|Year : 2022 | Volume
| Issue : 2 | Page : 92-93
Yellow-tinged cerebrospinal fluid: Is it safe to proceed with subarachnoid block?
Evelyn Eliza Minz, Geetanjali Tolia Chilkoti, Nikita Mundael, Anusha De, Janaki Nandnan
Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
|Date of Submission||07-Nov-2022|
|Date of Acceptance||12-Nov-2022|
|Date of Web Publication||02-Dec-2022|
Dr. Geetanjali Tolia Chilkoti
Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Isolated subarachanoid hemorrhage (SAH) could be one of the few causes of xanthochromia or yellow coloured cerebrospinal fluid (CSF). An incidental finding of yellow coloured CSF poses a dilemma to the anaesthesiologist in proceeding with the subarachnoid block (SAB) The present case report discusses the causes and implication of this incidental finding and highlights upon the evidence in literature in this context.
Keywords: Subarachnoid block, subarachnoid hemorrhage, xanthochromia
|How to cite this article:|
Minz EE, Chilkoti GT, Mundael N, De A, Nandnan J. Yellow-tinged cerebrospinal fluid: Is it safe to proceed with subarachnoid block?. J Ind Coll Anesth 2022;1:92-3
|How to cite this URL:|
Minz EE, Chilkoti GT, Mundael N, De A, Nandnan J. Yellow-tinged cerebrospinal fluid: Is it safe to proceed with subarachnoid block?. J Ind Coll Anesth [serial online] 2022 [cited 2023 Jun 8];1:92-3. Available from: https://www.jicajournal.in//text.asp?2022/1/2/92/362619
| Introduction|| |
Isolated sub-arachanoid hemorrhage (SAH) could be one of the few causes of xanthochromia or yellow-colored cerebrospinal fluid (CSF). An incidental finding of yellow-colored CSF poses a dilemma to the anesthesiologist in proceeding with the subarachnoid block (SAB). The present case report discusses the causes and implication of this incidental finding and highlights upon the evidence in the literature in this context.
| Case Report|| |
A 60-year-old male was scheduled for surgery for right subtrochanteric femur fracture under sub-arachnoid block. He had a history of fall from height (approx. 6 feets) 6 days back following which there was no history of any loss of consciousness, ENT bleed, vomiting, or seizure. He was a chronic smoker with no history of any chronic ailment or previous hospitalization. On preanesthetic checkup, the patient was conscious, oriented to time place and person, afebrile to touch, vitals were normal and no abnormality was detected in any of the systemic examinations. The patient was accepted for surgery under American Society of Anesthesiologists (ASA) physical status 2. All blood and urine investigations including coagulation profile were within the normal limits (WNL). No abnormality was detected in electrocardiogram and the chest X-ray showed chronic obstructive pulmonary disease (COPD) changes.
The patient was wheeled in the operation room after confirming the nothing by mouth status. A 18G IV cannula was inserted on the dorsum of the hand and all ASA recommended minimal mandatory monitoring were attached. The baseline hemodynamic parameters were noted and were WNL. Subarachnoid block (SAB) was planned. After preloading, lumbar puncture was done at L3-L4 intervertebral space under all sterile precautions using 25G Quincke's needle in a single attempt. Free flow of yellow-colored CSF was observed [Figure 1]. The flow and the consistency of the CSF were normal and no turbidity was noted. After consultation with the senior anesthesiologists, the CSF sample was sent for the biochemical and microbiological analysis. The yellowish discoloration of CSF raised the suspicion of undiagnosed subarachnoid hemorrhage but considering no significant past history or comorbidities, the decision was taken to proceed with the SAB with 3 ml of 0.5% of heavy bupivacaine. The sensory block of T10 and modified Bromage score 1 were achieved within 7 min of SAB. The perioperative period was uneventful with full recovery of the sensory and motor block. Neurosurgery opinion was sought and CSF analysis and computed tomography (CT) scan were advised.
Analyzed CSF samples showed elevated protein level of 380 mg/dl (normal level is 15-45 mg/dl) and rest of the biochemical parameters were normal. There was no growth on CSF culture and sensitivity. CT scan could not be done as the institute does not have the facility and later patient was lost to follow-up.
| Discussion|| |
The term Xanthochromia was proposed by Milian and Chiray while examining the CSF in patients with SAH. Xanthochromia or yellowish discoloration of CSF occurs due to the degradation of hemoglobin. It can be diagnosed by visual inspection and spectrophotometry remains the gold standard in the diagnosis xanthochromia.
The various causes of increased protein levels in CSF include infections (bacterial/viral), Guillain − Barre syndrome, SAH, neoplasm, spinal cord deformity, and Froin syndrome characterized by a triad of xanthochromia, increased CSF protein, and hypercoagulability.
Xanthochromia is important for the diagnosis of SAH. On the literature search, only two case reports have reported the incidental Xanthochromia while administration of SAB, Adabala et al. reported incidental xanthochromia in a patient with soft-tissue infection but the patient had a history of chronic liver diswith the recurrent episodes of jaundice and had fever and icterus on examination as well. The cause of xanthochromia could not be established as the bilirubin does not cross blood − brain barrier and patient did not give any history of trauma or raised intracranial pressure (ICP). In another case report by Singh et al., the patient had a history of polytrauma with transient loss of consciousness; however, no ENT bleed or signs and symptoms of raised ICP and they proceeded with SAB for providing anesthesia.
In our case, the patient had no history of loss of consciousness after fall from height and no signs and symptoms of raised ICP or fever was present. Hence, we concluded that yellow-colored CSF or xanthochromia could be due to an undiagnosed isolated traumatic SAH as show by CSF analysis. However, the limitation was that CT could not be done due to the unavailability of services.
The sensitivity to diagnose SAH in a CT scan is 95% in the initial 3 days which decreases to 50% after 1 week and 30% after 2 weeks and reduces to almost nil after 3 weeks. Our patient presented to us after 6 days of the injury. Despite the suspicion of isolated SAH, we decided to go ahead with SAB for providing anesthesia as the patient was a chronic case of COPD and had no signs and symptoms suggestive of raised ICP. As far as the clinical significance is concerned, a retrospective study concluded that isolated traumatic SAH with mild traumatic injury (GCS >13) did not require extensive observation and follow-up.
| Conclusion|| |
The presence of incidental xanthochromia while administration of SAB must raise the suspicion of isolated SAH. We hypothesize that the decision to proceed with SAB to be safer; however, it must be individualized based on the various factors such as the days lapse since trauma, presence of signs, and symptoms suggestive of raised ICP and presence of other comorbidities.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rosenberg DG, Galambos JT. Yellow spinal fluid. Diagnostic significance of cerebrospinal fluid in jaundiced patients. Am J Dig Dis 1960;5:32-48.
Blakeley J, Irani DN. Approach to patient with abnormal cerebrospinal fluid protein Content. Cerebrospinal Fluid Clin Pract 2009;3:290.
Chu K, Hann A, Greenslade J, Williams J, Brown A. Spectrophotometry or visual inspection to most reliably detect xanthochromia in subarachnoid hemorrhage: Systematic review. Ann Emerg Med 2014;64:256-64.e5.
Koton Y, Bisharat N. Nonne-Froin sign. QJM 2017;110:321-2.
Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, van Gijn J. Xanthochromia after subarachnoid haemorrhage needs no revisitation. J Neurol Neurosurg Psychiatry 1989;52:826-8.
Adabala V, Govil N, Agarwal R, Masaipeta K. Nonne-Froin sign – Dilemma for subarachnoid block. Arch Anesthesiol Crit Care 2019;5:71-2.
Singh T, Hooda S, Anand A, Bihani P. Subarachnoid block in an undiagnosed isolated traumatic subarachnoid hemorrhage. J Neurosurg Anesthesiol 2015;27:72-3.