Cerebrospinal Fluid

Physiology

Specimen Collection
 Collected by lumbar puncture between the third, fourth, or fifth lumbar vertebra.
 Volume is depending on the availability of the patient and opening pressure.
 STAT basis, highly contagious (use gloves and capped tubes for centrifugation)

Tube 1 (Freezer) Chemical and serologic tests (least affected by

blood or bacteria)
Tube 2 (Room temperature) Microbiology
Tube 3 (Refrigerator) Hematology - cell count (least likely to contain
cells)
Tube 4 Microbiology laboratory to better exclude skin
contamination or for additional serologic tests
 If only one tube can be collected: tube 1 = microbiology
 Check for cellular contamination by the puncture: cell counting at Tubes 1 and 4

Appearance
 Normal: Crystal clear
 Cloudy, turbid, or milky specimen: increased protein or lipid concentration; infection

Appearance Cause Major Significance

Crystal clear Normal

Hazy, turbid, WBCs Meningitis

milky, cloudy
Microorganisms Meningitis

Protein Disorders affecting blood–brain

barrier

Production of IgG within the

CNS
Oily Radiographic contrast media

Bloody RBCs Hemorrhage

Traumatic tap
Xanthochromic Hemoglobin Old hemorrhage
Lysed cells from traumatic tap
Bilirubin RBC degradation
Elevated serum
bilirubin level
 Carotene Increased serum
Levels
Protein Disorders affecting
blood–brain
barrier
Melanin Meningeal
melanosarcoma
Clotted Protein Disorders affecting blood–brain
barrier
Clotting factors Introduced by
traumatic tap
Pellicle Protein Disorders affecting blood–brain
barrier
Clotting factors Tubercular meningitis

Xanthochromia
 RBC degradation products
 Term used to describe CSF supernatant that is pink, orange, or yellow
 Occurs 4 to 5 hours after subarachnoid hemorrhage, clears approx. 3 weeks after the event
Pink Oxyhemoglobin
Orange Heavy hemolysis
Yellow Conversion of
oxyhemoglobin to
unconjugated bilirubin

 Other causes: elevated serum bilirubin, the presence of the pigment carotene, markedly increased
protein concentrations, and melanoma pigment.

Traumatic Tap Subarachnoid Hemorrhage

(Non-pathological) (Pathological)
Distirbution of blood Uneven Even
Clot formation Positive / clumped RBC Negative
Supernatant Clear and colorless Xanthochromic
Microscopic examination (+) erythrophagocytes
D-dimer test (+) fibrin degradation (latex
agglutination immunoassay)
Others >500 RBC for every WBC

 Coagulation factors also cause clot formation but do not usually produce a bloody fluid.
Examples: meningitis, Froin syndrome, and blocked CSF circulation through the
subarachnoid space.
 A classic web-like pellicle is associated with tubercular meningitis and can be seen after
overnight refrigeration of the fluid.
Counting

Cellular Constituents
 Adults: lymphocytes to monocytes (70:30) ratio
 Children: Higher
 Abnormal: pleocytosis