Cerebrospinal Fluid

CEREBROSPINAL FLUID

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Types of Fluids
Transudate
is fluid pushed through the capillary due
to high pressure within the capillary

Exudate
is fluid that leaks around the cells of the
capillaries caused by inflammation.

TRANSUDATES

Decrease plasma albumin

Increase venous pressure
Increase venous obstruction
Cardiac failure
Disturbance of circulation with
passive congestion and edema

EXUDATES
Damage of mesothelial linings

CLINICAL CONDITIONS
Transudates
Hypoproteinemia
Congestive heart failure
Liver cirrhosis

Exudates

TYPES OF EXUDATES

Serous
Fibrinous
Serofibrinous
Purulent
Hemorrhagic
Putrid
Chylous
Serosanguinopurulent

Diffrences

Transudates

Exudates

Origin

Non-inflammatory

Inflammatory

pH

Alkaline

Acidic

Specific gravity

<1.015/<1.018

>1.015.>1.018

Coagulation

No clot

Clot formation present

Protein

<3.0 grams

>3.0 grms

Glucose

Same with blood glucose

Lower than blood glucose

LDH

<200 IU/L

>200 IU/L

Chloride

Lower than blood chloride

Higher than blood chloride

Cells

Lymphocytes(rare)

Neutrophil (PMN)

Crystals

absent

Present

Cerebrospinal Fluid

CEREBROSPINAL FLUID
( liquor cerebrospiralis)
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Brief history
Robertson claims that
CSF came from
amniotic fluid by
conversion of the
colloidal molecules
throughout the
embryonic life.
Domenico Felice Cotugno
( 1764)
The third major fluid of
the body.

The Flow of CSF

Importance :

Acts as a mechanical buffer

Serves as an excretory channel
Serves as a nutrient to the brain

Importance of CSF Analysis

To detect infection & to differentiate

meningitis
To detect CNS disorders
To detect subarachnoid block

Method of Collection
1. Lumbar
puncture
Site
- lumbar 3
&4
(adults)
- lumbar 4 &
5 (children)

Lumbar Puncture

Cisternal Puncture
Recommende
d in cases
of paralysis
and
meningitis

Ventricular Puncture
For infants

The Needle

Tubes
1st tube = chemistry
and serology
2nd tube =
microbiology
section
3rd tube =
hematology section
4th tube = additional
test

Macroscopic Examination
Volume: 140 170 mL
pH: 7.3 7.45(7.31)
Sp.grav.: 1.006 1.008
Pressure: 50-200mmH2O(90-180)

10-100 mm H2O
Colorless

Coagulation

Variations in Color
Turbid
Causes: WBCs

RBCs

microorganisms

proteins
Bloody
Cause: RBCs

Xantochromic(pale pink to
orange,yellow)
Causes:
Hgb.
-old hemorrhage,lysed rbc

Bilirubin
-RBC breakdown
Protein
- Rbc breakdown

Melanin
-Meningeal
melanosarcoma

Grayish/Greenish

Cause:
increase pus cells
-acute

meningitis

DIFFERENTIATING SUB-ARACNOID BLOCK

FROM TRAUMATIC TAP

SUB-ARACNOID
BLOCK
Even distribution
of blood
Clot formation
Presence of
siderophage
Quekensted test

TRAUMATIC TAP
Uneven
distribution of
blood
No clot
No siderophage
D-dimer (-)

Quekensted test ( Tobey-Ayer test)

Method used
to detect subarachnoid
block
Done by
comprising the
internal
jugular vein

CHEMICAL EXAMINATION OF CSF

Protein
Normal value: 15-45mg/dl
Increase CSF protein may be found in
:
Infections, meningitis, multiple
sclerosis, hemorrhage

Qualitative test

Ross Jones
Nonne apelt
Pandys test
Noguchis test

Quantitative Test

Turbidimetric method
Nephelometric method
Dye binding technique
Biuret method

Glucose In CSF
Normal value 50 -80 mg/dl
Increase in :
diabetes mellitus
Infectious encephalitis
Decrease in :
Hypoglycemia
Pyogenic meningitis
Fungal miningitis
Toxoplasmosis
Sub arachnoid hemorrhage
Primary tumor of the brain

Comparison
Bacterial
meningitis

Viral
meningitis

Tubercular
meningitis

Glucose

decrease

normal

Decrease

Cells

PMN

lymphocytes lymphocytes

Chlorides
Normal value: 113-127 MEQ/L
Tests:
Schales & Schales
Cotlove chloridometer

Lactate
Normal vaule :
Newborn; 10-22 mg/dl (1.1 to 6.7
mmol/L)
Older children & adults 9.0 -26
mg/dl(1.0 2.9 mmol/L)
As adjuct to detect viral from bacterial,
mycoplasma ,tuberculous, and fungal
meningitis
Methods: automated analyzers

Glutamine
Normal value: 8 to 18 mg/dL
Reflects brain ammonia (ammonia +
a-ketoglutarate)
In cases of coma of unknown origin

CSF Enzymes
Lactate Dehydrogenase(LDH)
UPPER LIMIT: 40 U/L

70 U/L
Isoenzymes:
LD1 and LD2 - produce by the brain cells
LD2 and LD3 produced by the
lymphocytes
LD4 and LD5 produced by the
neutrophils

Creatine Kinase
Normal value: <5 U/L

<17 mg/mL

CK-BB- brain is the isoform

CK-MM- muscles is the isoform
CK-MB
brain and muscles is the isoform

Parameters

Bacterial

Viral

WBC
count

Elevated/N
eutrophils

Elevated/lymp Elevated/lym Elevated/

hocytes
phocytes
lymphocytes
&monocytes and
monocytes

Protein

Marked
increase

Moderate
increase

Modeerate to
marked
increase

Moderate to
marked
increASE

Glucose

Marked
decrease

Normal

Decrease

Normal or
decreased

Lactate
Other
tests

Increase

Normal

Increase

Increased

Pellicle
formation

(+) India ink

for
cryptococcus

M.
Tuberculosis

C.
neoformans

Common
agents

(+) Limulus
lysates with
gram(-) org
Enteroviruses
80%

Tubercular

Fungal

Note:
CSF leakage
usually present as Otorrhea or Rhinorrhea

Electrophoresis-Agarose gel
electrophoresis of concentrated CSF
widely used to look for CSF Oligo Clonal
bonds
CSF-Oligo Clonal bonds= 83%-94%of
patient with definite multiple sclerosis

Serologic Examination
CEA metastatic carcinoma
hCG choriocarcinoma and germ cell
tumors
CSF ferritin CNS malignancy,
patients with inflammatory disease

Microbiologic Examination
1. Staining
1. Gram stain most important, differentiates
bacterial pathogens
2. India ink C. neoformans and otheer fungi
3. Acid fast stain tuberculous agents
4. Auramine-Rhodamine stain tuberculous
agent
5. Acridine orange diferentiate amoeba
(brick red0 from leukocytes (bright green)

2. 2. Culture

Immunologic tests
1.Counterimmunoelectrophoresis
1.Limited for the detection and
identification of:
1.H. influenzae 1 month to 5 years
2.S. pneumoniae 29 yrs and older
3.N. meningitidid 5 to 29 yrs old
4.E. coli
5.Group B Streptococci

Agglutination tests
1.Latex Agglutination tests
For bacterial antigen tests (BATs), for
C. neoformans

2.ELISA

Limulus lysate Assay

1.For detection of
the presence of
endotoxin

Assignment:
1. What is PAM?

a. Causative agent
b.Pathogen (cause of infection)
c. Diagnosis and Detection
d. Treatment

CSF cell count (Refrence range for adult and

children)
Abnormal wbc/rbc count in the following:(specific)

encephalitis
meningitis
lymphoma in the brain
stroke

multiple sclerosis
cerebral aneurism
neurosyphilis
delirium

THANK YOU!