CEREBROSPINAL

FLUID
CSF DEFINITION AND PRODUCTION

DEFINITION
It is clear colorless fluid that is present in
subarachnoid space .
PRODUCTION
Most of csf(70%) is produced by choroid plexus
in lateral ,third and fourth ventricles while
remainder is produced by surface of brain and
spinal cord .
CSF COMPOSITION
 Normal composition of CSF
 Appearance ;colorless
 Rate of production ;500mlper day
 Total volume ;120-150 ml in adults ,10-60ml in
neonates .
 Specific gravity ;1.006-1.008
 Normal pressure ;60-150mm of water in adults ,10-
100mm of water in infants .
CSF COMPOSITION
 Protein ;14-45mg/dl
 Sugar ;50 -80mg/dl i.e 60% of plasma glucose
 Bacteria ;nil
 Chloride ;113meq/l ,Na 144meq/l,K+ 2.9mm/l
 Mg+2 2.2meq/l ,Ca+2 4.6 mg /dl ,hco-3
23.3mmol/l
 Ph 7.3
 Pco2 50.5mmhg
 Osmolality 289 mosm/kg
 Inorganic phosphate 3.4mg/dl
CSF COMPOSITION

 Lactate levels ;neonates 10-40mg/dl ,adults

10-22mg/dl .
 Glutamine levels ;8-18mg/dl
 LDH levels ;for newborn less than 70 units /l
for adults less than 40 units /l
SPECIMEN COLLECTION
 Lumbar puncture
 Cisterna puncture /sub occipital puncture
 Ventricular cannulas or shunts
 Lateral cervical puncture
VOLUME OF SPECIMEN

 Normally upto 2-3ml of csf is withdrawn and

collected in 3 tubes.
 Most often done by lumbar puncture
 Tube 1 biochemical analysis
 Tube 2 microscopic examination
 Tube 3 microbiological examination
TRANSPORT
 Speciment should be transported to labortary
immediately within 1 hour
 If this is not possible then innoculate
microbiological sample in trans –isolate
medium and remaing csf should be
maintained at room temperature 20-25 0C
before gram staining and other tests .
 If this is not available then incubate csf at
35-370C temperature e 5% co2
INDICATION FOR CSF SAMPLING
 Infection like meningitis ,encephalitis .
 Subarachnoid hemorrhage
 CNS malignant tumours
 Demyelinating diseases of brain
EXAMINATION OF CSF
 A :macroscopic examination
 B:microscopic examination /cytology
 C:biochemical analysis
 C:Microbiological
 D:immunological
MACROSCOPIC EXAMINATION

 Normal crystal clear and colorless

 Pathological
process :cloudy ,turbid,bloody ,viscous ,clotted .
 1:Bloody csf ;it is pink red .causes are traumatic and
SAH.
 2:xanthochromia ;yellowish appearance of supernatant
of centrifuged csf specimen result from lysis of RBC
 Causes ;traumatic tap ,jaundice ,elevated proteins
levels ,hpercarotenemia,premature infants and
malignant melanoma
 4:thick vicous csf ;
 Causes are severe meningitis ,cryptococcus
meningitis ,metastatic mucinous adenocarcinoma
MACROSCOPIC EXAMINATION
 Clot formation
 Delicate and fine clot :tuberculous
meningitis
 Large clot :purulent meningitis
 Complete clot/spontaneous clot :spinal
constriction
MICROSCOPIC/CYTOLOGY
EXAMINATION
It includes
1:Total cell count
2:differential leucocyte count
3:red blood cell count
4:malignant cells
TOTAL LEUCOCYTE COUNT /RBC
 Methods
 1:Manual method; done in improved neubar’s
chamber and fuch’s rosenthal chamber
 2:automated method
NEUBAR’S/FUCH’S ROSENTHAL
CHAMBERS
 Cover the counting chamber e cover slip .charge
the counting chamber e fluid and allowed to
stand for 5 minutes .
 Formula for calculating no of cells in neubars
chamber
 No of wbc cells /microlitre =total no of cells
counted/0.4
 No of rbc /microlitre=total no of cells
counted /.02
 Formula for calculating cells in fuch’s rosenthal
chamber
 No of cells /microlitre =total no cells counted /3.2
CAUSES OF INCREASED
LEUCOCYTES
 Meningitis
 Intracranial hemorrhage
 Multiple sclerosis
 Meningeal infiltration by malignancy
DIFFERENTIAL LEUCOCYTE
COUNT
 Centrifuge small amount of csf .
 Prepare smear from sediments
 Stain one smear e leishmania stain
 Examine under high power 100x and oil
immersion of microscope .
 Relative DLC; no of wbc type multiply by 100
/total no of cells
 Absolute DLC ;No of cells /mm3=
 %of wbc multiply by TLC
DLC
DLC
 Causes of increased neutrophils:bacterial meningitis
,brain abscess ,brain infarction ,repeated lumbar
puncture .
 Causes of increased lymphocytes :viral and
tuberculous meningitis ,parasitic meningitis , fungal
meningitis
 Causes of increased lymphocyte +monocytes :viral
+tuberculous meningitis ,fungal
meningites ,sarcoidosis of meninges
 Causes of increased eosinophils :parasitic and fungal
infection ,reaction to foreign matrial,degenerative
brain disorder
 C
DLC
 Causes of increased plasma cells :T.B
meningitis ,multiple myeloma, malignant
brain tumor ,syphilitic meningoencephalitis
MALIGNANT CELLS
 Methods
 Immunocytochemistry
 Flow cytometry
 Causes
 Metastatic cancer
 Leukemian
 Lymphoma
 Medulloblastoma
 Ependymoma
BIOCHEMICAL ANALYSIS OF CSF
 Protein
 Glucose
 Lactate levels
 Csf glutamine
 LDH
 Chloride
PROTEINS
 Tests
 Qualitative and quantitative test
 Qualitaive ;pandy test
 Pandy reagent ;7% solution of phenol in water
 Procedure ;add 1 drop of csf to 1 drop of pandy
reagent
 Appearance of cloudiness indicates presence of
proteins
 Quantitative test ;turbidimetric test
 Reagent ;sulphosalicyclic acid 3%
solution ,proteinometre standards
PROTEINS
Procedure ;1ml of csf +3ml of reagent in small
test tube .mix and allowed to stand for 5 minutes
Turbidity appears and is compared against tubes
of proteinometer
Causes of increased protein
1: lysis of contaminated blood i-e traumatic tap
2:increased permeability of BBB i-e in bacterial
and fungal infection and cerebral hemorrhage
3:increased production i-e in multiple sclerosis
and neurosyphilis ,SSPE,GBS
4:obstruction :tumor or abscess
GLUCOSE
 Methods
 Reducing method
 Condensation
 Enzymatic (GOD and POD)
 Strip method
 Causes of increased glucose levels
 Hyperglycemia and traumatic tap
 Causes of decreased glucose level
 Meningitis i-e bacterial and T.B
 Meningeal carcinomatosis
 Normal viral meningitis /encephalitis
LACTATE
 Increase in
 Inborn error of metabolism
 Bacterial meningitis >35mg/dl
 Viral meningitis <25mg/dl
 GLUTAMINE , LDH AND
CHLORIDE
 Glutamine increase in hepatic encephalopathy
 LDH
 Increase in primary brain tumors
 LDH 4,5 increase in bacterial meningitis
 LDH5 increase in metastatic brain tumor
 Chloride markedly decrease in bacterial meningitis
 Slightly decrease in viral meningitis and brain tumours
MICROBIOLOGICAL
EXAMINATION
 1:Direct wet mount
 Small quantity of csf e drop of saline
 Done for candida,cryptococcus and amoebic
encephalitis
 2:indian pink preparation :centrifuge csf for 5 to
10 min
 Mix drop of csf and drop of indian ink .covered e
cover slip and examine under 40 magnification
 Cryptococcus appears as budding yeast
surrounded by unstained capsule
 3:ziehl-neelson staining for AFB
MICROBIOLOGICAL
EXAMINATION
 4:Gram staining :smear is made from
sediment and is air dried and stain e gram
stain and observe it under oil immersion
 Streptococcus pnemococci appear purple
blue gram +ve diplococci lying end to end
 Neisseria meningitides stain pink red gram
_ve diplococci lying side by side
 H.influenza stain pink red gram _ve
coccobacilli
MICROBIOLOGICAL
 5:Csf culture;
 gold standard
 Indicated when
 Appearance of bacteria on gram staining
 Increase protein
 Increase cell count
 Medium used are choclate agar ,blood agar and
mackonky medium
 6:PCR of csf
 Viral infection of csf
 Requires only drop of csf
DIFFERENCE BETWEEN
DIFFERENT TYPES OF MENINGITIS
THANK YOU