CEREBROSPINAL FLUID Produce 500ml/day. 70%CSF is derived by ultrafiltration and secretion through the choroid plexus.

The remainder is from ventricular ependymal lining and cerebral subarachnoid space. Up to 20 ml CSF may normally be collected Obtained by lumbar puncture, cisternal puncture, lateral cervical puncture or ventricular cannulas Function : y y y y Physical support to brain Protect sudden changes in blood pressure Excretory waste Maintain cns ionic hemostasis

CSF examination : gross examination, microscopic examination, chemical examination Gross examination y y y y y Normal CSF : clear and colorless, viscosity similar to water Turbidity : leukocyte>200 cells/mikroliter. Erithrocyte>400cells/mikroliter Clot formation : traumatic tap, complete spinal block, suppurative or tuberculous meningitis Viscous : metastatic mucin-producing carcinomas, cryptococcal meningitis Xanthochromia : pink, orange or yellow ; due to RBC lysis or Hb breakdown ; bilirubin,protein>150mg/dl, carotenoid, melanin,

Microscopic examination y Total cell count o Leukocyte : normal 0-5 cells/mikroliter, neonates<30 cells/mikroliter o Use Fuchs-Rosenthal type chamber or Neubauer hemocytometer Differential cell count o Performed on a Wright s-stained smear o Normal : primarily lymphocytes&monocytes o Neutrophil increase : bacterial meningitis o Lymphocyte increase : viral menigitis o Eosinophil increase : parasitic & fungal infection

Chemical Analysis y Total protein o Derived from plasma, in concentration <1% blood level (15-45 mg/dL) o Elevated CSF protein may be caused by :  Increased permeability of blood brain barrier  Decreased resorption at the arachnoid villi  Mechanical obstruction of CSF flow due to spinal block above the puncture site  Increase intrathecal immunoglobulin synthesis o Methodology

 Turbidimetric method :simple,rapid,require no special instrumentation , but temperature sensitive and require much larger specimen volume  Calorimetric method : include Lowry-method , dye-binding method using CBB/ponceau. CBB technique is rapid, highly sensitive, and can be used with small sample size Other CSF protein o C-Reactive protein(CRP) : differentiative viral meningitis from bacterial menigitis o Fibronectin : increase in Burkitt s lymphoma, metastatic solid tumor, astrocytomas, bacterial meningitis o Bilirubin : increase in subarachnoid hemorrhage Glucose o Derived from blood glucose o Fasting CSF glucose 50-80mg/dl o Hypoglycorrhacia : bacterial, tuberculous, and fungal menigitis Lactate o Used as differentiation viral menigitis from bacterial, mycoplasma, fungal, and tuberculous meningitis o Viral<35mg/dL ; bacterial>35 mg/dL Enzymes o Adenosine deaminase (ADA) : catalyze irreversible hydrolytic deamination of adenosine to produce inosine. Higher ADA increase : tuberculous infection o Creatine Kinase (CK) Increase in hydrocephalus, cerebral infarction, primary brain tumor Tumor markers o Carcinoembryonic antigen (CEA) : oncofetal protein produce a variety of carcinoma

Microbial Examination : Gram Stain and culture y Fungal Menigitis Cryptococcus is the most frequently isolated fungal pathogen from CSF. Detection of cryptococcal antigen from csf using latex agglutination Viral menigitis Enteroviruses (echoviruses, coxsackieviruses, polioviruses) are responsible of meningitis case Tuberculous meningitis Abnormal CSF ith elevated protein and lymphocytic predominance