Aeta Neuroehirurgiea 32, 209--217 (1975) 9 b y Springer-Verlag 1975

Department of Neurosurgery and Department of Clinical Chemistry, Ullevs Hospital, Oslo, Norway

Creatine Kinase and Lactate I)chydrogcnase in the Cerebrospinal Fluid in Patients with Head Injuries By

H. K. Nordby, B. Tveit, and I. Ruud Summary The concentration of CK and LDI-I in the eerebrospinM fluid was determined in 290 patients with head injuries. The highest concentration of these enzymes appeared in patients with the most severe brain injury. CK correlated somewhat better than L D H with the severity of the head injury. In the group with moderate head injuries there was no significant difference statistically between patients with increased CK level and patients with normal CK level in the eerebrospinal fluid with regard to the dura.tion of posttraumatie headache, dizziness or working disability.

Introduction I n t h e central nervous s y s t e m a c u t e cell i n j u r y m a y result in measu r a b l e a m o u n t s of cell enzymes in t h e eerebrospinal fluid. To some e x t e n t these enzymes m a y also be p r e s e n t in samples from p e r i p h e r a l blood. L a c t a t e d e h y d r o g e n a s e (LDH) a n d creatine kinase (CK) are b o t h enzymes which h a v e been f o u n d in the eerebrospinal fluid of p a t i e n t s w i t h neurological disease or i n j u r y to t h e nervous s y s t e m (CulebrasFerns et al. 1971). A n increase of enzymes as a rule correlates b e t t e r with t h e p a r e n c h y m a l d a m a g e t h a n does t h e increase in t h e t o t a l p r o t e i n c o n c e n t r a t i o n (Wolitz et al. 1969). I n h e a d injuries K a l t i a l a et al. (1967) f o u n d an increase in L D H in t h e spinal fluid in p a t i e n t s with b r a i n contusion. P a t i e n t s w i t h simple concussion d i d n o t show this e n z y m e increase. I t was a s s u m e d t h a t h a e m o r r h a g e into t h e eerebrospinal fluid a c c o u n t e d for a p a r t of t h e e n z y m e increase. I n p a t i e n t s w i t h b r a i n turnouts studies of t h e isoenzymes of t h e L D H in the eerebrospinal fluid h a v e d e m o n s t r a t e d certain enzyme p a t t e r n s which correlate with t h e m a l i g n a n c y of t h e n e o p l a s m (Heller et al. 1971). Acta Neurochirl~rgica, Vol. 32, :Fasc. 3 - - 4

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H . K . Nordby et el. :

Some studies also indicate that the enzyme concentrations are different in different parts of the brain. In an autopsy material the measured activity of CK in the precentral gyrus was four times higher than t he e n z y m e a c t i v i t y in t h e m e d u ll a o b l o n g a t a (Kleine 1965). Th e e n z y m e increase is also d e p e n d e n t u p o n th e t i m e i n t e r v a l after t h e damage. A f t e r a c e r e b r o v a s c u l a r accident Schuller (1968) d e m o n s t r a t e d a r a p i d fall of t h e increased a c t i v i t y of C K in p l a s m a during t h e first five days. H o w e v e r , this a u t h o r did n o t m e a s u r e C K a c t i v i t y in the cerebrospinal fluid.

Purpose el the Investigation This study was started in an attempt to use enzyme ,determination as a diagnostic tool in the observation of patients with head injuries. It was necessary to obtain information about the increase in the concentration of enzymes in relation to the severity of the brain injury and to discover whether CK or LDH was the more significant. The possible prognostic value of increased enzyme levels was also of interest.

Material and Methods A. Patients I n 1972 CK and LDI-I were studied in the spinal fluid of approximately

290 patients with head injury admitted to the Neurosurgical Department of Ullev~l Hospital, Oslo. After a routine clinical and neurological examination the patients were classified according to the severity of the injury into six groups: 1. Head injury without loss of consciousness. 2. Probable but uncertain cerebral concussion (questionable concussion). 3. Cerebral concussion, defined as loss of consciousness with amnesia, with or without nausea, vomiting, headache or dizziness. 4. Cerebral concussion with traumatic meningeal haemorrhage. 5. Intraeranial haematoma, verified by operation or by autopsy. 6. Cerebral eontusion with or without haematoma. After discharge from hospital the patients were as a rule followed with outpatient control examinations. The spinal fluid enzyme concentrations were not known at the first neurological examinations. The patients were classified retrospectively, taking into account all relevant data from the hospitM stay, excluding enzyme data. The period of rehabilitation was defined as the number of weeks that passed before the patients were able to resume their previous oeeupations. Notes from the follow up examinations gave information about the duration of symptoms like headache or dizziness.

B. Material ]or Analysis Lumbar puncture was performed within 24 hours after the accident. The first millilitre of spinal fluid was used for cell counts and protein determinations. Two to three millilitres of the spinal fluid were stored in a re-

Creatine Kinase and Lactate Dehydrogenase

211

f r i g e r a t o r a t 4 ~ a n d t h e e n z y m e a n a l y s e s were p e r f o r m e d w i t h i n 72 hours. C o n t r o l s t u d i e s i n d i c a t e d t h a t n o s i g n i f i c a n t c h a n g e of a c t i v i t y t o o k place d u r i n g t h e first 3 - 4 days. B l o o d s t a i n e d spinal fluids were c e n t r i f u g e d before analysis. F o r i s o e n z y m e d e t e r m i n a t i o n t h e spinal fluid p r o t e i n s were c e n t r i f u g e d a n d c o n c e n t r a t e d a~ 2000 RPIV[ t h r o u g h Centriflo M e m b r a n e U l t r a f i l t e r s 50 (Amicon, L e x i n g t o n . Mass.).

C. Enzymatic Methods L D H a c t i v i t y was m e a s u r e d b y t h e m e t h o d of W r o b l e w s k i et L a D u e (1955), w i t h r e a g e n t k i t s f r o m K a b i (Sweden), a n d t h e a c t i v i t y was r e c o r d e d o n t h e L K B r e a c t i o n R a t e A n a l y z e r . F o r e a c h a s s a y 0.10 m l s p i n a l fluid was u s e d in a t o t a l v o l u m e of 1.75 ml. F o r C K m e a s u r e m e n t w i t h B o e h r i n g e r M o n o t e s t C K 0.5 m l s p i n a l fluid w a s ' u s e d in a t o t a l v o l u m e of 1.5 ml. I f t h e e n z y m e a c t i v i t y was h i g h t h e a s s a y h a d to be r e p e a t e d w i t h a s m a l l e r v o l u m e of t h e s p i n a l fluid. I n a few eases we d e t e r m i n e d C K i s o e n z y m e s in e o n c e n t r a t e d s p i n a l fluid. T h e m e t h o d for e l e e t r o p h o r e t i c s e p a r a t i o n a n d d e t e c t i o n of C K i s o e n z y m e s was a m o d i f i c a t i o n of t h e m e t h o d d e s c r i b e d b y V a n d e r W e e n e t W i l l e b r a n d (1966). A d i s t i n c t s e p a r a t i o n b e t w e e n CK-I, C K - I I , a n d C K - I I I was o b t a i n e d in 15 m i n u t e s , a n d c o n t r o l r u n s w i t h tissue e x t r a c t s f r o m h u m a n b r a i n , skeletal m u s c l e a n d h e a r t m u s c l e s h o w e d t h a t b y t h i s t e c h n i q u e we i d e n t i f i e d about. 8 0 % of t h e t o t a l a c t i v i t y as C K - I I I a n d a b o u t 20~o as C K - I I in h e a r t a n d skeletal muscle. I n b r a i n e x t r a c t s we f o u n d o n l y C K - I . I n spinal fluids w i t h C K a c t i v i t y of a b o u t 10 U / 1 or more, C K - I could b e d e t e c t e d . This was t e s t e d on several s p i n a l fluids, a n d in e a c h case w h e n C K a c t i v i t y c o u l d b e d e t e c t e d a f t e r electrophoresis, we f o u n d o n l y C K - L I n b l o o d s a m p l e s f r o m t h e s a m e p a t i e n t s we could n o t d e t e c t C K - I b y t h i s t e c h n i q u e . T a b l e 1. Normal Values el C K and L D H in Cerebrospinal 2Fluid

Enzyme

N u m b e r of persons

Mean = ~

LDt{ CK

28 27

20 U/1 0-1 U / l *

Standard deviation

Normal limits

9.5 U/1

5--40 U/1 0 - 2 U/1

* 1 p a t . 3 U/1.

D. Normal Values W e h a v e u s e d spinal fluids f r o m p a t i e n t s in w h o m a d e g e n e r a t i v e process in t h e n e r v o u s s y s t e m was n o t p r o b a b l e (e.g. sciatica, neurosis) (Table 1). B l o o d s t a i n e d spinal fluids w i t h some h a e m o l y s i s h a d h i g h e r t h a n n o r m a l levels of LDI-I. C o n t r o l a n a l y s i s of h a e m o l y s a t e s shouted t h a t u p to 20 U/1 of L D I t a c t i v i t y c o u l d b e d e r i v e d f r o m h a e m o l y s e d r e d b l o o d cells in s p i n a l fluid. T h e r e f o r e t h e u p p e r l i m i t for L D H a c t i v i t y of b l o o d s t a i n e d s p i n a l fluid was set a t 65 U/1. C K a c t i v i t y in similar h a e m o l y s a t e s was insignifieant. E. Statistical Evaluation S t u d e n t ' s t - t e s t h a s b e e n u s e d for t h e s t a t i s t i c a l e v M u a t i o n . 14"

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Results With the described technique it seems that CK in the cerebrospinal fluid is a more significant enzyme than L D H for the evaluation of central nervous system injuries. However, some patients with severe brain injury have normal enzyme levels. This was more often the case with L D H than with CK. The classifications of patients and resulting enzyme values are shown in Table 2 and 3. I n an a t t e m p t to evaluate the prognostic significance of the enzyme levels information has been collected with respect to headache, dizziness and the rehabilitation time for patients wit h concussion and traumatic meningeal haemorrhage. The duration of symptoms in weeks has been compared with enzyme levels in the acute stage (Table 4). There was no significant difference between the duration of headache, dizziness and incapacity in patients with normal enzyme levels as compared with those with increased enzyme levels. The mean time period of absence from work was 3,9 weeks for the group with pathological CK values and 3.8 weeks for the group with normal CK. Headache lasted 3 weeks and 2 weeks, vertigo or dizziness 4.5 and 3.5 weeks respectively.

Discussion For the t r e a t m e n t of patients with head injury information about the actual brain damage is most important. The intracellular enzymes L D H and CK are released from injured cells. Because of the blood brain barrier the leakage of enzymes takes place more easily into the cerebrospinal fluid than into the peripheral blood. I n our study the concentration of these enzymes in the cerebrospinal fluid showed, as a general trend, higher values with increasing severity of the injury. There is probably a relation between the concentration of enzymes in the cerebrospinal fluid and the mass of damaged brain substance. However, some patients with the clinical diagnosis of cerebral contusion had a normal concentration of enzymes. The cause could be t h a t the enzymes leaking from the brain cells had not mixed thoroughly with the lumbar spinal fluid in all eases. To minimize this possible error several spinal punctures in each patient could have been performed. But repeated lumbar punctures are not justified in cases with only minor head injuries. Patients with serious head injuries can perhaps be punctured once a day for some days. This m a y give additional information about the most appropriate timing of the spinal puncture in relation to the time of the accident. Another study is planned to answer these questions. I n a personal communication Kjekshus et al. (1973) have reported some results from a similar study of CK in the cerebrospinal fluid

Sum

C K ia U/I 0-2 3-8 9-27 28--64 65-125 126-216 217-343 344-512 513-729

10

t0

I-Iead trauma, no loss of consciousness

38

35 3

Questionable coucussion

143

122 18 1 2

Cerebral concussion

59

24 19 11 3 1 J.

Cerebral concussion and meningeal haemorrhage

3

1

2

intracranial haematoma

13

1

2

2 3 2 1 2

Brain contusion

Table 2. Concentration el CI~ in the Cerebrospinal :Fluid ( U / l ) in Di]]erent Groups el l~atients with Head Injuries. T h e n u m b e r of p a t i e n t s in e a c h g r o u p is g i v e n

b~