Clinical Use of Neurological Diagnostic Tests

Clinical Use of Neurological Diagnostic Tests Investigations Blood tests Cerebrospinal fluid (CSF) tests Electrophysiology tests Neuropsychological

tests (EEG, EMG, NCS) CT MRI Angiogram Eletrophysiology PET/ SPECT/ MEG Biopsy Molecular/ genetic tests CSF Synthesized in choroid plexus of ventricles ATPase (energy) dependent process Absorbed via villi of arachnoid granulations (project into dural venous sinuses) Production rate ʹ 0.5 ml/min Total volume ʹ 150ml Entire volume replaced every 5h Hydrocephalus ʹ when flow is obstructed Lumbar Puncture Informed consent Lateral recumbent position Aseptic technique, local anaesthetic L3-L4/ L4-L5 interspace Check for Opening pressure Cell counts ʹ WBC, RBC Microscopy, culture, staining Protein, glucose (paired with blood) Xanthochromia Oligoclonal bands (paired with blood) Cytology Molecular, PCR based ʹ TB, HSV, lyme Clinical Uses Diagnose infections of meninges Diagnose cancer involving meninges Diagnose herpes simplex encephalitis/ other encephalitis Diagnose a small subarachnoid haemorrhage Introduce medications into subarachnoid space/ contrast media (myelogram) љ CSF pressure (rarely) Multiple sclerosis, GBS, paraneoplastic syndrome Contraindications Space occupying lesion causing mass effect ј ICP (can cause cerebral/ cerebellar herniation) Local infection Coagulopathy (clotting-factor deficiency, thrombocytopenia) Suspected spinal cord mass lesion (perform with myelogram) Complications Unsuccessful tap (due to) y Obesity y Degenerative disease of spine y Previous spinal surgery y Recent lumbar puncture y Dehydration Traumatic tap (Arterial/ venous pressure) y Needle enters blood vessel (rather than spinal subarachnoid space) y Should be withdrawn and new needle used Post-LP headache y Mild headache, frontal, worse in upright position y Bed rest, hydration, simple analgesia, caffeine Post-LP brain herniation (rare) Results Analysis Test Normal Finding Appearance Clear, colourless against white background Opening pressure 70-180mm CSF in recumbent position RBCs < 5 RBC/mm3 WBCs 5-10 WBC/mm3 Differential Mainly mononuclear cells Total protein <45 - <60 mg/dL depending on assay technique (<30 mg/dL if cisternal CSF, <25 mg/dL if ventricular CSF) % Ig < 15% of total protein Oligoclonal bands None/ rarely 1 band Gram stain -ve Cultures Sterile for bacteria, mycobacteria, fungi, viruses CSF-VDRL test Non reactive Cytology No malignant cells

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