CEREBROSPINAL FLUID TYPES


OF PUNCTURE:
LUMBAR PUNCTURE
 CISTERNAL PUNCTURE
 3rd major fluid of the body  VENTRICULAR PUNCTURE
 Clear, colorless fluid
 Dialysate from the blood INDICATIONS FOR LUMBAR PUNCTURE
 Does not resemble a plasma ultrafiltrate
 Major constituents are: Suspected inflammation
- Protein  Meningitis
- Glucose  Encephalitis (neurosyphilis)
- Chloride  Brain abscess
 Subarachnoid hemorrhage
LOCATION OF THE FLUID  Leukemia in CNS
 Multiple sclerosis
 INTERNALLY  Spinal cord tumor
- ventricular fluid
- cisternal fluid Differential diagnosis
- spinal cord canal fluid  Cerebral infarct VS. Intracerebral hemorrhage
 EXTERNALLY
- between the pia and arachnoid membranes Introduction of radiographic dyes & drugs
 Anesthetics
PHYSIOLOGY AND SOURCES OF CSF:  Contrast media
 Methotrexate (Meningeal leukemia)
 Formed in the highly vascular choroids plexuses  Amphotericin (Fungal meningitis)
 Ventricles of the brain
 Secreted by the ependymal cells lining the ventricle Treatment
 Enters the subarachroid space through the Foramen  For patients with benign intracranial hypertension
of Lushcka and Magendie
 Enters venous blood through arachnoid villi of the EMERGENCY LUMBAR PUNCTURE
dural sinuses  Suspected meningitis
 Subarachnoid hemorrhage
CEREBROSPINAL FLUID  Leukemia in CNS

 NORMAL RATE OF CSF FORMATION COMPLICATIONS OF LUMBAR PUNCTURE:

- 500cc/day or 20 cc/hr
 NORMAL CSF volume of a healthy person Herniation
- 150 cc/day  Uncus through cerebellar tonsils, Foramen of
 Spinal canal Magnum
- 70cc
 Subarachnoid space Progressive paresis & paralysis
- 60cc  Increase intracranial pressure
 Ventricles  With spinal cord tumor
- 20cc
Paraplegia
FUNCTIONS OF THE FLUID  Result of extradermal or subdural hematoma on
patients with clotting defects (thrombocytopenia)
 Protection of the brain from injury by acting as a
fluid buffer Meningitis
 Acts as a medium of exchange for the transfer of  Presence of sepsis
dialyzable material between the blood stream and  Perforation of meninges
the spinal cord
 Equalizes the pressure between the brain and the Asphyxia (infants)
spinal cord  Excessive restraint
 Serves as an excretory channel in the elimination of  Tracheal obstruction
products of nervous metabolism
Epidermoid tumors
BARRIER CONCEPTS IN CSF  No stylet is used
 Period of development is 2-10 years
 Regulate inflow & outflow of fluid and ions
 Blood-CSF Barrier: between subarachnoid space & Introduction to infection
pia mater  Passing of needle superficially in lumbar region
 CSF-Brain Barrier: subarachnoid space, pia mater  Deep sepsis
& brain surface
 Blood-Brain Barrier: between pia mater & brain Post lumbar puncture headache / Spinal headache
 Resulting from leakage of CSF
BLOOD-CSF BARRIER opened reversibly by:
COMPOSITION OF NORMAL SPINAL FLUID
 Acute hypertension
 Seizures Glucose Urea
 Hypercapnea Sodium Potassium
 Radiograph dyes Phosphorus, inorganic Uric Acid
Chlorides PCO2
COLLECTION OF THE FLUID HCO3 Total protein
 Fibrinogen – none Prealbumin GRADING OF TURBIDITY
Albumin Alpha – globulin
Alpha 2 – globulin Beta and tetraglubin 0 - Crystal clear
Gamma globulin Calcium (lumbar) 1- Faintly cloudy, smoky, hazy, slight (barely visible) turbidity
Magnesium Creatinine 2 - Turbid but newsprint readable
Glutamic oxalacetic Lactic dehydrogenase 3 - Newsprint not readable
transaminase 4 - Newsprint cannot be seen
Phosphohexose isomerase
CAUSE OF TURBIDITY
MACROSCOPIC OR PHYSICAL EXAMINATIONS
 Leukocytes
 Amount  Erythrocytes
 Pressure  Microorganisms
 Color  Increase protein or glucose
 Transparency
 Coagulation CLINICAL SIGNIFICANCE OF CSF APPEARANCE
 Reaction
 Specific gravity

CHEMICAL EXAMINATION

 PROTEINS GLOBULIN QUALITATIVE TESTS

 GLUCOSE
 CHLORIDE
 ALBUMIN – GLOBULIN RATIO TEST – LANGE’S
COLLOIDAL GOLD TEST

Other Tests for CSF:

 Borowskaja’s Modification of Lange’s Test

 Mastic Test
 Alkaline – Saline Solution
 Colloidal Benzoin Test
 Turbidity Test
 Tryptophan Test
 Automated Tests

XANTHOCHROMIA

 ABNORMAL CSF COLOR

 Normal in premature infants
 Pigments contributing to xanthochromia:
- Pink: Methemoglobin / Oxyhemoglobin
- Yellow: Bilirubin
- Increase CSF Protein: Froin syndrome-yellow
color H CHON
- Antiseptic contamination: Iodine
SAMPLE COLLECTION OF CSF
- Carotenoids: Systemic hypercarotemia
- Melanin: Meningeal melanosarcoma
BOTTLE #1 - CHEMISTRY & SEROLOGY

left to right: normal, xanthochromic, hemolyzed, cloudy
Traumatic tap VS. Subarachnoid hemorrhage
- With clotting
- 1st bottle: bloody
- 2nd bottle: clear
- 3rd bottle: clear
- With xanthochromia
- No clotting
- 1st bottle: bloody
- 2nd bottle: bloody
- 3rd bottle: bloody
- With xanthochromia
 Glucose
 Total proteins
- Qualitative tests
 Lange Colloidal Gold test
 Pandy’s test
- Electrophoresis
- Myelin Basal reaction or C-Reactive Protein
 Normal values:
- Albumin: 10-30 mg/dl
- Calcium: 2.7-3.1 meq/L
- Cell count: 0-5 cells/uL
- Chloride: 110-132 meq/L
- Glucose: 50-80 mg/dL
- Protein
 Total CSF Protein: 15-45 mg/dL
 Ventricular CSF Protein 5-15 mg/dL
 Xanthochromia: Negative
Immunologic studies:
 CSF FTS-ABS Treponemal (Fluorescent
Treponemal Antibody Absorption Test): for
neurosyphilis
  VDRL Non-Treponemal (Venereal Disease
Research Laboratory)
 ELISA (Enzyme-Linked Immunosorbent Assay)
 Latex Agglutination: Cryptococcal antigen
 Millipore / Nucleopore filter techniques

BOTTLE # 2 - MICROBIOLOGY

 Gram stain: bacterial contamination or meningitis

 India ink preparation: fungal meningitis
 Acid fast stain: Tubercular meningitis INDIA INK & GRAM STAIN (Starburst pattern)
 Culture C. neoformans
BOTTLE # 3- CELL & DIFFERENTIAL COUNT

CSF WBC Count

 WBC added = WBC blood X RBC CSF

RBC blood
 CSF Proteins
 Differential Count
- Centrifugation with Wright’s stain & re-suspend
sediment
- Sedimentation methods
- Cytocentrifuge & related methods

CSF CONSTITUENTS IN DISEASES:

Broad spectrum of lymphocytes and monocytes in viral

meningitis