CSF Xanthochromia

CSF Xanthochromia
Pseudonyms – CSF bilirubin

For investigation of suspected subarachnoid haemorrhage (SAH) in CT negative patients
Xanthochromia is the yellow discoloration indicating the presence of bilirubin in CSF which appears
as oxyhaemoglobin released from the breakdown of red blood cells following haemorrhage into the
CSF is converted in vivo into bilirubin in a time‐dependent manner. A subarachnoid haemorrhage
(SAH) is a spontaneous arterial bleeding into the subarachnoid space, usually from a cerebral
aneurysm, and characterised by a severe sudden‐onset headache.
The majority of positive cases are detected by computed tomography (CT) scanning but for those CT‐
negative patients presenting with a history suggestive of SAH the measurement of xanthochromia in
CSF is advocated to detect those patients who actually have sustained a SAH and require treatment
and to eliminate the possibility of SAH in the remainder without the need of confirmatory
angiography. The CSF is collected by means of lumbar puncture (LP).
For full interpretation of the result other CSF and blood tests must be collected at the same time –
CSF protein and glucose; plasma glucose; and serum protein and bilirubin.
General information
CSF Xanthochromia sample collection kits are provided in the ACU (ORC) and AMU (Trafford) and
also available from the Specimen Receptions at the laboratories at both sites. Concurrent samples
should be requested for CSF protein and glucose, plasma glucose and serum LFTS (for protein and
bilirubin) using the sample containers supplied.
Collection container:
CSF xanthochromia: White topped Universal container
(In addition the following samples should be collected:‐
CSF glucose & protein: 1.2 mL fluoride‐EDTA glucose (Sarstedt yellow top)
Serum protein & bilirubin: 4.9 mL SST (Sarstedt brown top)
Plasma glucose: 2.7 mL fluoride‐EDTA glucose (Sarstedt yellow top)
Type and volume of sample:

1 mL CSF requested, minimum 400 µL required for analysis
Specimen transport/special precautions:

A CSF Xanthochromia sample collection kit should be used. These are located on the ACU (ORC) and
AMU (Trafford) and from the Laboratory Specimen Receptions at both sites.
The CSF Xanthochromia sample should be delivered to the lab:
1) Protected from light (use transport envelope provided in kit)
2) By hand and not via the pneumatic tube system
3) Within 30 minutes
Other CSF and blood biochemistry samples can be sent together with the CSF Xanthochromia sample,
but Microbiology samples should be sent separately and directly to the Microbiology Department.
NOTE: Samples should reach the laboratory by 4pm for same day analysis
Laboratory information
Method principle:
Spectrophotometric analysis.
CSF sample scanned between 350 and 600 nm and the net bilirubin absorbance (NBA) above the
predicted baseline at 476 nm calculated.
Biological reference range or cut off:

Results are reported as a qualitative interpretation, essentially as either positive or negative, and
reported as a comment stating either analysis is ‘Consistent with SAH’ or there is ‘No evidence to
support SAH’.
A result >0.007 AU (after any required correction has been applied) is reported as ‘positive’.
Turnaround time:
This test is only analysed Monday to Friday and samples should reach the laboratory by 4pm for
same day analysis.
Outside these hours samples are prepared and stored for analysis the next routine working day.
Clinical Information
Clinical decision point:
A result >0.007 AU (after any required correction has been applied) is reported as ‘Consistent with
SAH’.
Factors known to significantly affect the results

Sample collection time:
The guideline suggests the test is only valid for samples collected at least 12h after and up to 14 days
since a suspected SAH. Outside these times samples will be still analysed and may still be produce a
valid positive result but negative results will not be valid (and will be comment on appropriately).
Sample transport:
1) Bilirubin is photo‐sensitive, with measured levels decreasing with increasing length of
exposure to light. Therefore samples must be transported to the lab protected from light.
2) Samples should not be transported by the pneumatic tube system as this may cause in vitro
lysis of any red blood cells within the sample and release of oxyhaemoglobin. Excess
oxyhaemoglobin can impair the ability to detect bilirubin and is a confounding element in
interpretation.
3) The guideline recommends that the sample be delivered to the lab and prepared for analysis
(by centrifugation) within 1h of collection. We therefore request that samples are delivered
within 30 mins to allow for booking in and preparation within the 1h recommended.
Repeat collection:
A repeat LP for xanthochromia should not generally be performed due to the possibility of
generating a false positive result arising from the breakdown of blood introduced into the CSF space
during the original LP, however a negative result will be correct and samples would be analysed.
This information and precautions to limits these effects are all addressed by the provision of CSF
Xanthochromia sample collection kits which informs users of these specific requirements and
provides means (such as a transport envelope) to eliminate them.
References:
Cruickshank et al. National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected
subarachnoid. Ann Clin Biochem 2008; 45: 238‐244
(Last updated November 2019)

CSF Xanthochromia

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CSF Xanthochromia

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CSF Xanthochromia

Pseudonyms – CSF bilirubin

Type and volume of sample:

Specimen transport/special precautions:

Biological reference range or cut off:

Factors known to significantly affect the results

(Last updated November 2019)

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