Utility of cerebrospinal fluid lactate in aneurysmal subarachnoid hemorrhage

Abstract

Background:An external ventricular drain (EVD) treats hydrocephalus in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study examines the utility of cerebrospinal fluid (CSF) lactate collected from an EVD as a proposed biomarker to predict patient outcome and vasospasm/delayed cerebral ischemia.Methods:Consecutive adults admitted to Wake Forest Baptist Medical Center from 2010 to 2015 with aSAH were identified through the electronic medical record, and clinical variables were collected and analyzed for correlation with incidence of vasospasm and discharge outcome.Results:In all, 51 patients with aSAH and an EVD had CSF lactate measured which ranged from 1.9 to 6.2 mmol/L, with a median value of 3.2 mmol/L. Vasospasm based on transcranial Doppler assessment occurred in 29 patients (57%), of which 20 (45%) were clinically symptomatic. Good outcome (discharge to home/acute rehab) occurred in 35 patients (69%). Sixteen patients (31%) had an unfavorable outcome (died/discharged to nursing homes/long-term acute care facility). In multivariate regression analysis, unfavorable outcome at discharge (P = 0.02), elevated CSF protein (P = 0.04), and admission Hunt and Hess score 3–5 (P = 0.05) were significantly associated with higher CSF lactate. The risk of symptomatic vasospasm increased with lactate in univariate analysis, but did not reach statistical significance (P = 0.077).Conclusion:The measurement of the CSF biochemical markers using an EVD is feasible and safe. We found that elevated CSF lactate correlates with patient outcome. Larger prospective studies are needed to test the validity of this finding and for understanding the underlying pathophysiologic mechanisms.

Cerebral Metabolic Crisis in Pediatric Cerebral Malaria

“…Five children (10%) were categorized as "other" CBFV, all of whom had a pattern consistent with what has previously been described as microvascular obstruction in CM. 59 Median LPRs were significantly different between CBFV groups (insufficient flow group LPR: 184 , sufficient flow group LPR: 61 , and other flow group LPR: 77 [67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82], p ¼ 0.02). CBFV was more likely to be insufficient in children with a type 1 LPR and to be sufficient or elevated in children with a type 2 LPR (p ¼ 0.04; ►Table 2).…”

“…However, as values of these parameters in both types of fluid do seem to approximate one another, reports of utilizing CSF values from an external ventricular drain (rather than placing a microdialysis catheter to measure ECF concentrations) to monitor for CMEC following SAH have emerged. 32,54,55,[77][78][79][80] Of note, if baseline levels are roughly equivalent as the literature suggests, the ECF levels would be representative of "focal" levels of the measured metabolites, whereas the CSF levels are more representative of "global" levels of the measured metabolites. For some disease states, ECF measurements with the probe placed adjacent to a focal area of injury are potentially the most helpful measurements to be had.…”

Rethinking the initial changes in subarachnoid haemorrhage: Focusing on real-time metabolism during early brain injury

“…Lactate in CSF, as the intermediate product of the tricarboxylic acid cycle and energy metabolism, has been demonstrated to be a biomarker for early brain injury and tightly correlated with neurological outcomes in SAH patients. 34 , 35 Therefore, assessment of the lactate/pyruvate ratio in dialysate obtained as part of multimodal monitoring during early brain injury might be informative and beneficial for SAH patients. 36 The underlying mechanism of lactate-mediated pathophysiological processes might be much more complicated than previously thought, which is not just metabolomic production under hypoxia but acts as a pathogenic mediator, as it can regulate downstream gene expression by lactylation of histones 37 and of nonhistone proteins, 38 a newly reported posttranslational modification.…”

Spatial and temporal variation of routine parameters: pitfalls in the cerebrospinal fluid analysis in central nervous system infections

“…Since under anaerobic conditions the brain and CSF leukocytes produce lactate, lactate is not a specific marker of bacterial or fungal infection, but may be elevated in various conditions with elevated ICP or other causes of reduced cerebral perfusion. In 51 patients with subarachnoid hemorrhage and an external ventriculostomy, CSF lactate ranged from 1.9 to 6.2 mmol/L (median 3.2 mmol/l) [ 111 ]. The lactate concentration of ventricular and cisternal CSF in subarachnoid hemorrhage was approximately equal and depended on the severity of the hemorrhage [ventricular CSF, grade 1–2 of the World Federation of Neurosurgical Societies: 21.8 ± 7.0 mg/dl (2.4 ± 0.8 mmol/l), grade 3–5: 35.8 ± 18.8 mg/dl (4.0 ± 2.1 mmol/l); cisternal CSF, grade 1–2: 25.1 ± 5.5 mg/dl (2.8 ± 0.6 mmol/l), grade 3–5: 32.6 ± 7.4 mg/dl (3.7 ± 0.8 mmol/l)].…”