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Neuro Labs

Neurology

QuestionAnswer
LP: indications: Dx Obtain CSF for lab analysis; Determine spinal fluid pressure; administer radiopaque dyes into CNS for imaging
LP: indications: Tx Administer drugs (Abx, CTx, anesthesia) into CNS; remove excess CSF
Diagnostic LP: CNS infxn (meningitis, encephalitis); HA (SAH); Pseudotumor cerebri (idiopathic ICH); MS; Support dx of NPH & predict response to surgical shunting
LP: CI (1) Suspected brain abscess (CSF study usu not helpful); Elevated ICP: esp if papilledema is present; Risk of brain damage / death from brain herniation
LP: CI (2) Suspected mass lesion; Ventricular obstruction; Local infx at puncture site; Suspect epidural abscess; Anticoags/ coagulopathies/ low plt; Position-related cardioresp compromise; Acute spinal trauma or prior lumbar surgery
LP procedure Informed consent; may sedate; pt on side, knees bent, chin to chest; antiseptic/ anesthetic
LP: insert needle into: L3-L4 space
LP in kids: spinal cord extends more caudally, do low LP
LP in extreme elderly: may need to do cisternal procedure
LP Comorbidity Local skin infection or disease, spinal deformity: cisternal procedure done if lumbar site not accessible
LP: Intrathecal variability Higher conc pro & cells in lumbar sac than in ventricular or cisternal fluid (due to stagnation)
CSF collection: amount: 1-2 mL CSF per tube
LP: Most common AE: PDPH
PDPH: prevention: small bore atraumatic spinal needle, needle bevel parallel to longitudinal fibers of dura, & reinsertion of stylet prior to needle removal
PDPH: Tx time, bed rest, analgesics or epidural blood patch
Routine CSF analysis includes: Opening pressure; Appearance/color; Consistency; Tendency to clot; Diff cell count; Protein; Glucose
Additional CSF analysis Sediment stains (Gram, acid-fast); Culture (Bac, mycobac, yeasts/fungi); Serology (Syphilis, Ig (inc oligoclonal IgG in MS); Chem testing (Pro composition, bili, lactic a., urea, glutamine
CSF vs plasma: comp Most constituents present in equal/lower levels than in plasma (BBB usu restricts lg molecules: pro, cells)
CSF cloudy: Inc WBC or protein
CSF: Xanthochromia (yellow tinge): hyperbilirubinemia, hypercarotenemia, melanoma
CSF: Red tinge Blood from bleeding into SA space or traumatic tap
CSF: Cells Normal 0-5 small lymphs/ml; PMNs, lg monos & RBCs are never normal
CSF: RBCs & WBCs: only present via ruptured blood vessels or by meningeal response to inflammation or irritation
CSF Cell Count uses: Detect CNS infection or malig; Monitor response to tx
WBC in CSF Inc WBCs = inflam (>100, prob infxn); PMNs: bac infxn; Lymphs = viral or other (TB, fungal, ca); Eosinophils: shunt, parasitic infection & allergic rxn
CSF pressure Normal 60-200 mm H2O (mean = 120); manometer (read after fluid stops rising); Position may increase P slightly (sitting, holding breath, mx tension); P usu drops 5-10 mm for each ml CSF removed
CSF pressure: Marked elevation: consider purulent meningitis or intracranial tumors
CSF pressure: Moderate elevation: consider mild inflammation, encephalitis, neurosyphilis
CSF pressure: Elevated pressure with normal CSF: confirms pseudotumor cerebri (benign ICH): one instance where LP is done despite presence of papilledema
CSF protein: increased in: inc permeability of blood-CSF barrier (tumor, trauma, inflam), or increased intrathecal synthesis of Igs
CSF protein: decreased in: CSF protein leak, hyperthyroidism, water intoxication
CSF glucose Cf to plasma/serum glu values; CSF glu 60-70% of plasma glu (50-80 mg/dl); Used to evaluate meningitis; Low levels: assoc w/ bacterial or TB infection
CSF lactate: usu parallels blood levels; if markedly different from blood level = biochem abnormality in CSF
Increased CSF lactate associated with: CVA, IC bleed, bacterial meningitis; Not altered in viral meningitis; lactate may differentiate btw viral & bacterial
Organism conc required for detection on CSF smear: 10,000/ /ml (Gram & AFB stains may be neg despite org presence in CSF; cx on several media; consider empiric tx)
CSF antigen serology: More rapid, but less specific, than cx; cryptococcal Ag test very specific/accurate
LP w/ decreased glucose, increased protein Bacterial meningitis
LP w/ decreased protein, very few neutrophils syphilitic meningitis
Emergent eval of stroke CBC/plt; PT/ PTT; Lytes, glu, renal; ECG/ markers of cardiac ischemia; Brain CT or MRI
Seizure: labs Glucose; lytes; AED levels; LP if poss meningitis; EtOH/tox if susp; ABG if susp hypoxia; poss CXR, CT, MRI
MS: CSF findings oligoclonal bands, increased IgG index, myelin prodn/fragments
When do LP? suspect meningitis; not if suspect abscess
Glucose depressed: usually: bac mening, or TB or fungal
Increased WBC in CSF indicates: inflammation (not necessarily infection)
Tuberculous meningitis dx studies active TB elsewhere in body; CSF inc WBC (100-150), mostly lymphs; abnormal CXR; acid-fast normal
Brain tumor: VEGF higher the VEGF, worse the prognosis; anti-VEGF Ab’s effective in xenografts
CNS neoplasm CSF xanthochromic; inc pro, normal cell count & glucose
Wilson: labs Serum ceruloplasmin (Cu carrying pro) very low; urine Cu high
Use LP only after: normal CT obtained & platelet count is normal
LP should be performed if: Neuroimaging is normal or suggests dz that must be dx by measuring cerebrospinal fluid (CSF) pressure, cell count, and chem
Coma: labs GLUCOSE, lytes, renal, Ca, PO4, ABG, CBC, tox screen; CXR, imaging (after stabilization)
Diagnostic LP: indications CNS infxn (meningitis, encephalitis); HA (SAH); Pseudotumor cerebri (idiopathic ICH); MS; Support dx of NPH & predict response to surgical shunting
LP: CI Suspected brain / epidural abscess; elevated ICP, esp if papilledema; suspect mass lesion; Ventricular obstn;
LP: insert needle into: L3-L4 space (elderly: may need to do cisternal procedure)
LP in kids: spinal cord extends more caudally, do low LP
CSF collection: amount: 1-2 mL CSF per tube
Routine CSF analysis includes: Opening pressure; Appearance/color; Consistency; Tendency to clot; Diff cell count; Protein; Glucose
CSF cloudy = Inc WBC or protein
CSF: Xanthochromia (yellow tinge) = hyperbilirubinemia, hypercarotenemia, melanoma
CSF: Red tinge = Blood from bleeding into SA space or traumatic tap
CSF: Cells Normal 0-5 small lymphs/ml; PMNs, lg monos & RBCs are never normal
CSF: RBCs & WBCs: only present via ruptured blood vessels or by meningeal response to inflammation or irritation
WBC in CSF Inc WBCs = inflam (>100, prob infxn); PMNs: bac infxn; Lymphs = viral or other (TB, fungal, ca); Eosinophils: shunt, parasitic infection & allergic rxn
CSF pressure Normal 60-200 mm H2O (mean = 120); usu drops 5-10 mm for each ml CSF removed
CSF pressure: Marked elevation: poss purulent meningitis or intracranial tumors
CSF pressure: Moderate elevation: mild inflammation, encephalitis, neurosyphilis
CSF pressure: Elevated pressure with normal CSF: confirms pseudotumor cerebri (benign ICH): one instance where LP is done despite presence of papilledema
CSF protein: increased in: inc permeability of blood-CSF barrier (tumor, trauma, inflam), or increased intrathecal synthesis of Igs
CSF protein: decreased in: CSF protein leak, hyperthyroidism, water intoxication
CSF glucose Normal CSF glu 60-70% of plasma glu; Low levels assoc w/ bacterial or TB infection
CSF lactate: usually parallels blood levels; if markedly different from blood level = biochem abnormality in CSF
Increased CSF lactate associated with: CVA, IC bleed, bacterial meningitis; Not altered in viral meningitis; lactate may differentiate btw viral & bacterial
Organism concentration required for detection on CSF smear: 10,000/ /ml (Gram & AFB stains may be neg despite org presence in CSF; cx on several media; consider empiric tx)
CSF antigen serology: More rapid, but less specific, than cx; cryptococcal Ag test very specific/accurate
Primary lateral sclerosis: dx studies EMG, MRI (br & spcord), LP, evoked potls; B12, Lyme, RPR, long chain fatty acids
Myasthenia gravis Dx studies Tensilon test; Ach receptor & MuSK Abs; Repetitive nerve stim; Single fiber EMG; CT Chest to exclude thymoma
MD: labs/studies ultrastructural protein abnormalities; mx bx: mx fiber necrosis
Duchenne/Becker: Dx studies Mx bx; genetic testing (need complete sequencing); CK sometimes >10,000; FH
Wilson: dx high ceruloplasmin & copper; low copper on liver bx; Kayser Fleischer rings
Duchenne/Becker Dx genetic testing, elevated CK, EMG
Pathological hallmark of Parkinson: Lewy body (alpha-synuclein is main component)
MELAS dx studies Mitochondrial inheritance, labs: high pyruvate / lactate; stroke lesions (don’t conform to normal vasc distn)
oligoclonal bands in CSF = MS
Created by: Abarnard