Cerebrospinal fluid (CSF)

 Cerebrospinal fluid (CSF) is contained in a cavity that

surrounds the brain in the skull and the spinal column.
 It nourishes the tissues of the central nervous system
and helps to protect the brain and spinal cord from
injury.
 CSF replaces lymph in the CNS.

 The total quantity of CSF is about 150 mL, approx. 30 ml

in the spinal cord.

 It is formed at the rate of about 0.35 ml per min OR 500

ml per day
NORMAL CSF
 Normal CSF is a colorless, clear, watery fluid and no coagulum or pellicle is formed when it is allowed to stand
undisturbed in a refrigerator.
 It contains only 1-5 cells/mm3 and these are lymphocytes.
 Chemical composition is as follows:
 Proteins: 0.2-0.45 g/L (20-45 mg/dl).
 Glucose: 2.5-4.5 mmol/L (45-80 mg/dl)
 Chlorides: 118-127 mmol/L.
 Magnesium: 1.05 to 1.14 mmole/l
 Calcium: 0.7 - 9.90 mg/dL
 CSF Formation
• The bulk of CSF is formed by the Choroid plexuses of
lateral ventricles and lesser amount by the Choroid
plexuses of third and fourth ventricles.
• Choroid plexuses a network of blood vessels in each ventricle
of the brain, producing the cerebrospinal fluid.
• Possibly, it is also formed by Ependymal lining of
ventricular system and the capillaries on the surface of
brain and spinal cord
• The ependymal is the thin neuroepithelial (simple columnar
ciliated epithelium) lining of the ventricular system of the brain
and the central canal of the spinal cord.
 CSF Absorption
• Through the Arachnoid villi, a protrusion of
arachnoid membrane into the venous sinus and
other sinuses

• A valve opens when CSF pressure exceeds

venous pressure

• Absorption by veins and capillaries of CNS

 The dural venous sinuses (also called dural
sinuses, cerebral sinuses, or cranial sinuses) are
venous channels found between the endosteal and
meningeal layers of dura mater in the brain. They
receive blood from the cerebral veins, receive
cerebrospinal fluid (CSF) from the subarachnoid 
SAMPLE COLLECTION
PROCEDURE OF CSF
 Follow all appropriate biosafety precautions
 Label the collection tubes with appropriate information:
patient’s name, date and time of specimen collection,
and Unique Identification Number. Be sure this
number matches the number on both the request and
report forms.
 Ensure that the patient is kept motionless during the
lumbar puncture procedure, either sitting up or lying on
the side, with his or her back arched forward so that
the head almost touches the knees in order to
separate the lumbar vertebrae during the procedure
 Lumbar puncture needle 22 gauge/89 mm for adults
 And 23 gauge/64 mm for children
 Disinfect the skin 70% alcohol and povidone.
 Position the spinal needle between the 2 vertebral
spines at the L4-L5 level and introduce into the skin with
the bevel of the needle facing up.
 Accurate placement of the needle is rewarded by a flow
of fluid, which normally is clear and colorless.
 Remove CSF (1 ml minimum, 3-4 ml if possible) and
collect into sterile screw-cap tubes. If 3-4 ml CSF is
available, use 3 separate tubes and place approximately
1ml into each tube.
 Withdraw the needle and cover the insertion site with an
adhesive bandage
 Purpose of CSF Analysis
 The purpose of a CSF analysis is to diagnose
medical disorders that affect the central nervous
system.
 Diagnostic
1. Viral and bacterial infections, such as meningitis
and encephalitis .
2. Tumors or cancers of the nervous system.
3. Bleeding (hemorrhage) around the brain and
spinal cord.
4. Multiple sclerosis: a disease that affects the
myelin coating of the nerve fibers of the brain
and spinal cord.
5. Syphilis, a sexually transmitted disease .
 Tube 1 is used for determining biochemical analysis.

 Tube 2 is used for microbiologic and cytological studies

 Tube 3 is for cell counts and differential

 Complications

Headache After Lumbar Puncture

– Most common complication, occurs 5-30% of all spinal
taps, usually starts up to 48 hours after to procedure.
– Usually lasts 1-2 days.
– Caused by leaking of fluid through dural puncture site.
– Treatment: fluids, caffeine.
•Other complications
– local or referred pain
– bleeding, infection
– subarachnoid epidermal cyst
Macroscopic examination

 Appearance
• Normal CSF is crystal clear and the
consistency of water.
• The major terminology used to describe CSF
appearance includes crystal clear, cloudy or
turbid, milky, xanthochromic, and bloody.
 Cloudy, turbid or milky
• May be caused by WBCs (over 200 cells/µl).
• RBCs (over 400 cells/µl)
• Microorganisms (bacteria, fungi, amebas)
 Specific gravity: 1.006 – 1.008
 pH : Alkaline

 Spontaneous clotting
• Clotting occurs when there is an excess of fibrinogen
in the specimen, usually associated with a very high
protein concentration.
• This finding occurs classically in association with
tuberculous meningitis or with tumors in CNS.
Microscopic examination
 CSF cell count
 Normal CSF RBCs are less than 5/mm3.
 The cell count that is routinely performed on CSF
specimen is the WBC's count.
 NOTE: Cell counts should be done within 30 minutes
after withdrawal of the specimen to avoid cell
disintegration.
 Specimen that can't be analyzed immediately should be
refrigerated.
 Causes for increased Neutrophils

1. Meningitis (Bacterial meningitis, Early viral

meningoencephalitis).
2. Injection of foreign materials in
subarachnoid space.
 Causes for increased Eosinophil
1. Parasitic infestations.
 Xanthochromic
 Xanthochromia is a term used to describe CSF
supernatant that is pink, orange or yellow.
1. Pink: very slight amount of oxyhemoglobin
2. Orange: heavy hemolysis
3. Yellow: conversion of oxyhemoglobin to
unconjugated bilirubin

 It may be caused by the following:

1. Oxyhemoglobin: from lysed RBCs present in CSF
before lumber puncture, or traumatic tap with lysis of
RBCs after lumber puncture.
2. Bilirubin from lysed RBCs in CSF, or increased direct
bilirubin with normal blood-brain barrier, or in
premature infants an immature blood-CSF barrier plus
elevated total bilirubin.
 Bloody: grossly bloody CSF can be an
indication of subarachnoid hemorrhage,
but it also may be due to the puncture of
a blood vessel during the spinal tap
procedure.
 Glucose
 Glucose enters the CSF by active transport
across the blood-brain barrier.
 The CSF glucose concentration is slightly lower
than that plasma and usually between 60 – 70 %
of plasma glucose concentration.
 The normal range of CSF glucose is between 50
and 80 mg/dl
Clinical significance:
 LowCSF glucose values can be of considerable
diagnostic value in determining the causative
agents in meningitis.
 Thefinding of markedly decreased CSF glucose
accompanied by:
 An
increased WBC's count and a large percentage of
Neutrophil is most indicative of bacterial meningitis.
 WBC's count and a large percentage of lymphocytes
is most indicative of tubercular meningitis.
Proteins
 The most frequently performed chemical test on CSF is
the protein determination. Normal CSF contains a very
small amount of protein.
 Normal CSF protein concentration is less than 1% of
serum protein concentration (15-60 mg/dl)
A rise in CSF protein is seen in various diseases
as a result of three primary mechanisms:
 Decreased clearance of normal protein from the fluid and
degeneration of neural tissue.
 Increased local synthesis of immunoglobulin.
 Increased capillary permeability due to the blood-brain barrier
damage.
 CSF Lactate
 Measurement of lactate concentrations in cerebrospinal
fluid (CSF) may be useful as part of the investigation of
inborn errors of metabolism in which lactic acidosis occurs.

 This includes disorders of gluconeogenesis, pyruvate

dehydrogenase complex, the Krebs cycle and the
mitochondrial electron transport chain.

 Normal rang: 1.1-2.4 mmol\L

 In bacterial, tubercular and fungal meningitis elevations of

CSF lactate greater than 25mg/dl.

 Destruction of tissue within the CNS owing to oxygen

deprivation (hypoxia) causes the production of increased
CSF lactic acid levels.
Microbiology test
 Bacterial Infections
• Gram staining.
• Gram-negative diplococci intracellular or
extracellular are indicative of Neisseria
meningitidis
• Small Gram-negative bacilli may include
Haemophilus influenza, especially in
children.
• Gram-positive cocci indicates
Streptococcus pneumoniae, other
Streptococcus species, or Staphylococcus.
Serologic testing
 Serologic testing of the CSF is performed to
detect the presence of neurosyphilis.
However, detection of the antibodies
associated with syphilis in the CSF still
remains a necessary diagnostic procedure.

 Serologic tests:
• VDRL (Venereal Disease Research Laboratory )
 Summary

Condition Cell type Cell count Glucose Protein Gram

stain

Normal l/106× 0-4 of blood 60%< Up to 0.45 g/l ve-

Lymphocytes glucose
Viral Lymphocytes 10-2000 Normal Normal ve-

Bacterial Polymorphs 1000-5000 Low Normal/elevated ve+

T.B Polymorphs/lymp 50-5000 Low Elevated - Often

hocytes/mixed
Fungal Lymphocytes 50-500 Low Elevated ±

Malignant Lymphocytes 0-100 Low Normal/elevated ve-