BRAIN AND MIND SYSTEM

KELAINAN CAIRAN OTAK

Dept. Patologi Klinik FK USU
dr. Tapisari Tambunan SpPK (K)
dr. Ozar Sanuddin SpPK (K)
Physiology

* Cerebrospinal fluid (CSF) :
* merupakan produk aktifitas ventricular choroid
plexuses
* bersirkulasi melalui ventricles dan subarachnoid
spaces
* diabsorbsi oleh arachnoid villi venous sinuses
aliran darah
* fungsi utama : proteksi, memberi bantalan untuk
brain dan spinal
* Blood Brain Barrier bekerja dgn proses metabolik
aktif menjaga kons sbgn besar substansi dlm CSF
dlm kadar yg berbeda dari dlm darah, dgn rentang
kadar yang sempit

Pengambilan spesimen untuk pemeriksaan
Biasanya dgn Lumbal punksi
Indikasi LP:
- Suspek Meningitis, Encephalitis, Brain
abscess, subarachnoid hemorrage
- DD cerebral infark dgn cerebral
hemorrhage (80%)
- Pemberian anestesi, media kontras,
obat-obat
- Treatment pada bbrp pasien dgn
hipertensi intracranial benigna
Komplikasi LP:
Komplikasi LP:
- Herniasi, mortalitas meningkat (pd tek.
Intracranial tinggi)
- Paresis sampai paralisis (pd spinal cord tumor)
- Extradural @ Subdural hematoma (pd
gangguan pembekuan darah)
- Perforasi meninges (pd kasus sepsis)
- Kematian pada bayi jk tindakan berlebihan
(aspiksia, obst trachea)
- Infeksi ( tidak aseptik)
- Postpuncture headache
Pelaksanaan LP:
Pelaksanaan LP utk pengambilan spesimen :
- Sebaiknya pagi hari dan jk dapat setelah puasa 1malam
- Dilakukan pada dewasa : L3-L4
anak : L4-L5
- Ditaruh pada 3 tube sentrifus steril yg ditandai
dgn no. 1, 2 dan 3. Masing-masing 2-4 ml
Spesimen tube 1, biasanya tdk digunakan karena dapat
bercampur darah dari trauma punksi
Spesimen tube 2 : utk sel & hitung jenis dan pemeriksaan
kimia atau imunologi
Spesimen tube 3 : kultur
Kadar Protein, Ca, Glukosa bervariasi tergantung tempat
spesimen diambil (ventricle, cisterna magna, lumbar
spinal area)
Composition of Normal Spinal Fluid
Amount : 90-150 ml
Color : colorless, like water
Transparency : clear, like water
Specific Gravity : 1.006-1.008
Glucose : 45-100 mg/100ml
(60-70% KGD)
Urea : 8-28 mg/100ml
Sodium : 117-137 mEq/L
Pottasium : 2.33-4,59 mEq/L
Acid-base balance :
pH : 7.31
Pco
2
: 47.9 mmHg
HCO
3
: 22.9 mEq/L
Uric acid : 0.07- 2.8 mEq/L
Total protein : 20-40 mg/100ml
Lumbar : 20-40 mg/100ml
Cisternal : 15-25 mg/100ml
Ventricular : 5-10 mg/100ml

Electrophoretic separation of lumbar fluid, mean
values :
Prealbumin : 4.6 13%
Albumin : 49.5 6.5 %

1
-globulin : 6.7 2.0 %

2-
globulin : 8.3 2.1%
- and - globulin : 18.5 4.8 %
-globulin : 11.2 2.7 %

Calcium (lumbar) : 2.32 mEq/L
Magnesium : 2.20 mEq/L
Creatinine : 0.4 1.5 mg/100ml
Lactic dehydrogenase : 8-50 units
Cell : 1-5 cells/mm
3
(lymphocytes)

Pemeriksaan Lab
Makroskopis
Mikroskopis
Analisa Kimia
Imunologi
Mikrobiologi
Makroskopis
Jernih, tidak berwarna
Darah : - merah
* gross abaikan pem. Kimia
* koreksi perhitungan lekosit :
jlh lekosit = jlh leko terhitung a
a = jlh eri dlm darah x leko dlm darah
jlh eri dlm CSF
- Bloody tap (traumatic tap) :
* Cedera pbl darah pada tindakan LP
* Tube 1, 2, 3 berturut-turut jlh darah makin kurang
* Jk ragu, bandingkan hitung sel tube 1 dan ke 3
* Supernatan setelah disentrifus : jernih, tak berwarna
- Hemorrhage :
* Darah pada tube 1,2 dan 3 sama banyak
* Supernatan kekuningan
* Eritrosit crenated
* Jk darah banyak, bisa terlihat clot
* Pada intracerebral hemorrage bisa terlihat jernih
Xanthochromia :
Xanthochromia :
- Kekuningan
- Bisa warna bilirubin (jk jaundice berat, kronis, @ prematur),
derivat Hb, lipidlike substance karena destruksi jar. otak
- Jk mengandung banyak protein dan clot, indikasi adanya
obstruksi, mis. tumor
Transparansi :
- > 200 lekosit : cloudy
200 500 lekosit : keruh
> 500 : turbid
- acute meningitis : bervariasi berawan s/d spt pus
- encephalitis, tuberculous meningitis : jernih
Sedimen : Normal tdk ada
Clot : adanya fibrinogen
Mikroskopis
Diperiksa pada sedimen
Total lekosit normal - dewasa : 0 - 6 mononuclear /mm3
- neonati : 0 30
Eritrosit : bedakan dulu trauma atau tidak
Hitung jenis :
- netrofil tinggi : infeksi bakteri, masa dini (1-2 hari) viral,
TB, jamur
- limfosit meninggi : Viral. TB, jamur, Syphilic
- plasma sel meninggi : multiple sclerosis
- eosinofil meninggi : non infeksi : vaksinasi rabies, alergi


Kimia Klinik
Total Protein
Glukosa : Normal : 60 70 % KGD (seimbang 2-4 jam)
Meninggi : hiperglikemia
Menurun : - hipoglikemia
- pemakaian meningkat oleh CNS,
lekosit, eritrosit, jar, mo
- gangguan transport dari plasma ke
CSF
LDH : - normal 5 10 % kadar plasma
- DD bacterial @ viral meningitis
- Prognose encephalitis :jelek jk LDH tinggi
Lain-lain
Serologis : sifilis, VDRL, FTA (fluorescent treponemal
antibody
Elektrolit
Mikrobiologi
Cerebrospinal fluid in disease
Disease Preasure
(mm
water)
Appearance Clot No & Type of Cell Protein
(mg/100ml)
Sugar
(mg/1
00ml)
Chlorides
(mEq/L)
Remarks
Normal 100-200 Clear,
colorless
0 0-5 lymphocytes 20-40 45-100 113-127
Meningitis
Pyogenic
Tuberculous

Lymphocytic
choroimeningitis


3+
3+
2+

Cloudy
Clear or
slightly turbid
Clear or
opalescent

Large
Web

0

3+ PMN
2+ lymphocytes

50-2000 lymphocytes


3+
2+

+

D(0)
20-40

20-40

Slightly D
D<100

N


Tubercle bacilli
Cord Tumor N Clear & deep
yellow
Mass N to + lymphocytes

3+ N N
Brain Abscess 1+ to 3+ Clear or
turbid


+ PMN + to 2+ N N to slightly
D
Brain Tumor 3+ Clear yellow

N lymphocytes

to 2+ N N
Poliomyelitis N Clear or
opalescent

0 50-2000 PMN early
lymphocytes
leter
+ N N to slightly
D

Filtrable virus
Encephalitis N to Clear,
colorless

0 N to + lymphocytes

N N Filtrable virus
Subarachnoid
hemorrhage
1+ to 2+ Bloody
yellow
0 Blood 3+ N N
Neurosyphilis
Meningovascular

Tabes
Paresis


+

+
+

Clear,
colorless

Rare

Rare
Many,
small

20-100 PMN early,
lymphocytes leter
25-75 lymphocytes
25-50 lymphocytes


+ to 2+

+
+

N

N
N


N

N
N
Serologic test for
syphilis nearly always
reactive
80% reactive
100% reactive
Cerebrospinal fluid in disease
Disease Preasure
(mm
water)
Appearance Clot No & Type of Cell Protein
(mg/100ml)
Sugar
(mg/1
00ml)
Chlorides
(mEq/L)
Remarks
Normal 100-200 Clear,
colorless
0 0-5 lymphocytes 20-40 45-100 113-127
Meningitis
Pyogenic
Tuberculous

Lymphocytic
choroimeningitis


3+
3+
2+

Cloudy
Clear or
slightly turbid
Clear or
opalescent

Large
Web

0

3+ PMN
2+ lymphocytes

50-2000 lymphocytes


3+
2+

+

D(0)
20-40

20-40

Slightly D
D<100

N


Tubercle bacilli
Cord Tumor N Clear & deep
yellow
Mass N to + lymphocytes

3+ N N
Brain Abscess 1+ to 3+ Clear or
turbid


+ PMN + to 2+ N N to slightly
D
Brain Tumor 3+ Clear yellow

N lymphocytes

to 2+ N N
Cerebrospinal fluid in disease
Disease Preasure
(mm water)
Appearance Clot No & Type of Cell Protein
(mg/100ml
)
Sugar
(mg/100ml)
Chlorides
(mEq/L)
Remarks
Poliomyelitis N Clear or
opalescent

0 50-2000 PMN
early
lymphocytes
leter
+ N N to slightly
D

Filtrable virus
Encephalitis N to Clear,
colorless

0 N to + lymphocytes

N N Filtrable virus
Subarachnoid
hemorrhage
1+ to 2+ Bloody
yellow
0 Blood 3+ N N
Neurosyphilis
Meningovascular

Tabes
Paresis


+

+
+

Clear,
colorless

Rare

Rare
Many,
small

20-100 PMN early,
lymphocytes leter
25-75 lymphocytes
25-50 lymphocytes


+ to 2+

+
+

N

N
N


N

N
N
Serologic test for
syphilis nearly
always reactive
80% reactive
100% reactive