II. Pathophysiology: Xanthochromia

  1. Xanthochromia is yellow, red or orange supernatant discoloration of centrifuged CSF (due to oxyhemoglobin, Bilirubin)
  2. Hemoglobin breaks down into oxyhemoglobin (after 2 hours) and then Bilirubin (after 10 hours)
  3. Indication of free Hemoglobin or a breakdown product in the CSF
  4. Follows RBC lysis, occuring within hours of at least 400 RBCs first present in CSF
  5. Xanthochromia may persist for 2 weeks after bleeding event

III. Technique

  1. Count Red Blood Cells in first and third tubes

IV. Interpretation: For each 500-1000 RBCs/mm3

  1. CSF Leukocytes increase by 1
  2. CSF Protein rises 1 mg/deciliter

V. Causes: CSF Red Blood Cells

  1. Subarachnoid Hemorrhage or Intracranial Bleeding
    1. RBC Count unchanged between first and third tubes
    2. Blood does not clot
    3. Xanthochromia suggests bleeding
      1. See CSF Color
      2. CSF supernatant xanthochromic on centrifugation
      3. Requires at least 2 to 4 hours from onset of bleeding, and peaks at 24-46 hours
      4. Traumatic tap with >5000 to 10,000 RBC/uL can also cause Xanthochromia
  2. Traumatic tap
    1. RBC Count decreases between first and third tubes
    2. CSF becomes clear on centrifugation
    3. Consider repeating tap at higher interspace

VI. Causes: Xanthochromia

  1. Subarachnoid Hemorrhage
    1. Xanthochromia at 6 hours: 20% of Subarachnoid Hemorrhage
    2. Xanthochromia at 12 hours: 90% of Subarachnoid Hemorrhage
    3. Sentinel bleeds in prior 2 weeks in half of SAH patients may also persist as Xanthochromia
  2. Increased Serum Bilirubin >10-15 mg/dl
  3. CSF Protein >150 mg/dl
  4. Traumatic Lumbar Puncture (if CSF RBC>100,000)

VII. References

  1. Aldeen and Rosenbaum (2017) 1200 Questions Emergency Medicine Boards, 3rd ed, Wolters Kluwer, Baltimore, p. 123
  2. Kooiker in Roberts (1998) Procedures in ER, p. 1067-75
  3. Ravel (1995) Lab Medicine, Mosby, p. 294-9
  4. Tunkel in Mandell (2000) Infectious Disease, p. 974-8
  5. Seehusen (2003) Am Fam Physician 68:1103-8 [PubMed]

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