Annals of Clinical Biochemistry > Volume 45, Number 3 > Pp. 238-244

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Guidelines

Revised national guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage

Anne Cruickshank¹, Peter Auld², Robert Beetham³, Gillian Burrows⁴, William Egner⁵, Ian Holbrook⁶, Geoff Keir⁷, Emma Lewis⁸, Dina Patel⁵, Ian Watson⁸ and Peter White, Produced by the UK NEQAS Specialist Advisory Group for EQA of CSF Proteins and Biochemistry⁵

¹ Department of Biochemistry, Southern General Hospital, Glasgow G51 4TF; ² Department of Clinical Biochemistry, Belfast Trust Hospital, Belfast BT12 6BA; ³ Department of Clinical Biochemistry, Frenchay Hospital, Bristol BS16 1LE; ⁴ Department of Biochemistry, Stepping Hill Hospital, Stockport SK2 7JE; ⁵ Department of Immunology, Northern General Hospital, Sheffield S5 7YT; ⁶ Department of Clinical Biochemistry, York Hospital, York YO31 8HE; ⁷ Department of Neuroimmunology, National Hospital for Neurology and Neurosurgery, London, WC1 N 3BG; ⁸ Department of Clinical Biochemistry, University Hospital, Aintree, Liverpool L9 7AL, UK

Corresponding author: Dr Anne Cruickshank. Email: anne.cruickshank{at}sgh.scot.nhs.uk

It is crucially important to detect subarachnoid haemorrhage (SAH) in all patients in whom it has occurred to select patients for angiography and preventative surgery. A computerized tomography (CT) scan is positive in up to 98% of patients with SAH presenting within 12 h, but is positive in only 50% of those presenting within one week. Cerebrospinal fluid (CSF) bilirubin spectrophotometry can be used to determine the need for angiography in those few CT-negative patients in whom clinical suspicion of SAH remains high; it may remain positive up to two weeks after the event. A lumbar puncture (LP) should only be performed >12 h after the onset of presenting symptoms. Whenever possible collect sequential specimens. Always ensure that the least blood-stained CSF sample taken (usually the last) is sent for bilirubin analysis. Protect the CSF from light and avoid vacuum tube transport systems, if possible. Always use spectrophotometry in preference to visual inspection. All CSF specimens are precious and should always be analysed unless insufficient sample is received. Centrifuge the specimen at >2000 rpm for 5 min as soon as possible after receipt in the laboratory. Store the supernatant at 4°C in the dark until analysis. An increase in CSF bilirubin is the key finding, which supports the occurrence of SAH but is not specific for this. In most positive cases, bilirubin will occur with oxyhaemoglobin.

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