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CEREBROSPINAL FLUID

ANALYSIS
I Nyoman Wande
Clinical Pathology Department

Medicine School of Udayana University


06/04/15

PRODUCE OF CSF
Produced at
choroid plexus of ventricel walls (70%) ,
ependymal cells of ventricel &
cerebral subarachnoid

500 mL of CSF is formed/day, although

only 90-150 ml is present in the system at any


one time.
Reabsorption of CSF occurs at the arachnoid
villi
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COMPOSITION OF CSF
Protein (<<) : 15-45 mg/dL
Glucose (<) : 60-80% of blood glucose
K+, Ca++, Phosphat, Sulphat (<)
Na+, Cl-, :10-15% higher than blood

by active secretion of choroid


plexus
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FUNCTION OF CSF
MECHANICAL FUNCTION
Shock absorben prevent to shaky
Lubbricant, between brain-skull; medullaspinalis- columna
vertebrae

CONTROL TO VOLUME (PRODUCTION)


As the filler of space due to atrophic region
or decrease volume production if space occupying lession
happened

TRANSPORT FUNCTION
To clean/wash the brain from metabolite & toxic agent & than
excreted
Transport food to cells of CSF

INDICATION OF LP
Always check the papilledema before attempting lumbar
puncture (funduscopie)
Diagnosis
Convulsion, Paresis / Paralyse, Coma
Great Fontanel : bulging
Neck stiffnes + altered consciousness
Milliary TB , Leukemia
Intra cranial pressure (ICP) increased
Therapy
To increased ICP (Hydrocephallus)
Direct Th/. intratecal
Follow up th/.

CONTRA INDICATION of LP
ICP : brain tumor (angulus pontocerebeller,
infratentorial, V. III)
Danger herniated brain to foramen magnum
before LP funduscopie.

Infection at location of LP
Intracranial bleeding Hemorrhagic stroke
Brain abscess
Septic conditons

Specimen Collection
Lumbar puncture (LP) is the insertion of a needle into

the subarachnoid space (the area under the membrane


that surrounds the brain and spinal cord) of the lumbar
(lower back) region for diagnostic or therapeutic purposes.
This allows access to the cerebrospinal fluid (CSF) in
which the brain and spinal cord float.
Although the subarachnoid space can be accessed from
other levels, the lumbar region is most often used as it
allows the needle to be inserted below the end of the
spinal cord.

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Position & site of LP

SEATED POSITION

LYING POSITION

CSF STORAGE
CSF should be analysed immediately (i.e. <1 h)
after collection.
If storage is required for later investigation this can be
done at 48C (short term) or at 20C (long term).
Only protein components and RNA
(after
appropriate preparation) can be analysed from stored
CSF (Good Practice Point).

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CSF ANALYSIS
Macroscopic
Microscopic
Microbiology
Chemistries
Serology
PCR
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Recommended Laboratory Test


on CSF

Routine

Opening CSF Pressure


Total cell count
Differential cell count (stained smear)
Glucose (CSF/plasma ratio)
Protein

Useful in certain circumstances


Cultures (bacteria, fungi, viruses, Mycobacterium tuberculosis)
Stains (Grams stain, acid-fast stain)
Fungal and bacterial antigens
Polymerase chain reaction (TB, viruses)
Cytology
Protein electrophoresis
VDRL test for syphilis
Fibrin-derivative D-dimer

CSF Macroscopic
1. Turbidity / cloudy
2. pH
3. Specific Gravity (SG)
4. Color
5. Sediment
6. Pellicle
7. Pressure
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CSF color and appearance


Normal CSF is crystal clear, with the
appearance and viscosity of water.
Abnormal CSF may appear hazy, cloudy,
smoky, or bloody
Clotting of CSF is abnormal and indicates
increased protein or fibrinogen levels

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TURBIDITY / CLOUDY :
Opalescent
Turbid
1. Hemorrhage
2. Present of inflamation cells, bacteria, or fungi
Cells (400-600/cmm pleocytosis)
4. Pleocytosis in clear CSF
Meningitis TBC
Tabes dorsalis
Poliomyelitis
Meningitis luetica

pH : normal : alkalis
SG : 1.003 1.008
COLOR : clear & colorless
1.

Xanthochromia:

2.

subarachnoid hemorrhage,
traumatic LP,
delayed processing of sample,
jaundice (especially bilirubin > 4 mg/dL),
protein > 150 mg/dL,
presence of carotene pigment
Red : artificial bleeding, subarachnoid bleeding

3.

Brown : long time bleeding + hemolysis

4.

Gray : leukocyte (purulent inflamation)

5.

Green

: meningitis meningococcen

PELLICEL
Normally : formed if CSF allow 24 hours at
room temperature
Meningitis
purulenta
Pellicel fast formed
minute - 1 hour, big
form, coarsely

Meningitis TBC
Pellicel formed after
12-24 hours, form like
spider nest

CSF Microscopic
Examination of cells, Total cell count,
differential cell count

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CELL COUNT
1. Fuchs-Rosenthal chamber (4X4X0,2cmm)
2. Improved Neubauer chamber (3X3X0,1cmm)
3. Dilution: 10/9X (turk reagent)
4. Formula
Fuchs-Rosenthal
Improved Neubauer

= 1/3N cell/cmm
= 5/4N cell/cmm

5. Normally = 0-5/cmm
Child < 5thn: N < 20/cmm)
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DIFFERENTIAL CELLS COUNT


1. Differentiated to PMN & MN
PMN > MN : purulent, acute
MN > PMN : serous, chronis / reconvalesence

2. Diff. Count do in smear of CSF, with


Wright staining / methylene blue
3. Count of 100 cells,
4. Result report in % of
PMN = %,
MN = %)
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MiCROBIOLOGY EXAMINATION
1.
2.
3.

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Direct smear
Culture & Sensitivity test
Viral isolation

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CHEMISTRIES ANALYSIS
1. Protein Qualitative
None Apelt (Rose-Jones)
Pandy

2. Protein Quantitative
SSA method
Biuret method

3. Special presumptive test for Dx Meningitis TBC


Levinson test
Tryptophan test

4. Glukosa
Autoanalyzer
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CHEMICAL ANALYSIS
qualitative protein
None Apelt (Rose-Jones)
To know elevation of globulin concentration
Principle of the test :
globulin sedimented in saturated (NH4)2SO4 solution
In to reaction tube 7mm + 1ml saturated (NH4)2SO4 sol.
And than add 0,5 ml CSF
Allow for 3 minute
+ WHITE RING appearing at the juncture of the liquid

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INTERPRETTION OF NONE APELT TEST


- : No appearing of WR
+ : WR slightly, mixing WR less
+2 : WR clear, mixing opalescent
+3 : WR more clear, mixing turbid
+4 : WR very clear, mixing very turbid

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CHEMICAL ANALYSIS
qualitative protein
PANDY TEST
To know elevation of globulin and albumin
concentration
Principle of the test:
protein sedimented in saturated phenol
solution in water
To a watch glass + 1 ml Pandy reagen,
Add 1 drop of CSF
cloudiness againts a black bacground indicates
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INTERPRETATION OF PANDY TEST

: clear & colorless

+ : Opalescent ~ 50-100 mg% of protein


+2 : Cloudy ~ 100-300 mg% of protein
+3 : Very cloudy ~ 300-500 mg% of protein
+4 : Cloudy like milk and formed
sedimentation ~ > 500 mg% of protein

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CSF SEROLOGY
Serology test for sifilis (VDRL)
CSF immunoglobulins
Specific antibodies (measles, rubella, HSV, HIV,CMV,
Toxoplasma)

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Average and Range of


Cerebrospinal Fluid Protein

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CSF Parameters in some


Neurological Disease

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Typical Cerebrospinal Fluid Finding


in Various Types of Meningitis

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Learning Task
Trigger scenario:
A boy two years old taken by his mother to emergency
department with chief complained fever and convulsion.
His mother also complained cough since 4 days.
Learning task:
1. Mention the kind of CSF test should be done!
2. Described the location of CSF puncture in this patient!
3. What are the CSF findings in bacterial meningitis?
4. What are the CSF findings in tuberculous meningitis?
5. Mention the differential diagnosis of this patient!

Self assessment:
1. How is CSF product ?
2. What is the indication and contraindication of lumbar
puncture ?
3. How to interprete the result of each test ?
4. How to differentiate the red colour of CSF due to the
artificial bleeding and the subarachnoidal bleeding ?
5. How to make 5X dilution of CSF with sodium chloride
0.9%?
6. Procedure collection of CSF?
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