Cytopathology of

Cerebrospinal Fluid
Geneviève Warner Learmonth

Histopathologist /Cytopathologist.
Royal Free Hospital, London
and
Groote Schuur Hospital,
University of Cape Town
 Diagnostic Cytopathology
• Cytopathology is a
complementary diagnostic
tool.
• Correlation with other
other diagnostic
modalities:
1. Clinical information:
Age, gender, previous
illness, check database
results.
2. Ultrasound, MRI, CTscan.
3. Communicate with the
clinical team.
 Cytopathology Laboratory
• Communicate with
Laboratory Staff
• Check laboratory
facilities
• Discuss difficulties

• Availability of special
stains
• Residual specimen
for Flow Cytometry
 What is Cerebrospinal Fluid?
Where does it come from?
Where does it go?
• THE NORMAL CSF obtained at lumbar puncture:
• The cerebrospinal fluid (CSF) is clear fluid, produced from arterial blood by
the choroid plexuses of the lateral and fourth ventricles by a combined
process of diffusion, active transfer.
• The choroid plexus consists of tufts of capillaries with thin fenestrated
endothelial cells.
• VOLUME: 140 ml. The volume of the ventricles is about 25 ml. CSF is
produced at a rate of 0.2 - 0.7 ml per minute or 600-700 ml per day.
• Circulation of CSF is aided by the pulsations of the CSF acts as a cushion
that protects the brain from shocks and supports the venous sinuses.
• Chemistry :CSF from the lumbar region contains 15 to 45 mg/dl protein
and 50-80 mg/dl glucose (two-thirds of blood glucose).
• Cellularity: Normal CSF contains 0-5 mononuclear cells.
• The CSF pressure: lumbar puncture (LP), 8-15 mm Hg with the patient
lying on the side, twice that value with the patient sitting up.
 Safety procedures
Infective specimens

• Tuberculosis
• HIV
• Hepatitis
• Septic meningitis
• Viral meningitis
 Processing Cerebrospinal Fluid
Specimen --- Cytospin Technique
Is there enough fluid for processing?
2-10ml usually received
Colour of fluid ?
/clear/cloudy/bloodstained
Xanthochromia”( blonde colour) seen in
SAH
Consistency? (Mucoid)
Processing Cerebrospinal fluid
Cytospin method
 Staining the cells
May Grunwald Giemsa ( MGG)
air dried

Papanicolaou stain
alcohol fixed
Check the origin of “CSF “ specimen

• Is it really lumbar puncture CSF?

• Is it from an ventricular drain ?

( hydrocephalic patient)

Is it from a cystic brain lesion?

• Is it an intra –operative fluid specimen?

• Is it a smear from an intra operative procedure?
 Microscopy
• Cytopathologist needs
the best quality
microscope.
• No oil immersion
used!
• Examine at low power
first. x40, x100, x400
• Check the background
• Before issuing report
Check all clinical
details again.
 “ Normal CSF” and “Abnormal
CSF”

• NORMAL
• Acellular ---- check that
this is a clear fluid
specimen
• ?Problems with
preparation
• Scanty cells
 Abnormal CSF
• ABNORMAL
• Very cellular
• Mixed Inflammatory exudate
• Lymphocytic cells
• Clusters of cells
• Abnormal cells
• Background
• Bacteria
• Pigment
• Fungi
• “mucoid” material
• Contaminants
 Background -- very very important
Children on a safe happy
holiday in Namibia

Bloodstained fluid –
intact erythrocytes
 Specimens from Neurology/
Neurosurgery / HIV/AIDS Clinic, A&E
• Neurology: often non specific symptoms and signs ----
MS, ME, sarcoidosis, Parkinsons, Alzheimers.
• Lymphoid cells, plasma cells, macrophages
• Neurosurgery---- surgery for subarachnoid
haemorrhage, tumours of brain tissue, pituitary tissue,
cystic lesions of brain, metastatic neoplasms.
• Macrophages, Neoplastic cells, “foreign cells,
• HIV/AIDS --- Cerebral deterioration, ? lymphoma ?
Tuberculosis ? Fungal infection
• A & E ---- acute meningitis, meningococcal, streptococcal,
“stroke”, SAH
Acute Inflammation Meningitis
Lymphoid Cells
Mixed Inflammatory Infiltrate
Camouflage !
What are these small round structures?
 Mixed Plasma cells and Lymphocytes and
small round structures with concentric rings
Special stain – mucicarmine.

( PAS for glycogen stains cells and talc granules too)

Sputum from same patient when
reviewed showed Cryptococci
 This patient was a fit healthy man.
Admitted with severe dyspnoea.
Sputum: ?abnormal cells, TB bacilli, Sputum NAD
TB culture negative.
Patient developed severe headaches
? Miliary Tuberculosis
CSF showed cryptococci.
Hobby: exploring caves.
Cryptococcal infection is usually an opportunistic
organism in patients with HIV/AIDS or
immunosuppression.
 Tuberculosis in CSF
• Cytological appearances are not specific,
maybe lymphocytic or mixed inflammatory cells

• Maybe cloudy fluid, with necrotic background

• Area of endemic TB/ “at risk” person
• Clinical Suspicion
• HIV/AIDS
• Immunosuppression
• History of previous/current TB
Tuberculosis and HIV/AIDS
The “Terrible Twins”

•Ziehl Neehlsen stain for acid fast

TB bacilli
Examine Papanicolaou stained slide under
Fluorescent light at 450 μm
TB bacilli are fluorescent !
“CSF” received from a five year old
sheep farmer’s daughter

• CSF was actually from

the orbit !
• Refractile hooklets
from Echinococcus
granulosus
• Hydatid disease spread
by the black - backed
jackal to sheep and
sheep dogs.
Hydatid disease presents as a cyst in any tissue of
the body. Clear fluid is aspirated . Hooklets seen.
Sometines scolices and the laminated membrane
 Hydatid Disease ( Echinococcus
granulosus) Histology of Cyst wall
Abnormal Cells in CSF
• Lymphoma /Leukaemia
• Metastatic tumours
• Childhood tumours
• Primary Intracranial
“Tumours” /Cysts
• Primary Intracerebral
Tumours
• Patients are often in
Oncology Clinic
 Lymphoma/ Leukaemia
AIDS patients develop cerebral and other extranodal B-cell lymphomas due to loss

.
of the surveillance function of T-cells

P
a
p
 Metastatic Malignant Melanoma
with Macronucleoli --- “Big Mac”

Cell types: Small “lymphoid”, Binucleate, Multinucleate,

Balloon. **Prominent macronucleoli ( L.Koss)
 Metastatic neoplasms
Breast, lung, ovary, testis
Metastatic Retinoblastoma
Medulloblastoma
Retinoblastoma and ?
pinealoblastoma
Craniopharyngioma Cyst
Or ? squamous carcinoma
Capillary Haemangionblastoma
Intraoperative smears
Primary Brain Tumours
Intra operative smears
 Pitfalls and Mimicry in Cytology
• Oogpister or “Eye
pisser” in the Namib
desert mimics a lizard

Pollen grain which can be mistaken

for parasitic remnants
 Report on what you see,
not what you expect to see.
Scan, look for the “odd man out”.
Be aware of odd/ unusual appearances,
Avoid complacency !
This is a giraffe in Etosha, Namibia
White bone in mouth !

Giraffes are herbivorous!

Lack of calcium in leaves of

local acacia trees.
Giraffes suck bones to avoid
osteoporosis !!

Look carefully!
 Remember !
There is more to Cytology than meets the Eye.

So keep an eye out !

 Further Reading
• J. Bell, J.Clin Pathol, 1994;47:573-378
Update on Central nervous System.
Cerebrospinal Fluid.
• Website : Neuropathology, Dimitri P.
Agamonolis, Akron Childrens’ Hospital, N.E
Ohio, University Colleges of Medicine. (excellent
images, videos, discussions).
 Dedication
• This presentation is dedicated to the memory of

• The late Mr Patrick Carey , Neurosurgeon,

RCSI, Dublin.
and
• The late Professor P.J. Bofin, Neuropathologist,
RCSI, Dublin.