CEREBROSPINAL FLUID ANALYSISI Nyoman Wande

Clinical Pathology DepartmentMedicine School of Udayana University

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PRODUCE OF CSFProduced at choroid plexus of ventricel walls (70%) , ependymal cells of ventricel & cerebral subarachnoid500 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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VOLUME CSFAdult : 120-180 mL8-10 years : 100-140 mLInfant (-28 days): 40-60 mLNeonatus premature : 20 30 mL**

COMPOSITION OF CSF

Protein (

FUNCTION OF CSFMECHANICAL FUNCTIONShock absorben prevent to shakyLubbricant, between brain-skull; medullaspinalis- columna vertebraeCONTROL TO VOLUME (PRODUCTION)As the filler of space due to atrophic region or decrease volume production if space occupying lession happenedTRANSPORT FUNCTIONTo clean/wash the brain from metabolite & toxic agent & than excreted Transport food to cells of CSF

INDICATION OF LPAlways check the papilledema before attempting lumbar puncture (funduscopie)DiagnosisConvulsion, Paresis / Paralyse, ComaGreat Fontanel : bulgingNeck stiffnes + altered consciousness Milliary TB , LeukemiaIntra cranial pressure (ICP) increasedTherapyTo increased ICP (Hydrocephallus)Direct Th/. intratecalFollow up th/.

CONTRA INDICATION of LPICP : brain tumor (angulus pontocerebeller, infratentorial, V. III)Danger herniated brain to foramen magnum before LP funduscopie.Infection at location of LPIntracranial bleeding Hemorrhagic strokeBrain abscess Septic conditons

Specimen CollectionLumbar 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 LPSEATED POSITIONLYING POSITION

CSF STORAGE CSF should be analysed immediately (i.e.

CSF ANALYSISMacroscopicMicroscopicMicrobiologyChemistriesSerologyPCR

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Recommended Laboratory Test on CSFRoutineOpening CSF PressureTotal cell countDifferential cell count (stained smear)Glucose (CSF/plasma ratio)ProteinUseful in certain circumstancesCultures (bacteria, fungi, viruses, Mycobacterium tuberculosis)Stains (Grams stain, acid-fast stain)Fungal and bacterial antigensPolymerase chain reaction (TB, viruses)CytologyProtein electrophoresisVDRL test for syphilisFibrin-derivative D-dimer

CSF MacroscopicTurbidity / cloudypHSpecific Gravity (SG)ColorSedimentPelliclePressure

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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 bloodyClotting of CSF is abnormal and indicates increased protein or fibrinogen levels

TURBIDITY / CLOUDY : Opalescent Turbid HemorrhagePresent of inflamation cells, bacteria, or fungi Cells (400-600/cmm pleocytosis)Pleocytosis in clear CSF Meningitis TBCTabes dorsalisPoliomyelitisMeningitis luetica

pH : normal : alkalisSG : 1.003 1.008COLOR : clear & colorlessXanthochromia:subarachnoid hemorrhage, traumatic LP, delayed processing of sample, jaundice (especially bilirubin > 4 mg/dL), protein > 150 mg/dL, presence of carotene pigmentRed: artificial bleeding, subarachnoid bleedingBrown: long time bleeding + hemolysisGray: leukocyte (purulent inflamation)Green: meningitis meningococcen

PELLICEL

Normally : formed if CSF allow 24 hours at room temperatureMeningitis purulentaMeningitis TBCPellicel fast formed minute - 1 hour, big form, coarselyPellicel formed after 12-24 hours, form like spider nest

CSF MicroscopicExamination of cells, Total cell count, differential cell count

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CELL COUNTFuchs-Rosenthal chamber (4X4X0,2cmm)Improved Neubauer chamber (3X3X0,1cmm)Dilution: 10/9X (turk reagent)FormulaFuchs-Rosenthal = 1/3N cell/cmmImproved Neubauer = 5/4N cell/cmmNormally = 0-5/cmm Child < 5thn: N < 20/cmm)

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DIFFERENTIAL CELLS COUNTDifferentiated to PMN & MNPMN > MN : purulent, acuteMN > PMN : serous, chronis / reconvalesenceDiff. Count do in smear of CSF, with Wright staining / methylene blueCount of 100 cells, Result report in % of PMN = %, MN = %)**

MiCROBIOLOGY EXAMINATIONDirect smear Culture & Sensitivity testViral isolation**

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CHEMISTRIES ANALYSISProtein QualitativeNone Apelt (Rose-Jones)PandyProtein QuantitativeSSA methodBiuret methodSpecial presumptive test for Dx Meningitis TBCLevinson testTryptophan test4. GlukosaAutoanalyzer

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CHEMICAL ANALYSISqualitative proteinNone Apelt (Rose-Jones)To know elevation of globulin concentrationPrinciple of the test : globulin sedimented in saturated (NH4)2SO4 solutionIn to reaction tube 7mm + 1ml saturated (NH4)2SO4 sol.And than add 0,5 ml CSFAllow for 3 minute + WHITE RING appearing at the juncture of the liquid**

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**

CHEMICAL ANALYSISqualitative proteinPANDY TESTTo know elevation of globulin and albumin concentrationPrinciple of the test: protein sedimented in saturated phenol solution in waterTo a watch glass + 1 ml Pandy reagen, Add 1 drop of CSF cloudiness againts a black bacground indicates increased amount of globulin**

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 SEROLOGYSerology test for sifilis (VDRL)CSF immunoglobulinsSpecific antibodies (measles, rubella, HSV, HIV,CMV, Toxoplasma)**

Average and Range of Cerebrospinal Fluid Protein**

CSF Parameters in some Neurological Disease **

Typical Cerebrospinal Fluid Finding in Various Types of Meningitis**

Learning TaskTrigger 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:Mention the kind of CSF test should be done!Described the location of CSF puncture in this patient!What are the CSF findings in bacterial meningitis? What are the CSF findings in tuberculous meningitis?Mention the differential diagnosis of this patient!

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

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****Lumbar punctureLumbar 3rd and 4th (4th or 5th)Slide 34Slide 34DD BACTERIAL MENINGITIS OR TUBERCULOUS MENINGITIS

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