Cerebrospinal fluid syndromes in HIV-positive patients with acute consciousness compromise.

We reviewed the cerebrospinal fluid (CSF) syndromes of 100 consecutive HIV-positive patients presenting acute consciousness compromise in emergency rooms, and correlated them with clinical data. The most frequent CSF syndromes were: absolute protein-cytological dissociation (21), viral (19), neurocryptococcosis (7), relative protein-cytological dissociation (6) and septic (4), moderate hypoglycorrachia (4), severe hypoglycorrachia (4) and hydroelectrolytic disturbance (3). One fifth of the patients had CSF syndromes considered sufficient for diagnosis or an immediate clinical decision. The most common clinical data were infective and neurological. There was little correlation between the clinical data and the CSF syndromes. We conclude that in HIV-positive individuals presenting acute consciousness disturbances there are frequently non-specific results in the CSF analysis that must be weighed against a detailed history and thorough physical examination. Taking this into account, in about one fifth of cases the CSF analysis can offer useful information for treatment.

The diagnosis of delirium in 80 emergency unit patients.

We evaluated the initial and final diagnosis of 80 patients with delirium arriving at the emergence unit of a university hospital in a large Brazilian city over a period of 30 months up to December 1991. The diagnosis was based on the DSM-IIIR criteria. Patients with a known history of head trauma or epileptic seizure and patients younger than 13 years were excluded. Only patients with a disease of up to 7 days were included. The patients were subdivided into four etiologic groups: vascular; associated with the use of alcohol; infectious-parasitic; miscellaneous. The results showed a rate of correct diagnosis ranging from 65 to 80% with the use of kappa test (standard good to excellent). Sensitivity, specificity, positive predictive and negative predictive values had results showing different conditions for initial diagnosis in each group. This study can help the initial diagnosis of delirium and the choice for diagnostic testing.

Cerebrospinal fluid syndromes in patients with acute consciousness compromise.

We reviewed the laboratorycards of 200 analysis of cerebrospinal fluid (CSF) performed to evaluate acute alterations of consciousness in adult patients attended in a neurological emergency room. 61% were men; the mean age was 46 years. The most common clinical data were infective and neurologic. The CSF was abnormal in 149 (74.5%) patients and the most common syndromes were: compressive (21%), hemorrhagic (11.5%), "viral" (8.5%), septic (7.5%), moderate hyperglycorrachia (6.5%), hydroelectrolytic disturbances (5.5%). There were some statistically significant correlations between CSF syndromes and clinical data: septic syndrome and fever and meningeal signs, hemorrhagic syndrome and headache and meningeal signs, CSF hydroelectrolytic disturbance syndrome and seizures, severe hyperproteinorrachia and headache, fever, meningeal signs and vomiting, moderate hyperproteinorrachia and age over 65 and male sex. We classified the abnormal results in two groups: 1--sufficient for an immediate clinical decision; 2--nonspecific. The former group was found in 27.5% of the patients and in 36.9% of the abnormal CSF results. In patients attending to neurologic emergency rooms with acute alterations of consciousness, the examination of the CSF frequently could contribute to an etiologic diagnosis. It must be performed after a rigorous clinical evaluation of the patient.

[Subarachnoidal hemorrhage with cranial tomography without bleeding signals]. / Hemorragia subaracnoídea com tomografia de crânio sem sinais de sangramento.

UNLABELLED: We observed 23 patients with clinical hypothesis of subarachnoidal hemorrhage (SAH) having cranial tomography (CT) without bleeding signals. The final diagnosis of SAH was made upon the cerebrospinal fluid (CSF) results. Twenty cases were submitted to brain angiography. They were focused under the clinical classification of Hunt & Hess. The main results were 1) 1/3 of patients had interval time between 24 and 48 hours after ictus and before CT and CSF making; this was the most sensitive CT time; 2) 55% of patients with brain angiography had aneurysm predominantly in the carotid and anterior cerebral artery territory; 3) the dominant clinical degree was Hunt & Hess I e II. CONCLUSION: the results demonstrate the need of CSF test in case of SAH clinical diagnosis with CT showing no bleeding signals.

[Cerebrospinal fluid in the diagnosis of cerebro-meningeal metastasis from malignant melanoma arising from giant congenital melanocytic nevus: case report]. / Líquido cefalorraquiano no diagnóstico de metástase cérebro-meníngea de melanoma maligno derivado de nevo melanocítico gigante congênito. Relato de caso.

We describe the case of a 28-year-old man with a giant congenital melanocytic nevus (GCMN) with malignant transformation to melanoma and metastasis on the central nervous system (CNS). We also make a summary of the pathological features from both lesions (GCMN and Melanoma), the occurrence of malignancy of GCMN, the organs more frequently involved with metastatic melanoma--with emphasis to involvement of CNS--just as the factors that cause malignant transformation of GCMN; the methods to diagnose metastases in CNS--emphasizing the importance of cerebrospinal fluid--and some therapeutical modalities for the metastatic melanoma in CNS.

Líquido cefalorraquiano no diagnóstico de metástase cérebro-meníngea de melanoma maligno derivado de nevo melanocítico gigante congênito: relato de caso / Cerebrospinal fluid in the diagnosis of the cerebro-meningeal metastasis from malignant melanoma arising from giant congenital melanocytic nevus: case report

Relatamos o caso de um paciente, de 28 anos, portador de nevo melanocítico gigante congênito(NMGC), com transformaçao em melanoma e metátase no sistema nervoso central (SNC). Descreveremos resumidamente as características patológicas de ambas as lesoes (NMGC e melanoma), a frequência de malignizaçao no NMGC, os órgaos mais frequentemente acometidos pelas metástases do melanoma - dando ênfase ao acometimento do SNC - além dos fatores que podem levar à malignizaçao do NMGC, os exames usados para o diagnóstico das metástases no SNC - ressaltando a importância do líquido cefalorraquiano - e algumas modalidades terapêutica para o melanoma com acometimento do SNC.

[CSF total proteins in the prognosis of patients with subarachnoid hemorrhage]. / Proteínas totais do LCR no prognóstico do paciente com acidente vascular encefálico hemorrágico.

The main purpose of this study was to verify the value of CSF total proteins level on the prognosis of subarachnoid hemorrhage. In order of this, samples of 254 patients with diagnosis of intracranial bleeding were analyzed, with special attention to the rate of CSF total proteins. Statistical tests for evaluation of the results have been accomplished, revealing a close relationship between the total proteins rates increase and death in patients with subarachnoid hemorrhage, independent of sex and age. The limit score of total proteins level for survive was 3000 mg/100 ml (nephelometric method).

[Comparison between CSF samples from AIDS and non AIDS patients with neurocryptococcosis]. / Estudo comparativo do LCR de pacientes com neurocriptococose sem AIDS e com AIDS.

Neurocryptococcosis was a rare nervous system infection. With the rising number of patients with AIDS it became a very frequent disease. This infection is supposed to infect patients with some kind of immunodeficiency and the CSF alterations often simulate tuberculous meningitis. The purpose of this research was to compare the CSF changes in AIDS and non-AIDS patients with meningoencephalitis caused by Cr. neoformans. There were analysed 41 CSF samples from non-AIDS patients with neurocryptococcosis and 23 CSF samples from AIDS patients with neurocryptococcosis. The results of this research allowed to conclude that the inflammatory changes in the CSF from AIDS patients showed a lower intensity compared to those non-AIDS patients. These results showed as well, that the CSF samples from non-AIDS patients always revealed some changes besides the yeast cells. In some samples of AIDS patients, however the unique change was the presence of the yeast. It was demonstrated also, that the presence of Cr. neoformans in CSF, not accompanied by any other change, may suggest that is a patient with AIDS. In non-AIDS patients CSF alterations often simulates tuberculous meningitis. However these alterations were rare in AIDS patients. The yeast cells were more numerous in CSF samples from AIDS patients than in those from non-AIDS patients.

[CSF eosinophils in malignant tumors: a case report]. / Eosinofilorraquia em tumor maligno: apresentação de caso.

It is presented a case of a patient with a cerebral malignant astrocytoma in which the spinal fluid cytomorphology showed numerous eosinophilic granulocytes.

[Differential counting of cerebrospinal fluid cells by the facilitated gravitational sedimentation method. 2. The concept of normality]. / Contagem diferencial das células do líquido cefalorraquiano pelo método da sedimentação gravitacional facilitada. 2. Conceito de normalidade.

Cisternal or lumbar cerebrospinal fluid (CSF) specimens of 59 healthy persons were examined for differential cell count with a new improved sedimentation chamber, similar to that one of Sayk. The purpose of this study was to compare our results to those already described in the literature. Technical care was taken in order to increase the accuracy of this investigation and it consisted mainly of counting all the existing cells in the preparation, and not only 100 cells or a lesser number, recorded in percentage. The results of this survey have shown that the normal mean values for the CSF cytomorphology are 58.8 per cent lymphocitic cells, 41.0 per cent monocytoid cells, and 0.2 per cent neutrophilic granulocytes. These figures are in good agreement with those already reported by numerous authors, when we consider the lymphocytic and monocytoid cells, but they revealed a fact seldom seen reported: the possibility of a few neutrophilic granulocytes as a constituent of the normal CSF cytomorphology.

Contagem diferencial das celulas do liquido cefalorraquiano pelo metodo da sedimentacao gravitacional facilitada. 2. Conceito de normalidade. / Differential counting of cerebrospinal fluid cells by facilitated gravitational sedimentation method. 2.Concept of normality

O estudo citologico diferencial de amostras de LCR sub-aracnoideo cisternal ou lombar foi feito em 59 pessoas sem doenca atual e com composicao normal deste liquido organico. Os preparados com as celulas foram obtidos com a camara de sedimentacao gravitacional facilitada de Reis. A finalidade deste trabalho foi confrontar estes resultados com aqueles ja estabelecidos na literatura especializada. Um cuidado especial foi tomado para obter maior fidelidade de informacao, o qual consistiu na enumeracao de todas as celulas existentes no sedimento e nao somente 100 celulas ou numero menor, expresso em percentagem do total. O resultado desta pesquisa mostrou que o quadro citologico diferencial normal e constituido, em media por 58,8% de celulas linfocitaria, 41,0% de celulas monocitoides e 0,2% de granulocitos neutrofilos.Estes numeros concordam com aqueles assinalados na literatura, na parte referente as proporcoes relativas de celulas linfocitarias e celulas monocitoides, porem revelam um fato raramente referido, que e a possibilidade da presenca de raros granulocitos neutrofilos no quadro citologico diferencial normal do LCR

[Incidence of neurosyphilis and incidence of its clinical forms 1962-1981]. / Incidência da neurossífilis e frequênica de suas formas clínicas no período 1962-1981.

After 1950 it was observed an increase in the incidence of syphilis in the general population and this fact determined an investigation in order to evaluate the possible repercussion of this occurrence on the central nervous system, as an after effect of the elevated incidence. However, in this first study it was verified that there was a progressive and marked decrease of the neurosyphilis incidence in the 1936-1964 period, and that the frequency of meningovascular forms of the disease had increased lately in regard to the parenchymatous forms. The aim of the present work has been the continuation of this study after so many years. The material for this survey consisted of the clinical records of 148 patients picked out from 34.430 cases seen at the Neurological Department of Escola Paulista de Medicina (São Paulo, Brasil), during the 1962-1981 period, i.e., on twenty consecutive years. The results of this complementary investigation have shown instead that the incidence of neurosyphilis remained steady, changing very little every year, with an incidence at the rate of about 1:200. On the other hand, the frequency of the clinical forms of neurosyphilis changed very much. The usual forms such as general paresis and tabes are now scant and the observation of the uncommon forms, seldom seen in the past, is now progressively increasing through the years, so that they are the preponderant clinical forms today.

[Ventriculo-lumbar gradient of concentration of total cerebrospinal fluid proteins: 1 - mechanisms of origin]. / Gradiente ventrículo-lombar de concentração das proteínas totais do líquido cefalorraquiano: 1 - Mecanismo de origem.

In normal conditions there is a concentration gradient of proteins along the neuraxis. From a low level in the ventricles, ranging from 5 to 15 mg/10C ml, to an intermediate level in the cisterna magna, the protein content reaches its highest level in the lumbar sac, 12 to 44 mg/100 ml. Several mechanisms were considered to elucidate the origin of this gradient but many investigators think that the progressive increase of the protein concentration is best explained by the transfer of proteins from serum to the cerebrospinal fluid due to the relatively raised permeability of blood-cerebrospinal fluid barrier in the spinal subarachnoid space. This paper presents a study of the protein concentrations in cisternal and lumbar cerebrospinal fluid samples of patients with neurocysticercosis in activity. The 11 patients of the first group had free subarachnoid space communication between the cisterna magna and the lumbar sac; the 6 patients of the second group had a complete block of the subarachnoid space between these two levels. In every cerebrospinal fluid specimen the quantitative complement fixation test for cysticercus was performed and the titer determined in order to make an assessment of the central nervous system humoral immune response. The analysis of the data of this investigation shows that the concentration gradient of proteins is evident in the cerebrospinal fluid of patients with patency of the spinal subarachnoid space, and the ratio of concentrations of protein contents in simultaneous cisternal and lumbar samples was similar to that one observed in normal individuals. This gradient is also detected when the intensity of the humoral immune response is determined by quantitative complement fixation test for cysticercus in simultaneous cisternal and lumbar specimens. After the onset of spinal subarachnoid block, the confront of the results of the tests in cerebrospinal fluid samples, obtained before and after the blockage, shows a large increase both in the total protein content as well as the intensity of the humoral immune response, in the lumbar level. The similar increases both in protein concentration and titer of cysticercus complement fixation test in the lumbar fluid, in comparison with the cisternal fluid, in patients with patent spinal subarachnoid space, and the large simultaneous and similar increases in both protein content and titer of the cysticercus complement fixation test in the lumbar fluid of patients with spinal subarachnoid block are in disagreement with the usual explanation of the origin mechanisms of the gradient.(ABSTRACT TRUNCATED AT 400 WORDS)

[Ventriculo-lumbar gradient of concentration of total cerebrospinal fluid proteins: 2.- Influence of CSF drainage by ventriculoatrial shunt]. / Gradiente ventrículo-lombar de concentração das proteínas totais do líquido cefalorraquiano: 2 - Influencia da drenagem do LCR pela derivação ventrículo-atrial.

On a previous paper, based upon the data obtained from comparative studies of cerebrospinal fluid samples of two groups of patients with neurocysticercosis in activity, one with patency, the other one with blockage of the spinal subarachnoid space, evidence was presented that the concentration gradient of proteins along the neuraxis was the consequence of the escape of water from cerebrospinal fluid. The second paper is a continuance of that one. The material for this survey consisted of the clinical records of 11 patients with neurocysticercosis who during the course of the disease presented severe intracranial hypertension which required ventriculoatrial shunt as an emergency operation in order to allow survival. After surgery, it was observed a marked improvement in the clinical picture. Later, it was noticed a large increase in the protein content of the spinal fluid of the majority of the patients, as compared with the results verified prior to surgery. However, in these spinal fluid samples the increase in protein content was observed without a simultaneous rise in cell count, suggesting an improvement in the inflammatory condition. It seems very likely that this large elevation of the protein content in the subarachnoid fluid is the consequence of a reduction in the spinal fluid flow rate due to the ventricle-venous shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

[Function of purification drainage of the central nervous system through the cerebrospinal fluid]. / Função de drenagem purificadora do sistema nervoso central pelo líquido cefalorraquiano.

It has long been known that the cerebrospinal fluid can not be the nervous system lymph, and Mestrezat, in his authoritative book of the year 1912, demonstrated it plainly. Davson has undertaken this subject and suggested the hypothesis of a sink action of cerebrospinal fluid, allowing a slow leakage of solutes from nervous tissue extracellular space. In order to test this hypothesis, Oldendorf and Davson performed a series of animal experiments and they demonstrated that there was leakage of the solute into cerebrospinal fluid. Based on the idea of this sink action of cerebrospinal fluid, some possible physiological implications were considered such as the mechanism of origin of the ventricle-subarachnoid cerebrospinal fluid protein gradient; the mechanism of protection of the central nervous system against the harmful substances of the blood stream; and the homeostatic mechanism whereby the concentration of some ions of the fluid remains constant. Also, it is considered the possibility of a sink action of cerebrospinal fluid in the resolution of brain edema in water intoxication and other types of central nervous system edema.