National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage

Ann Clin Biochem 2003;40:481-488
© 2003 Association for Clinical Biochemistry

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Review Articles

UK National External Quality Assessment Scheme for Immunochemistry Working Group

It is crucially important to detect subarachnoid haemorrhage(SAH) in all patients in whom it has occurred in order to selectpatients for angiography and preventative surgery. A computedtomography (CT) scan is positive in up to 98% of patients withSAH presenting within 12h but is positive in only 50% of patientspresenting within 1 week.

Cerebrospinal fluid (CSF) bilirubin spectrophotometry can beused to determine the need for angiography in those few CT-negativepatients in whom clinical suspicion of a SAH remains high; itmay remain positive for up to 2 weeks after the event. The lumbarpuncture (LP) should only be performed >12h after the onsetof presenting symptoms. Whenever possible, collect four sequentialCSF specimens. Always ensure that the last CSF sample takenis sent for bilirubin analysis. Protect the CSF from light andavoid vacuum tube transport systems if possible.

Always use spectrophotometry in preference to visual inspection.All CSF specimens are precious and should be analysed no matterhow they were transported, where necessary with appropriatenotice of the caveats regarding oxyhaemoglobin. Centrifuge thespecimen at >2000 rpm for 5 min as soon as possible afterreceipt in the laboratory and in any case within 1 h of collection.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 it is not specific for this. In most positive cases bilirubin will occur with oxyhaemoglobin. Oxyhaemoglobin occurring on its own is difficult to interpret and may be increased as a result of in vitro haemolysis of red cells introduced intothe CSF during lumbar puncture. This process is exacerbatedby vacuum tube transport systems. Results should be interpretedin the light of other investigations (e.g. if scan shows bilirubinthen measure serum bilirubin and CSF oxyhaemoglobin and protein)and other confounding variables such as the time elapsed frompresentation to LP.

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