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Overview:
Pathogenic organisms may reach the central nervous system by hematoge-
nous spread or local extension and cause infections of the meninges (men-
ingitis), infections of the brain and spinal cord parenchyma (encephalitis,
myelitis), focal purulent collections (brain abscess, subdural empyema,
epidural abscess), or infections of the nerve roots (radiculitis, polyradiculi-
tis). Depending on the causative organism, the infection may take an acute,
subacute or chronic course and may be self-limiting or destructive and life-
threatening. Prions are the causative agents of several neurodegenerative
diseases. Many CNS infections can be treated if diagnosed in timely fash-
ion. The cerebrospinal fluid examination, including culture, and neuro-
imaging studies (CT and MRI), together with the clinical findings, are gen-
erally sufficient to enable a differentiation among bacterial, viral, mycotic,
and parasitic pathogens and a precise etiologic diagnosis. In general, anti-
microbial therapy is given on an empirical basis until the causative organ-
ism is identified and the treatment can be tailored to it.
a Sinus sagittalis
superior
6
Dura
5 mater
Arachnoidea
1
Subarach-
noidalraum
2 3 4 Pia mater
b
Kortex
Substantia alba
Periost
Epiduralraum
5
Dura mater
1
2 Arachnoidea
Subarachnoidalraum
6
Pia mater
Rckenmark : Gehirn :
1 = Arachnoiditis 1 = Meningitis
2 = Myelitis 2 = Enzephalitis
3 = Zerebritis (= Frhstadium)
Hirnabszesse
4 = Abszess (= Sptstadium)
5 = spinaler Subduralabszess 5 = subdurales Empyem
6 = spinaler Epiduralabszess 6 = Epiduralabszess
Table 2.21 Diseases associated with ele- matory process (588, 941). The gam-
vated cerebrospinal fluid protein concen- maglobulins can be nonquantitatively
tration separated by electrophoresis into
Elevated protein with elevated cell mono-, poly- and (usually two to five)
count: oligoclonal bands. Isoelectric focusing
> Acute and chronic meningitides and is a more sensitive test, based on the
encephalitides different isoelectric points of differ-
> Bacterial ent proteins, which can be combined
> Viral
with immune fixation (the use of spe-
> Fungal
cific antisera) (938) for still greater
> Spirochetal
sensitivity. Oligoclonal bands found
> Parasitic
> Neoplastic
in the cerebrospinal fluid, but not in
> Chemical/physical an appropriately diluted serum sam-
> Poliomyelitis ple tested alongside it, are indicative
of an inflammatory process in the
Protein elevation [ cell count eleva- central nervous system. Such CSF-
tion:
specific bands are found in more than
> Acute inflammatory polyradiculitis 90 % of patients with multiple sclero-
(Guillain-Barr
e syndrome) sis, and less commonly in patients
> Chronic inflammatory demyelinating with other types of central nervous
polyneuropathy (CIDP)
>
disease.
Tabes dorsalis, meningovascular
syphilis
> Myxedema Glucose. The concentration of glucose
> Diabetes mellitus in the cerebrospinal fluid is 5060 %
> Schwannoma of that in serum. Thus, a CSF glucose
> Chronic arachnoiditis concentration that is normal in abso-
> Status post subarachnoid hemorrhage lute terms may be abnormally low if
> Cerebral venous (and venous sinus) the serum glucose concentration is
thrombosis
elevated, and a low CSF glucose con-
> Brain tumors
>
centration may be normal in hypogly-
Metachromatic leukodystrophy
> Obstructed CSF flow at spinal level
cemia. Diseases associated with CSF
(Froin syndrome) pleocytosis lower the CSF glucose
> Vitamin B12 deficiency concentration, particularly chronic
> Mitochondrial encephalomyelopathy meningitides (Table 2.22).
Elevated protein with or without ele-
vated cell count:
| Brain Biopsy
> CNS vasculitis A biopsy is an invasive diagnostic
> Gliomatosis cerebri procedure that should only be per-
> Epidural abscess formed after a careful consideration
of the indications and when all rele-
Mildly elevated protein with or without
mildly elevated cell count: vant noninvasive studies have failed
to yield a diagnosis.
> Multiple sclerosis Brain biopsy is a neurosurgical proce-
> Epilepsy dure that can be performed either
> Brain infarct
> Abscess
through an open craniotomy, or ste-
> Uremia
reotactically under radiologic guid-
ance. In most centers, its use is re-