High-Lipid Cerebrospinal Fluid: A Case Report
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.284355
Source of Support: None, Conflict of Interest: None
Cerebrospinal fluid (CSF) is a fluid in the brain and spinal cord, which plays an important role in buffering, transporting, and regulating intracranial pressure. It consists of water, various proteins, and glucose. Normal CSF contains small amounts of lipids, mainly phospholipids. The triglyceride content is extremely low, with no lipoprotein and other components. However, in the rare cases of cerebral and subarachnoid hemorrhage, fat in the CSF can be seen with the naked eye. This study aimed to report the case of a patient with hyperlipidemia of CSF caused by ventricular hemorrhage.
A 37-year-old male patient was admitted to the intensive care unit of Zhongshan People's Hospital on October 21, 2018, with “coma for three hours.” The patient had undergone resection of craniopharyngioma in the hospital ten years ago. The cerebral computed tomography scanning revealed ventricular system blood accumulation and dilation and brain swelling. The physical examination showed GCS 6, bilateral pupil diameter of 3 mm, slow reflection of light, and neck stiffness. The patient accepted bilateral ventricular drainage in an emergency.
The patient was routinely sterilized in the supine position, 3 cm behind the hairline and 3 cm beside the midline. The skin and subcutaneous tissue were cut to the bone surface, the skull was drilled, the dura was cut, and the ventricle was punctured on both sides. The strawberry milk–like CSF was sprayed out. The CSF was continuously drained after the surgery [Figure 1].
CSF and blood samples (during surgery, 1 day after the surgery, and before discharge) were evaluated using a microscope (Olympus CX31) and Cobas 8000 automatic analyzer (Japan) [Table 1].
The patient underwent DSA examination the next day. It showed three aneurysms in the A1 segment of the left anterior cerebral artery, and the largest volume was about 12 mm. A coil and an LVIS 3. × 30 mm stent was used to seal the bleeding aneurysms [Figure 2].
On January 22, 2019, the patient accepted ventriculoperitoneal shunt due to hydrocephalus. On February 28, 2019, the patient was discharged with GCS 12.
The serum may appear milky after blood coagulation in patients with severe hyperlipidemia. Normal CSF contains a very small amount of lipids. In the present case, the CSF in the extraventricular drainage had a strawberry milk–like appearance after a cerebral hemorrhage. Also, the mixing of blood and CSF, blood cell coagulation, and mixing of serum and CSF were observed. The blood lipid content was still very high after mixing with the CSF. The blood clots mixed with the blood cells, giving the CSF a strawberry milk–like appearance.
Very few reports have been published in this regard. In 1974, Younes et al. reported that patients with cerebral hemorrhage had a large amount of lipids in the lumbar CSF. In 1981, a British doctor Burke also analyzed CSF in a patient using protein electrophoresis. Lipoproteins assist in the diagnosis of hyperlipidemia in patients. Thus, it was confirmed that the lipid levels in CSF change in cerebral hemorrhage, and blood lipids enter the CSF. In the present case, the patient's symptoms were typical.
Hyperlipidemia can lead to systemic atherosclerosis. It causes a decrease in vascular elasticity and accommodation capacity. Also, it results in vascular and cerebrovascular infarction in the central nervous system. It is associated with spontaneous cerebral hemorrhage.
This patient was treated with atorvastatin for hyperlipidemia. A previous study showed that statin use increased the risk of long-term cerebral hemorrhage. However, a recent study found that statin use can reduce the risk of rupture of aneurysms. An observational study of Asian patients found that excessive use of statin did not increase the risk of rebleeding. Statin therapy is still necessary for patients with severe hyperlipidemia.
This study reported the case of a patient with high-lipid CSF having a strawberry milk–like appearance. The patient was diagnosed with right anterior communicating artery aneurysm and hyperlipidemia. He was healed after extraventricular drainage, interventional surgery, and ventriculoperitoneal shunt. Lumbar puncture and neurosurgery indicated hyperlipidemia, and statin therapy was safe and necessary.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was funded by the Zhongshan Social Welfare Science and Technology Research Project (2018B1004).
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]