What is suggested by xanthochromia in CSF from lumbar puncture (LP)?

Updated: Aug 02, 2018
  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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The best way of distinguishing RBCs related to intracranial bleeding is to examine the centrifuged supernatant CSF for xanthochromia (yellow color). Although xanthochromia can be confirmed visually, it is more accurately identified and quantified in the laboratory.

Although xanthochromia can be produced by spillover from a very high serum bilirubin level (> 15 mg/dL), patients with severe hyperbilirubinemia (eg, from jaundice or known liver disease) usually have been identified before lumbar puncture. With this exception, xanthochromia in a freshly spun specimen is evidence of preexistent blood in the subarachnoid space. However, it should be remembered that an extremely high CSF protein level, as seen in lumbar punctures below a complete spinal block, also renders the fluid xanthochromic, though without RBCs.

Xanthochromia can persist for as long as several weeks after a subarachnoid hemorrhage (SAH). Thus, it has greater diagnostic sensitivity than computed tomography (CT) of the head without contrast, especially if the SAH occurred more than 3-4 days before presentation. Patients with aneurysmal leaks (eg, sentinel hemorrhages) may present days after the onset of headache, and this increases the likelihood of a false-negative head CT scan.

In some cases, the CSF may be another color that strongly suggests a diagnosis. For example, pseudomonal meningitis may be associated with bright-green CSF.

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