Parameter

Normal Values

Protein
15-45 mg/dl
Glucose
50-80 mg/dl
WBC
< 5 mm3
RBC
0-5
Opening pressure
5-20 cm
Clarity, color
Clear and colorless
Normal values typically range as follows:

Pressure: 70 - 180 mm H20

Appearance: clear, colorless

CSF total protein: 15 - 60 mg/100 mL

Gamma globulin: 3 - 12% of the total protein

CSF glucose: 50 - 80 mg/100 mL (or greater than 2/3 of blood sugar level)

CSF cell count: 0 - 5 white blood cells (all mononuclear), and no red blood cells

Chloride: 110 - 125 mEq/L

Note: mg/mL = milligrams per milliliter; mEq/L = milliequivalents per liter

Note: Normal value ranges may vary slightly among different laboratories. Talk to your doctor
about the meaning of your specific test results.
The examples above show the common measurements for results for these tests. Some
laboratories use different measurements or may test different specimens.

What Abnormal Results Mean

If the CSF looks cloudy, it could mean there is an infection or a build up of white blood cells or
protein.
If the CSF looks bloody or red, it may be a sign of bleeding or spinal cord obstruction. If it is
brown, orange
yellow, it may be a sign of increased CSF protein or previous bleeding (more than 3 days ago).
Occasionally, there may be blood in the sample that came from the spinal tap itself. This makes it
harder to interpret the test results.
CSF PRESSURE

Increased CSF pressure may be due to increased intracranial pressure (pressure within the
skull).
Decreased CSF pressure may be due to spinal cord tumor, shock, fainting, or diabetic
coma.

CSF PROTEIN

Increased CSF protein may be due to blood in the CSF, diabetes, polyneuritis, tumor,
injury, or any inflammatory or infectious condition.
Decreased protein is a sign of rapid CSF production.

CSF GLUCOSE

Increased CSF glucose is a sign of high blood sugar.

Decreased CSF glucose may be due to hypoglycemia (low blood sugar), bacterial or
fungal infection (such as meningitis), tuberculosis, or certain other types of meningitis.

BLOOD CELLS IN CSF

Increased white blood cells in the CSF may be a sign of meningitis, acute infection,
beginning of a chronic illness, tumor, abscess,stroke, or demyelinating disease (such as
multiple sclerosis).

Red blood cells in the CSF sample may be a sign of bleeding into the spinal fluid or the
result of a traumatic lumbar puncture.

OTHER CSF RESULTS

Increased CSF gamma globulin levels may be due to diseases such as multiple sclerosis,
neurosyphilis, or Guillain-Barre syndrome.

Additional conditions under which the test may be performed:

Chronic inflammatory polyneuropathy

Dementia due to metabolic causes

Encephalitis

Epilepsy

Febrile seizure (children)

Generalized tonic-clonic seizure

Hydrocephalus

Inhalation anthrax

Normal pressure hydrocephalus (NPH)

Pituitary tumor

Reye syndrome

Risks
Risks of lumbar puncture include:

Bleeding into the spinal canal

Discomfort during the test

Headache after the test

Hypersensitivity (allergic) reaction to the anesthetic

Infection introduced by the needle going through the skin

There is an increased risk of bleeding in people who take blood thinners.

Brain herniation may occur if this test is done on a person with a mass in the brain (such as a
tumor or abscess). This can result in brain damage or death. This test is not done if an exam or
test reveals signs of a brain mass.

Damage to the nerves in the spinal cord may occur, particularly if the person moves during the
test.
Cisternal puncture or ventricular puncture carry additional risks of brain or spinal cord damage
and bleeding within the brain.

Considerations
This test is particularly dangerous for people with:

A tumor in the back of the brain that is pressing down on the brain stem
Blood clotting problems

Low platelet count (Thrombocytopenia)

Alternative Names
Spinal tap; Ventricular puncture; Lumbar puncture; Cisternal puncture; Cerebrospinal fluid
culture

References
Griggs RC, Jozefowicz RF, Aminoff MJ. Approach to the patient with neurologic disease. In:
Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier. 2007:
chap 418.
Rosenberg GA. Brain edema and disorders of cerebrospinal fluid circulation. In: Bradley WG,
Daroff RB, Fenichel GM, Jankovic J, eds. Bradley: Neurology in Clinical Practice. 5th ed.
Philadelphia, Pa: Butterworth-Heinemann Elsevier; 2008:chap 63.

Normal Values

White cell count

Neutrophils
Lymphocytes

Biochemistry
Protein
Glucose

(x 106 /L)

(x 106/L)

(g/L)

(CSF:blood ratio)

< 0.4

0.6 (or 2.5

mmol/L)

Normal
(>1 month of
age)

Normal neonate
(<1 month of
age)

< 20

<1.0

0.6 (or 2.5

mmol/L)

The presence of any neutrophils in the CSF is unusual in normal children and should raise
concern about bacterial meningitis
Meningitis can occur in children with normal CSF microscopy.
If it is clinically indicated, children who have a normal CSF should still be treated with IV
antibiotics pending cultures.
CSF white cell count and protein level are higher at birth than in later infancy and fall fairly
rapidly in the first 2 weeks of life. In the first week, 90% of normal neonates have a white cell
count less than 18, and a protein level < 1.0 g/L.

Interpretation of abnormal results

White cell count

Biochemistry
Glucose
Protein

Neutrophils

Lymphocytes

(x 106 /L)

(x 106/L)

(g/L)

(CSF:blood
ratio)

< 0.4

0.6 (or 2.5

mmol/L)

0*

< 20

< 1.0

0.6 (or 2.5

mmol/L)

> 1.0

< 0.4
(but may be
normal)

10-1000

(but may be
normal)
0.4-1

(but may be
normal)
50-1000

(but may be
normal)
1-5

Usually normal

(but may be
normal)

(but may be
normal)

(but may be
normal)

Normal
(>1 month of
age)
Normal term
neonate
Bacterial
meningitis

Viral meningitis

TB meningitis

100-10,000
(but may be
normal)
Usually <100

Usually <100

Usually < 100

< 0.3

* Some studies have found up to 5% of white cells in neonates without meningitis comprise
neutrophils

Gram stain may be negative in up to 60% of cases of bacterial meningitis

even without prior antibiotics.
Neither a normal Gram stain, nor a lymphocytosis excludes bacterial
meningitis.

Neutrophils may predominate in viral meningitis even after the first 24 hours.

CSF findings in bacterial meningitis may mimic those found in viral meningitis
(particularly early on). It may be possible with modest accuracy to judge
whether bacterial or viral is more likely based on CSF parameters. However
if the CSF is abnormal the safest course is to treat as if it is bacterial
meningitis.

Other factors affecting results

Antibiotics prior to lumbar puncture
Prior antibiotics usually prevent the culture of bacteria from the CSF.
Antibiotics are unlikely to significantly affect the CSF cell count or
biochemistry in samples taken <24 hours after antibiotics.
Seizures
Recent studies do not support the earlier belief that seizures can increase cell
counts in the absence of meningitis.
It is safest to assume that seizures do not cause an increased CSF cell count.
Traumatic tap
Some guidelines suggest that in traumatic taps you can allow 1 white blood
cell for every 500 to 700 red blood cells and 0.01g/L protein for every 1000
red cells. However rules based on a predicted white cell count in the CSF are
not reliable.
In order not to miss any patients with meningitis, guidelines relating to
decisions about who not to treat for possible meningitis need to be
conservative. The safest interpretation of a traumatic tap is to count the
total number of white cells, and disregard the red cell count. If there
are more white cells than the normal range for age, then the safest option is
to treat.

Additional tests

PCR

PCR is routinely available for Neisseria meningitidis, Herpes Simplex and

Enterovirus.
As results are not immediately available, they will only help with decisions
concerning discontinuing treatment.

Enterovirus PCR should be requested on CSF from patients with clinical and/or
CSF features of viral meningitis.

HSV PCR should be requested for patients with clinical features of

encephalitis.

Meningococcal PCR is particularly useful in patients with a clinical

picture consistent with meningococcal meningitis, but who have
received prior antibiotics.

Bacterial antigens
CSF bacterial antigen tests have low sensitivity and specificity.
They should therefore never influence treatment decisions and have
little role if any in current management.
Please remember to read the disclaimer.

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Jika mungkin, pastikan diagnosis dengan pungsi lumbal dan
pemeriksaancairan serebrospinal (CSS). Jika CSS keruh dan reaksi Nonne dan
Pandypositif, pertimbangkan meningitis dan segera mulai berikan
pengobatansambil menunggu hasil laboratorium. Pemeriksaan mikroskopik
CSS padasebagian besar meningitis menunjukkan peningkatan jumlah sel
darah putih(PMN) di atas 100/mm3. Selanjutnya dilakukan pengecatan Gram.
Tambahaninformasi bisa diperoleh dari kadar glukosa CSS (rendah: < 1.5

mmol/liter),protein CSS (tinggi: > 0.4 g/l), dan biakan CSS (bila
memungkinkan).Jika terdapat tanda peningkatan tekanan intrakranial, tunda
tindakan pungsilumbal tetapi tetap lakukan pengobatan.

Penyebab spesifk meningitis

Pertimbangkanmeningitistuberkulosisjika:
o Demam berlangsung selama 14 hario Demam timbul lebih dari 7 hari dan
a d a a n g g o t a k e l u a r g a ya n g m e n - d e r i t a T B
oHasilfotodadamenunjukkanTB
o Pasien tetap tidak sadar o CSS tetap mempunyai jumlah sel darah putih
yang tinggi (tipikal < 500sel darah putih per ml, sebagian besar berupa
limfosit), kadar protein
meningkat(0.8
4g/l)dankadarguladarahrendah(<15mmol/liter).
PadapasienyangdiketahuiataudicurigaimenderitaHI
V-po s i ti f, p er lu pu la
d i p e r t i m b a n g k a n a d a n ya T B a t a u m e n i n g i t i s k r i p t o k o k a l .
Bilaadakonfirmasiepidemimeningitismeningokokald
anterdapatpetekie
atau purpura, yang merupakan karakteristik infeksi meningokokal,
tidakperlu dilakukan pungsi lumbal dan segera berikan Kloramfenikol
Tatalaksana
Antibiotik
Berikan pengobatan
antibiotik lini pertama
sesegera mungkin.
oseftriakson:100mg/kgBBIV-drip/kali,selama30-60menitsetiap
12 jam; atau
osefotaksim:50mg/kgBB/kaliIV,setiap6jam.
Pada pengobatan
antibiotik lini kedua
berikan:
oKloramfenikol:25mg/kgBB/kaliIM(atauIV)setiap6jamoditamba
hampisilin:50mg/kgBB/kaliIM(atauIV)setiap6jam

Jika diagnosis sudah pasti, berikan pengobatan secara parenteralselama sedikitnya

5 hari, dilanjutkan dengan pengobatan per oral 5 haribila tidak ada gangguan
absorpsi. Apabila ada gangguan absorpsi makaseluruh pengobatan harus diberikan
secara parenteral. Lama pengobatanseluruhnya 10 hari.Jika tidak ada perbaikan:Pertimbangkan komplikasi yang sering terjadi seperti efusi subduralatau abses
serebral. Jika hal ini dicurigai, rujuk.- Cari tanda infeksi fokal lain yang mungkin
menyebabkan demam,seperti selulitis pada daerah suntikan, mastoiditis, artritis,
atau

Pemeriksaan None-Pandy
Posted on February 15, 2009 by Yayan_Akhyar | 9 Comments

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Pemeriksaan None-Pandy
-

Test Nonne
Percobaan ini juga dikenal dengan nama test Nonne-Apelt atau test RossJones, menggunakan larutan jenuh amoniumsulfat sebagai reagens (ammonium
sulfat 80 gr : aquadest 100 ml : saring sebelum memakainya). Test seperti dilakukan
di bawah ini terutama menguji kadar globulin dalam cairan otak.
Cara :
1. Taruhlah 1 ml reagens Nonne dalam tabung kecil yang bergaris tengah
kira-kira 7 mm.
2. Dengan berhati-hati dimasukkan sama banyak cairan otak ke dalam tabung
itu, sehingga kedua macam cairan tinggi terpisah menyusun dua lapisan.

3. Tenangkan selama 3 menit, kemudian selidikilah perbatasan kedua cairan itu.

Catatan :
Seperti juga test Pandy, test Nonne ini sering dilakukan sebagai bedside test pada
waktu mengambil cairan otak dengan lumbal pungsi. Dalam keadaan normal hasil
test ini negative, artinya : tidak terjadi kekeruhan pada perbatasan. Semakin tinggi
kadar globulin semakin tebal cincin keruh yang terjadi. Laporan hasil test ini
sebagai negative atau positif saja. Test Nonne memakai lebih banyak bahan dari
test Pandy, tetapi lebih bermakna dari test Pandy karena dalam keadaan normal
test ini berhasil negative : sama sekali tidak ada kekeruhan pada batas cairan.

Test Pandy
Reagen Pandy, yaitu larutan jenuh fenol dalam air (phenolum liquefactum 10
ml : aquadest 90 ml : simpan beberapa hari dalam lemari pengeram 37 oC dengan
sering dikocok-kock) bereaksi dengan globulin dan dengan albumin.
Cara :

1. Sediakanlah 1 ml reagens Pandy dalam tabung serologi yang kecil bergaris

tengah 7 mm.
2. Tambahkan 1 tetes cairan otak tanpa sedimen.
3. Segeralah baca hasil test itu dengan melihat derajat kekeruhan yang terjadi.
Catatan :
Test Pandy ini mudah dapat dilakukan pada waktu melaukan punksi dan
memang sering dijalankam demikian sebagai bedside test. Dalam keadaan normal
tidak akan terjadi kekeruhan atau kekeruhan yang sangat ringan berupa kabut
halus. Sedemikian tinggi kadar protein, semakin keruh hasil reaksi ini yang selalu
harus segera dinilai setelah pencampuran LCS dengan reagen ini. Tidak ada

kekeruhan atau kekeruhan yang sangat halus berupa kabut menandakan hasil
reaksi yang negatif.