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    Cerebrospinal Fluid Examination: Preview Only

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    Malliga Sundareshan
    This document provides an overview of cerebrospinal fluid examination, including physiology, specimen collection, and microscopic, chemical, and microbiological tests. It describes normal ranges and abnormalities for various tests including opening pressure, cell counts, protein and glucose levels, and enzymes. Differential diagnoses are discussed for abnormalities in these values, including various types of meningitis and brain injuries. Microscopic examination may reveal organisms like Cryptococcus, and special stains can identify features to diagnose fungal infections.

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    Cerebrospinal Fluid Examination: Preview Only

    Uploaded by

    Malliga Sundareshan
    285 views14 pages
    This document provides an overview of cerebrospinal fluid examination, including physiology, specimen collection, and microscopic, chemical, and microbiological tests. It describes normal ranges and abnormalities for various tests including opening pressure, cell counts, protein and glucose levels, and enzymes. Differential diagnoses are discussed for abnormalities in these values, including various types of meningitis and brain injuries. Microscopic examination may reveal organisms like Cryptococcus, and special stains can identify features to diagnose fungal infections.

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    examination of CSF

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    This document provides an overview of cerebrospinal fluid examination, including physiology, specimen collection, and microscopic, chemical, and microbiological tests. It describes normal ranges and abnormalities for various tests including opening pressure, cell counts, protein and glucose levels, and enzymes. Differential diagnoses are discussed for abnormalities in these values, including various types of meningitis and brain injuries. Microscopic examination may reveal organisms like Cryptococcus, and special stains can identify features to diagnose fungal infections.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    285 views14 pages

    Cerebrospinal Fluid Examination: Preview Only

    Uploaded by

    Malliga Sundareshan
    This document provides an overview of cerebrospinal fluid examination, including physiology, specimen collection, and microscopic, chemical, and microbiological tests. It describes normal ranges and abnormalities for various tests including opening pressure, cell counts, protein and glucose levels, and enzymes. Differential diagnoses are discussed for abnormalities in these values, including various types of meningitis and brain injuries. Microscopic examination may reveal organisms like Cryptococcus, and special stains can identify features to diagnose fungal infections.

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    of 14

    PREVIEW ONLY

    Cerebrospinal Fluid
    Examination
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    OVERVIEW
    1.
    2.
    3.
    4.
    5.
    6.
    7.

    8.

    9.

    10.

    11.

    Physiology
    Functions of CSF
    Indications
    Recommended laboratory tests
    Specimen collection
    Opening pressure
    Gross examination
    Color
    Appearance (Clear/clot/cobweb/coagulum)
    Viscosity
    Microscopic examination
    Total count
    Differential count
    i. Lymphocytes
    ii. Neutrophils
    iii. Plasma cells
    iv. Eosinophils
    v. Monocytes and macrophages
    vi. Tumor cells
    Chemical examination
    Proteins
    i. Total protein
    ii. Albumin
    iii. IgG
    iv. Other CSF proteins
    Glucose
    Lactate
    F2 isoprostanes
    Enzymes
    i. Adenosine Deaminase (ADA)
    ii. Creatinine Kinase (CK)
    iii. Lactate Dehydrogenase (LDH)
    iv. Lysozyme
    Ammonia, amines and aminoacids
    Microbiological examination
    Bacterial meningitis
    Spirochetal meningitis
    Viral meningitis
    Fungal meningitis
    Tuberculous meningitis
    Primary amebic meningoencephalitis
    Reference values

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    * Physiology
    1. CSF is derived from ultrafilteration and secretion through the choroid plexus.
    2. CSF resorption occurs at arachnoidal villi predominantly along superior sagittal sinus.

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    * Opening pressure
    1. Opening pressure can be measured by a manometer before collection of CSF
    2. The pressure varies with postural changes, blood pressure, venous return and valsalva
    maneuver etc.
    3. Pressure should be noted in lateral decubitus position with legs and neck in neutral
    position.

    manometer tube with graduation from -4 cm to +34 cm and attached to three way tap

    Normals
    CSF opening pressure

    Adult 90-180 mm of water


    Children (upto 8 years) 10-100 mm of water

    Abnormals
    If pressure is elevated more than 200 mm of water, no more than 2 ml should be withdrawn
    as it can lead to herniation

    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    9.

    Elevated pressure
    straining
    congestive heart failure
    meningitis
    superior venacaval syndrome
    thrombosis of venous sinuses
    cerebral edema
    mass lesions
    hypoosmolality
    Idiopathic intracranial hypertension
    (pseudotumor cerebri)

    1.
    2.
    3.
    4.

    Decreased pressure
    spinal-subarachnoid block
    dehydration
    circulatory collapse
    CSF leakage like from cribriform
    plate in case of head injury

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    11

    B. Appearance
    Normal
    Appearance

    Clear

    Abnormals
    Turbid/cloudy

    Bloody
    Clot

    Cobweb

    Leucocyte count >200 cells/mm3


    RBCs >400 cells/ mm3
    Microorganisms (bacteria, fungi, amebas)
    Radiographic contrast material
    Aspirated epidural fat
    Protein level greater than 150mg/dl
    RBC counts >6000 cells/mm3
    Traumatic tap
    Complete spinal block (Froins syndrome)
    Suppurative or tuberculous meningitis
    *Not seen in patients with subarachnoid hemorrhage
    Tuberculous meningitis

    Cobweb in tuberculous meningitis in CSF

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    13

    * Microscopic examination
    (A) Total cell count
    Methods:
    1. Manual count using Neubauers chamber or a Fuchs-Rosenthal type chamber (most
    commonly used)
    2. Count with an automated cell counter (poor precision)
    3. automated flow cytometry of CSF (rapid and reliable, but expensive)
    Counting using a neubauers chamber:
    1. Sample in tube 3 is used
    2. No dilution of CSF is usually required. A diluent (0.05ml CSF + 0.95 ml diluent, 1:20
    dilution) is used only if CSF is cloudy and likely to contain increased number of
    leucocytes. Diluent mostly used is Turk solution (glacial acetic acid + methylene blue +
    distilled water)
    3. Put coverslip on chamber.
    4. Charge it from sides, take care that no fluid goes into the drain.
    5. allow to stand for two minutes, cells will settle down.
    6. Cells are counted in four corner WBC counting squares, marked W in the figure.
    7. Total count (per/mm3)= No. of cells counted x 10
    No. of squares counted

    Improved Neubauers chamber

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    14

    Counting cells in WBC counting chamber

    Normals
    Total count

    Adults - 0-5 cells/mm3


    Children 0-30 cells/mm3
    RBCs Zero / hpf

    Abnormals
    Increased counts

    1.
    2.
    3.
    4.
    5.

    Meningitis and other infections of CNS


    Intracranial hemorrhage
    Meningeal infiltration by malignancy
    Repeated lumbar punctures
    Injection of foreign substances (contrast media/drugs) in
    subarachnoid space.
    6. Multiple sclerosis

    Correction for presence of blood in CSF


    Presence of blood either due to traumatic tap or subarachnoid hemorrhage artefactually
    raises the total count. This needs to be corrected by the following formula Corrected WBC (/mm3) = WBC counted - WBC count in blood x RBC count in CSF
    RBC count in blood

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    15

    (B) Differential cell count


    Methods:
    1. counting chamber poor precision, identification of different cell types difficult, not
    recommended
    2. Direct smears of centrifuged CSF specimen subjected to significant error from
    cellular distortion# and fragmentation, but most commonly performed
    3. Using a cytocentrifuge recommended method for all body fluids
    # cellular distortion can be minimized by adding 2 drops of 22% bovine albumin to the
    specimen
    Normals:
    Cell type
    Lymphocytes #
    Monocytes
    Neutrophils
    Histiocytes
    Ependymal cells
    Eosinophils

    Adults (%)
    62 +/- 34
    36 +/- 20
    2 +/- 5
    Rare
    Rare
    Rare

    Children (%)
    20 +/- 18
    72 +/- 22
    3 +/- 5
    5 +/- 4
    Rare
    Rare

    #Blast like lymphocytes may be seen admixed with small and large lymphocytes in CSF of
    neonates
    Abnormals:
    1. Increased neutrophils
    Meningitis
    1. Bacterial meningitis # (PMN >60%)
    2. Early viral meningoencephalitis (PMN <60%, changes to lymphocytic in 2-3 days)
    3. Early tuberculous meningitis
    4. Early mycotic meningitis
    5. Amebic encephalomyelitis
    Other infections
    1. Cerebral abscess
    2. Subdural empyema
    3. AIDS related CMV radiculopathy
    Following seizures
    Following CNS hemorrhage
    1. subarachnoid
    2. Intracerebral
    Following CNS infarct
    Reaction to repeated lumbar punctures
    Injection of foreign material in subarachnoid space (e.g. methotrexate, contrast media)
    Metastatic tumor in contact with CSF
    #A total neutrophil count of >1180 cells/mm3 has 99% predictive value for bacterial meningitis
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    21

    (B) Albumin
    1.
    2.
    3.
    4.

    Albumin is around 56-76% of total proteins in CSF.


    Normal CSF albumin (in gm/dl) : serum albumin (in gm/dl) ratio is 1:230.
    But this yields a very difficult decimal of 0.004 to deal with.
    Hence the permeability of Blood brain barrier is assessed by CSF albumin : serum
    albumin index, where value of CSF albumin is taken in mg/dl.
    5. A traumatic tap invalidates the calculation.
    CSF ALBUMIN / SERUM ALBUMIN ratio = CSF ALBUMIN (g/dl)
    Serum albumin (g/dl)

    CSF ALBUMIN / SERUM ALBUMIN INDEX = CSF ALBUMIN (mg/dl)


    Serum albumin (g/dl)

    Normals:
    CSF albumin: Serum albumin ratio
    CSF albumin:Serum albumin index (mg/gm)
    Slightly elevated in infants upto 6 months of
    age
    Index increases gradually after age 40

    0.004
    <9
    Reflects immaturity of blood brain barrier

    Abnormals:
    9-14
    14-30
    >30

    Slight impairment
    Moderate impairment
    Severe impairment

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    24

    Glucose
    1. CSF glucose levels should be compared with plasma levels, ideally following a 4 hour
    fast, for adequate clinical interpretation.
    2. CSF glucose levels normalize before protein levels and cell counts following recovery
    from meningitis, hence it is a useful parameter in assessing response to treatment.
    Normals:
    Fasting CSF glucose levels
    Normal CSF glucose:Plasma
    glucose ratio

    60% of plasma level


    (50-80 mg/dl)
    0.3-0.9

    Abnormals:
    Decreased CSF fasting glucose (<40mg/dl or
    ratio <0.3)
    a.k.a. Hypoglycorrhachia
    Due to: increased anaerobic glycolysis in
    brain tissue and leucocytes
    Seen in
    1. Bacterial, tuberculous and fungal
    meningitis
    2. meningeal involvement by malignant
    tumor, sarcoidosis, cysticercosis,
    trichinosis, ameba, syphilis
    3. intrathecal administration of
    radioiodinated serum albumin
    4. subarachnoid hemorrhage
    5. symptomatic hypocglycemia
    6. rheumatoid meningitis

    Increased CSF fasting glucose values

    Due to: No clinical significance

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    28

    (B) Creatine Kinase (CK)


    1. CK-BB comprises of nearly 90% of brain CK activity, other 10 % being contributed by
    mitochondrial CK (CKmt)
    2. CK-BB starts rising in CSF after about 6 hours of ischemic insult with peak levels in
    about 48 hours.
    3. It is also raised following a subarachnoid hemorrhage and predicts chance of
    unfavourable outcome.
    Abnormals:
    FOLLOWING ISCHEMIC INSULT
    CK-BB
    CK-BB
    CK-BB
    CK-BB

    <5 U/L
    5-20 U/L
    21-50 U/L
    >50 U/L

    Minimal neurologic damage


    Mild to moderate CNS injury
    Correlated with death
    Death occurs in all patients

    FOLLOWING SUBARACHNOID HEMORRHAGE


    CK-BB

    >40 U/L

    Death

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    37

    (D) Fungal Meningitis


    Cryptococcus is the most common fungus isolated from CSF
    Microbiological Methods:
    1. India ink or nigrosin stains for capsule
    2. Detection of cryptococcal antigen from CSF using latex agglutination
    3. Culture

    Cryptococcus in CSF stained with India Ink

    Findings in CSF:
    Test
    Opening pressure
    Leucocyte count
    Differential count
    Protein
    Glucose
    CSF : serum glucose ratio
    Lactic acid

    Findings
    Variable
    Variable
    Mainly lymphocytes
    Increased
    Decreased
    Low
    Mild to moderate increased

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    Test
    Opening pressure
    Leucocyte count
    Differential count
    Protein
    Glucose

    CSF : serum
    glucose ratio
    Lactic acid

    41

    Bacterial
    meningitis
    Elevated
    >/= 1000/mm3
    Mainly
    neutrophils
    Mild-moderate
    increase
    Usually <40
    mg/dL

    Viral
    Meningitis
    Usually normal
    <100 / mm3
    Mainly
    lymphocytes
    Normal mild
    increase
    Normal

    Fungal
    meningitis
    Variable
    Variable
    Mainly
    lymphocytes
    Increased

    Tuberculous
    Meningitis
    Variable
    Variable
    Mainly
    lymphocytes
    Increased

    Decreased

    Normal /
    decreased
    Increased

    Usually normal

    Low

    Decreased
    (may be <45
    mg/dL)
    Low

    Normal mild
    increase

    Mild to
    moderate
    increased

    Mild to
    moderate
    increased

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    Test
    Opening pressure
    Leucocyte count
    Differential count
    Protein
    Glucose

    CSF : serum
    glucose ratio
    Lactic acid

    41

    Bacterial
    meningitis
    Elevated
    >/= 1000/mm3
    Mainly
    neutrophils
    Mild-moderate
    increase
    Usually <40
    mg/dL

    Viral
    Meningitis
    Usually normal
    <100 / mm3
    Mainly
    lymphocytes
    Normal mild
    increase
    Normal

    Fungal
    meningitis
    Variable
    Variable
    Mainly
    lymphocytes
    Increased

    Tuberculous
    Meningitis
    Variable
    Variable
    Mainly
    lymphocytes
    Increased

    Decreased

    Normal /
    decreased
    Increased

    Usually normal

    Low

    Decreased
    (may be <45
    mg/dL)
    Low

    Normal mild
    increase

    Mild to
    moderate
    increased

    Mild to
    moderate
    increased

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