Laboratory Findings in Neurological

and Psychiatric Disorders

 I.Laboratory Procedures

 Include Studies in:

 History & Physical Examination→guide
the tests
 Laboratory Studies
 Blood, Urine, CSF (cerebrospinal fluid)
 Imaging studies

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 I.Laboratory Procedures
PROCEDURE Lumbar Puncture, mostly
wellknown as Spinal Tap
OPERATOR To be performed by
 Established Neurologist
 Legally licenced physician
INDICATION Indication
 To evaluate intracranial pressure &
CSF abnormalities; categories:
1. Meningeal infections
2. Metastatic malignancy, 1mary or 2ndary
 To administer intrathecal drugs or
radiopaque agent for myelography.

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 I.Laboratory Procedures

Contraindication • Infection at the puncture

site
• Bleeding diathesis
• Increased intracranial
pressure
• Chiary I type
malformation

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 I.Laboratory Procedures

Specimen • A manometer is
collection & attachedrecord opening
Opening pressure)
pressure (OP)
 Normal OP:
• 90-180 mmH2O
• Lateral decubitus position
 slightly:
• Sit up
• Obese
• Vary up to 10 mmH2O with
respiration

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 I.Laboratory Procedures

Specimen • OP seen in:

collection &  Spinal-subarachnoid block
Opening pressure
 Circulatory collaps
 Dehydration
 CSF leakage

• Dramatic pressure drop

after removal 1-2
mlsuggest herniation or
spinal blockno further
withdrawing
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 I.Laboratory Procedures

Specimen • OP seen with/ in:

collection &  Patient tension or straining
Opening pressure
 Congestive Heart Failure,
Meningitis, Superior Vena
Cava Syndrome, thrombosis
of venous sinuses, cerebral
edema, mass lesions,
hypoosmolality, and condition
inhibiting CSF absorption

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 I.Laboratory Procedures

Specimen • Up to 20 ml may normally

collection & removed
Opening pressure
• Divided into 3 sterile tubes
1. Chemistry & Immunologic
studies
2. Microbiological examination
3. Cell count & differential

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 I.Laboratory Procedures

Indication of • 4 categories of disease

Lumbar Puncture
1. Meningeal infection
2. Subarachnoid hemorrhage
3. CNS malignancy
4. Demyelinating disease

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I.Laboratory Procedures

 Most Important indication: Identification of

Meningitis esp.bacterial
Diseases detected by Lab.Exam.of CSF
 sensitivity,  specificity
•Bacterial, tuberculous, and Fungal
 sensitivity, moderate specificity
•Viral meningitis
•Subarachnoid hemorrhage
•Multiple sclerosis
•CNS syphilis Sensitivity: ability of test to detect
•Infectious polyneuritis
disease when it is present
•Paraspinal abscess
Specificity: ability of a test to exclude
disease when it is not present

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 I.Laboratory Procedures

 Most Important indication: Identification of Meningitis

esp.bacterial
Diseases detected by Lab.Exam.of CSF
Moderate sensitivity,  specificity
•Meningeal malignancy
Moderate sensitivity, moderate specificity
•Intracranial hemorrhage
•Viral encephalitis
•Subdural hematome Sensitivity: ability of test to detect
disease when it is present
Specificity: ability of a test to exclude
disease when it is not present

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 I.Laboratory Procedures
Recommended CSF Lab.Tests

Routine •Opening of CSF Pressure

•Total Cell Count (WBC & RBC)
•Differential Cell Count (stained smear)
•Glucose (CSF/plasma ratio)
•Total protein

Useful under •Cultures (bacteria, fungi, viruses, MTbc)

certain •Gram stain, acid-fast stain
condition •Fungal and bacterial antigens
•Enzymes (LD, CK-BB)
•Lactate
•Polymerase chain reaction, PCR (TB, viruses)
•Cytology
•Electrophoresis (protein, immunofixation)
•etc
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 II. Examination of CSF

1.Gross Examination
NORMAL
 clear, viscocity similar to water.
ABNORMAL
 Cloudy, frankly purulent, pigment tinged
• Turbidity/ cloudness begins to appear:
WBC>200 cells/µL or RBC >400
cells/µL
• Grossly bloody CSF: > 6000/µL
• Varying degree of cloud:
microorganisms, radiographic
contrast material, aspirated epidural
fat, protein >150 mg/dL
 Clot formation:
 Traumatic taps
 Complete spinal block

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 II. Examination of CSF

1.Gross Examination
ABNORMAL  Viscous CSF:
 Metastatic mucin-producing
adenocarcinomas
 Liquid nucleus pulposus (needle
injury to annulus fibrosus)
 Pink-red:
 Indicates presence of blood,
originate from subarachnoid
hemorrhage, intracerebral
hemorrhage, cerebral infarct, or
traumatic tap

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 II. Examination of CSF

1.Gross Examination
ABNORMAL  Xanthochromia
 Refer to pale pink to yellow color of
the supernatant of centrifuged CSF
 Owing to RBC lysis and Hgb
breakdown
 Pink→orange color
 Oxyhemoglobin release
 2-4 hrs after subarachnoid
hemorrhage, peak ≈ 24-36 hrs,
disappear the next 4-8 days

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II. Examination of CSF

1.Gross Examination
ABNORMAL  Xanthochromia
 Yellow →orange color
 Derived from bilirubin
 12 hrs after subarachnoid
hemorrhage, peak ≈ 2-4 days,
may persist 2-4 wks

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 II. Examination of CSF

1.Gross Examination
ABNORMAL  Xanthochromia
 Also visible in:
 Artefactual RBC lysis cause by
detergent or delay > 1 hr without
refrigeration
 Bilirubin in jaundiced patients
 CSF protein > 150mg/dL
(traumatic tap, complete spinal
block, polyneuritis,meningitis,
carotenoids (dietary
hypercarotenemia), meningeal
metastatic melanoma (melanin),
rifampicin therapy

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 II. Examination of
CSF
1.Gross Examination
TRAUMATIC  Traumatic vs Pathologic hemorrhage
 3 tubes: clear CSF in the 2nd
 RBC lysis begins as early as 1-2 hrs
after spinal tap
 Latex agglutination immunoassay (test
for fibrin degradation (derivative D-
dimer): negative

 3 tubes: remains xanthochromic in 2nd

in subarachnoid hemorrhage
PATHOLOGIC  Microscopic evidence:
erythrophagocytosis, hemosiderin-
laden macrophages
 Latex agglutination immunoassay (test
for fibrin degradion (derivative D-
dimer): positive

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 II. Examination of CSF

2.Microscopic Examination
Total Cell Count  Fuchs-Rosenthal or Neubauer counting
chamber
 WBC
 Normal, adult: 0-5 cell/µL
 Neonates: higher, 0-30 cell/µL
 RBC should be negative.

WBC Differential  Normal DIFF

Count  Lymphocytes: 62 ± 34 %
 Monocytes: 36 ± 20 %
 Neutrophils: 2 ± 5 %
 Eosinophils: rare
 Histiocytes: rare
 Ependymal cells: rare

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 II. Examination of CSF

3.Chemical Analysis
1.Proteins
 Normal: 15-45 mg/dL
 :
 Traumatic spinal puncture
 Increased blood-CSF permeability
 Arachnoiditis (MTX therapy)
 Meningitis (bact, viral, fungal, tbc)
 Hemorrhage (subarachnoid,
intracerebral)
 Endocrine-metabolic disorders
 Milk-alkali syndrome w/ hypercalcemia
 Ethanol, phenothiazines, phenytoin
 CSF circulation defects
 Mechanical obstruction (tumor, abscess,
herniated disk)
 Loculated CSF effusion
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 II. Examination of CSF
3.Chemical Analysis
1.Proteins  :
 Increased IgG synthesis
 Neurosyphilis, multiplesclerosis,
subacute sclerosing
panencephalitis
 Increased IgG synthesis &
blood-CSF permeability
 Guillain-Bare syndrome
 Collagen vascular disease (lupus,
periarteritis)
 Chronic inflammatory,
demyelinating polyradiculopathy

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 II. Examination of CSF
3.Chemical Analysis
2.Glucose  Normal
 50-80 mg/dL
 Glu CSF/Plasma ratio: 0.3-0.9
 Hypoglycorrhachia
 Bacterial, tuberculous, & fungal
infections (characteristic)
 Meningoencephalitis (some
cases)
 Other conditions involving
meniges (tumor, sub arachnoid
hemorrhage, cysticercosis,
sarcoidosis, etc)

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 II. Examination of CSF

3.Chemical Analysis
3.Lactate  9.0 – 26 mg/dL; higher in
newborns
 Viral meningitis (<25-35
mg/dL) vs
Bacterial,mycoplasma,
fungal and tbc meningitis
(>35 mg/dL)
 Persistent : associated
with poor prognosis

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 II. Examination of CSF

3.Chemical Analysis
4.Enzymes   in pleural, peritoneal and meningeal
• Adenosine tuberculosis
deaminase  Lower level in nontuberculous
(ADA)
 > 15 U/L : strong indication of meningeal
tbc.
• Creatinie kinase
(CK)
  In hydrocephalus, cerebral
infarction, brain tumors,
subarachnoid hemorrhage
 CK-BB  associated with outcome
of subarachnoid hemorrhage

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II. Examination of CSF

3.Chemical Analysis
4.Enzymes
• Lactodehydrogenase
(LDH)  Upper limit: 80 U/L
  in bacterial meningitis,
CNS leukemia, lymphoma,
metastatic carcinoma, sub
5.Electrolytes arachnoid hemorrhage.
& Acid Base
Balance
 No clinically indication

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 II. Examination of CSF

6.Tumor 3.Chemical Analysis

markers
•Carcinoembyonic  Increased CEA in metastatic
antigen (CEA) brain tumors (44%), metastatic
carcinome of the
•Human chorionic leptomeninges.
gonadotropin
(HCG), -Feto
protein
 Useful for diagnosis &
monitoring of response to
therapy in patients cell
tumors.
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 II. Examination of CSF
• Bacterial meningitis
4.Microbial Examination
• Spirochetal meningitis
• Viral meningitis  Microbial Department
• HIV
• Fungal meningitis
• Tuberculous meningitis

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 Cerebrospinal Fluid Abnormalities in
Various Disorders
Predominant
Condition Pressure WBC/μL Glucose Protein
Cell Type
Normal 100–200 0–3 L 50–100 20–45
mm H2O mg/dL mg/dL
Acute  100– PMN  > 100
bacterial 10,000 mg/dL
meningitis
Subacute N or ↑ 100–700 L  
meningitis
(TB,
Cryptococc
us infection,
sarcoidosis,
leukemia,
carcinoma)

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Cerebrospinal Fluid Abnormalities in
Various Disorders

Predominant
Condition Pressure WBC/μL Glucose Protein
Cell Type
Acute N or ↑ 25–2000 L N 
syphilitic
meningitis
Paretic N or ↑ 15–2000 L N 
neurosyphi
lis
Lyme N or ↑ 0–500 L N N or ↑
disease of
CNS

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 Cerebrospinal Fluid Abnormalities in
Various Disorders

Predominant
Condition Pressure WBC/μL Glucose Protein
Cell Type
Brain N or ↑ 0–1000 L N 
abscess or
tumor
Viral N or ↑ 100–2000 L N N or ↑
infections
Cerebral  Bloody RBCs N 
hemorrhage
Cerebral N or ↑ 0–100 L N N or ↑
thrombosis

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Cerebrospinal Fluid Abnormalities in
Various Disorders

Predomina
Condition Pressure Wbc/μL nt Cell Glucose Protein
Type
Spinal cord N 0–50 L N N or 
tumor
Guillain- N 0–100 L N > 100
Barré mg/dL
syndrome
Lead  0–500 L N 
encephalo
pathy
Pseudotum  N L N 
or cerebri

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