Cerebrospinal fluid (CSF) is a clear, colorless fluid that surrounds the brain and spinal cord, formed primarily by the choroid plexus. CSF serves several functions including protection, nutrition, waste removal, and lubrication, and its examination is crucial for diagnosing infections, inflammatory conditions, and other neurological disorders. The document outlines the formation, circulation, characteristics, and examination procedures for CSF, including lumbar puncture techniques and potential complications.
Cerebrospinal fluid (CSF) is a clear, colorless fluid that surrounds the brain and spinal cord, formed primarily by the choroid plexus. CSF serves several functions including protection, nutrition, waste removal, and lubrication, and its examination is crucial for diagnosing infections, inflammatory conditions, and other neurological disorders. The document outlines the formation, circulation, characteristics, and examination procedures for CSF, including lumbar puncture techniques and potential complications.
Cerebrospinal fluid (CSF) is a clear, colorless fluid that surrounds the brain and spinal cord, formed primarily by the choroid plexus. CSF serves several functions including protection, nutrition, waste removal, and lubrication, and its examination is crucial for diagnosing infections, inflammatory conditions, and other neurological disorders. The document outlines the formation, circulation, characteristics, and examination procedures for CSF, including lumbar puncture techniques and potential complications.
Cerebrospinal fluid (CSF) is a clear, colorless fluid that surrounds the brain and spinal cord, formed primarily by the choroid plexus. CSF serves several functions including protection, nutrition, waste removal, and lubrication, and its examination is crucial for diagnosing infections, inflammatory conditions, and other neurological disorders. The document outlines the formation, circulation, characteristics, and examination procedures for CSF, including lumbar puncture techniques and potential complications.
colourless transparent fluid present in the cerebral ventricles, spinal canal, and subarachnoid spaces. CEREBROSPINAL FLUID [FORMATION] CSF is largely formed by the choroid plexus of the lateral ventricle and remainder in the third and fourth ventricles.
CSF is a selective ultrafiltrate of plasma.
Small amount of the CSF is also formed from the
ependymal cells lining the ventricles and other brain capillaries. Rate of formation:
About 20 ml/hour ( 0.3 – 0.4 ml/min)
500 ml/day in adults. Turns over 3.7 times a
day
Total quantity: 90 - 150 ml in adults
30 - 40 ml within the ventricles
About 110-120 ml in the subarachnoid space [of
which 75-80 ml in spinal part and 25-30 ml in the cranial part]. CIRCULATION OF CSF Lateral ventricle Foramen of Monroe [Interventricular foramen] Third ventricle:
Cerebral aqueduct
Fourth ventricle:
Foramen of magendie and
formen of Luschka Subarachnoid space of Brain and Spinal cord ABSORPTION OF CSF THROUGH ARACHNOID VILLI
The arachnoid villi are finger like inward projections of
the arachnoid membrane through the walls into venous sinuses.
Villi form arachnoid granulations protruding into the
sinuses. CHARACTERISTICS OF CSF Nature : Color - Clear, transparent fluid Specific gravity - 1.004-1.007 Reaction - Alkaline and does not coagulate
Cells - Adults : 0-5 cells/cumm
Infants : 0-30 cells/cumm 1-4 years : 0-20 cells/cumm 5-18 years : 0-10 cells/cumm
Pressure - 60-180 mm of H2O (adult)
10-100 mm of H2O (newborn) COMPOSITION OF CSF FUNCTIONS OF CSF
procedure where a sample of cerebrospinal fluid is taken for examination.
First performed by Quincke in 1891.
LUMBAR PUNCTURE PROCEDURE
•Patient usually lie on a bed on side (lateral
recumbent position) with knees pulled up against the chest. • It may also done with sitting up and leaning forward on some pillows. Sterilize the area. • Push a LP needle through the skin and tissues between two vertebra into the space around the spinal cord which is filled with CSF. • CSF leaks back through the needle and is collected in three tubes.
Generally up to 6-7 ml can be taken from an
adult, if pressure is normal (50-180 mm H2O). LUMBAR PUNCTURE [Complications]
Post lumbar puncture headache
Introduction of infection in the spinal canal
Subdural hematoma
Failure to obtain CSF (dry tap)
Herniation of brain
Subarachnoidal epidermal cyst
CONTRA-INDICATIONS for Lumbar Puncture
ABSOLUTE RELATIVE Local skin infections Raised intracranial over proposed pressure (ICP); puncture site exception is pseudo- tumor cerebri. Intracranial mass Uncontrolled bleeding lesion (based on diathesis lateralizing neurological findings) with raised ICT Spinal column deformities (may require fluoroscopic assistance)
Lack of patient cooperation Glass tubes – X Refrigeration - X Routine When Indicated
Gross Cultures examination Stains [Gram, Cell Counts + Differential Acid Fast] Glucose [60-70% Cytology plasma] Electrophoresis Protein [15 - 40 VDRL mg/dL] Macroscopic Examination Normal CSF appearance is crystal clear and colourless Pathological processes can cause fluid to appear cloudy, turbid, bloody, viscous, or clotted. The clarity of the fluid is of little clinical use, except to provide an immediate indication of abnormality of the CSF. A very useful point to remember is that a large number of cells can be present without affecting the clarity. APPEARANCE
1. Blood Mixed. 2. Xanthochromic. 3. Thick Viscous. 4. Clot/ Cob web. 1. Traumatic Tap or CNS Hemorrhage ~20% of LPs result in bloody specimens.
hemorrhage. Traumatic tap. Jaundice. Elevated protein level (>150 mg/dl) Premature infants (with immature blood- CSF barrier & elevated bilirubin. Hypercarotenemia. Meningeal malignant melanoma. CSF Subarachnoi finding Traumatic d LP Hemorrhage Gross Blood more in Blood uniform in all appearance initial tubes, tubes, Blood does not Blood clot on clot on standing standing Centrifugatio Clear supernatant Pink or yellow n supernatent Microscopy Progrresive RBC count uniform in decrease in RBC all tubes count in later tubes CSF Pressure Normal Increased CSF Protein Normal Increased 3. Thick viscous CSF. Severe meningitis. Cryptococcal meningitis. Metastatic mucinous adenocarcinoma.
4. Clot formation:(cob web)
Increased proteins( >150 mg) Tuberculous meningitis. Spinal block Differentiation on the basis of type of clot Delicate and fine clot - Tuberculous meningitis.
Large clot - Purulent meningitis
Complete and spontaneous clot - Spinal
constriction. Causative Organisms – Age Wise 0- 6 months - Group B streptococcus, E. coli. Listeria monocytogens. 6months- 6 years – Streptococcus pneumonia, Neisseria meningitidis, Haemophilus influenzae type- b. 6-60 years - Neisseria meningitidis, Herpes simplex. >60 years - Streptococcus pneumoniae , Listeria monocytogenes. Microscopic Examinations
ttp://www.neuropat.dote.hu/jpeg/liquor/kmcarc1.jpg METHOD( Total leukocyte count)
Properly mix the CSF sample.
Nine drops of CSF is diluted with one drop of CSF diluting fluid (in the ratio 9: 1) The counting chamber is covered with a cover slip. Charge the counting chamber with fluid and allowed to stand for 5 min for the cells to settle. Cells are counted in all the nine squares. CSF Diluting Fluid: Add 10 ml of glacial acetic acid and 0.2 grams of crystal violet to a 100-ml volumetric flask. Dilute to the mark with distilled water. Calculation: Number of cells counted x 10 9 (as neubauer’s chamber has a depth of 0.1 mm and total counting area is 9 sq. mm.) Fuch’s rosenthal chamber: Cells are counted in five large squares. Calculation = no. of cells counted x 10 5x2 (depth is 0.2 mm. and total counting area is 16 sq.mm.) Cell Counts “Normal” adult CSF 0-5 cells/ml Lymphocytes.
RBC count is of limited use, but can
be used to correct CSF leukocyte counts* & CSF protein values of a traumatic tap CSF. W* = WBCf - WBCb x RBCf RBCb
http://www.tpub.com/content/medical/14295/img/14295_279_1.jpg Causes of increased cell count :
Meningitis. Intracranial hemorrhage. Meningeal infiltration by malignancy. Multiple sclerosis. Differential Performed on a stained* smear made from CSF. It is recommended that stained smears be made even when the total cell count is within normal limits. Count 100 cells in consecutive oil- power fields. Report percentage of each type of cell present.
* usually Wright’s stain. Predominant Neutrophils-
1.Meningitis(bacterial, early viral ,early tubercular an
fungal. 2.Sub arachnoid hemorrhage. 3.Metastasis. Predominant Lymphocytes- I. Meningitis (viral or tubercular) II. Incompletely treated bacterial meningitis. III. Toxoplasmosis and cysticercosis. Predominant Eosinophils
I. Parasitic and fungal infections.
II.Reaction to foreign material.
Mixed cell pattern
1.Tubercular meningitis. 2.Chronic bacterial meningitis. Cells Observed in CSF B
CSF cytoprep, Wright-Giemsa. 1000x
A – PMNs, Lymphocytes; B – Lymphocytes; C – Monocyte. Features of Malignant Cells
Multi-layered formations LARGE cells Irregular nuclear membrane Multi-nucleation Nuclear hyperchromasia Unevenly distributed chromatin Irregularly-sized/shaped nuceloli Large cells with convoluted nuclei and moderate amounts of Prominent nucleoli basophilic cytoplasm, intermixed with some small lymphocytes (cytospin preparation of fresh cerebrospinal fluid, High N:C ratio stained with Diff-Quik, original magnification 3600). (Courtesy of Dr Andrew Schriner, department of cytopathology, New York-Presbyterian Hospital/Weill Cornell Medical Center.) URL Bizarre accessed http://theaidsreader.consultantlive.com/display/article/1145619/1362837?ver vacuolization/inclusions ify=0 , 2009.
Uneven staining of cytoplasm Chemical Analysis of CSF
Protein(15-45mg/dl)
80% plasma derived
LMW Transthyretin (prealbumin) Albumin Transferrin IgG – very small amount 20% intrathecal synthesis. Glucose(45-80 mg/dl)
Need to know plasma value
Increased Hyperglycemia 2/3rd Traumatic tap OF Decreased PLASMA (Hypoglycorrhachia) VALUE Hypoglycemia Meningitis (bacterial, tuberculous & fungal) Tumors(meningeal carcinomatous) Note: CSF glucose normal in viral meningitis. Glucose Estimation Pipette in 3 test tubes labelled as Blank, Standard and Test. Ingredients Blank Standard Test
Glucose 1.5ml 1.5ml 1.5ml
Working Solution Distilled 0.02ml - - Water
Standard - 0.02ml -
Sample - - 0.02ml (CSF)
Incubate in water bath for 15mins and then add 1.5ml of
distilled water to each tube. CSF glucose levels normalize before protein level and cell counts during recovery from meningitis, making it an useful parameter in assessing the response to the treatment. Qualitative Test - Pandy’s Test CSF is added in concentrated solution of phenol, appearance of cloudiness indicates increased protein (globulins).
Pandy’s Reagent – 30 gm phenol 500 ml distilled water. Quantitative Test - Proteins Turbidimetric method: Principle : In the presence of sulphosalicylic acid and sodium sulphate, protein yields a uniform turbidity which absorbs maximum at 520 nm or green filter and is directly proportional to the concentration of proteins.
Composition: CSF Protein Reagent - Sulphosalicylic acid-30 gms/lt. Sodium sulphate-70 gms/lt. Standard – Albumin fraction-100 mgs/ lt. MANUAL METHOD: Ingredient Blank Standard Test
CSF Protein 1.5 ml 1.5 ml 1.5 ml
Reagent
Distilled 0.1 ml - - Water
CSF Protein - 0.1 ml -
Standard
Sample - - 0.1 ml (CSF)
Pipette in 3 test tubes labelled as Blank, Standard and Te
Note :- False elevation of protein occurs if CSF is contaminated with blood, this can be corrected by deducing 1 mg/ dl of protein for every 1000 RBC’s. Causes of Raised CSF Protein Lysis of contaminated blood from traumatic tap (each 1000 RBC/mm3 raise the CSF protein by 1mg/dl). Increased Permeability of epithelial membrane(Blood Brain Barrier) - CNS Bacterial or fungal Infections(Meningitis) Cerebral Hemorrhages Increased production by CNS tissue as in - Multiple Sclerosis, Neurosyphilis (Increased production of local immunoglobulin) Subacute sclerosing panencephalitis (SSPE) Guillain Barre syndrome. Multiple sclerosis 1. Mononuclear cell pleocytosis. 2. Increased intrathecal production of IgG. 3. IgG index: ratio of IgG and albumin in the CSF to the ratio of IgG and albumin in the serum. 4. Measurement of oligoclonal band. 5. Paired serum samples studied to exclude peripheral i.e., non CSF production of oligoclonal bands. 6. Pleocytosis of >75 cells /microlt.with presence of neutrophils and protein >1 mg/dl excludes the diagnosis. Albumin and IgG
Albumin – neither IgG sourced from
synthesized, nor inside and outside. metabolized in CNS. CSF IgG index = ratio ALB used to address IgGCSF/IgGserum X ALB blood-brain barrier serum/ALBCSF integrity Reference range 0.3 Evaluate CSF/serum ALB – 0.7 index > 0.7 = CNS Index < 9 = normal sourced 9 – 14 minimal < 0.3 = impairment compromised > 100 = not intact BBB barrier Electrophoresis Normal = 4 bands ALB Transthyretin Transferrin b1 t = unique to CSF Oligoclonal bands ~ multiple sclerosis Myelin basic protein Monitoring disease progression
2.A sustained CSF pleocytosis suggestive of an alternative diagnosis i.e., viral myelitis. Microbiological examintion: Direct wet mount- candida, crytococcus infection, amoebic encephalitis.
Indian ink preparation- a drop of CSF and
Indian ink is placed on a slide and covered with cover slip and observe it under 40x – crytococcus appears as budding yeast surrounded by unstained capsule. Gram’s Stain-
Smear is made from the sediment and is air
dried, stain it with gram’s stain and observe it under oil immersion. Streptococcus pneumococci – Diplococci, gram positive, lying end to end. Neisseria meningitides - Diplococci gram negative, lying side by side. Haemophilus influenza - coccobacilli gram negative Ziehl- Neelsen stain: AFB smears are negative in 70% of cases however florescent auramine stain have better sensitivity.
Serologic test for Neurosyphilis :
Combination of VDRL test in CSF and FTA- ABS test in serum is diagnostic. CSF CULTURE- Gold standard 1. Appearance of bacteria on gram stained smears. 2. Increased proteins or cell count. 3. Inoculated on chocolate agar. 4. Sensitivity -90%.
PCR :- Viral infection of CNS.
Requires only a drop of CSF. Featur Norma Bacter Viral TB Fungal Brain SAH -es l i-al Menin Menin Menin Tumou Menin g-itis g-itis g-itis r g-itis Appear- Clear, Cloudy, Clear, Slightly Clear, Clear, Xantho- ance Colurle Large No clot cloudy No clot No clot chromic ss clot No clot WBC 0–5 >500 10 – 200 – 0–5 0–5 0–5 (cells/ Lympho PMN 200 500 lympho lympho cumm) lympho lympho + + + + Total 15 – 45 +++ ++ +++ Normal + +++ Protein mg/dl
Globuli low + - + Normal - +
n (mg/dl) Glucose 45 – 80 --- Normal --- --- + - mg/dl
