Examination of CSF
Dr. Md. Razib hasan
Clinical pathologist,MMC
CEREBROSPINAL FLUID (CSF)
CSF is a modified tissue fluid.
It is contained in the ventricular system of
the brain and in the subarachnoid space
around the brain and spinal cord.
CSF replaces lymph in the CNS .
CEREBROSPINAL FLUID
Formation:
1. 70% of CSF is derived by ultrafiltration and
secretion through choroid plexus of lateral
ventricles.
2. The ependymal lining of the ventricles and
cerebral sub arachnoid space account for the
remainder.
Absorption:
Absorbed mainly in cerebral veins & dural sinuses
through arachnoid villi and partly by perineural
lymphatics.
Circulation:
CSF passes from lateral
ventricle
F.Monro
3rd ventricle
Aqueduct of sylvius
4th ventricle
Cisterna magna
Sub arachnoid space around
the brain and spinal cord.
CEREBROSPINAL FLUID
Rate of production:
20 ml /hours
500 ml /day (approximately)
Volume:
Adult– (90 -150) ml
Neonate - (10-60) ml
Functions of CSF:
1. Provide nutrition.
2. Maintains intra cerebral pressure.
3. Maintains CNS ionic homeostasis.
4. Act as a cushion & lubricant of CNS and give
protective effect.
5.Remove the waste of products.
Indications of CSF Collection:
For diagnostic purpose
Meningeal infection
Sub arachnoid hemorrhage
CNS malignancy disease
Demyelinating disease
For therapeutic purpose
Administration of drugs
CSF Pressure
Removal of exudates and blood from sub arachnoid space.
For prognostic purpose
Myelogram
CSF collection
Contraindications:
1. Raised intracranial pressure
2. Cerebral lesion
3. In heparin or aspirin therapy.
4. Depressed level of consciousness.
Complication:
1. Headache
2. Pain
3. Introduction of infections
CSF
Opening pressure:
Measured by Manometer which has been attached before any fluid
is removed to record the opening pressure.
Adult :(90-180) mm of H2O
Infants and young children :(10-100) mm of H2O
CSF under normal pressure flows from needle at
the rate of 20-60 dl/min
If pressure is more than 200 mm of H2O in a
relaxed patient, fluid should not be removed more
than 2ml.
Causes of increased pressure
Meningitis
Cerebral oedema
SOL
Intracranial hemorrhage
Pt’s having tension or straining
CCF
Superior vena cava syndrome
Mass lesion
Hypo-osmolality
Causes of Decreased pressure
Spinal subarachnoid block
Dehydration
Circulatory collapse
CSF leakage
CSF Collection
Collection site:
Lumber puncture(Adult L 3-4)
Cisternal puncture
Lateral cervical puncture
Through ventricular canulas or shunts
CSF Collection
CSF to be collected
aseptically from
subarachnoid space.
Total of 6 to 10 ml may
be collected.
Collected in 3 to 4
sterile tubes &
immediately labeled
with patient’s name.
CSF Collection
CSF Collection
CSF is to be collected for-
Microbiological study: (2-3) ml
Biochemistry & immunology study
Cell count & cytology: 1ml
Additional tube may be used for cytology if
malignancy suspected.
CSF Collection
Precaution:
CSF is an urgent test & should be done by one hour
after collection. Should never be refrigerated
because fastidious organism (H.influenzae,
N.meningitidis) will not survive.
If not rapidly processed, CSF can be incubated at
35oC or left at room temperature. CSF can be
refrigerated for viral study only.
CSF Examination
Lab Procedures
A. Initial processing
Specimen should be processed immediately and all
results to be reported to the physician directly
Centrifuge the specimen in air-dried cytocentrifuged
preparation to reduce error
Sediment to be used for microscopy and
microbiological examination
B. Physical examination:
1.Volume : Minimum 1ml is required
viscosity : similar to water.
2. Color : Normally clear and colorless with a
yellow : Xanthocromia
Due to RBC lysis- Subarachnoid hemorrhage
Obstructive jaundice
Traumatic tap.
Brownish :Meningeal metastatic melanoma
Red orange :Rifampicin therapy
Red :Due to presence of RBC > 6000/µl
Greenish :Pneumococcal meningitis
3. Appearance: Clear normally.
Turbid / Cloudy (>200 leucocytes or >400 RBC/µl )
Micro organism (Bacteria, Fungus, Amoeba )
Radiographic contrast material
Elevated protein level
Aspirated epidural fat
Clot formation indicates increased protein with
increased fibrinogen
Suppurative and Tuberculus meningitis
Traumatic tap
4. Viscosity : Normal – Similar to water
Increased in-
metastatic mucin producing adenocarcinoma,
Cryptococcal meningitis
D. Chemical analysis:
1. Proteinestimation:
Tubidimetric method
Colorimetric method
Dyebinding method
Immunoturbidimetry method
Imunonephelometry method
Adult :(15 – 45) mg/dl
[Normal plasma level:66 to 87 mg/dl]
Neonate : up to 150 mg/dl
In premature infants : as high as 400 mg/dl
Conditions associated with increased CSF total protein:
Increased blood CSF permeability
Arachnoiditis (e.g. following methotrexate therapy)
Meningitis (bacterial, fungal, tuberculous etc.)
Hemorrhage (subarachnoid, intracerebral)
Endocrine/metabolic disorders
Milk alkali syndrome with hypercalcemia
Diabetic neuropathy
Hereditary neuropathies and myelopathies
Decreased endocrine function (thyroid, parathyroid)
Drug toxicity : Ethanol, phenothiazines, phenytoin
CSF circulation defects
Mechanical obstruction (tumor, abscess, herniated disk)
Loculated CSF effusion
Increased IgG synthesis
Neurosyphilis, multiple sclerosis, SSPE
Increased IgG synthesis and blood CSF permiability
Guillain-Barré syndrome
Collagen vascular diseases (e.g. SLE, periarteritis
CSF Examination
Causes of decreased protein
Removal of large volume
CSF leaks by trauma
Increased ICP
Hyperthyroidism
2. Glucose estimation:
Strip method
Colorimetric method
Enzymatic method
Fasting (50-80 mg/dl) - 60% of plasma values.
Causes of Decreased glucose :
Viral meningoencephalitis
Meningeal involvement by-
Malignant tumor
Sarcoidosis
Cysticercosis
Trichinosis
Ameba (Naegleria)
Acute syphilitic meningitis
Subarachnoid haemorrhage
3. Lactate: Older children and adults: 9.0-26.0 mg/dl
Newborns(1st 2 days): 10.0-60.0 mg/dl
(3rd to 10th days): 10.0-40.0 mg/dl
Viral meningitis: < 25 mg/dl
4. Enzyme: Lactate dehydrogenase: 40 U/L (adult)
Help to Differentiate traumatic tap from ICH
70 U/L (neonate)
Adenosine deaminase: 15 u/l (increased in TB)
Creatine kinase: <5 U/L (increased in CNS disorder)
C. Microscopic examination:
Wet preparation
Total cell count (TC):In Neubauer counting chamber
Normal Range : 0-5 WBC/cmm (adults),
0-30 WBC/cmm (neonates)
N Cells/cumm
TC =
4 X 1/10
(N = No. of cells in 64 small square )
If necessary, dilution with acetic acid is needed if the fluid is blood
mixed.
N X D Cells/cumm
TC =
4 X 1/10
Differential cell count (DC): By Leishman stain or Giemsa stain.
Cause of increased nutrophils in CSF
Meningitis
Bacterial meningitis
Early viral meningoencephalitis
Early tuberculous meningitis
Early mycotic meningitis
Amoebic encephalomyelitis
Other infections
Cerebral abscess
Subdural empyema
AIDS related CMV radiculopathy
Following seizures
Following CNS hemorrhage
Subarachnoid hemorrhage
Intracerebral hemorrhage
Reaction to repeated lumber puncture
Metastatic tumor in contact with CSF
Causes of increased lymphocyts in CSF
Meningitis
Viral meningitis
Tuberculous meningitis
Fungal meningitis
Syphilitic meningoencephalitis
Leptospiral meningitis
Bacterial meningitis (due to L monocytogenes)
Parasitic infestations of the CNS e.g. cysticercosis, toxoplasmosis
Degenerative disorder
Subacute sclerosing panencephalitis
Multiple sclerosis
Encephalopathy due to drug abuse
Guillain-Barré syndrome
Other condition
Handle syndrome
Polyneuritis
Periarteritis involving the CNS
Cause of CSF plasma cytosis in CSF
Tuberculous meningitis
Syphilitic meningoencephalitis
Multiple sclerosis
Parasitic infestation of CNS
Subacute sclerosing panencephalitis
Guillain-Barré syndrome
Sarcoidosis
Acute viral infection
E. Bacteriological examination
1. Staining: Gram staining
ZN Stain
India ink staining: Cryptococcus
Immunofluorescent staining: H.influenza
Fluorescent auramine rhodamine
staining- TB highly sensitive
2. Culture: Blood agar media
Mac conkeys agar
Chocolate agar media
Sabouraud’s agar media
Causes of meningitis
Bacterial Viral Fungal Protozoal
According to age Enterovirus Cryptococcus Amoebic
1st 4 weeks: HSV Blastomyces Neglaria
Group B strep. Measles Candida
Gram-Neg. bacilli
Mumps Histoplasma
L monocytogenes
Varicella zoster Coccidiodes
Meningococci
EBV Sporothrix
4 wks – 6 m
H influenzae HIV
Meningococci Influenza
Pneumococci
Over 6 years
Meningococci
Pneumococci
All ages:
Tuberculosis
Bacterial antigen detection
Latex agglutination test : E coli
H influenzae
Streptococcus group B
Meningococci
Pneumococci
Counter immunoelectrophoresis
Coagglutination test
Rapid extraction of antigen procedure
ELISA-DOT for TB
Antibody detection:
VDRL
TPHA in neurosyphilis
FTA-ABS
Cytokine study: IL -1 , TNF α and other cytokines are
elevated in acute meningitis
Tumor marker:
CEA: Elevated in CSF in some metastatic
tumors
AFP : In germs cell tumors
HCG: In choriocarcinoma and malignant germ cell
tumors
PCR: for the nucleic acid detection,
for detecting M TB DNA.
Light or phase contrast microscopy in direct wet mounts,
for motile Nagleria trophozoites ( a rare finding) .
CSF findings in meningitis
Meningitis Openingpressure Lukocytes/uL Protein Glucose
(mg/dl) (mg/dl)
1. Acute Increased usually 1,000 – 10,000 80 – 500 < 40
bacterial usually
2. Viral Normal to 5 - 300 30 – 100 Normal
Moderate Some > 1,000
increased Lymphocytes
3. Fungal Increased 40 – 400 50 – 300 Decrease
Eosinophilia in Avg. 100 d
coccidioides
4.Tubercul Increased, 100 – 600 50 – 300, Decrease
ous decreased with up to 1200 marked d
spinal block lymphocyte Îed with <45
spinal bl.
7.Carcinom Normal to 0 – 100 Lym. Increase Decrease
atous increased variable tumor d most d in most
cells seen <500 cases
