Lab4: Cerebral spinal fluid (CSF)

Faisal Klufah
M.S.H.S, MLS(ASCP)
Body fluid counts and Morphology: a
Pediatric Perspective

Please read this article posted on

blackboard
Why is CSF important to
study?
Third major fluid of the body

What are the other two?

Physiology & Function
Anatomy & Physiology
brain & spinal cord covered by three
membranes: dura mater, arachnoid mater,
pia mater
CSF occupies subarachnoid space

Functions
protective cushion for nervous tissue
move metabolic wastes
circulation of nutrients to nervous tissue
 Anatomical view
of brain and
meninges

http://www.nfra.net/images_templ/CsfHead2.gif
 Anatomy of spinal
Chord and meninges

http://www.emory.edu/ANATOMY/AnatomyManual/back.html
CellsCells
from choroid
from choroid plexus plexus

May be found
in CSF
cytospin
CSF Formation
ventricular choroid plexus of brain
Produces 2/3 of CSF
About 20 mls/hr
absorption of CSF occurs through the
arachnoid villi to maintain volume
Only 20% of CSF in ventricles at one time
Filtration of Substances
Endothelium of capillaries in contact
w/CSF regulate passage of molecules

Blood-brain barrier: control and filtration

of blood components to the CSF and
then to brain
How much CSF is collected
Dependent on age of person and CSF
pressure
adults: 140-170 ml
neonates: 10-60 ml

Every 24 hours 50-500ml of CSF

produced and total volume replaced 3-4
times /day
 Comparison of CSF to plasma
Constituent CSF plasma
Protein 15-45 mg/dl 6-8 g/dl
Glucose 45mg/dl or higher 70-110 mg//dl

Questions:
If the blood glucose is high what happens to CSF glucose?

What is the biggest difference between CSF protein and

Plasma protein?
Indications for Lumbar
puncture
Meningitis infections
Subarachnoid hemorrhage
Neurologic disease MS
Malignancy
Tumor
Chemotherapy
Specimen Collection
Lumbar puncture at L3, L4, or L5
Sterile kit used for aseptic collection
pressure reading done before fluid
withdrawn
normal adult 70-150 mmHg
can remove up to 20 ml CSF

Three-Four samples of 2ml each put

into tubes marked 1,2,3,4
1-Chem, 2-Micro, 3-Heme, 4- other
 CSF and Intracranial Pressure
Since CSF enclosed in rigid skull, if
volume of one increases, others must
decrease or ICP rises
See website below for video on how
CSF pressure measured

http://meds.queensu.ca/courses/assets/modules/lumbar_puncture/
Causes of CSF Pressure
Changes
Increased
Congestive heart failure
Meningitis
Thrombosis
Mass lesion, tumor, abscess
Cerebral edema
Decreased
CSF leakage
Spinal-subarachnoid block
Circulatory collapse
Gross Exam
Appearance: clear, colorless
record total volume from all tubes
Cloudy, turbid: presence of bacteria,
WBCs
Bloody: hemorrhage or traumatic tap
even distribution of cells?
color of supernatant?

Xanthochromia: pale orange or yellow

Cell count
Manual cell count using hemacytometer
Dilution not necessary if clear
Count RBCs and WBCs separately at same
time
Count all nine large squares
Total cell count dilutions are made using
normal saline
For WBC, lyse RBCs using 3% acetic acid
Normal values
0-5 WBC/l in adults
0-30 mononuclear cells/l in children
# of cells X dilution X 10 = cells/l
area
Cytocentrifugation
Concentrating method that yields
maximum number of cells with
morphology intact
Fluid portion of specimen absorbed on
filter paper
Cellular material concentrated in
monolayer within 6mm circle on
microscope slide
CSF Cell Identification
Red blood cells Plasma cells
Neutrophils Malignant cells
Eosinophils Blasts
Lymphocytes Tumor cells
Monocytes
Macrophages
Lymphocytes

Erythrophage

Segmented neutrophils
Chemical analysis
Protein
CSF contains <1% of plasma
(Normal =15-45mg/dl)
Elevated protein most pathologic finding
Total Protein
Turbidimetric (SSA,TCA), colorimetric (biuret)
CSF/serum albumin Index
CSF albumin (mg/dl)
Serum albumin (g/dl)
Index values <9 = intact blood-brain barrier
CSF protein, cont
IgG index
CSF IgG(mg/dl)/serum IgG(g/dl)
CSF albumin(mg/dl)/serum albumin(g/dl)
Measures intrathecal production of IgG
Normal = 0.5; values exceeding 0.77 suggest
increased IgG synthesis (90% MS pts)
Protein electrophoresis
protein fractionation
detection of oligoclonal bands(two or more
discrete bands in gamma region)
CSF chemical analysis, cont.
Myelin Basic protein
Indicative of recent destruction of myelin sheath
assists in early diagnosis of multiple sclerosis and
follow of disease
Glucose
Enters CSF by active transport and diffusion
Normally 70% of plasma level
decreased due to bacterial, tuberculous, fungal
meningitis
CSF chemical analysis cont.
Lactate
Source is anaerobic metabolism in the CNS so
Independent of blood lactate
Any condition associated with tissue hypoxia may
cause increased CSF lactate
Glutamine
Synthesized by brain from ammonia & glutamic
acid
Indirectly reflects CNS ammonia level
increased CSF glutamine can be seen in Reyes
syndrome and hepatic encephalopathy
Microbiologic exam
Culture to identify causative agent
Gram stain for rapid information for
treatment
India Ink: to detect cryptococcus
neoformans
Acid fast stain: Mycobacteria
Limulus lysate: detects endotoxin
produced by gnb
India Ink Prep

Gram stain
Immunologic tests
Tests for neurosyphilis
Reactive VDRL diagnostic
FTA-ABS

Latex agglutination
Series of reagents containing latex
particles sensitized to purified antigen
fractions, H. influenza, S. pneumoniae, N.
meningitidis, E. coli
 Clinical correlations
Bacterial Tubercular Viral
WBC>50,000 increased mild to
neutrophils lymphs severe
glucose dec. glucose dec. glucose norm
lactate inc. lactate inc. lactate norm
H.influenza Mycobacteria Enterovirus
N. men.
S.pneumo