Cerebral Spinal Fluid

Csf is collected for the investigation of clinical disorder of the central nervous system (CNS)

Csf is mainly composed of water, dissolved oxygen and solids.

Average volume is between 100ml and 150ml produced at rate of 430ml/day.

Csf is produced by choroid plexus of ventricles and re-absorption occurs at arachnoid villi

Csf passes from lateral into 3rd ventricles via foramen of monro down to cerebral aquaduct into 4th ventricle.

Csf then flows from 4th ventricles down to spinal cord through openings (foramina) into subarachnoid space.

Specimen for Csf is collected by Lumbar Puncture (LP) or cervical puncture.

Done by using a needle with a stylette inside

Needle is introduced between 3rd and 4th lumbar vertebrae into spinal sub-arachnoid space.

This is because the cord stops at the level of 1st lumbar vertebrae.

A manometer should be attached prior to fluid removal to record opening pressure

Csf for glucose estimation is collected in fluoride oxalate preservative to prevent glycolysis

Pressure changes with postural changes, blood pressure and even venous return

Normal opening pressure is 90-180mmHg in lateral position

Upto 20mls of Csf may be removed and should be divided into 3parts:
• For chemistry and immunology studies
• For microbiological examination
• For cell count and differential

Functions of CSF

Provides physical support since 1500g of brains weighs 50g when suspended in Csf

Confers protective effect against sudden change in arterial pressure/impact pressure (shock absorber)

Provides excretory waste function

Transports hypothalamus releasing factors

Maintains CNS ionic homeostasis

Carries nutrients to the brain and spinal cord

Keeps the brain and the spinal cord moist

Maintains constant pressure inside the head and around spinal cord.

Possible complications of Lumbar Puncture

Production of cerebral pressure

Paralysis if spinal cord in cases of spinal cord tumor

Infections can be inadvertently introduced if aseptic precautions are not observed

Headache is commonly experienced

Infantile death can occur due to asphyxiation resulting from pushing the head forward during flexing.

Composition of a normal Csf

Csf is similar in composition to plasma but:-
• Conc. Of Na+, Cl-, Mg2+ and Glutamine are greater in Csf than in plasma
• Conc. of Glucose, protein K+, Ca2+, Fe2+,Cholestrol & Uric acid and are higher in plasma than in Csf

Cells : 0-5 leucocytes (lymphocytes) and no rbc s

Glucose: 45-100mg% by copper reduction method

Total protein: 15-40mg% lower than plasma protein

Globulin: Not detectable

Urea: 15-40mg% similar in composition in plasma and in Csf.

Chloride: 118-132Mmol/L.

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 Routine Examination of CSF
Appearance: - Normal Csf is clear and colorless
Turbidity:
• Abnormal Csf may appear cloudy or pigment tinged
• A purulent or turbid/ cloudy Csf is associated with meningitis
• Turbidity begins to appear with leaucocytes over 200 cells/ul or red cells over 400 cell/ul
• Microorganisms, aspirated epidural fat and proteins over 150mg% may produce varied degree of cloudiness.

Viscosity: Viscous Csf may be encountered in patients with metastatic mucin producing adenocarcinomas &
Viscosity is similar to that of water without a coagulum of fibrin or deposits

Blood: Presence of blood indicates:-

• Traumatic lumbar puncture
• Recent sub-arachnoid bleeding
• Meningoencephalitis caused by amoeba naegleria sp.

Xanthocromia: this describe pale yellow and yellow colored Csf. It is associated with:-
• Sub-arachnoid haemorrhage leading to high breakdown of hemoglobin
• Contamination of Csf by iodine or methiolate used to disinfect the skin
• High level of protein over 100mg%
• Cerebral tumor
• Jaundice
Clot :- Clotting or coagulation occurs on Csf specimen on standing containing enough fibrinogen
• This indicates elevated levels of protein concentration
• Also occurs in moderately elevated protein conc. in TB meningitis.
• Clotting is also a common feature in traumatic tap.

Chemical Examination of Csf

Glucose estimation:
• Uses glucose oxidase method as blood glucose
• Owing to low value use double the volume but half the results

Urea estimation:
• Since Urea concentration is the same as blood estimation, estimation is not done

Chloride estimation:
• Uses schales and schales method

Total protein estimation:

• Total protein is the sum total of albumin and globulin fractions
• Estimated by turbidimetric method using 3% Trichloro-Acetic Acid (TCA)
• Can also e done using Mulemans reagent (3% sulphosalicylic acid and 7% sodium sulphate)
Principle of TCA & Mulemans reagent
TCA & Mulemans reagent - precipitates protein to form turbidity which is proportional to the amount of
protein present

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 Globulin detection tests:
This is performed on blood free Csf specimen.

Pandy s test
Principle:
Excess globulin molecules dehydrates pandy s reagent (saturated aqueous solution of phenol) and displaces
phenol from the solution causing fine persistent turbidity.
Method:

Add 1 drop of Csf to 0.5ml of pandy s reagent in a small test tube

Look for immediate turbidity/ cloudness around the drop of Csf
Result:

Cloudness/ turbidity against a dark background indicate increase in globulin content.

Quantify and report turbidity as: Nil, +, ++, +++ or ++++.

If no cloudiness is seen, report as: - Nil or Pandy s test Negative

Nonne-Apelt s test
Principle:
Globulin is precipitated by a solution of saturated ammonium sulphate
Method:

Carefully layer 1.0 ml of clear Csf to 1.0 ml of saturated ammonium sulphate
Result:

A thin white ring of precipitation appears at the interface of the two fluids if globulin is present.

On mixing, the ring may disappear and this dictates a + reaction

Quantify cloudiness as heavy cloudiness indicates a ++++ reaction

Radial Immuno-diffusion test

Useful test for measurement of concentrations of albumin and globulin in Csf

It involves diffusion of antigen (IgG or Albumin) in the Csf through a semisolid medium containing an
antibody (anti-IgG or anti-Albumin) thereby forming a visible zone of precipitation.

Measurement of the zones of precipitation corresponds to the concentration of the antigen

This method also determines IgG/albumin ratio important in diagnosis of multiple sclerosis.

NB: Electrophoresis of Csf protein can also be carried out to evaluate the albumin and globulin content in Csf.
Ratio of Albumin and globulin ratio in Csf is 8:1

Clinical Significance
Increase in Csf proteins:

Mild increase seen in viral meningitis, cerebral thrombosis, multiple sclerosis, brain tumor or neurosyphilis

Csf globulins IgG is f raised in cases multiple sclerosis and neurosyphilis

Pronounced increase in Csf proteins is seen in bacterial meningitis, TB meningitis, spinal cord tumor.
Glucose:
Csf glucose of less than 40mg% is considered reduced level.
Csf glucose is estimated in the same way as for blood glucose.

No significant change in Csf glucose is seen in Viral meningitis, neurosyphilis, multiple sclerosis, cerebral
thrombosis

Moderate reduction in Csf glucose is seen in CNS leukemia, subarachnoid hemorrhage.

Marked reduction in Csf glucose is seen in bacterial meningitis, Tuberculous meningitis & fungal Meningitis

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