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Xanthochromia, from the Greek xanthos (ξανθός)=yellow and chroma (χρώμα)=colour, is the yellowish appearance of cerebrospinal fluid that occurs several hours after bleeding into the subarachnoid space caused by certain medical conditions, most commonly subarachnoid hemorrhage.^[1] Its presence can be determined by either by spectrophotometry (measuring the absorption of particular wavelengths of light) or simple visual examination. It is unclear which method is superior.^[2]

Physiology

Cerebrospinal fluid, which fills the subarachnoid space between the arachnoid membrane and the pia mater surrounding the brain, is normally clear and colorless. When there has been bleeding into the subarachnoid space, the initial appearance of the cerebrospinal fluid can range from barely tinged with blood to frankly bloody, depending on the extent of bleeding. Within several hours, the red blood cells in the cerebrospinal fluid are destroyed, releasing their oxygen-carrying molecule heme, which is then metabolized by enzymes to bilirubin, a yellow pigment. The most common cause for bleeding into the subarachnoid space is a subarachnoid hemorrhage from a ruptured cerebral aneurysm.^[3]

The most frequently employed initial test for subarachnoid hemorrhage is a computed tomography scan of the head, but it detects only 98% of cases in the first 12 hours after the onset of symptoms, and becomes less useful afterwards.^[4] Therefore, a lumbar puncture ("spinal tap") is recommended to obtain cerebrospinal fluid if someone has symptoms of a subarachnoid hemorrhage (e.g., a thunderclap headache, vomiting, dizziness, new-onset seizures, confusion, a decreased level of consciousness or coma, neck stiffness or other signs of meningismus, and signs of sudden elevated intracranial pressure), but no blood is visible on the CT scan.^[1] According to one article, a spinal tap is not necessary if no blood is seen on a CT scan done using a third generation scanner within six hours of the onset of the symptoms. However, this is not standard of care.^[5]^[6]

Heme from red blood cells that are in the cerebrospinal fluid because a blood vessel was nicked during the lumbar puncture (a "traumatic tap") has no time to be metabolized, and therefore no bilirubin is present.

After the cerebrospinal fluid is obtained, a variety of its parameters can be checked, including the presence of xanthochromia. If the cerebrospinal fluid is bloody, it is centrifuged to determine its color.

Spectrophotometry

Many laboratories rely on only the color of the cerebrospinal fluid to determine the presence or absence of xanthochromia.^[7] However, recent guidelines suggest that spectrophotometry should be performed. Spectrophotometry relies on the different transmittance, or conversely, absorbance, of light by different substances or materials, including solutes.^[8] Bilirubin absorbs light at wavelengths between 450–460 nm.^[9] Spectrophotometry can also detect the presence of oxyhemoglobin and methemoglobin, which absorb light at 410-418 nm and 403-410 nm, respectively, and also may indicate that bleeding has occurred; to identify substances in cerebrospinal fluid that absorb light at other wavelengths but are not due to bleeding, such as carotenoids;^[1]^[7] and to detect very small amounts of yellow color saturation (about 0.62%) which may may be missed by visual inspection, especially when the cerebrospinal fluid has been examined under incandescent lighting or a tungsten desk lamp (corresponding to International Commission on Illumination standard illuminant A).^[8]

Visual inspection is the most frequent method used in the United States to assess cerebrospinal fluid for xanthochromia,^[10] while spectrophotometry is used on up to 94% of specimens in the United Kingdom.^[1]^[9] There is still disagreement about whether or not to routinely use spectrophotometry or whether visual inspection is adequate, and one group of authors has even advocated measuring bilirubin levels.^[11]

References

^ ^a ^b ^c ^d Cruickshank, A; Auld, P.; Beetham, R.; et al. (May 2008). "Revised National Guidelines for Analysis of Cerebrospinal Fluid for Bilirubin in Suspected Subarachnoid Haemorrhage". Annals of Clinical Biochemistry. 45 (Pt 3): 238–244. doi:10.1258/acb.2008.007257. PMID 18482910.
^ Chu, K; Hann, A; Greenslade, J; Williams, J; Brown, A (Mar 10, 2014). "Spectrophotometry or Visual Inspection to Most Reliably Detect Xanthochromia in Subarachnoid Hemorrhage: Systematic Review.". Annals of Emergency Medicine. 64: 256–264.e5. doi:10.1016/j.annemergmed.2014.01.023. PMID 24635988.
^ van Gijn, J.; Kerr, R.S.; Rinkel, G.J. (2007). "Subarachnoid Haemorrhage". Lancet. 369 (9558): 306–318. doi:10.1016/S0140-6736(07)60153-6. PMID 17258671.
^ van der Wee, N.; Rinkel, G.J.; Hasan, D.; van Gijn J., J. (March 1995). "Detection of Subarachnoid Haemorrhage on Early CT: Is Lumbar Puncture Still Needed After a Negative Scan?". Journal of Neurology, Neurosurgery, and Psychiatry. 58 (3): 357–359. doi:10.1136/jnnp.58.3.357. PMC 1073376. PMID 7897421.
^ Perry, J.J.; Stiell, I.G.; Sivilotti, M.L.; et al. (July 2011). "Sensitivity of Computed Tomography Performed Within Six Hours of Onset of Headache for Diagnosis of Subarachnoid Haemorrhage: Prospective Cohort Study". British Medical Journal. doi:10.1136/bmj.d42777.
^ Stewart, H.; Reuben, A.; McDonald, J. (September 2014). "LP or not LP, That is the Question: Gold Standard or Unnecessary Procedure in Subarachnoid Haemorrhage?". Emergency Medicine Journal. 31 (9): 720–723. doi:10.1136/emermed-2013-202573. PMID 23756363. Retrieved 21 May 2016.
^ ^a ^b Edlow, J.A. (July 2004). "The Worst Headache". Morbidity & Mortality Rounds on the Web. Agency for Healthcare Research and Quality. Retrieved 2008-06-22.
^ ^a ^b Williams, Anna (2004). "Xanthochromia in the cerebrospinal fluid" (PDF). Practical Neurology. 126 (4): 174–175.
^ ^a ^b Petzold, Axel; Keir, Geoffrey; Sharpe, Lindsay T. (2004). "Spectrophotometry for Xanthochromia". New England Journal of Medicine. 351: 1695–1696. doi:10.1056/nejm200410143511627.
^ Edlow, J.A.; Bruner, K.S.; Horowitz, G.L. (April 2002). "Xanthochromia". Archives of Pathology and Laboratory Medicine. 126 (4): 413–415. doi:10.1043/0003-9985(2002)126<0413:X>2.0.CO;2. PMID 11900563. Retrieved 21 May 2016.
^ Florkowski, Christopher; Ungerer, Jacobus; Southby, Sandi; George, Peter (17 December 2004). "CSF Bilirubin Measurement for Xanthochromia" (PDF). Journal of the New Zealand Medical Association. 117 (1207).

UpToDate Contents

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1. 脳脊髄液：疾患状態における検査の生理学および有用性 cerebrospinal fluid physiology and utility of an examination in disease states
2. 動脈瘤性くも膜下出血の臨床症状および診断 clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage
3. 雷鳴頭痛 thunderclap headache
4. 腰椎穿刺：成人における手技、適応、禁忌、および合併症 lumbar puncture technique indications contraindications and complications in adults
5. 中枢神経系結核 central nervous system tuberculosis

English Journal

Outcomes of CSF spectrophotometry in cases of suspected subarachnoid haemorrhage with negative CT: two years retrospective review in a Birmingham hospital.

Bakr A1, Silva D1, Cramb R1, Flint G1, Foroughi M1.
British journal of neurosurgery.Br J Neurosurg.2016 Dec 8:1-4. [Epub ahead of print]
AIM: The aim of this study was to evaluate the adherence to current guidelines for the investigation of suspected subarachnoid haemorrhage and the prevalence and outcome of computed tomography (CT)-negative aneurysmal subarachnoid haemorrhage.DESIGN: A retrospective review in a single large tertiary
PMID 27931120

Posterior reversible encephalopathy syndrome (PRES) associated with liquorice consumption.

O'Connell K1, Kinsella J2, McMahon C3, Holian J4, O'Riordan S2.
Irish journal of medical science.Ir J Med Sci.2016 Nov;185(4):945-947. Epub 2014 Oct 24.
IMPORTANCE: Posterior reversible encephalopathy syndrome (PRES) is a medical emergency but prompt recognition, early institution of supportive care and identifying and removing potential triggers are associated with a good clinical outcome. We report an unusual case of PRES associated with liquorice
PMID 25342161

New clinical decision rule to exclude subarachnoid haemorrhage for acute headache: a prospective multicentre observational study.

Kimura A1, Kobayashi K1, Yamaguchi H2, Takahashi T3, Harada M3, Honda H4, Mori Y5, Hirose K1, Tanaka N6.
BMJ open.BMJ Open.2016 Sep 9;6(9):e010999. doi: 10.1136/bmjopen-2015-010999.
OBJECTIVE: To ensure good outcomes in the management of subarachnoid haemorrhage (SAH), accurate prediction is crucial for initial assessment of patients presenting with acute headache. We conducted this study to develop a new clinical decision rule using only objectively measurable predictors to ex
PMID 27612533

Japanese Journal

ヒト・プラセンタ・エキス投与と関連があると思われたreversible cerebral vasoconstriction syndrome（RCVS）の1例

臨床神経学 52(3), 182-185, 2012
NAID 130004505256

葛根湯加川きゅう辛夷が誘因と考えられたＲｅｖｅｒｓｉｂｌｅ　ｃｅｒｅｂｒａｌ　ｖａｓｏｃｏｎｓｔｒｉｃｔｉｏｎ　ｓｙｎｄｒｏｍｅ（ＲＣＶＳ）の１例

臨床神経学 48(4), 267-270, 2008
NAID 130004504495

Neuroendoscopic Appearance of an Intraventricular Cavernous Angioma Blocking the Foramen of Monro : Case Report

Neurologia medico-chirurgica 46(11), 548-551, 2006-11-15
NAID 110005519339

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リンク元	「キサントクロミー」

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Xanthochromia
Classification and external resources
ICD-9-CM	792.0
ICD-O	R83.8
DiseasesDB	14197
	[edit on Wikidata]

　　[★]

英: xanthochromia
同: 髄液キサントクロミー
関: 脳脊髄液

脳脊髄液が黄色を呈するもの

原因：(1)出血に由来する場合(破壊された赤血球からの間接ビリルビン)、(2)高蛋白による場合

(1)出血による場合、脳脊髄液は出血後2-3時間から上清が黄色となり始め、1週間で著明となり、15-20日で退色する(LAB.253)

[Cruickshank-1] Cruickshank, A; Auld, P.; Beetham, R.; et al. (May 2008). "Revised National Guidelines for Analysis of Cerebrospinal Fluid for Bilirubin in Suspected Subarachnoid Haemorrhage". Annals of Clinical Biochemistry. 45 (Pt 3): 238–244. doi:10.1258/acb.2008.007257. PMID 18482910.

[2] Chu, K; Hann, A; Greenslade, J; Williams, J; Brown, A (Mar 10, 2014). "Spectrophotometry or Visual Inspection to Most Reliably Detect Xanthochromia in Subarachnoid Hemorrhage: Systematic Review.". Annals of Emergency Medicine. 64: 256–264.e5. doi:10.1016/j.annemergmed.2014.01.023. PMID 24635988.

[vanGijn-3] van Gijn, J.; Kerr, R.S.; Rinkel, G.J. (2007). "Subarachnoid Haemorrhage". Lancet. 369 (9558): 306–318. doi:10.1016/S0140-6736(07)60153-6. PMID 17258671.

[4] van der Wee, N.; Rinkel, G.J.; Hasan, D.; van Gijn J., J. (March 1995). "Detection of Subarachnoid Haemorrhage on Early CT: Is Lumbar Puncture Still Needed After a Negative Scan?". Journal of Neurology, Neurosurgery, and Psychiatry. 58 (3): 357–359. doi:10.1136/jnnp.58.3.357. PMC 1073376. PMID 7897421.

[5] Perry, J.J.; Stiell, I.G.; Sivilotti, M.L.; et al. (July 2011). "Sensitivity of Computed Tomography Performed Within Six Hours of Onset of Headache for Diagnosis of Subarachnoid Haemorrhage: Prospective Cohort Study". British Medical Journal. doi:10.1136/bmj.d42777.

[6] Stewart, H.; Reuben, A.; McDonald, J. (September 2014). "LP or not LP, That is the Question: Gold Standard or Unnecessary Procedure in Subarachnoid Haemorrhage?". Emergency Medicine Journal. 31 (9): 720–723. doi:10.1136/emermed-2013-202573. PMID 23756363. Retrieved 21 May 2016.

[Edlow-7] Edlow, J.A. (July 2004). "The Worst Headache". Morbidity & Mortality Rounds on the Web. Agency for Healthcare Research and Quality. Retrieved 2008-06-22.

[Williams-8] Williams, Anna (2004). "Xanthochromia in the cerebrospinal fluid" (PDF). Practical Neurology. 126 (4): 174–175.

[Petzold-9] Petzold, Axel; Keir, Geoffrey; Sharpe, Lindsay T. (2004). "Spectrophotometry for Xanthochromia". New England Journal of Medicine. 351: 1695–1696. doi:10.1056/nejm200410143511627.

[10] Edlow, J.A.; Bruner, K.S.; Horowitz, G.L. (April 2002). "Xanthochromia". Archives of Pathology and Laboratory Medicine. 126 (4): 413–415. doi:10.1043/0003-9985(2002)126<0413:X>2.0.CO;2. PMID 11900563. Retrieved 21 May 2016.

[SpectrophotometryControversy-11] Florkowski, Christopher; Ungerer, Jacobus; Southby, Sandi; George, Peter (17 December 2004). "CSF Bilirubin Measurement for Xanthochromia" (PDF). Journal of the New Zealand Medical Association. 117 (1207).

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xanthochromia