Consensus guidelines for lumbar puncture in patients with neurological diseases.
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ABSTRACT: Introduction
Cerebrospinal fluid collection by lumbar puncture (LP) is performed in the diagnostic workup of several neurological brain diseases. Reluctance to perform the procedure is among others due to a lack of standards and guidelines to minimize the risk of complications, such as post-LP headache or back pain.Methods
We provide consensus guidelines for the LP procedure to minimize the risk of complications. The recommendations are based on (1) data from a large multicenter LP feasibility study (evidence level II-2), (2) systematic literature review on LP needle characteristics and post-LP complications (evidence level II-2), (3) discussion of best practice within the Joint Programme Neurodegenerative Disease Research Biomarkers for Alzheimer's disease and Parkinson's Disease and Biomarkers for Multiple Sclerosis consortia (evidence level III).Results
Our consensus guidelines address contraindications, as well as patient-related and procedure-related risk factors that can influence the development of post-LP complications.Discussion
When an LP is performed correctly, the procedure is well tolerated and accepted with a low complication rate.
SUBMITTER: Engelborghs S
PROVIDER: S-EPMC5454085 | biostudies-literature | 2017
REPOSITORIES: biostudies-literature
Publications
Consensus guidelines for lumbar puncture in patients with neurological diseases.
Engelborghs Sebastiaan S Niemantsverdriet Ellis E Struyfs Hanne H Blennow Kaj K Brouns Raf R Comabella Manuel M Dujmovic Irena I van der Flier Wiesje W Frölich Lutz L Galimberti Daniela D Gnanapavan Sharmilee S Hemmer Bernhard B Hoff Erik E Hort Jakub J Iacobaeus Ellen E Ingelsson Martin M Jan de Jong Frank F Jonsson Michael M Khalil Michael M Kuhle Jens J Lleó Alberto A de Mendonça Alexandre A Molinuevo José Luis JL Nagels Guy G Paquet Claire C Parnetti Lucilla L Roks Gerwin G Rosa-Neto Pedro P Scheltens Philip P Skårsgard Constance C Stomrud Erik E Tumani Hayrettin H Visser Pieter Jelle PJ Wallin Anders A Winblad Bengt B Zetterberg Henrik H Duits Flora F Teunissen Charlotte E CE
Alzheimer's & dementia (Amsterdam, Netherlands) 20170518
<h4>Introduction</h4>Cerebrospinal fluid collection by lumbar puncture (LP) is performed in the diagnostic workup of several neurological brain diseases. Reluctance to perform the procedure is among others due to a lack of standards and guidelines to minimize the risk of complications, such as post-LP headache or back pain.<h4>Methods</h4>We provide consensus guidelines for the LP procedure to minimize the risk of complications. The recommendations are based on (1) data from a large multicenter ...[more]
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Project description:A lumbar puncture is performed to obtain cerebral spinal fluid. It is implemented in the clinic on a routine basis to aid the diagnosis of neurologic diseases, such as dementia. This video will show the lumbar puncture procedure as routinely performed in the VUmc Alzheimer Center.
| S-EPMC5454130 | biostudies-literature
Project description:ObjectiveLumbar 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.MethodsIn 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.ResultsIn 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).ConclusionLumbar puncture is an important procedure for the diagnosis of several neurological diseases. Further studies including neuroimaging and therapeutic measures are recommended in this regard.
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Project description:BackgroundCritical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support.MethodsThese guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels.ResultsWe identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts.ConclusionsThe impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.
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Project description:Background and purposeThe recent SARS-CoV-2 pandemic has posed multiple challenges to the practice of clinical neurology including recognition of emerging neurological complications and management of coexistent neurological diseases. In a fast-evolving pandemic, evidence-based studies are lacking in many areas. This paper presents European Academy of Neurology (EAN) expert consensus statements to guide neurologists caring for patients with COVID-19.MethodsA refined Delphi methodology was applied. In round 1, statements were provided by EAN scientific panels (SPs). In round 2, these statements were circulated to SP members not involved in writing them, asking for agreement/disagreement. Items with agreement >70% were retained for round 3, in which SP co-chairs rated importance on a five-point Likert scale. Results were graded by importance and reported as consensus statements.ResultsIn round one, 70 statements were provided by 23 SPs. In round two, 259/1061 SP member responses were received. Fifty-nine statements obtained >70% agreement and were retained. In round three, responses were received from 55 co-chairs of 29 SPs. Whilst general recommendations related to prevention of COVID-19 transmission had high levels of agreement and importance, opinion was more varied concerning statements related to therapy.ConclusionThis is the first structured consensus statement on good clinical practice in patients with neurological disease during the COVID-19 pandemic that provides immediate guidance for neurologists. In this fast-evolving pandemic, a rapid response using refined Delphi methodology is possible, but guidance may be subject to change as further evidence emerges.
| S-EPMC7675361 | biostudies-literature
Project description:Neuroinflammation is evident and one of the primary induced responses after central nervous system (CNS) injury, lumbar puncture and CNS surgery. In rare cases, complications could arise after the lumbar puncture or CNS surgery leading to inflammation, bleeding or other problems such as cerebrospinal fluid (CSF) leakage. The present dataset describes the occurrence of such a condition after the dura breakage or postoperative complication leading to the development of neuroinflammation in the adult Wistar rats. Therefore, objective of the study is to report such a rare condition and detect the most reliable glial proteins upregulated 2-3 weeks after the lumbar puncture which may help the neuroscience community to a better understanding their cause of action. In response to neuroinflammation, glial cells leak into the extracellular space, where they can be identified in the CSF or serum and may act as diagnostic biomarkers. Laminectomy was performed at the thoraco-lumbar (T12-L1) region and the dura was punctured. After that, the exposed part was covered with silica gel and adhesive followed by dental cement. The skin was closed using sterile sutures. After, the rats were given buprenorphine (0.05 mg/kg, every 8 h for 3 days) and carprofen (5 mg/kg, once a day for 5 days) as analgesic and anti-inflammatory and baytril (5 mg/kg, once a day for 10 days) as antibiotic drugs. Note, the buprenorphine and lidocaine were also given before starting the procedure. After the laminectomy, the functional outcomes of the rats were tested (starting from the day of surgery to the last day) and the rats which were locomoting normally using all the limbs were included in the study. In case of any decompression, the functional outcomes showing any kind of laming or partial paralysis of hindlimbs were excluded from the study. Unexpected neuroinflammation has occurred 2-3 weeks after performing the given procedure. Data presented in the article implicate active microglia measured by using protein biomarker such as Iba-1 [1, 3] and astrocytes measured by using Glial fibrillary acidic protein (GFAP) [2, 3] and S100 (strongly targets S100B and weakly A1) [7, 8] in the CSF collected two-three weeks after the laminectomy and dura breakage from the adult rats. Later paraformaldehyde (PFA) fixed spinal cord slices were also collected from the animals and immunolabelled with the same biomarkers. Western blots were performed with the collected CSF which showed high expression of glial markers such as GFAP, Iba-1 and S100 which has shown to target S100B with no expression of A1 (or A2, play an important role in neuroprotection) astrocytes which have recently been shown to be produced by microglia at the site of injury [9]. However, S100B [10] and GFAP [2] are known to be adequately discharged by the distinct cells in stress conditions which seems to occur in the present report. In addition, the spinal slices immunolabelled with the same biomarkers also showed increased expression of glia. Cross-talk between microglia-astrocyte in CNS stress is crucial for the neurons to survive and function after the injury. Reactive microglia (shown by high Iba-1 expression) leading to microgliosis comprise the first line of defense to phagocytose the dead cells [11]. Astrocytes act as the second line of defense leading to a process known as astrogliosis and upregulate GFAP and S100B to limit the damage [12]. Further studies are needed to explain the molecular mechanism/s of different astrocytes release such as A2 and their interaction with microglia after the lumbar puncture.
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Project description:ImportanceCoagulopathy may deter physicians from performing a lumbar puncture.ObjectiveTo determine the risk of spinal hematoma after lumbar puncture in patients with and without coagulopathy.Design, setting, and participantsDanish nationwide, population-based cohort study using medical registries to identify persons who underwent lumbar puncture and had cerebrospinal fluid analysis (January 1, 2008-December 31, 2018; followed up through October 30, 2019). Coagulopathy was defined as platelets lower than 150 × 109/L, international normalized ratio (INR) greater than 1.4, or activated partial thromboplastin time (APTT) longer than 39 seconds.ExposuresCoagulopathy at the time of lumbar puncture.Main outcomes and measuresThirty-day risk of spinal hematoma. Risks were provided as numbers and percentages with 95% CIs. Secondary analyses included risks of traumatic lumbar puncture (>300 × 106 erythrocytes/L after excluding patients diagnosed with subarachnoid hemorrhage). Adjusted hazard rate ratios (HRs) were computed using Cox regression models.ResultsA total of 83 711 individual lumbar punctures were identified among 64 730 persons (51% female; median age, 43 years [interquartile range, 22-62 years]) at the time of the procedure. Thrombocytopenia was present in 7875 patients (9%), high INR levels in 1393 (2%), and prolonged APTT in 2604 (3%). Follow-up was complete for more than 99% of the study participants. Overall, spinal hematoma occurred within 30 days for 99 of 49 526 patients (0.20%; 95% CI, 0.16%-0.24%) without coagulopathy vs 24 of 10 371 patients (0.23%; 95% CI, 0.15%-0.34%) with coagulopathy. Independent risk factors for spinal hematoma were male sex (adjusted hazard ratio [HR], 1.72; 95% CI, 1.15-2.56), those aged 41 through 60 years (adjusted HR, 1.96; 95% CI, 1.01-3.81) and those aged 61 through 80 years (adjusted HR, 2.20; 95% CI, 1.12-4.33). Risks did not increase significantly according to overall severity of coagulopathy, in subgroup analyses of severity of coagulopathy by pediatric specialty or medical indication (infection, neurological condition, and hematological malignancy), nor by cumulative number of procedures. Traumatic lumbar punctures occurred more frequently among patients with INR levels of 1.5 to 2.0 (36.8%; 95% CI, 33.3%-40.4%), 2.1 to 2.5 (43.7%; 95% CI, 35.8%-51.8%), and 2.6 to 3.0 (41.9% 95% CI 30.5-53.9) vs those with normal INR (28.2%; 95% CI, 27.7%-28.75%). Traumatic spinal tap occurred more often in patients with an APTT of 40 to 60 seconds (26.3%; 95% CI, 24.2%-28.5%) vs those with normal APTT (21.3%; 95% CI, 20.6%-21.9%) yielding a risk difference of 5.1% (95% CI, 2.9%-7.2%).Conclusions and relevanceIn this Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for lumbar puncture.
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Project description:BackgroundPerforming cranial imaging prior to lumbar punctures (LPs) in patients with suspected central nervous system (CNS) infections has been associated with delayed treatments and poor outcomes. Various guidelines provide different criteria for cranial imaging prior to LP.MethodsWe describe the use of cranial imaging in a cohort of adult patients with suspected CNS infections, and evaluated adherence to the recommendations made in the Infectious Disease Society of America (IDSA), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Swedish, and Dutch guidelines. We also analyzed the association between cranial imaging and the time between emergency department entrance and intravenous antibiotic administration.ResultsFrom 2012-2015, 203 patients with suspected CNS infections were included, of whom 56 (27%) were diagnosed with CNS infections and 16 were diagnosed with bacterial meningitis (8%). Cranial imaging, in all cases computed tomography (CT), was performed in 130 patients (64%) and led to the deferral of LPs in 7 (5%). Criteria by the IDSA, ESCMID, Swedish, and Dutch guidelines showed indications for imaging in 64%, 39%, 39%, and 40% of patients, respectively. The times between emergency department arrivals and the start of antibiotic therapy between patients with and without CT before LP were similar (median 134 [interquartile range (IQR) 58-292] vs. 141 minutes [IQR 52-227], respectively; Mann-Whitney U P = .74).ConclusionsA cranial CT prior to LP was done in the majority of patients with a suspected CNS infection, irrespective of guideline indications. The ESCMID, Swedish, and Dutch guidelines were more restrictive in advising imaging, compared to the IDSA guidelines. Performing cranial imaging prior to LP was not associated with treatment delays in this Dutch cohort study.
| S-EPMC7286381 | biostudies-literature
Project description:In much of sub-Saharan Africa, lumbar punctures (LPs) are performed less frequently than indicated. This is often attributed to patient/family refusal; however, other factors have not been systematically evaluated. We investigated predictors of LP performance for a prospective cohort of people with HIV and new-onset seizures at three hospitals in Zambia. We enrolled 257 participants, including 184 (72%) adults and 144 (56%) urban participants. LPs were performed for 65% of adults and 33% of children, and for 69% of urban and 38% of rural participants. In multivariate logistic regression analyses, LP completion was significantly less likely at one rural site and among children compared to adults. The worst WHO HIV disease stage was associated with increased odds of undergoing LP. Low LP completion rates in Zambia are multifactorial and related to health system and provider factors and patient/family preferences. Further research is necessary to understand this complex problem and develop interventions to improve LP uptake.
| S-EPMC8592202 | biostudies-literature
Project description:ObjectiveLumbar puncture (LP) is increasingly common in Alzheimer disease research; however, agreement to undergo LP varies. We sought to determine factors influencing LP consent at Alzheimer's Disease Centers (ADCs) in the United States.MethodsA 3-part survey was distributed to each ADC: (1) ADC LP Experience; (2) LP Requestor Experience; and (3) Patient LP Experience (both Initial and Follow-up). In all, 64 LP Requestor, 579 Patient/Initial, and 404 Patient/Follow-up surveys were collected. Logistic regression analyses with generalized estimating equations were used to assess factors associated with LP agreement and post-LP complications.ResultsAsians and those viewing LP negatively were less likely to agree to LP. Three hundred fifty-two participants had an LP; LP headache occurred in 11.9% (blood patch required in 1.4%) and 9.9% reported other complications. Younger individuals, women, those diagnosed with mild cognitive impairment, use of a Quincke needle, ≤20 mL cerebrospinal fluid drawn, and hemorrhage during LP were associated with LP headache. Use of gravity flow during LP was associated with fewer other complications (nausea, dizziness, vasovagal response, back pain, neck stiffness, and/or nerve root pain).ConclusionsLP in Alzheimer disease research is generally safe and well tolerated. Factors influencing LP agreement potentially could be studied to advance participant acceptance of the procedure.
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Project description:ObjectivesAtraumatic needles are known to reduce complication rates of blind lumbar punctures (LP), however, their use in fluoroscopically guided LP is less studied. This study assessed the comparative difficulty of performing fluoroscopic lumbar puncture with atraumatic needles.MethodsSingle-centre retrospective case-control study comparing atraumatic and conventional or "cutting" needles using fluoroscopic time and radiation dose (Dose Area Product or DAP) as surrogate markers. Patients were assessed from two comparable eight-month periods before and after a policy change to primary use of atraumatic needles.Results105 procedures with a cutting needle were performed in the group prior to the policy change. Median fluoroscopy time was 48 sec and median DAP was 3.14. Of 102 procedures performed in the group after the policy change, 99 were performed with an atraumatic needle and three with a cutting needle after initial attempt with an atraumatic needle. Median fluoroscopy time was 41 sec and median DAP was 3.28. The mean number of attempts was 1.02 in the cutting needle group and 1.05 in the atraumatic needle group. There was no significant difference in median fluoroscopy time, median DAP, or mean number of attempts.ConclusionFluoroscopic screening time, DAP and mean number of attempts were not significantly increased with primary use of atraumatic needles for LP. Use of atraumatic needles should be considered in fluoroscopic LP given the lower complication rates.Advances in knowledgeThis study provides new data showing that the use of atraumatic needles does not increase the difficulty of fluoroscopically guided LP.
| S-EPMC10230379 | biostudies-literature