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Uva-DARE (Digital Academic Repository) UvA-DARE (Digital Academic Repository) Lumbar puncture in bacterial meningitis Costerus, J.M. Publication date 2018 Document Version Other version License Other Link to publication Citation for published version (APA): Costerus, J. M. (2018). Lumbar puncture in bacterial meningitis. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl) Download date:01 Oct 2021 TECHNOLOGICAL ADVANCES AND CHANGING INDICATIONS FOR LUMBAR PUNCTURE IN NEUROLOGICAL DISORDERS Joost M. Costerus Matthijs C. Brouwer Diederik van de Beek Lancet Neurology. 2018 Mar;17(3): 268-278 15475-J-Costerus_BNW.indd 87 728-08-18 16:37 Chapter 7 Abstract Technological advances have changed the indications for and the way in which lumbar puncture is done. Suspected CNS infection remains the most common indication for lumbar puncture, but new molecular techniques have broadened CSF analysis indications, such as the determination of neuronal autoantibodies in autoimmune encephalitis. New screening techniques have increased sensitivity for pathogen detection and can be used to identify pathogens that were previously unknown to cause CNS infections. Evidence suggests that potential treatments for neurodegenerative diseases, such as Alzheimer’s disease, will rely on early detection of the disease with the use of CSF biomarkers. In addition to being used as a diagnostic tool, lumbar puncture can also be used to administer intrathecal treatments as shown by studies of antisense oligonucleotides in patients with spinal muscular atrophy. Lumbar puncture is generally a safe procedure but complications can occur, ranging from minor (eg, back pain) to potentially devastating (eg, cerebral herniation). Evidence that a conic needle tip design reduces complications of lumbar puncture is compelling, and reinforces the need to change clinical practice. 88 15475-J-Costerus_BNW.indd 88 28-08-18 16:37 Technological advances and changing indications for lumbar puncture in neurological disorders INTRODUCTION Lumbar puncture is imperative to diagnose many neurological diseases. The procedure is reasonably easy to do and highly available, even in resource-limited settings.1 Principal indications for diagnostic lumbar puncture are a suspected CNS infection and measurement of the CSF opening pressure, but it is also used in the differential diagnosis of subarachnoid haemorrhage, CNS autoimmune disease, neoplastic meningeal disease, and dementia.2 Over the past 10 years, technological advances have decreased the necessity of CSF examination for some diseases—eg, improved neuroimaging techniques in cases of leptomeningeal metastasis3 and the introduction of imaging-guided stereotactic aspiration of brain abscess.4 However, new laboratory techniques have broadened indications for CSF examination in other diseases—eg, biomarkers of neurodegenerative diseases,5 neuronal autoantibodies in autoimmune encephalitis,6 and discovery of previously unidentified pathogens by sequencing.7 Intrathecal delivery of antisense oligonucleotides or other treatments can be used in patients with previously untreatable neurodegenerative disease.8 Also, technological advances in lumbar puncture are continuously taking place, with new findings from many randomised controlled studies on the use of atraumatic 7 lumbar puncture needles9 and the emergence of ultrasound and x-ray guidance.10 In this Review, we summarise indications for lumbar puncture, describe clinical applications and contraindications, and discuss technological advances in lumbar puncture, CSF diagnostics, and the use of biomarkers. We propose some practical guidance for lumbar puncture and the interpretation of CSF analysis and discuss ongoing developments in the field. Clinical Applications CNS infection remains the major indication for diagnostic lumbar puncture.2,11 CSF analysis can aid diagnosis of various neurological inflammatory diseases—eg, autoimmune encephalitis,6 acute transverse myelitis,12 Guillain-Barre syndrome,13 and primary CNS vasculitis.14 In patients with suspected subarachnoid haemorrhage and non-conclusive results from neuroimaging, the presence of CSF haemoglobin breakdown products are crucial for clinical management decisions.15 In suspected leptomeningeal metastases, cytology and flow cytometry of CSF can confirm the diagnosis.3 One retrospective study16 including 326 patients who underwent elective diagnostic lumbar puncture in an academic hospital (Iowa City, IA, USA) showed that the procedure was successful in 264 patients (81%), and high body-mass index was identified as the most predictive factor for an unsuccessful procedure (p<0·0001). Lumbar puncture was regarded successful if quantifiable CSF was obtained.16 89 15475-J-Costerus_BNW.indd 89 28-08-18 16:37 Chapter 7 Lumbar puncture can itself be used therapeutically—eg, in patients with cryptococcal meningitis and acute communicating hydrocephalus, the procedure directly relieves headache as a result of lowering of CSF pressure.17,18 In an observational cohort study19 including 248 patients with HIV-associated cryptococcal meningitis, therapeutic lumbar punctures were associated with a 69% relative improvement of survival. Lumbar puncture is essential in the diagnosis of idiopathic intracranial hypertension because the diagnostic criteria include a raised CSF opening pressure (>25 cm H2O) and normal CSF composition.20 In hydrocephalus with normal CSF opening pressure, the CSF tap test can be done by removal of 30–50 mL CSF to predict efficacy of CSF catheter placement.21 In a prospective case series22 including 115 patients with idiopathic normal pressure hydrocephalus, the tap test had a positive predictive value of 88% and a negative predictive value of 18% for clinical improvement after catheter placement. Lumbar puncture can also be used to deliver treatment—eg, intrathecal injection of nusinersen, an antisense oligonucleotide that increases the amount of functional survival motor neuron protein that is deficient in patients with spinal muscle atrophy.23 A phase 2 randomised controlled study23 in 20 patients aged 3–7 months showed acceptable safety of nusinersen in this previously untreatable disease and an encouraging clinical response. A randomised doubleblind sham-controlled phase 3 study8 in 121 patients aged 7 months or younger was ended early after a positive interim analysis. In the nusinersen group 37 (51%) of 73 infants had a motor-milestone response compared with none of 37 infants in the control group. In an ongoing open-label phase 3 study (SHINE, NCT02594124) long-term safety of intrathecal nusinersen is being assessed in patients with spinal muscle atrophy. Intrathecal administration is also commonly used in chemotherapy, allowing treatment of CNS or leptomeningeal localisation of malignancies,3,24 and intrathecal baclofen is used to treat spasticity.25 Additionally, perioperative intrathecal administration of fluorescein enables visualisation of CSF leaks in the skull base.26 Contraindications Lumbar puncture has several contraindications to be aware of (panel 1). In patients with hydrocephalus, care should be taken to differentiate between communicating and non-communicating obstructive hydrocephalus (which is a contraindication for lumbar puncture).27 In patients with a cerebral mass lesion causing brain shift, withdrawal of CSF in the lumbar region reduces the counter pressure from below, which can increase brain shift leading to compression of vital brain structures (figure 1).4,28 90 15475-J-Costerus_BNW.indd 90 28-08-18 16:37 Technological advances and changing indications for lumbar puncture in neurological disorders To exclude a cerebral mass lesion as a cause of brain shift, cranial imaging can be done (figure 2; panel 2). The bacterial meningitis guideline of the European Society of Clinical Microbiology and Infectious Diseases29 recommends doing cranial CT before lumbar puncture in patients with new-onset seizures, a severe immunocompromised state, focal neurological deficits, or a moderate-to-severe impairment of consciousness defined as a score less than ten on the Glasgow Coma Scale. This guideline29 was composed by an international committee consisting of European experts on neurological infectious diseases, and the Meningitis Research Foundation, a UK-based patient organisation, participated in its development. Panel 1. Contraindications for lumbar puncture Relative contraindications: • Platelet count 20-40 x 109/L50* • Thienopyridines therapy34† Absolute contraindications: • Non-communicating hydrocephalus27 • Uncorrected bleeding diathesis34 7 • Anticoagulant therapy34 • Platelet count <20 x 109 /L50 • Spinal stenosis/ spinal cord compression above level of puncture30 • Local skin infections31
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