CSF Examination
Presented By- Dr Arpita Bhagabati
Cerebrospinal fluid (CSF)
• CSF is a clear, colorless fluid formed in the ventricles of the brain
mainly by choroid plexus. It is mainly ultrafiltrate of plasma.
• It is absorbed through the Arachnoid villi.
• Total quantity-90-150ml in adults.
Functions of C.S.F
1. Protection of brain and spinal cord from injury by
acting as a shock absorber.
2. To serve as a medium between blood and brain for
supply of nutritions to and removal of waste
products from brain.
COLLECTION OF C.S.F
➢Lumber puncture or LP is the procedure whereby a
sample of CSF is obtained.
➢LP was first performed by Quincke in 1891.
➢Spinal or LP needle is passed between 3rd and 4th or
between 4th and 5th lumber vertebra and CSF is obtained
from the subarachnoid space.
• CSF is collected in sterile plain tubes as follows-
➢Tube 1- Chemistry (glucose and protein) and serology-
1ml
➢Tube 2- Microbiology ( Gram staining, bacterial C/S, AFB,
Fungal study etc)- 2ml
➢Tube 3- Hematology (Total cell count and differential
count)- 1ml
➢Tube 4- Cytology and special studies.
INDICATIONS OF LP
1. Examination of CSF for diagnosis in suspected case of-
• CNS infections
• Meningeal involvement of leukemia or malignancy
• Subarachnoid hemorrhage (if CT scan is not available)
• Inflammatory disease eg- multiple sclerosis, Guillain-Barre
syndrome
• Neoplasms of CNS
2. To reduce CSF pressure in benign intracranial hypertension
(pseudotumor cerebri)
INDICATIONS OF LP
3.Administration of medications- Anesthetic agent, Antibiotics,
Anticancer drugs.
4.Introduction of radiographic contrast media for myelography.
5.For Queckenstedt’s test-Both jugular veins are compressed and then
released and subsequent changes in CSF pressure are observed.
Normally upon compression, CSF pressure raised rapidly and with
release, rapidly falls. In the presence of a spinal block, there is no
rise of CSF pressure with jugular vein compression.
COMPLICATIONS OF LP
1. Post puncture headache
2. Introduction of infection in spinal canal
3. Subdural hematoma
4. Failure to obtain CSF (dry tap)
5. Herniation of brain through tentorium of foramen
magnum
6. Subarachnoid epidermal cyst
CONTRAINDICATIONS OF LP
•-
1. Raised intracranial pressure
2. Cardiorespiratory compromise
3. Bleeding diathesis
4. Local infection at the site of lumber puncture
Examination of CSF includes-
1. Opening pressure
2. Appearance
3. Total and differential cell count
4. Chemical examination
5. Microbiological examination
6. Special investigation
OPENING PRESSURE
• Normal- Adult – 60-180 mm of water, Infant- 10-100 mm of water
• Causes of increased CSF pressure-
1. Tense and anxious patient
2. Intracranial mass lesion
3. Meningitis
4. Cerebral edema
5. Subarachnoid hemorrhage
6. Congestive cardiac failure
7. Benign intracranial hypertension ( Pseudotumor cerebri)
CAUSES OF DECREASED CSF PRESSURE
1. Leakage of CSF fluid following trauma or previous LP
2. Complete spinal block ( due to tumor, abscess etc)
GROSS APPEARANCE OF CSF
• Normal- Clear and colorless
• Turbid- due to Leukocytes, RBCs, Microorganisms, Radiological
contrast media, raised protein
• Blood mixed CSF- May result from
1. Traumatic- Blood more in initial tubes as compared to later
tubes. Blood clots on standing. After centrifugation- Supernatant
is clear.
2. Subarachnoid hemorrhage- Uniform in all tubes. Blood does not
clot on standing. After centrifugation- supernatant is pink or
yellow.
• Xanthochromia- Yellow discoloration of CSF. Causes-
1. Subarachnoid hemorrhage (12hrs after bleeding
episode)
2. Jaundice ( when serum bilirubin >6.0 mg/dl)
3. CSF protein >150 mg/dl
• Other abnormal colors of CSF-
1. Pink- Red cell lysis
2. Brownish- Meningeal metastatic melanoma
3. Orange- High carotene ingestion
• Clot Formation- Pellicle or clot formation indicates increased
proteins (150mg/dl). It occurs in tuberculous meningitis,
purulent meningitis, spinal block, traumatic LP.
• Thick viscous CSF- Seen in Cryptococcal meningitis,
meningeal metastatic mucinous adenocarcinoma, severe
meningitis etc.
CELL COUNTS IN CSF
• Total leukocyte count- Cell count on CSF is done manually on
undiluted sample in a counting chamber (improved
Neubauer chamber).
• If CSF appears cloudy or turbid, 1:20 dilution is made with
Turk solution.
CAUSES OF INCREASED CELL COUNT IN CSF
(PLEOCYTOSIS)
1. Meningitis and other infections of CSF
2. Intracranial hemorrhage
3. Meningeal infiltration by malignancy
4. Repeated lumber puncture
5. Injection of foreign substances (eg- radiographic contrast
media, drugs) in subarachnoid space
6. Multiple sclerosis
• Differential leukocyte count- It provides information about relative
proportion of various leukocytes. In normal adult, differential count
shows- 70% lymphocytes and 30% monocytes. Causes of increased
differential counts-
Predominant Predominant Mixed cell pattern Predominant
neutrophils lymphocytes eosinophil
Meningitis- Bacterial, Meningitis- Viral, Tuberculous meningitis Parasitic and fungal
Early viral, fungal, early Tuberculous infection
tuberculous
Subarachnoid Incompletely treated Fungal meningitis Reaction to foreign
hemorrhage bacterial meningitis materials ( eg- stunts)
Repeated lumber Cysticercosis, Chronic bacterial
puncture toxoplasmosis meningitis
Introduction of Multiple sclerosis
anticancer drugs or
contrast media in
subarachnoid space
Meningeal metastasis Subacute sclerosing
panencephalitis
• Other cells- Apart from normal blood cells, CSF may contain
immature hematopoietic cells, tissue cells and malignant
cells.
• CSF examination carried out in ALL to detect involvement of
CNS. Increased WBC count with lymphoblast is evidence of
CNS involvement.
CHEMICAL EXAMINATION OF CSF
• Estimation of protein-
• Normal value in adult 15-45 mg/dl. Increased in CSF protein
is sensitive but not specific indicators of CNS diseases.
➢Significant elevation (>150 mg/dl) occurs in bacterial
meningitis.
➢Method for estimation- Turbidometric method using
trichloroacetic acid for precipitation of protein.
CSF PROTEINS ARE ELEVATED IN-
1. Increased capillary permeability of BBB- Meningitis
2. Mechanical obstruction of circulation of CSF- Spinal cord
tumor
3. Increased local (intrathecal) IgG production- Multiple
sclerosis, neurosyphilis, subacute sclerosing panencephalitis
4. Both increased capillary permeability and increased lacal
production of IgG- Guillain-Barre syndrome
5. Hemorrhage in CSF- Traumatic tap, subarachnoid
hemorrhage.
ESTIMATION OF GLUCOSE IN CSF
• Normal CSF glucose is 2/3rd of blood glucose. Normal value – 45-80 mg/dl.
➢ CSF glucose is measured by glucose oxidase method.
➢Decreased CSF glucose occurs in-
1. Acute bacterial meningitis
2. Tuberculous meningitis
3. Fungal meningitis
4. Meningeal involvement of malignant tumor (meningeal
carcinomatosis)
5. Hypoglycemia
➢CSF glucose is normal in viral meningitis.
MICROBIOLOGICAL EXAMINATION
• Direct wet mount of CSF- in suspected case of cryptococcosis, amebic
meningoencephalitis, candida infection and trypanosomiasis.
• Gram’s smear- should be done if CSF is turbid and neutrophils are
increased.
• Ziehl-Neelsen smear- if tuberculous meningitis is suspected
• Latex agglutination tests- for detection of bacterial and cryptococcal
antigens
• Serologic tests for syphilis
• Culture for bacteria and MTB
• PCR for MTB and viruses.
Special Investigations
• CSF protein electrophoresis- used –
1. For identification of oligoclonal bands- Multiple sclerosis, neurosyphilis, GB
syndrome.
2. To determine whether fluid submitted for examination is CSF.
• Measurement of albumin and IgG- Helpful for diagnosis in multiple
sclerosis
CSF findings in different types of meningitis
Condition Appearance Leukocytes Proteins in Glucose in mg/dl Additional
mg/dl investigations
1. Normal Clear, Colorless < 5 /cumm 15-45 45-80
(mostly
lymphocytes)
2. Acute Turbid or Increased Increased, Decreased, <40 Gram’s stain,
pyogenic purulent (>1000/cumm) 50-1500 Culture, Latex
meningitis Mostly agglutination test
neutrophils
3. Tuberculous Clear or cloudy Increases (100- Increased, Decreased, ZN staining,
meningitis 600/cumm), 45-300 10-45 Culture, PCR
mostly
lymphocytes or
both
lymphocytes and
neutrophils
4. Viral Clear or cloudy Increased (6- Increased Normal PCR
meningitis 300/cumm),
Lymphocytes
Thank you
