Blood tests | |
Essential tests | FBC, U+E, liver function tests, C reactive protein, glucose, magnesium, calcium, phosphate |
Clinical feature | Tests to consider |
Evidence of sepsis | Blood cultures and urinalysis |
Systemic features (rash, arthralgia etc), suggestive changes on MRI and CSF | Neuroinflammatory screen: ESR, antinuclear antibody, antineutrophil cytoplasmic antibody, antidouble-stranded DNA, antiextractible nuclear antigen, ACE level, serum complement, antiphospholipid antibody, anticardiolipin antibody and lupus anticoagulant |
Risk factors in history | HIV, tuberculosis PCR/T-Spot |
Clinical suspicion | Toxicology screening for drugs of abuse and alcohol Serum ammonia |
Underlying malignancy | Paraneoplastic antibody screen, N-methyl-D-aspartate (NMDA) receptor and voltage-gated potassium channel antibodies |
Cognitive or neuropsychiatric features, movement disorders | NMDA, potassium channel antibodies, thyroid antibodies |
Neuroimaging | |
Almost all patients will require brain imaging. The main choice lies between MRI and CT, though other modalities may be needed. | |
CT scan of head | ■ Quick, cheap and readily available ■ Avoids need for sedation ■ Demonstrates blood, abscess, tumours, oedema, infarcts, bony injuries and changes accompanying venous sinus thrombosis |
MR scan of brain | ■ Differentiates between acute and chronic ischaemia ■ Better imaging of posterior fossa and brainstem ■ Better demonstration of changes in encephalitis and inflammatory conditions ■ More likely to show smaller mass lesions and vascular malformations |
CT or MR cerebral venogram | Consider with papilloedema and features of raised intracranial pressure, focal neurological signs |
Lumbar puncture | |
We advise a low threshold for performing a lumbar puncture in patients with acute symptomatic seizures (providing no contraindications), particularly if there is no head trauma or metabolic derangement, and no clear aetiology demonstrated on examination or neuroimaging. | |
Opening pressure | Raised in; ■ Venous sinus thrombosis ■ Brain swelling – meningitis (especially cryptococcal), encephalitis, trauma |
Cell count | ■ >5 White cells mm-3 is abnormal ■ Neutrophils – consider bacterial meningitis ■ Lymphocytes – consider viral meningitis or encephalitis, mycobacterial, and fungal infection ■ Mixed or either cell type predominant in inflammatory conditions ■ Prior antimicrobial treatment may give a false negative result |
Protein | Raised protein suggests active central nervous system (CNS) pathology, infection, inflammation, malignancy or haemorrhage |
Glucose | Significantly reduced in bacterial infection (ratio with serum glucose <60% is abnormal) |
Other infectious tests | Viral PCR Cryptococcal antigen India ink stain Ziehl–Neelsen stain, tuberculosis PCR and culture JC virus PCR |
Cytology (+/- immunophenotyping) | Malignant cells |
Xanthochromia | If subarachnoid haemorrhage suspected |
EEG | |
Although non-specific (especially in the older people), the EEG can sometimes help: ■ distinguishing seizures from non-epileptic attacks ■ identifying non-convulsive status epilepticus ■ in showing diffuse slowing of background rhythms, a non-specific abnormality which may be seen postictally, following traumatic brain injury or CNS infection and accompanying any encephalopathy ■ in showing focal slowing or periodic lateralising epileptiform discharges, which occur with any localised pathology, including viral encephalitis, tumours and vascular events CSF, cerebrospinal fluid; FBC, full blood count; ESR, erythrocyte sedimentation rate. |