first puncture success rates, but these were assessed both only in one study, which creates uncertainty to the finding.

Feasibility analysis of intrathecal administration strategy of nusinersen based on Cobb angle in children with spinal muscular atrophy

AIM

This retro-prospective observational study described the experience in lumbar puncture procedures in children with spinal muscular atrophy (SMA) with and without neuromuscular scoliosis in a single center. The technical feasibility of intrathecal nusinersen administration was the main limiting factor.

STUDY DESIGN

A total of 457 technically successful intrathecal injections based on a hierarchical strategy in Cobb angle were reviewed in 81 SMA children aged 0.75-13.5 years who were referred for nusinersen injections in our hospital from October 2019 to December 2022.

RESULTS

Under local anesthesia, conventional lumbar puncture was performed on 47 patients without spinal deformity (Cobb angle of 0-10°) and 20 patients with moderate scoliosis (Cobb angle of 10-50°). Ultrasound-assisted lumbar puncture was performed on 12 patients with moderate scoliosis but lordosis. A combination of ultrasound imaging and three-dimensional CT under sedation was performed in the remaining 14 patients with severe scoliosis (Cobb angle >50°). No severe complications were found.

CONCLUSION

Cobb angle is an important basis for intrathecal administration of nusinersen. It is feasible and suitable to carry out intrathecal nusinersen injection under ultrasound combined with three-dimensional CT imaging for children with severe scoliosis.

Role of lumbar puncture in clinical outcome of suspected acute bacterial meningitis

BACKGROUND

Meningitis remains a significant source of mortality and morbidity, with an incidence of 1 per 100000 persons in the United States. Guidelines recommend obtaining blood cultures and cerebrospinal fluid (CSF) studies in patients presenting with acute meningitis syndrome, and beginning treatment with broad spectrum antibiotics based on the age and certain predisposing conditions. In some patients however, the diagnostic lumbar puncture (LP) is not performed due to a multitude of reasons, ranging from increased intracranial pressure to failed attempt. In such situations, appropriate therapy is initiated empirically and often continued without establishment of a definitive diagnosis.

AIM

To determine whether a diagnostic LP in acute meningitis syndrome was associated with a better outcome and less duration of antibiotic therapy, along with potential causes for deferral of procedure.

METHODS

A retrospective study was conducted amongst the patients presenting to a 360 bedded community hospital in central Massachusetts with a diagnosis of acute meningitis syndrome between January 2010 – September 2022. The electronic health records were accessed to collect necessary demographic and clinical data, including etiology of meningitis, lumbar puncture results, reason for procedure deferral, duration of antibiotic therapy and clinical outcome. The patients were subsequently divided into two groups based on whether they received a LP or not, and data was analyzed.

RESULTS

A total of 169 patients admitted with acute meningitis syndrome between September 2010-2022 were included in the study. The mean age of the participants was 54.3 years (SD +/- 19.2 years). LP was performed for 130 (76.9%) participants, out of which, 28 (21.5%) showed some growth in CSF culture. The most commonly identified organism was streptococcus pneumoniae. Amongst the 39 patients in whom LP was deferred, the major reasons recorded were: Body habitus (n = 6, 15.4%), and unsuccessful attempt (n = 4, 10.3%). While 93 (71.5%) patients with LP received antibiotic therapy, only 19 (48.7%) patients without LP received the antibiotics, with the principal reason being spontaneous improvement in sensorium without any diagnosed source of infection. The mean duration of antibiotic use was 12.3 days (SD +/- 5.6) in the LP group and 11.5 days (SD +/- 7.0) in the non-LP group (P = 0.56; statistically not significant). We observed higher long term sequalae in the non-LP group (n = 6, 15.4%) compared to the LP group (n = 9, 6.9%). Similarly, the death rate was higher in the non-LP group (n = 7, 18.0%) compared to the LP group (n = 9, 6.9%).

CONCLUSION

LP remains the cornerstone for diagnosing meningitis, but often CSF results are unavailable, leading to empiric treatment. Our study identified that body habitus and unsuccessful attempts were the most common reasons for LP not being performed, leading to empiric antibiotic coverage. There was no difference between the duration of antibiotics received by the two groups, but a lower proportion of patients without LP received antibiotics, attributed to a spontaneous improvement in sensorium. However, the residual neurological sequelae and death rates were higher in patients without LP, signifying a potential under-treatment. A LP remains crucial to diagnose meningitis, and a lack of CSF analysis predisposes to under-treatment, leading to higher neurological sequelae and increased chances of death.

Success and complications in lumbar punctures of pediatric patients with leukemia: a study protocol for a randomized clinical crossover trial of a bioimpedance needle system versus conventional procedure

BACKGROUND

Acute lymphoblastic leukemia (ALL) is the most common malignancy diagnosed in children. At present, the long-term survival from pediatric ALL is well over 90%. However, the probability of event-free survival is reduced if the lumbar puncture (LP) procedures at the beginning of the patient's intrathecal therapy cause blood leakage into the spinal canal and blast cells contaminate the cerebrospinal fluid. According to the literature, such traumatic LP procedures concern one out of five pediatric patients with ALL. Recently, a novel medical device measuring the tissue bioimpedance at the tip of a spinal needle was found feasible in pediatric patients with ALL. The LP procedure was successful at the first attempt in 80% of procedures, and the incidence of traumatic LPs was then 11%. The purpose of the present study is to compare the bioimpedance spinal needle system with the standard clinical practice resting on a conventional spinal needle and investigate its efficacy in clinical practice.

METHODS

The study is a multicenter, randomized, two-arm crossover noninferiority trial of pediatric hemato-oncology patients that will be conducted within the usual clinical workflow. Patients' LP procedures will be performed alternately either with the IQ-Tip system (study arm A) or a conventional Quincke-type 22G spinal needle (study arm B). For each enrolled patient, the order of procedures is randomly assigned either as ABAB or BABA. The total number of LP procedures will be at least 300, and the number of procedures per patient between two and four. After each study LP procedure, the performance will be recorded immediately, and 1-week diary-based and 4-week record-based follow-ups on symptoms, complications, and adverse events will be conducted thereafter. The main outcomes are the incidence of traumatic LP, first puncture success rate, and incidence of post-dural puncture headache.

DISCUSSION

The present study will provide sound scientific evidence on the clinical benefit, performance, and safety of the novel bioimpedance spinal needle compared with the standard clinical practice of using conventional spinal needles in the LP procedures of pediatric patients with leukemia.

TRIAL REGISTRATION

ISRCTN ISRCTN16161453. Registered on 8 July 2022.

Measuring blood glucose before or after lumbar puncture

Background

The ratio of cerebrospinal fluid (CSF) to peripheral blood glucose at the same period is an important index for diagnosing and monitoring the efficacy of central nervous system infection, especially bacterial meningitis. Some guidelines refer that blood glucose measurement should be carried out before lumbar puncture. The main reason is to avoid possible effect of stress response induced by lumbar puncture on the level of blood glucose. However, there is no consensus on whether it should be followed in actual clinical work, since up to now no research work having been published on whether lumbar puncture will induce the changes on blood glucose. Our study aimed to investigate the changes of peripheral blood glucose before and after lumbar puncture.

Methods

In order to clarify the influence of timing of peripheral blood glucose measurement at the same period of lumbar puncture, a prospective study was conducted including children with an age range from 2 months to 12 years old in the neurology department of a medical center. For those children who need lumbar puncture due to their illness, their blood glucose was measured within 5 min before and after lumbar puncture, respectively. The blood glucose level and the ratio of CSF to blood glucose before and after lumbar puncture were compared. Meanwhile, the patients were divided into different groups according to the factors of sex, age and sedation or not for further comparison. All statistical analyses of the data were performed using SPSS version 26.0 for Windows.

Results

In total, 101 children who needed lumbar puncture during hospitalization from January 1, 2021, to October 1, 2021, were recruited with 65 male and 36 female respectively. There was no significant difference on the level of blood glucose, CSF to blood glucose ratio before and after lumbar puncture among the children (p > 0.05). No differences were observed within different groups (sex, age, sedation or not) either.

Conclusion

It is unnecessary to emphasize blood glucose measurement should be carried out before lumbar puncture, especially for pediatric patients. From the perspective of facilitating smoother cerebrospinal fluid puncture in children, blood glucose measurement after lumbar puncture might be a better choice.

Evaluation of patients presenting with febrile seizures in an Iranian referral hospital: emphasis on the frequency of meningitis and co-infections

INTRODUCTION

Febrile seizures are one of the most common diseases that physicians encounter in pediatric emergency departments. Two important aspects of managing patients presenting with a febrile seizure are meningitis exclusion and co-infection investigation. This study was designed to determine any infection that occurs concomitantly with a febrile seizure episode and also to assess the frequency of meningitis among children presenting with febrile seizures.

METHODS

This retrospective cross-sectional study was conducted at the Children's Medical Center, an Iranian pediatric referral hospital. All patients aged 6 months to 5 years presenting with febrile seizures from 2020 to 2021 were included. Patients' data were collected from the medical report files. The presence of respiratory, gastrointestinal, and urinary infections was evaluated. Moreover, the detection of SARS-CoV-2 using reverse transcription polymerase chain reaction (RT-PCR) was performed for suspicious cases. The results of urine and stool analysis, as well as blood, urine, and stool cultures were checked. The frequency of lumbar puncture (LP) performance and its results were studied. The relationship between white blood cells (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein in meningitis was evaluated.

RESULTS

A total of 290 patients were referred to the Children's Medical Center, Tehran, Iran, due to fever and seizures. The mean age of the patients was 21.5 ± 13.0 months, and 134 (46.2%) were female. Out of 290 patients, 17% presented with respiratory infections. Nasopharyngeal SARS-CoV-2 RT-PCR was requested for 50 patients (17%), of which nine (3%) were reported positive and two patients had multi-inflammatory syndrome in children (MIS-C). Fever without local signs, gastroenteritis, and urinary tract infections were found in 40%, 19%, and 14% of the patients, respectively. LP was requested for 97 participants (33.4%) to evaluate central nervous system infection, of which 22 cases were suggestive of aseptic meningitis. Among laboratory tests, leukocytosis was significantly related to aseptic meningitis (odds ratio = 11.1, 95% CI = 3.0- 41.5). The blood culture testing result was positive in seven patients; all of them were due to skin contamination.

CONCLUSION

Evaluation of patients for possible meningitis is necessary for febrile seizure management. Although the prevalence of bacterial meningitis in these patients is not high, according to this study and other studies conducted in Iran, aseptic meningitis, especially after Measles, Mumps, and Rubella (MMR) vaccination should be considered. Leukocytosis and increased CRP can predict the occurrence of aseptic meningitis in these patients. However, further studies with a larger sample size are highly recommended. Moreover, during the COVID-19 pandemic, it is recommended to pay attention to an acute COVID-19 infection or evidence of MIS-C in children with fever and seizure.

Endoscopic third ventriculostomy for management of hydrocephalus associated with Chiari malformation type II in children

BACKGROUND

Hydrocephalus is commonly associated with Chiari malformation (CM) particularly CM type II. The traditional treatment of hydrocephalus in these patients has been cerebrospinal fluid diversion by shunts. Endoscopic third ventriculostomy (ETV) has emerged as an alternative procedure in these patients.

PURPOSE

Assessment of the clinical and radiological outcomes of ETV in the management of hydrocephalus in children with CM II.

METHODS

This is a prospective study conducted on 18 patients with CM II associated with hydrocephalus admitted to Cairo University hospitals between January 2020 and June 2021. These patients had been managed surgically by ETV. Clinical outcome was assessed based on improvement of manifestations of increased intracranial pressure while radiological outcome was based on the findings of postoperative computed tomography. In cases with early failure, serial lumbar puncture (LP) was performed for 2 days.

RESULTS

ETV was performed as a secondary procedure in 4 cases. The overall success rate of the procedure was 72%, and its success rate as a secondary procedure was 100%. Serial LP was effective in decreasing early failure in 44.4% of cases. Radiological regression of hydrocephalic changes was detected in 50% of the cases.

CONCLUSION

ETV is an efficient and safe procedure in the treatment of hydrocephalus in children with Chiari malformation II, particularly when performed as a secondary procedure. Serial LP following the procedure increases the success rate in patients with early failure.

Persistently elevated intracranial pressure in cryptococcal meningitis- 76 therapeutic lumbar punctures

Cryptococcal meningitis still remains the most common form of adult meningitis in sub-Saharan Africa, due to the burden of HIV/AIDS. Increased intracranial pressure (ICP) is a major complication of cryptococcosis and requires aggressive management with therapeutic lumbar punctures (LPs). In this report, we describe a patient with persistently elevated ICP who underwent 76 LPs over 46 days with good outcome. While unusual, this highlights the importance of serial therapeutic LPs. 2012 Elsevier Ltd. All rights reserved.

Lumbar puncture-verified subarachnoid hemorrhage: bleeding sources, need of radiological examination, and functional recovery

BACKGROUND

The primary aim was to determine the diagnostic yield of vascular work-up, the clinical course during neurointensive care (NIC), and rate of functional recovery for patients with computed tomography (CT)-negative, lumbar puncture (LP)-verified SAH.

METHODS

In this retrospective study, 1280 patients with spontaneous SAH, treated at our NIC unit, Uppsala University Hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiological examinations (CT angiography (CTA) and digital subtraction angiography (DSA)), treatments, and functional outcome (GOS-E) at 12 months were evaluated.

RESULTS

Eighty (6%) out of 1280 SAH patients were computed tomography (CT)-negative, LP-verified cases. Time between ictus and diagnosis was longer for the LP-verified SAH cohort in comparison to the CT-positive patients (median 3 vs 0 days, p < 0.001). One fifth of the LP-verified SAH patients exhibited an underlying vascular pathology (aneurysm/AVM), which was significantly less common than for the CT-verified SAH cohort (19% vs. 76%, p < 0.001). The CTA- and DSA-findings were consistent in all of the LP-verified cases. The LP-verified SAH patients exhibited a lower rate of delayed ischemic neurological deficits, but no difference in rebleeding rate, compared to the CT-verified cohort. At 1-year post-ictus, 89% of the LP-verified SAH patients had recovered favorably, but 45% of the cases did not reach good recovery. Having an underlying vascular pathology and an external ventricular drainage were associated with worse functional recovery (p = 0.02) in this cohort.

CONCLUSIONS

LP-verified SAH constituted a small proportion of the entire SAH population. Having an underlying vascular pathology was less frequent in this cohort, but still occurred in one out of five patients. Despite the small initial bleeding in the LP-verified cohort, many of these patients did not reach good recovery at 1 year, this calls for more attentive follow-up and rehabilitation in this cohort.

Low Risk Profile of Long-Term Repeated Lumbar Puncture for Intrathecal Delivery of 2-Hydroxypropyl-Beta-Cyclodextrin in Patients With Niemann-Pick Type C

BACKGROUND

Intrathecal delivery of 2-hydroxypropyl-beta-cyclodextrin (VTS-270, adrabetadex) by lumbar puncture (LP) has been performed on a biweekly schedule for over nine years for the treatment of Niemann-Pick type C1 (NPC1) at Rush University Medical Center.

METHODS

Over this time 59 patients with NPC1 have been treated with 2935 infusions, performed with either a 22-G 3-inch Whitacre or a 22-G 2-inch Gertie Marx atraumatic needles, with or without general anesthesia. Adverse events potentially related to the LP infusion were collected from records for all patients treated for NPC. The NPC1 cohort ranged in age from one to 31 years at the initiation of treatment.

RESULTS

Of the 59 patients treated 33 (55.9%) had no adverse events ever after an LP and 26 (44.1%) had adverse effects at some time. Of the 2935 LPs, adverse events occurred after 3.3% of LPs. Adverse events most observed were headache (1.2% of LPs), nausea (0.3%), vomiting (1.0%), and back pain (1.3%).

CONCLUSIONS

This study shows that frequent repeated LPs are possible for delivery of intrathecal therapy and can be accomplished with a very low rate of post-LP adverse events.

Lumbar puncture training with healthcare simulation improves self-confidence and practical skills of French medical residents in geriatrics

PURPOSE

To assess the skill level and self-confidence of medical residents in geriatrics with regard to conducting the lumbar puncture (LP) procedure and to study the potential benefits of training with simulation and virtual reality.

METHODS

First, a questionnaire survey was conducted among all French residents in geriatrics in the Paris area to assess their knowledge and self-confidence regarding the practice of LP in older adults. Second, we set up a simulation LP training session combined with virtual reality (3D video) training for selected respondents of the first survey. Third, we performed post-simulation survey for the attendees of the simulation training. Finally, a follow-up survey was conducted to examine the change in self-confidence and the success rate in clinical practice.

RESULTS

Fifty-five residents responded to the survey (response rate = 36.4%). The importance of mastering LP was fully recognized by the residents in geriatrics (95.3%), so most of them (94.5%) advocated for the need for additional practical training. Fourteen residents took part in the training (average rating = 4.7 on a 5-point scale). Simulation was regarded by 83% of the respondents as the most useful tool for their practice. We observed a significant pre/post-training mean improvement in self-estimated success of 20.6% (Wilcoxon matched-pairs signed-rank W = - 36, p = 0.008). The post-training success rate of the residents in real-life clinical practice was good (85.8%).

CONCLUSION

Residents were aware of the importance of mastering LP and requested additional training. Simulation may represent a major driver to improve their self-confidence and practical skills.

A mixed-reality stimulator for lumbar puncture training: a pilot study

BACKGROUND

The simulation is one of the basic methods of medical education, which is often used for procedural skills training. However, the existing simulator lacks internal anatomical landmarks. The study developed a mixed-reality stimulator and evaluated its usability and feasibility in lumbar puncture training.

METHODS

The study recruited 40 subjects, including medical students, residents and faulty with varied levels of experience. Before training, participants completed the questionnaire about the basic information and watched a presentation about mixed reality. After practicing on mixed-reality stimulator, which provided internal anatomical structure, the examination was carried out and the results were documented. At the end of the training, trainees completed a survey of MR technology.

RESULTS

In this study, participants generally believed that the MR technology was very realistic (90%), and that the presentation of internal anatomy could help the operation (95%). Moreover, 72.5% and 75%, respectively, strongly agreed that the MR technology promoted learning and should be used in medical training. After this training, the success rate of puncture and the puncture time were significantly improved in experienced and non-experienced participants.

CONCLUSION

The existing simulator was easy to be transformed into MR simulator. This study showed the usability and feasibility of MR simulator in lumbar puncture training. As a potentially good tool to simulated medical skills training, next, MR technology would be developed and evaluated in more clinical skills teaching scenarios.

Lumbar puncture for treating acute hydrocephalus after aneurysmal subarachnoid haemorrhage

BACKGROUND

External ventricular drainage (EVD) for acute hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH) carries a risk of complications. We studied the proportion of patients in whom EVD can be avoided by treating acute hydrocephalus with ≥1 lumbar punctures (LP).

METHODS

From a prospectively collected database, we retrieved data on all aSAH patients admitted between 2007 and 2017 who developed acute hydrocephalus (i.e. neurological deterioration and ventricular enlargement <72 h after aSAH). Our regime is to consider LP as initial treatment. We calculated the proportions of patients (with corresponding 95% confidence interval (CI)) who improved after the initial LP and the extent of clinical improvement, the proportions of patients who were treated with only ≥1 LP(s), and those of patients needing continuous external ventricular or external lumbar drainage, or permanent ventriculoperitoneal or lumboperitoneal drainage.

RESULTS

Of 1391 consecutive aSAH patients, 473 (34%) had acute hydrocephalus, of whom 388 (82%) were treated. Of the 86 patients with LP as initial treatment, 70 (81% [95% CI 72-88]) showed initial improvement (with increase in median Glasgow Coma Score from 10 (IQR 7-12) to 12 (IQR 9-14) after initial LP), 39 (45% [95% CI 35-56]) improved with LP only, 41 (48% [95% CI 37-58]) needed continuous drainage and six (7% [95% CI 3-14]) needed permanent drainage.

CONCLUSION

Around half the patients treated with LP for deterioration from acute hydrocephalus after aSAH does not require continuous extraventicular or extralumbar drainage.

Can we lower the platelet threshold of ≥ 50 × 109/L for performing a lumbar puncture safely in patients with hematological malignancies?

Lumbar punctures (LP) are routinely used to administer intrathecal chemotherapy for children and adults with hematologic malignancies. The current guidelines suggest a platelet threshold of ≥ 50 × 10⁹/L prior to LP for intrathecal chemotherapy (ITC). This can be challenging in patients with hematological malignancies who are thrombocytopenic. We conducted a retrospective chart review of 900 LPs for ITC and compared adverse events in patients with a platelet count of ≥ 50 × 10⁹/L and < 50 × 10⁹/L. Cohort 1 included 682 LPs (75.8%) with a pre-procedure platelet count ≥ 50 × 10⁹/L, and cohort 2 included 218 LPs (24.2%) with a pre-procedure platelet count < 50 × 10⁹/L. Cohort 2 was further subdivided into pre-procedure platelet counts of 41 × 10⁹/L-49 × 10⁹/L (n = 43), 31 × 10⁹/L-40 × 10⁹/L (n = 77), 21 × 10⁹/L-30 × 10⁹/L (n = 84), and 11 × 10⁹/L-20 × 10⁹/L (n = 14). Among 900 LP procedures, a pre-procedure platelet count < 50 × 10⁹/L did not demonstrate a higher rate of post-procedure adverse events (6.5% vs 6.8%, p = 0.8237). When cohort 2 was further stratified, the cohort with a pre-procedure platelet count of 21 × 10⁹/L-30 × 10⁹/L had the highest percentage of complications from LP (9.5%) and the highest rates of traumatic taps with observed LP RBC count > 200 (35.7%, p = 0.0015). The rate of red blood cells (RBC) in the CSF was significantly higher in the group with platelets < 50 × 10⁹/L with observed LP RBC count ≥ 200 (31.2% vs 20.5%, p = 0.0016), ≥ 500 (27.1% vs 14.6%, p < 0.0001), and ≥ 1000 (23% vs 11.6%, p < 0.0001). No instances of epidural hematomas were seen. We found no significant difference in bleeding complications between patients undergoing LPs for ITC with a platelet count above or below 50 × 10⁹/L.

Safety of lumbar puncture for people who are treated with ADP receptor antagonists

BACKGROUND

Current guidelines state that clopidogrel and other adenosine-diphosphate receptor antagonists (ADPra) should be stopped for at least 7 days before lumbar puncture (LP). This practice may delay the diagnosis of treatable neurological emergencies and may increase the risk of cardiovascular morbidity due to withholding antiplatelets. We aimed to summarize all cases under our care, in which LP was performed without discontinued ADPra.

METHODS

A retrospective case series study of all patients who underwent LP without interruption of ADPRa or with treatment interruption that was shorter than 7 days. Medical records were searched for documented complications. Traumatic tap was defined as cerebrospinal fluid red cell count ≥ 1000 cell/μL. Incidence of traumatic tap among people who underwent LP under ADPRa was compared to traumatic tap incidence in two control groups: LP under aspirin and LP without any anti-platelet.

RESULTS

159 patients underwent LP under ADPRa [Age: 68.4 ± 12.1, Female: 63 (40%), 81 (51%) were treated with both aspirin and ADPRa]. 116 procedures were carried out without any interruption of ADPRa. In the other 43, the median delay between treatment interruption and the procedure was 2 days (range: 1-6 days). Incidence of traumatic tap was 8/159 (5%), 9/159 (5.7%) and 4/160 (2.5%) among those who underwent LP under ADPRa, under aspirin and without any anti-platelet, respectively. [X²(2) = 2.13, P = 0.35)]. No patient developed spinal hematoma or any neurological deficit.

CONCLUSIONS

Lumbar puncture without discontinuation of ADP receptor antagonists seems safe. Similar case series may ultimately lead to guidelines change.

Change in Prevalence of Meningitis among Children with Febrile Seizure after the Pentavalent Vaccination

Introduction

One of the most significant current discussions in pediatrics is whether lumbar puncture (LP) should be performed in children with febrile seizure (FS) as in the past.

Objectives

We compared the prevalence of meningitis among FS children before and after the pentavalent vaccine to determine the importance of the LP in these children.

Methods

We performed a retrospective cross-sectional study on the prevalence and etiology of bacterial meningitis (BM) in 1314 children with FS before and after pentavalent vaccination.

Results

We found that complex FS was more prevalent in patients aged under 12 months compared to other patients. The peak incidence of aseptic meningitis and BM was in the age group of 12- to 18- and 18- to 36-month-old, respectively (P value <0.001 and <0.05, respectively). Children with complex FS had a significantly higher rate of BM and a lower rate of seizure recurrence than those with simple FS (P value <0.05). There was a significant relationship between getting the pentavalent vaccine and reducing the prevalence of BM and Hib-induced BM, but no SP-induced BM (P value <0.05 and 0.05 and 0.104, respectively).

Conclusion

This study offers some insights into the effectiveness of the pentavalent vaccine. In addition, the low prevalence of BM in vaccinated FS cases does not support strong recommendations for LP in FS children.

Is Lateral Decubitus or Upright Positioning Optimal for Lumbar Puncture Success in a Teaching Hospital?

BACKGROUND

Lumbar puncture is a common procedure performed by emergency physicians and trainees. The optimal patient positioning for lumbar puncture procedures has not been studied adequately.

OBJECTIVES

We performed a prospective randomized study in an urban, level I academic trauma center. Patients of all ages were included. Patients were randomized to either lateral decubitus or upright positioning. Patient demographic characteristics, level of physician training and experience, number of needle insertions and redirections, need for repositioning, alternative operator use, and laboratory results of the cerebrospinal fluid were recorded. We compared the success rate of each position as our primary outcome measure. We also evaluated number of needle insertions and re-directions and success rates based on experience and patient age.

RESULTS

A total of 116 patients were enrolled, with 55 patients assigned to lateral decubitus and 61 to upright position for initial lumbar puncture attempt. Spinal fluid was obtained successfully in 47 of the lateral decubitus group (85.5%; 95% CI 73.8-92.4%) vs. 49 (80.3%; 95% CI 68.7-88.4%) in the upright assignment group. Comparable results were also obtained for first-pass success, number of failures, and number of bloody taps. Postgraduate year 2 residents or those with 31-50 previous lumbar punctures had the highest success rates at 94.3% (95% CI 81.2-98.4%) and 90.3% (95% CI 75.1-96.7%), respectively.

CONCLUSIONS

Lateral decubitus and upright positioning for emergency lumbar puncture yielded equal success rates in emergency physicians and trainees.

The lumbar subcutaneous fat gradient in spinal anesthesia seen for morbidly obese patient with pre-procedure ultrasonography - A case report

It has been reported that pre-procedure ultrasonography rises the success rate of spinal anesthesia in obese patients. In this article, we performed spinal anesthesia for morbidly obese patient with pre-procedure ultrasonography. And recognizing the lumbar subcutaneous fat gradient in morbidly obese patient was the key to success. A cesarean section was scheduled for a primigravida in her 30 s with BMI 61 kg/m2. The lumbar spine was not palpable. Pre-procedure ultrasonography revealed lumbar subcutaneous tissue getting thicker caudally in the sagittal view. Considering this fact, we adjusted the puncture site and succeeded. Postoperative complications were not observed. The pre-procedure ultrasonography is effective even in morbidly obese patients. It is important to recognize the lumbar subcutaneous fat gradient, the so-called back fat slope, for spinal anesthesia in obese patients.

Multiple lumbar punctures aiming to relieve headache results in iatrogenic spinal hematoma: a case report

BACKGROUND

Multiple lumbar punctures have historically been a strategy to relieve headaches associated with idiopathic intracranial hypertension despite limited clinical evidence of long-term efficacy. Lumbar puncture is typically a straightforward procedure with minimal complications reported, however, serious complications can occur. Lumbar-puncture-related spinal hematomas are rare but can lead to irreversible paralysis.

CASE PRESENTATION

We report a case of a 28-year-old Caucasian woman who was treated with multiple lumbar punctures to manage headache, thought to be attributed to idiopathic intracranial hypertension. The patient developed a lumbosacral epidural hematoma following a lumbar puncture, which led to incomplete cauda equina syndrome. Multiple lumbar punctures had been the long-term management for the patient's chronic headaches associated with her diagnosis of idiopathic intracranial hypertension. She had no risks of an underlying coagulopathy. Following a lumbar puncture, she re-presented with lower back pain and bilateral paresthesia. Over the subsequent 48 hours, this progressed to urinary incontinence and saddle paresthesia. Imaging revealed an epidural hematoma, which was conservatively managed. She continued to report saddle paresthesia and urinary incontinence 7 months following the lumbar puncture. Between 1974 to 2022, our literature search found 41 case reports detailing lumbar-puncture-related spinal hematomas. It is an established but rare complication of lumbar puncture and there are limited studies looking at the incidence of its occurrence. Whilst coagulopathy has been found to be a risk factor, it is unclear if the gauge of the needle is relevant. Case evidence suggests there may be no significant difference in outcomes between surgical and conservative management of spinal hematomas. This case highlights that lumbar punctures can be invasive, with potentially serious complications. A lumbar puncture should therefore only be performed when clinically justified.

CONCLUSIONS

This case highlights a rare complication of lumbar puncture and emphasizes the importance of a risk-benefit discussion for each procedure. Spinal hematoma following lumbar puncture is a rare complication but with potentially devastating consequences. Within the setting of idiopathic intracranial hypertension, the evidence base for the long-term benefit of headache relief by repeat lumbar puncture is low.

Accuracy and reliability of magnetic resonance imaging in the diagnosis of idiopathic intracranial hypertension

PURPOSE

To determine the diagnostic utility of brain magnetic resonance imaging (MRI) findings in patients with idiopathic intracranial hypertension (IIH) and to investigate the significance of evaluating radiological findings together with neurological and ophthalmological data in the diagnosis of IIH.

MATERIALS AND METHODS

All consecutive patients diagnosed with IIH in our tertiary neuro-ophthalmology center between January 1, 2018 and March 15, 2020, were included in the study. The clinical, radiological, and ophthalmological findings of IIH patients were compared with the control group with similar demographic characteristics.

RESULTS

A total of 98 patients, 49 cases and 49 controls, were included in the study. Lateral ventricular index had the highest area under the curve (AUC) value (0.945) for prediction of disease group followed by sella height category (AUC = 0.915) and optic nerve tortuosity (AUC = 0.855) According to the multivariate model we developed, caudate index (OR = 0.572, 95% CI 0.329-0.996), lateral ventricle index (OR = 3.969, 95% CI 1.851-8.509) and bilateral optic nerve tortuosity (OR = 22,784, 95% CI 2.432-213.450) were significant predictors for disease group.

CONCLUSION

Tortuosity in the optic nerve, lateral ventricular index and caudate index can be used as MRI parameters supporting the diagnosis of IIH in clinically suspicious cases. A holistic approach to the clinical and radiological findings of the cases in the diagnosis of IIH can prevent overdiagnosis and enable early correct diagnosis.

Post-dural puncture headache: a prospective study on incidence, risk factors, and clinical characterization of 285 consecutive procedures

Background

Lumbar puncture (LP) is a common and relatively safe neurological procedure. It can be complicated by post-dural puncture headache (PDPH) after both diagnostic and therapeutic procedures. The aim of this study is to identify the incidence, risk factors and clinical characterization of PDPH in the inpatient setting of the main tertiary neurology hospital in Kuwait.

Methods

We conducted a prospective observational cohort study that included patients who were admitted to neurology department at Ibn Sina hospital, Kuwait, from January 1, 2019 to December 31, 2020, on whom, LP was performed for diagnostic and/or therapeutic reasons. Multivariate logistic regression analysis was performed to evaluate the association between PDPH and different clinical parameters.

Results

A total of 285 patients were included; 225 females (78.9%), mean age of 32.9 ± 11.7 years. PDPH was reported by 84 patients (29.5%), with mean headache onset of 1.7 ± 0.8 days, and mean duration of 2.4 ± 2.1 days. The commonest headache type was dull aching in 49 patients (58.3%). Headache severity was mild to moderate in 64 patients (76.2%), with mean NRS of 4.1 ± 0.9. Most PDPH (99.3%) resolved with conservative medical management, with only 2 patients (0.7%) requiring epidural blood patch. In multivariate logistic regression model, there was a statistically significant correlation between development of PDPH and young age (p = 0.001), female gender (p = 0 .001), low BMI (p < 0 .001), pre-LP headache (p = 0.001), history of previous PDPH (p = 0.001), and number of LP attempts (p < 0.001). PDPH was statistically significantly higher in patients with optic neuritis (p = 0.009), and cerebral venous thrombosis (p = 0.007), and lower in patients with peripheral neuropathy (p = 0.011) and spinal muscular atrophy (p = 0.042).

Conclusions

Findings from clinical practice in the main tertiary neurology hospital in Kuwait were in line with literature findings. Younger age, female gender, lower BMI, pre-procedural headache, previous history of PDPH, and number of LP attempts were found to be independent risk factors for developing PDPH. To our knowledge, this study represents the first comprehensive description of PDPH in a population from the Arabian Gulf Region.

Nusinersen for Patients With Spinal Muscular Atrophy: 1415 Doses via an Interdisciplinary Institutional Approach

BACKGROUND

Spinal deformity and prior spinal fusion pose technical challenges to lumbar puncture (LP) for nusinersen administration for patients with spinal muscular atrophy (SMA). In this retrospective study over two study phases, we evaluated (1) factors associated with difficult LP or unscheduled requirement for image guidance and (2) effectiveness of a triage pathway for selective use of image guidance and nonstandard techniques, particularly for patients with spinal instrumentation/fusion to the sacrum.

METHODS

With institutional review board approval, electronic health records, imaging, and administrative databases were analyzed for patients receiving nusinersen from January 2012 through September 2021. Descriptive statistics and univariate analyses were used.

RESULTS

From January 2012 to March 2018 (phase 1), among 82 patients with SMA, 461 of 464 (99.4%) LP attempts were successful. Univariate analyses associated difficulty with prior spinal instrumentation, higher body mass index, and severity of the spinal deformity. Based on this experience, starting in April 2018 (phase 2), 125 patients were triaged selectively for ultrasound, fluoroscopy, or Dyna computed tomography. Patients with spinal instrumentation/fusion to the sacrum were treated primarily via intrathecal ports (137 doses) or transforaminal LP (55 doses). From April 2018 through September 2021, 704 of 709 (99.3%) LPs were successful. In total from January 2012 to September 2021, 1415 doses were administered. Over 50% of LPs were performed by neurology nurse practitioners without image guidance. Safety outcomes were excellent.

CONCLUSIONS

A stratified approach resulted in successful intrathecal nusinersen delivery and efficient resource allocation for patients with SMA, with or without complex spinal anatomy.

Capnocytophaga canimorsus meningitis in a 38-year-old immunocompetent woman from household pet exposure

A 38-year-old otherwise healthy woman with no history of immunocompromise, recent travel, or concerning exposures presented to the ED with several days of nonspecific cold-like symptoms with associated generalized headache. After the patient was symptomatically treated and discharged, she returned several hours later with worsening of symptoms and new vomiting, confusion, and sensorineural hearing loss. Blood and cerebrospinal fluid cultures eventually returned positive for a Capnocytophaga canimorsus infection, a bacterial pathogen found in the saliva of dogs and cats. Only after that, the patient recalled being scratched and licked by her pets, two dogs and a cat. She was treated with a course of systemic steroids, antibiotics and discharged home.

Retrospective study comparing success rates of lumbar puncture positions in infants

BACKGROUND

A lumbar puncture (LP) is performed in the emergency room for diagnostic purposes; unsuccessful or traumatic LPs can complicate decision making. The sitting position has a larger interspinous process compared to lateral recumbent and is safer in sick neonates at risk for cardiac and respiratory instability.

PURPOSE

Our study aims to determine which position (lateral recumbent or sitting) is associated with a greater likelihood of successful lumbar puncture in infants <3 months when performed in the emergency room.

BASIC PROCEDURES

This is a retrospective chart review in infants aged <3 months who had a LP performed in a pediatric emergency room. The primary outcome was the rate of successful LPs, defined as obtaining adequate CSF to send for all studies. The secondary outcome was the proportion of atraumatic LPs by position, defined as <500 RBCs or < 10,000 RBCs.

MAIN FINDINGS

A total of 557 charts were reviewed with 116 in the sitting position and 441 in the lateral recumbent position. The primary outcome of adequate CSF fluid collection was not significantly different between groups (63% sitting position versus 58% lateral recumbent position; p = 0.22). In addition, the proportion of atraumatic LPs showed no significant difference regardless of RBC cutoff (<500 RBCs p = 0.83, <10,000 RBCs p = 0.60).

PRINCIPLE CONCLUSIONS

This study found no evidence that there is a difference in rate of LP success nor the proportion of traumatic LP in infants less than 3 months of age when positioned in the sitting position compared to the lateral recumbent position.

Using virtual reality in lumbar puncture training improves students learning experience

BACKGROUND

Lumbar puncture (LP) is a commonly performed medical procedure in a wide range of indications. Virtual reality (VR) provides a stimulating, safe and efficient learning environment. We report the design and the evaluation of a three dimensions (3D) video for LP training.

METHODS

We recorded a stereoscopic 180-degrees 3D video from two LPs performed in clinical settings in Fernand Widal Lariboisière University Hospital, Paris, France. The video was administered to third-year medical students as well as to a residents and attendings group during LP simulation-based training sessions.

RESULTS

On 168 participants (108 novice third-year medical students, and 60 residents and attendings with prior LP experience), satisfaction after video exposure was high (rated 4.7 ± 0.6 on a 5-point scale). No significant discomfort was reported (comfort score graded 4.5 ± 0.8 on 5). LP-naive students displayed higher satisfaction and perceived benefit than users with prior LP experience (overall, P < 0.05). Trainees evaluated favorably the 3D feature and supported the development of similar tutorials for other medical procedures (respectively, 3.9 ± 1.1 and 4.4 ± 0.9 on 5).

CONCLUSION

We report our experience with a 3D video for LP training. VR support could increase knowledge retention and skill acquisition in association to LP simulation training.

Blood amyloid and tau biomarkers as predictors of cerebrospinal fluid profiles

Introduction

Blood biomarkers represent a major advance for improving the management, diagnosis, and monitoring of Alzheimer's disease (AD). However, their context of use in relation to routine cerebrospinal fluid (CSF) analysis for the quantification of amyloid peptides and tau proteins remains to be determined.

Methods

We studied in two independent cohorts, the performance of blood biomarkers in detecting “nonpathological” (A−/T−/N−), amyloid (A+) or neurodegenerative (T+ /N+) CSF profiles.

Results

Plasma Aβ_1–42/Aβ_1–40 ratio and phosphorylated tau (p-tau(181)) were independent and complementary predictors of the different CSF profile and in particular of the nonpathological (A−/T−/N−) profile with a sensitivity and specificity close to 85%. These performances and the corresponding biomarker thresholds were significantly different from those related to AD detection.

Conclusion

The use of blood biomarkers to identify patients who may benefit from secondary CSF testing represents an attractive stratification strategy in the clinical management of patients visiting memory clinics. This could reduce the need for lumbar puncture and foreshadow the use of blood testing on larger populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00702-022-02474-9.

Higher levels of neurofilament light chain and total tau in CSF are associated with negative outcome after shunt surgery in patients with normal pressure hydrocephalus

Background

Lumbar punctures are a common examination in the work-up of patients with idiopathic normal pressure hydrocephalus (iNPH) and cerebrospinal fluid (CSF) biomarkers should therefore be available for use in selection of shunt candidates. The aim of this study was to investigate if CSF biomarkers are associated with outcome after shunt surgery alone or in combination with comorbidity and imaging markers, and investigate associations between CSF biomarkers and symptoms.

Methods

Preoperative CSF biomarkers were analyzed in 455 patients operated with shunt surgery for iNPH at a single center during 2011–2018. Symptoms before and 12 months after shunt surgery were graded with the Swedish iNPH scale. Neurofilament light chain protein (NfL), total tau (T-tau), phosphorylated tau (P-tau) and amyloid beta1-42 (Aβ1-42) CSF levels were measured. Evans’ index and disproportionately enlarged subarachnoid space hydrocephalus were measured on preoperative CT-scans. Preoperative evaluation and follow-up 12 months after shunt surgery were available in 376 patients.

Results

Higher levels of NfL and T-tau were associated with less improvement after shunt surgery (β = − 3.10, p = 0.016 and β = − 2.45, p = 0.012, respectively). Patients whose symptoms deteriorated after shunt surgery had higher preoperative levels of NfL (1250 ng/L [IQR:1020–2220] vs. 1020 [770–1649], p < 0.001) and T-tau (221 ng/L [IQR: 159–346] vs. 190 [135–261], p = 0.0039) than patients with postoperative improvement on the iNPH scale. Among the patients who improved ≥ 5 levels on the iNPH scale (55%), NfL was abnormal in 22%, T-tau in 14%, P-tau in 6% and Aβ1-42 in 45%, compared with normal reference limits. The inclusion of CSF biomarkers, imaging markers and comorbidity in multivariate predictive Orthogonal Projections to Latent Structures (OPLS) models to did not improve predictability in outcome after shunt surgery.

Conclusions

Higher levels of T-tau and NfL were associated with a less favorable response to shunt surgery, suggesting a more active neurodegeneration in this group of patients. However, CSF levels of these biomarkers can be elevated also in patients who respond to shunt surgery. Thus, none of these CSF biomarkers, alone or used in combination, are suitable for excluding patients from surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12987-022-00306-2.

Central Nervous System Involvement in Adults with Acute Leukemia: Diagnosis, Prevention, and Management

PURPOSE OF REVIEW

Recent treatment advances in both acute myeloid leukemia and acute lymphoblastic leukemia have drastically improved outcomes for these diseases, but central nervous system (CNS) relapses still occur. Treatment of CNS disease can be challenging due to the impermeability of the blood-brain barrier to many systemic therapies.

RECENT FINDINGS

The diagnosis of CNS leukemia relies on assessment of clinical symptoms, cerebrospinal fluid sampling for conventional cytology and/or flow cytometry, and neuroimaging. While treatment of CNS leukemia with systemic or intrathecal chemotherapy and/or radiation can be curative in some patients, these modalities can also lead to serious toxicities. In the modern era, prophylaxis with intrathecal chemotherapy is the most important strategy to prevent CNS relapses in high risk patients. Accurate risk stratification tools and the use of risk-adapted prophylactic therapy are imperative to improving the outcomes of patients with acute leukemias and preventing the development of CNS leukemia.

Cerebrospinal fluid findings in COVID-19: a multicenter study of 150 lumbar punctures in 127 patients

BACKGROUND

Comprehensive data on the cerebrospinal fluid (CSF) profile in patients with COVID-19 and neurological involvement from large-scale multicenter studies are missing so far.

OBJECTIVE

To analyze systematically the CSF profile in COVID-19.

METHODS

Retrospective analysis of 150 lumbar punctures in 127 patients with PCR-proven COVID-19 and neurological symptoms seen at 17 European university centers RESULTS: The most frequent pathological finding was blood-CSF barrier (BCB) dysfunction (median QAlb 11.4 [6.72-50.8]), which was present in 58/116 (50%) samples from patients without pre-/coexisting CNS diseases (group I). QAlb remained elevated > 14d (47.6%) and even > 30d (55.6%) after neurological onset. CSF total protein was elevated in 54/118 (45.8%) samples (median 65.35 mg/dl [45.3-240.4]) and strongly correlated with QAlb. The CSF white cell count (WCC) was increased in 14/128 (11%) samples (mostly lympho-monocytic; median 10 cells/µl, > 100 in only 4). An albuminocytological dissociation (ACD) was found in 43/115 (37.4%) samples. CSF L-lactate was increased in 26/109 (24%; median 3.04 mmol/l [2.2-4]). CSF-IgG was elevated in 50/100 (50%), but was of peripheral origin, since QIgG was normal in almost all cases, as were QIgA and QIgM. In 58/103 samples (56%) pattern 4 oligoclonal bands (OCB) compatible with systemic inflammation were present, while CSF-restricted OCB were found in only 2/103 (1.9%). SARS-CoV-2-CSF-PCR was negative in 76/76 samples. Routine CSF findings were normal in 35%. Cytokine levels were frequently elevated in the CSF (often associated with BCB dysfunction) and serum, partly remaining positive at high levels for weeks/months (939 tests). Of note, a positive SARS-CoV-2-IgG-antibody index (AI) was found in 2/19 (10.5%) patients which was associated with unusually high WCC in both of them and a strongly increased interleukin-6 (IL-6) index in one (not tested in the other). Anti-neuronal/anti-glial autoantibodies were mostly absent in the CSF and serum (1509 tests). In samples from patients with pre-/coexisting CNS disorders (group II [N = 19]; including multiple sclerosis, JC-virus-associated immune reconstitution inflammatory syndrome, HSV/VZV encephalitis/meningitis, CNS lymphoma, anti-Yo syndrome, subarachnoid hemorrhage), CSF findings were mostly representative of the respective disease.

CONCLUSIONS

The CSF profile in COVID-19 with neurological symptoms is mainly characterized by BCB disruption in the absence of intrathecal inflammation, compatible with cerebrospinal endotheliopathy. Persistent BCB dysfunction and elevated cytokine levels may contribute to both acute symptoms and 'long COVID'. Direct infection of the CNS with SARS-CoV-2, if occurring at all, seems to be rare. Broad differential diagnostic considerations are recommended to avoid misinterpretation of treatable coexisting neurological disorders as complications of COVID-19.

Reassessing accuracy of blood cell correction factor for traumatic lumbar puncture

OBJECTIVE

This study assessed the utility of correction formulas for procedural peripheral blood admixture with cerebrospinal fluid (CSF) in adult patients using in vitro addition of peripheral blood.

METHODS

Participants from the Johns Hopkins CSF Disorders Center were recruited if greater than 18 years old, not acutely ill, and able to tolerate lumbar puncture (LP). Peripheral blood was added in vitro to acellular CSF and then cellular concentration and protein were quantified.

RESULTS

Correction formulas for white blood cell (WBC) count determined by linear regression for samples with more than 100,000 RBCs per uL were inaccurate. Linear correction formulas close to 1 WBC per 1000 red blood cells (RBCs) were more precise than the formula based on peripheral blood WBC to RBC ratio. Correction formulas for protein level derived by linear regression had minimal error.

DISCUSSION

This study confirms in a controlled manner that CSF admixture with peripheral blood cannot always be reliably corrected for in a predictable manner. Use of correction formulas for protein level and for WBC count when CSF admixture with peripheral blood has RBCs less than 10,000 per microliter is possibly useful but will need to be assessed in larger studies that can confirm diagnostic utility.

Diagnostic value of lumbar puncture for the etiological assessment of uveitis: a retrospective cohort of 188 patients

AIM

To assess the relevance of lumbar puncture (LP) for the etiological diagnosis of uveitis and to establish predictive factors associated with its contributory use.

METHODS

We performed a retrospective study of patients with de novo uveitis who were referred to our tertiary hospital for etiological diagnosis of uveitis, between January 2003 and July 2018. We included patients who underwent a LP as part of the etiological assessment of uveitis. LP was considered as contributory if it led to the etiological diagnosis or to correct the initially suspected diagnosis.

RESULTS

One hundred eighty eight of the 1211 patients referred for evaluation (16%) had an LP, among these patients, 93 (49.4%) had abnormal results including 69 (36.7%) patients with hypercellularity, 69 (36.7%) with hyperproteinorachia, and 28 (14.9%) with oligoclonal bands and/or increased IgG index. LP was considered as contributing to the diagnosis in only 31 (16.4%) cases, among which there were 10 (5.3%) contributions to the etiological diagnosis and 21 (11.2%) modifications in the diagnosis classification. Multivariate analysis established that African ethnicity (p < 0.001), bilateral uveitis (p = 0.01), presence of macular edema or retinal serous detachment (p = 0.048), presence of retinal vasculitis (p < 0.001), presence of neurological signs or symptoms (p = 0.01), and contributing cerebral MRI (p < 0.001) were all significantly associated with a contributory LP. LP did not lead to any therapeutic modification.

CONCLUSION

LP direct contribution to the diagnosis was rare and most often detected non-specific abnormalities. LP should be performed only in cases of neurological clinical signs or symptoms, suspicion of multiple sclerosis, Vogt-Koyanagi-Harada, or syphilis.

Lumbar Puncture in the prone position for Low Birth Weight Neonates

Background

Lumbar puncture in the lateral decubitus position will make the neonates uncomfortable and is likely to cause position change and unstable vital signs, and the application of sedative drugs will cause adverse effects. This study explored a novel method for lumbar puncture in the prone position for low weight neonates.

Methods

The neonates were randomly assigned into the standard position group receiving lumbar puncture in the lateral decubitus position; and the improved position group receiving lumbar puncture in the prone position. The success rate of first time attempts and the overall success rate of lumbar puncture, incidence of adverse effects, NIAPAS scores were collected and compared between these two groups. The difference in success rate and adverse effects incidence rate was analysed through Chi-square. Student’s t-test was used for the test of NIAPAS rating.

Results

The improved position group had a higher success rate of first attempt and overall success rate, significantly lower incidence of adverse effect and lower NIAPAS scores than those of the standard position group (P<0.05).

Conclusion

This lumbar puncture in the prone position is safer, more effective, and more comfortable for preterm neonates and those with low birth weight. Thus, this method is worth of further promotion.

Trial registration

Registration number, ChiCTR2100049923; Date of Registration, August 11, 2021; Retrospectively registered.

Updates in the Diagnostic Approach of Headache

PURPOSE OF REVIEW

In this review, we summarize updates in the diagnostic approach of headaches with the aim of facilitating the distinction between primary and secondary etiology in headaches.

RECENT FINDINGS

In the USA, headache is the fifth most common complaint in the emergency department, but only a minority will have a secondary etiology. Initial suspicion and diagnostic workup of secondary headache relies on a patient's medical history due to a scarcity of validated biomarkers. A special interest group under the International Headache Society recently synthesized information on red flags (information that indicates a secondary etiology) and green flags (information that indicates a primary etiology). A systematic diagnostic approach using red flags and green flags can help reduce unnecessary testing and shift attention to patient care. Going forward, further validation of these concepts is needed to properly introduce them for clinical use.

Epidemiology of findings of lumbar puncture among pediatric patients

Objective

Lumbar Puncture (LP) is a common invasive procedure where cerebrospinal fluid is obtained for the diagnosis of neurological anomalies. The purpose of this study was to evaluate the results of CSF analysis in patients admitted to pediatric wards.

Methods

In this retrospective descriptive study, records of the pediatric patients (aged <18 years) who were referred to our centers for lumbar puncture were evaluated. A checklist was prepared for all the patients where demographic data, findings of CSF and blood analysis and clinical presentations were recorded. The data obtained was analyzed using SPSSv22.

Results

In this study a total number of 247 patients were included where 57.9% of the cases were of boys. 55.8% patients aged under 1 year and 62.3% of patients had a body temperature of 38 °C and above. 15.3% of the children were diagnosed with meningitis, 27.1% had febrile seizures, 9.3% had neonatal sepsis and for 48.2% cases other clinical diagnoses were made. There was a significant relationship between the diagnosis and the number of WBCs seen in CSF (P < 0.001). Also, there was a significant relationship between the diagnosis and amount of protein (P < 0.001) and glucose in CSF (P = 0.005). The age group and the type of fever and seizure were also significantly correlated, (P < 0.001).

Conclusion

Lumbar puncture is an important procedure for the diagnosis of several neurological diseases. Further studies including neuroimaging and therapeutic measures are recommended in this regard.

Predicting asymptomatic neurosyphilis using peripheral blood indicators

Background

The high misdiagnosis rate of asymptomatic neurosyphilis (ANS) has long challenged infectious disease clinicians. We aim to develop a model for diagnosing ANS in asymptomatic syphilis (AS) patients without CSF indicators.

Results

277 AS patients with HIV-negative and underwent lumbar puncture were enrolled in this horizontal study.The area under the curve for predicting ANS by CSF leukocytes and protein was 0.643 and 0.675 [95% CI, 0.583–0.699VS.0.616–0.729]. Through LRM, the AUC increased to 0.806 [95% CI, 0.732–0.832], and the Youden's index was 0.430. If the score is ≤ 0.159, ANS can be excluded with a predictive value of 92.9%; we can identify ANS while the score is over 0.819, with a predictive value of 91.7% and a specificity of 99.25%. This study showed that the LRM can diagnose ANS in AS patients effectively.

Conclusion

Given a large number of misdiagnosis ANS patients and CSF results' insufficiency, the model is more practical. Our research will help clinicians track suspected syphilis, especially those who cannot accept the CSF test.

Non-invasive intracranial pressure monitoring in idiopathic intracranial hypertension and lumbar puncture in pediatric patient: Case report

Background

Intracranial pressure (ICP) monitoring has been variously explored as a diagnostic and therapeutic modality in many pathological conditions leading neurological injury. This monitoring standardly depends on an invasive procedure such as cranial or lumbar catheterization. The gold standard for ICP monitoring is through an intraventricular catheter, but this invasive technique is associated with certain risks such as haemorrhage and infection. (1) Also, it is a high-cost procedure and consequently not available in a variety of underprivileged places and clinical situations in which intracranial hypertension is prevalent (3). An accurate non-invasive and low-priced method to measure elevated ICP would therefore be desirable. Under these circumstances, Brazilian scientists developed a non-invasive method for intracranial pressure monitoring (ICP-NI), which uses an electric resistance extensometer that measures micro deformations of the skull and transforms it into an electrical signal. In this case report, the authors describe a pediatrician patient with the diagnosis of idiopathic intracranial hypertension who was successfully submitted to a lumbar puncture under monitorization with this device.

Case description

7 year old girl with progressive symptoms that lead to the diagnosis of idiopathic intracranial hypertension. The patient was submitted to a lumbar punction with continuous non-invasive ICP monitoring.

Conclusion

Estimating ICP (non-invasive) from LP monitoring (invasive) often reflect inaccurate ICP results, and affects negatively on IIH diagnosis and a non-invasive diagnostic method could reduce the requirement for invasive approaches, improving patient health outcomes.

Lumbar puncture in infants with urinary tract infection: Assessment of infant management in the emergency department

BACKGROUND

Neonatal bacterial infections must be bacteriologically confirmed from laboratory samples to best adjust antibiotic therapy. Lumbar puncture (LP) has been recommended for infants younger than 1 month with suspected serious bacterial infection (SBI) to manage possible meningitis. However, the incidence of bacterial meningitis associated with other infections and particularly with urinary tract infections (UTIs) is low. Recourse to systematic LP may be less essential if infants have a UTI. We aimed (a) to determine the management and frequency of bacterial meningitis coexisting with a documented diagnosis of UTI in infants aged < 1 month who had an LP, and (b) to evaluate the management of infants in emergency admissions with suspected SBI while assessing antibiotic treatment.

METHODS

We conducted a retrospective single-center study from January 2010 to April 2019 including all cases of neonatal bacterial infections, and collected data on the clinical, laboratory, and radiological features.

RESULTS

In all, 409 infants were included in the study. Of these, 162 (39.6%) presented with a UTI and eight (2%) had bacterial meningitis. Of the infants diagnosed with UTI, 74.7% had an LP, of whom 34.7% experienced LP complications. No coexistence of UTI and bacterial meningitis was found among infants who had an LP and a documented UTI.

CONCLUSION

Although not all infants had an LP and a urine culture at the same time, these results show that bacterial meningitis coexisting with a confirmed UTI diagnosis in infants is rare. Furthermore, LP can be traumatic in some cases and therefore its utility should be assessed according to the clinical context.

Evaluation of the signs and symptoms of pseudotumor cerebri syndrome in pediatric population

PURPOSE

Pseudotumor cerebri syndrome (PTC) is characterized by increased intracranial pressure without a space-occupying lesion and a normal cerebrospinal fluid (CSF) composition without evidence of CSF infection. In this study, we aimed to compare the symptoms, signs, and clinical characteristics of patients presenting with a preliminary diagnosis of pseudotumor cerebri syndrome (PTC) who were diagnosed and not diagnosed with PTC.

METHOD

We conducted a retrospective study of patients who were referred to our clinic with signs and symptoms of PTC. We compared the patients' symptoms, signs, and clinical characteristics who were diagnosed with PTC with those who were not diagnosed with PTC using modified Dandy criteria.

RESULTS

Ninety-four patients with the pre-diagnosis of PTC were included in the study. LP procedure was done in all patients. After LP, 75.3% of the patients were diagnosed with PTC, but 24.7% did not meet the criteria for PTC. A statistically significant relationship was found between the increase in headache complaints when leaning forward, headache that keeps the child from playing, and the CSF pressure level (p = 0.014, p = 0.019; p < 0.05). There was no statistically significant correlation between papilledema and CSF pressure level (p > 0.05). A statistically significant relationship was found between papilledema grade and CSF pressure level (p = 0.038; p < 0.05), and the rate of high CSF pressure in the groups with Grades 2-3 and Grade 4 papilledema was higher than that in the group with Grade 1 papilledema. Cranial nerve 6 palsy (CN6) (p = 0.048) and flattening of the posterior aspect of the globe (FPS) are found independent risk factors (p = 0.004 p < 0.05).

CONCLUSIONS

PTC signs and symptoms show variability among pediatric population.

Material and sedation-analgesia in the neonatal lumbar puncture procedure

INTRODUCTION

Lumbar puncture (LP) is a frequent procedure during the neonatal period. Correctly performing this technique can avoid many of its complications.

OBJECTIVE

To evaluate the LP procedure in neonates in Spanish hospitals, studying the type of material and the sedation-analgesia used.

MATERIAL AND METHODS

Cross-sectional study conducted in Spain gathering data through a survey research distributed by email through the Segurneo-SEN Hospital Network and the Spanish Neonatal Society. Data on the LP technique in neonates were collected.

RESULTS

A total of 301 participants were analysed. Most professionals used a trocar needle with a stylet as the first option (89.7%); however, when the LP failed or was blood-stained, 32.2% changed the type of needle. A total of 143 doctors gave their subjective feeling about the type of needle: they only use trocar needles with stylet (41.3%), the technique is easier using scalp-vein needles (32.2%), there is less probability of a blood-stained LP, or failed using scalp-vein needles (7.7%), they choose the type of needle depending on the size of the newborn (10.5%), indifference when using one type or another needle (8.4%). Almost all (99%) of the surveyed doctors used some type of analgesia. The most widely used measures were topical anaesthetics (90.3%) and sucrose (82.2%).

CONCLUSIONS

Currently, the LP procedure in the neonatal period is mainly performed with a trocar needle with a stylet and with the widespread use of different analgesic measures.