CEREBROSPINAL FLUID

-500 mL of cerebrospinal fluid (CSF) is produced each day (0.3–0.4 mL/min).

-The total adult volume varies from 90 to 150 mL, about 25 mL of which is in the ventricles and the remainder in the subarach- noid space.

-In neonates, the volume varies from 10 to 60 mL.

-Thus, the total CSF volume is replaced every 5 to 7 hours

-An estimated 70% of CSF is derived by ultrafiltration and secretion through the choroid plex- uses.

>The ventricular ependymal lining and the cerebral subarachnoid space account for the remainder.

-CSF leaves the ventricular system through the medial and lateral foramina, flowing over the brain and spinal cord surfaces within the subarachnoid space. CSF
resorption occurs at the arachnoid villi, predominantly along the superior sagittal sinus.

CSF has several major functions:

(1) It provides physical sup- port because a 1500-g brain weighs about 50 g when suspended in CSF;

(2) it confers a protective effect against sudden changes in acute venous (respiratory and postural) and arterial blood pressure or impact pressure;

(3) it provides an excretory waste function because the brain has no lym- phatic system;

(4) it is the pathway whereby hypothalamus releasing factors are transported to the cells of the median eminence;

and (5) it maintains central nervous system (CNS) ionic homeostasis.

SPECIMEN COLLECTION AND OPENING PRESSURE

-may be obtained by lumbar, cisternal, or lateral cervical puncture or through ventricular cannulas or shunts

-A manometer should be attached before fluid removal to record the opening pressure.

>CSF pressure varies with postural changes, blood pres- sure, venous return, Valsalva maneuvers, and factors that alter cerebral blood flow.

>The normal opening adult pressure is 90 to 180 mm of water in the lateral decubitus position with the legs and neck in a neutral position.

>It may be slightly higher if the patient is sitting up and varies up to 10 mm with respiration.

>In infants and young children, the normal range is 10 to 100 mm of water,

>Opening pressures above 250 mm H2O are diagnostic of intracranial hypertension, which may be due to meningitis, intracranial hemorrhage, and tumors

>If the opening pressure is greater than 200 mm H2O in a relaxed patient, no more than 2.0 mL should be withdrawn.

>When an elevated opening pres- sure is noted, CSF must be removed slowly and the pressure carefully monitored.
-Elevated pressures may be present in patients who are tense or straining and in those with congestive heart failure, meningitis, superior vena cava syndrome,
thrombosis of the venous sinuses, cerebral edema, mass lesions, hypoosmolality, or conditions inhibiting CSF absorption. Opening pres- sure elevation may be the only
abnormality in cryptococcal meningitis and pseudotumor cerebri (Hayward et al., 1987). Decreased CSF pressure may be present in spinal-subarachnoid block,
dehydration, circulatory collapse, and CSF leakage. A significant pressure drop after removal of 1 to 2 mL suggests herniation or spinal block above the puncture site,
in which case no further fluid should be withdrawn.

-Up to 20 mL of CSF may normally be removed.

NOTE: Prior to collecting the sample, the clinician should be aware of the quantity of CSF required for the requested tests to ensure that a sufficient sample is
submitted. In addition, the clinician should always provide an appropriate clinical his- tory to the laboratory. The sample site (e.g., lumbar, cisternal) should be noted
because cytologic and chemical parameters vary at different sites. The necessity for a simultaneous serum glucose should also be considered. This is best obtained 2 to 4
hours before lumbar puncture because of the delay in serum-CSF equilibrium.

-The CSF specimen is usually divided into three serially collected sterile tubes:

tube 1 for chemistry and immunology studies;

tube 2 for microbio- logical examination;

and tube 3 for cell count and differential.

An additional tube may be inserted in the No. 3 position for cytology if a malignancy is suspected.

-Glass tubes should be avoided because cell adhesion to glass affects the cell count and differential

-Specimens should be delivered to the labora- tory and processed quickly to minimize cellular degradation, which begins within 1 hour of collection.

-Refrigeration is contraindicated for culture specimens because fastidious organisms (e.g., Haemophilus influenza, Neis- seria meningitidis) will not survive.

-It is also contraindicated for samples in which flow cytometry is likely to be needed for detection of leukemia or lymphoma cells, as refrigeration may affect
expression and/or detection of certain surface antigens on these cells.

INDICATIONS AND RECOMMENDED TESTS

-Indications for lumbar puncture can be divided into four major disease cat- egories:

meningeal infection,

subarachnoid hemorrhage,

primary or metastatic malignancy,

and demyelinating diseases

GROSS EXAMINATION

-Normal CSF is crystal clear and colorless and has a viscosity similar to that of water.

-Abnormal CSF may appear cloudy, frankly purulent, or pigment tinged.

-Turbidity or cloudiness begins to appear with leukocyte (white blood cell [WBC]) counts over 200 cells/μL or red blood cell (RBC) counts of 400/μL.

-However, grossly bloody fluids have RBC counts greater than 6000/μL.
-Microorganisms (bacteria, fungi, amebas), radiographic contrast material, aspirated epidural fat, and a protein level greater than 150 mg/dL (1.5 g/L) may also produce
varying degrees of cloudiness.

Clot formation may be present in patients with traumatic taps, com- plete spinal block (Froin syndrome), or suppurative or tuberculous menin- gitis.

-not usually seen in patients with subarachnoid hemorrhage

-Clots may interfere with cell count accuracy by entrapping inflammatory cells and/or by interfering with automated instrument counting.

Viscous CSF may be encountered in patients with metastatic mucin- producing adenocarcinomas, cryptococcal meningitis due to capsular poly- saccharide, or liquid
nucleus pulposus resulting from needle injury to the annulus fibrosus.

Pink-red CSF usually indicates the presence of blood and is grossly bloody when the RBC count exceeds 6000/μL. It may originate from a subarachnoid hemorrhage,
intracerebral hemorrhage, or cerebral infarct, or from a traumatic spinal tap.

XANTHOCHROMIA

-refers to a pale pink to yellow color in the supernatant of centrifuged CSF, although other colors may be present

-To detect xanthochromia, the CSF should be centrifuged and the supernatant fluid compared with a tube of distilled water.

Xanthochromic CSF is pink, orange, or yellow owing to RBC lysis and hemoglobin breakdown.

Pale pink to orange xanthochromia from released oxyhemo- globin is usually detected by lumbar puncture performed 2 to 4 hours after the onset of subarachnoid
hemorrhage, although it may take as long as 12 hours. Peak intensity occurs in about 24 to 36 hours and then gradually disappears over the next 4 to 8 days.

Yellow xanthochromia is derived from bilirubin. It develops about 12 hours after a subarachnoid bleed and peaks at 2 to 4 days but may persist for 2 to 4 weeks.

Visible CSF xanthochromia may also be due to the following: (1) oxyhemoglobin resulting from artifactual RBC lysis caused by detergent con- tamination of the needle
or collecting tube, or a delay of longer than 1 hour without refrigeration before examination; (2) bilirubin (bilirachia) in jaun- diced patients; (3) CSF protein levels over
150 mg/dL, which are also pres- ent in bloody traumatic taps (>100,000 RBCs/μL) or in pathologic states such as complete spinal block, polyneuritis, and meningitis;
(4) disinfectant contamination; (5) carotenoids (orange) in people with dietary hypercaro- tenemia (i.e., hypervitaminosis A); (6) melanin (brownish) from meningeal
metastatic melanoma; and (7) rifampin therapy (red-orange).

Differential Diagnosis of Bloody CSF

-A traumatic tap occurs in about 20% of lumbar punctures.

-Therefore, dis- tinction of a traumatic puncture from a pathologic hemorrhage is of vital importance

The following observations may be helpful in distinguishing the two forms of bleeding.

1. In a traumatic tap, the hemorrhagic fluid usually clears between the first and third collected tubes but remains relatively uniform in subarachnoid
hemorrhage.

2. Xanthochromia, microscopic evidence of erythrophagocytosis, or hemosiderin-laden macrophages indicate a subarachnoid bleed in the absence of a prior
traumatic tap. RBC lysis begins as early as 1 to 2 hours after a traumatic tap. Thus, rapid evaluation is necessary to avoid false-positive results

3. A commercially available latex agglutination immunoassay test for cross-linked fibrin derivative D-dimer is specific for fibrin degrada- tion and should
theoretically be negative in traumatic taps (Lang et al., 1990). However, it has been shown to not effectively distinguish suba- rachnoid hemorrhage from
traumatic lumber puncture (Eclache et al., 1994).

MICROSCOPIC EXAMINATION
Total Cell Count

Differential Cell Count

CHEMICAL ANALYSIS

Proteins

Glucose

Lactate

F2-Isoprostanes

Enzymes

Ammonia, Amines, and Amino Acids

Electrolytes and Acid-Base Balance

Tumor Markers

MICROBIOLOGICAL EXAMINATION

Bacterial Meningitis

Spirochetal Meningitis

Viral Meningitis

Human Immunodeficiency Virus

Fungal Meningitis

Tuberculous Meningitis

Primary Amebic Meningoencephalitis