Cerebrospinal fluid

Formation and Physiology

~First recognized by Cotugno in 1764, CSF is the third major
fluid of the body.

PHYSIOLOGIC SYSTEM
1. To supply nutrients to the nervous system
2. To remove metabolic wastes
3. To produce a mechanical barrier to cushion the brain and
spinal cord against trauma.

MENINGES LAYERS
1. Dura mater - outer layer
2. Arachnoid mater - middle layer
3. Pia mater - inner layer
• CSF flows through the subarachnoid space
between the arachnoid and pia mater

• 20 ml of fluid produced every hr in choroids

plexus and reabsorbed by arachnoid villi
Specimen Collection and handling

CSF is collected by lumbar puncture between third,

fourth, fifth lumbar vertebrae. It requires certain precautions
and careful technique to prevent the introduction of
infection or the damaging of neural tissue.

CSF usually collected in three sterile tubes

•Label 1 / Tube 1 – used for chemical and serologic test
( tubes are frozen)
•Label 2 / Tube 2 – used for microbiology lab
( room temp.)
•Label 3 / Tube 3 – used for hematology (cell count)
( refrigerated)
APPEARANCE

Major terminology used to describe CSF appearance:

 Crystal clear

 Cloudy or turbid – result of an increased protein or lipid

conc/presence of WBC
 milky

 hemolyzed / bloody

 xanthochromic – supernatant is pink, orange, or yellow

1. pink – very slight amount of oxyhemoglobin

2. orange – heavy hemolysis

3. yellow – conversion of oxyhemoglobin to unconjugated

bilirubin
* other causes:
 Elevated serum bilirubin

 Presence of the pigment carotene

 Markedly increase protein conc

 Melanoma pigment
TRAUMATIC COLLECTION
 Grossly bloody CSF can be an indication of intracranial
hemorrhage or due to the puncture of a blood vessel during
spinal tap procedure (traumatic tap)
UNEVEN DISTRIBUTION OF BLOOD
 From the three test tubes whereas the heaviest
concentration of blood was in the first tube then gradually
diminishing amounts in tube 2 and 3.
CLOT FORMATION
 Meningitis, Froin’s syndrome, and blockage of CSF
circulation through subarachnoid space
XANTHOCHROMIC SUPERNATANT
 Additional testing for differentiation includes microscopic
examination and the D-dimer test
CELL COUNT
 RBC and WBC count

METHODOLOGY
 Normal adult 0 – 5 WBCs/µL
 Children 30 mononuclear cells/µL ( 200WBC/ 400RBCs)
TOTAL CELL COUNT
WBC COUNT
CORRECTIONS FOR CONTAMINATION
QUALITY CONTROL OF CSF AND OTHER BODY FLUID CELL
COUNTS

DIFFERENTIAL COUNT ON A CSF SPECIMEN

 Identifying the types of cells in the CSF is a valuable diagnostic
aid.the differential count should be performed on a stained smear
and not from the cells in the counting chamber. Poor visualization
of the cells as they appear in the counting chamber led to the
laboratory practice of reporting only the percentage of mononuclear
and polynuclear cells present.
CSF CONSTITUENTS
 Cells found in normal CSF are lymphocytes and

monocytes
 Pleocytosis is considered abnormal cells.

 WBC count majority of the cells are neutrophils

considered bacterial meningitis. And if moderately

high percentage o flymphocytes and monocytes,
meningitis of viral, tubercular, fungal, or parasitic
origin.
 CSF PROTEIN

CSF SERUM RATIO

mg/dl mg/dl

Prealbumin 1.7 23.8 14

Albumin 15.5 3600 236
Ceruloplasmin 0.1 36.6 366
Transferrin 1.4 204 142
Immunoglobulin 1.2 987 802
G
Immunoglobulin 0.13 175 1346
A
CLINICAL SIGNIFICANCE OF ELEVATED PROTEIN VALUES
 Elevated total protein values are most frequently seen in
pathologic conditions. Abnormally low values will be present
when fluid is leaking from the CNS. Cause of elevated CSF
protein include the damage to the blood brain barrier
 Protein fractions
 Electrophoreseis
 Myelin basic protein

CSF GLUCOSE
 Glucose enters the CSF by selective transport across the blood-brain
barrier, which result in a normal value that is approximately 60 – 70
percent that of the plasma glucose. The diagnostic significance of CSF
glucose is confined to the finding of values that decreased in relation to
plasma values.low CSF glucose can be considerable diagnostic value in
determining the causative agents in meningitis.
CSF LACTATE
 The determination of CSF lactate levels aid in the diagnosis and
management of meningitis cases. In bacterial, tubercular and fungal
meningitis.elevations of CSF lactate greater than 25mg/dl. Destruction
of tissue within the CNS owing to oxygen deprivation (hypoxia) causes
the production of increaded CSF lactic acid levels.

CSF GLUTAMINE
 Glutamine is produced in the CNS by the brain cells from ammonia
and alpha-ketoglutarate. This process serves to remove the toxic
metabolic waste product ammonia from the CNS. Normal concentration
of ammonia is 8-18 mg/dl. Elevated levelsassociated with liver
disorders.

CSF ENZYMES
 LDH – LD1, LD2, LD3, LD4, LD%
 CK – BB
MICROBIOLOGY TEST
For positive identification, the microorganism must be recovered
from the fluid by growing it on the appropriate culture medium. Can take
24 hrs I cases of bacterial meningitis to 6 weeks for tubercular meningitis.
In many instances, CSF culture is actually a confirmatory test

GRAM STAIN
Is routinely performed on CSF from all suspected cases of meningitis
although its value lies on the detection of bacterial and fungal organisms.

 Organisms most frequently encountered:

 S. pneumoniae (gram positive cocci)
 H. influenzae ( pleomorphic gram negative rods)
 E. coli (gram negative rods)
 Acid-fast is not routinely performed on
specimens unless tubercular menoingitis is
suspected.

 Latex Agglutination and ELISA provides a

rapid means for detecting microorganisms in
CSF.
SEROLOGIC TESTING
Serologic testing of the CSF is performed to detect the
presence of neurosyphilis. However, detection of the
antibodies associated with syphilis in the CSF still remains a
necessary diagnostic procedure.

Serologic tests:
 VDRL
 FTA –ABS

TEACHING CSF ANALYSIS

Many of the problems that occur in the analysis of CSF
are result of inadequate training of the personnel performing
the tests. This is considered that not only is CSF is difficult
to collect.