CSF analysis Flashcards by Don Filomeno Marfori Agus

it is a major fluid of the body. CSF provides a physiologic system to supply nutrients to the nervous tissue, remove metabolic wastes, and produce a mechanical barrier to cushion the brain and spinal cord against trauma

Cerebrospinal fluid (CSF)

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Enumerate the purposes of CSF examination

1) Evaluate the function of the Central Nervous System

2) CSF greatly indicates presence of infections, autoimmune disorders, diseases of the brain & the spinal cord (such as encephalitis, meningitis, multiple sclerosis, & hemorrhage)

3) Detects early signs of seizures & dementia

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CSF covers what parts of the CNS?

Brain
Spinal cord

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Main source of CSF; Comprises 70% of the CSF formation

Choroid plexus

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Comprises 30% of the CSF formation

Subarachnoid space

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Epithelial cells that lines the choroid plexus; main cells responsible for the formation of the blood- brain barrier

Choroidal cells

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Regulates the movement of ions, molecules, and cells between the blood and the brain

Blood brain barrier

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What are the layers of the brain (meninges)?

Dura mater
Arachnoid space
Pia mater

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what are the three (3) types of epithelial cells?

Ependymal cells
Choroidal cells
Pia Arachnoid Mesothelial cells (PAM)

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*Cells that lines the cerebral ventricles & neural canals of the spinal cord
*Range in shape from squamous to columnar
*May be ciliated

Ependymal cells

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these cells lines the mesoderm of the pia & arachnoid layers

Pia Arachnoid Mesothelial cells (PAM)

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what are the CSF ion components?

H, K, Ca, bicarbonate and, Mg

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T or F: Glucose, urea and creatinine diffuse freely and require 2 or more hours to regulate

True

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How many CSF is produced each day?

500 mL (0.3 - 0.4 mL/min)

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Volume of CSF in adults?

90 - 150 mL
25 mL in the ventricles and subarachnoid space

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Volume of CSF in neonates?

10 to 60 mL

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How many hours does CSF is replaced?

every 5 to 7 hours

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Common site for lumbar puncture is the intervertebral space
Adult:
Children:

between L3 and L4
between L4 and L5

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CSF obtained through what procedure?

cisternal or lumbar puncture through ventricular cannulas or shunts

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Normal opening pressures
adults:
obese:
infants & children:

90 to 180 mm of water
250 mm of water
10 to 100 mm of water (6-8 yrs)

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greater then 250 mm of water opening pressure indicates what underlying conditions?

increased intracranial pressure which might be caused by meningitis, intracranial hemorrhage & tumors

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what precaution should be observed when there is >200 opening pressure in a relaxed patient?

no more than 2.0 ml should be withdrawn

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this tool indicates the pressure of the CSF fluid

Manometer

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Distribution of CSF tubes
Which lab section does tube #1 belongs to and what tests are applied?

Chemistry and/or Serology section
protein, glucose, lactate, VDRL, latex agglutination test

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Distribution of CSF tubes Which lab section does tube #2 belongs to and what tests are applied?

- Microbiology section - Gram stain, culture and India ink

Distribution of CSF tubes Which lab section does tube #3 belongs to and what tests are applied?

- hematology section - cell count and differential

Microbiology should be stored in what tube?

- tube 2 (sterile)

Gross examination Normal CSF color and appearance

- Crystal clear and colorless

Gross examination What are the causes for turbidity or cloudiness of CSF specimens?

- WBC > 200/uL - RBC > 400/uL - Microorganisms - radiographic contrast media - aspirated epidural fat - proteins > 150 mg/ dL ( 1.5 g/L)

Gross examination What are the causes for bloody/pink specimen

- RBC > 6000/uL - Subarachnoid and Intracerebral hemorrhage; - cerebral infarct or traumatic spinal tap

pertains to the presence of oxidized hemoglobin from lysed RBCs

Xanthochromia

Give the corresponding causes for xanthochromia of CSF pink: ________ orange : ________ ________ : RBC lysis/hemoglobin breakdown ________ : Hyperbilirubinemia (biliverdin) Brown : ________

- RBC lysis - RBC lysis/hemoglobin breakdown - yellow - green - Meningeal matastatic melanoma

*2-4 hrs after subarachnoid hemorrhage and take as long as 12 hrs, peak 24- 36 hrs and disappears on 4-8 days *Hypervitaminosis A (carotenoids)

Orange xanthochromia

*Hyperbilirubinemia; develops after 12 hrs after subarachnoid bleed, peaks 2-4 days and persists for 2-4 weeks *CSF protein > 150 mg/dL (1.5 g/L)

Yellow xanthochromia

Differentiate Hemorrhage from traumatic tap in terms of appearance, supernatant. and presence of clots

Hemorrhage: all tubes equally red (bloody), xanthochromic, and absent Traumatic tap: subsequent clearing in each tube, clear, and present due to fibrinogen

Causes for Clot formation in CSF samples

- Traumatic taps - Complete spinal block (Froin’s syndrome) - Suppurative or tuberculous meningitis

Causes for Viscous CSF samples

- Metastatic mucin producing adenocarcinomas - Cryptococcal meningitis - Liquid nucleus pulposus

T or F: Proper storage of CSF must be at room temperature and should be examined immediately

True

*18 large squares (1mm^2) *depth of 0.2 mm *total volume of 3.6 uL *CV = 48%

Fuch's-Rosenthal chamber

*9 squares (1mm each) *depth of 0.1mm *CV = 45%

Neubauer hemocytometer

Yield rapid and reliable WBC and RBC counts

UF-100 flow cytometer

Normal leukocyte count adult: neonates:

- 0-5 cells/uL - 0-30 cells/uL

recommended method for the differential count of all body fluids

cytocentrifuge

Disadvantages in performing differential count in counting chamber

- unsatisfactory because of low numbers and low precision - Direct smears of the centrifuged CSF sediment are also subject to significant error from cellular distortion and fragmentation

WBC added = ?

leukocytes added to CSF by traumatic tap

Stain used for CSF

Wright's stain

Lymphocyte to monocyte ratio among adults

70:30 ratio

CSF examination for tumor cells has the sensitivity to: Leukemic patients Metastatic carcinoma Primary CNS malignancies

- 70% - 20-60% - 30%

dark blue cytoplasm & clump chromatins; can also be seen during Multiple sclerosis

Reactive lymphocyte

Presence of ___________ in CSF indicates previous hemorrhage

Macrophage

1% of the plasma level Increase proteins = pathologic conditions Decrease proteins = fluid leakage

CSF Protein

Reference value Adults: ________ CSF protein fell rapidly from birth to 6 months of age ___________ plateaud 3-10 years __________ rose slightly from 10-16 years of age __________ Classic Lowry method __________ Trichloroacetic acid- ponceau S method ___________ Biuret method

- 15-45 mg/dL - 118 →40 mg/dL - 32 mg/dL) - 41 mg/dL - 24.1- 48 mg/dL - 15-49 mg/dL - 22.3-50.3 mg/dL

___________ makes up most of CSF protein

Albumin

___________ is the second most prevalent fraction in CSF.

Serum albumin

*Seen in MS Correlate with CSF leukocyte count, *Surrogate marker during acute MS exacerbations

Myelin Basic Protein

Increased in pinocytic vesicles which reflects hemorrhage or breakdown of BBB, as occurs in bacterial meningitis

Alpha-2-macroglobulin (A2M)

*Marker of neuro-Bechet’s syndrome *HIV-1 and various malignancies have been associated

Beta-2-macroglobulin (B2M)

Differentiating viral (aseptic) meningitis from bacterial meningitis

C-Reactive Protein

Cell adhesion allows leukocytes to adhere and pass through the vascular endothelia and migrate to the inflammatory site

Fibronectin

*present in Creutzfeldt-Jacob disease (CJD) *Determined by immunoassay &False (+) = stroke and meningoencephalitis

Protein 14-3-3

Subarachnoid hemorrhage and intracerebral hemorrhage

Methemoglobin and bilirubin

________ present in the body ________ that is only present in the CNS

Beta-1-transferrin Beta-2-transferrin

this enzyme converts Beta-1-transferrin

neuroaminidase

Normal values for CSF glucose

50-80 mg/dL (60% plasma values)

T or F: Results should be compared with plasma following 4 hour fast

True

Normal values for CSF lactate children & adults newborns for the 1st 2 days of life 3 to 10 days old tissue hypoxia

- 0-26 mg/dL (1.0- 2.9 mmol/L) - 10-60 mg/dL - 10-40 mg/dL (1.1- 4.4 mmol/L) - Elevated levels reflect CNS anaerobic metabolism

Normal values for CSF Lactate Viral meningitis Bacterial meningitis

- > 25 mg/dL - > 35 mg/dL; cut off value 30-36 mg/dL

Elevated levels in existing hepatic encephalopathy

CSF Glutamine

synthesized from ammonia and glutamic acid serves as the means for CNS ammonia removal

cerebral Glutamine

Normal values of CSF Glutamine

8-18 mg/dL

Gram’s stain sensitivity ranges from __________ with greatest sensitivity corresponding to higher concentrations of bacteria

60-90%

Immunochromatographic membrane assay with Streptococcus Latex agglutination bacterial antigen on which microorganisms?

- Haemophiles influenzae, - Neisseria meningitidis - Streptococcus pneumoniae

When performing microbiological studies, CSF samples must kept at?

room temperature