Cerebrospinal Fluid Examination

dr. Ahmad Rizal, SpS

Neurology Department UNPAD Faculty of Medicine Bandung 2007
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Aim of the examination

Diagnostic Treatment evaluation or follow up Prognostic

Cerebrospinal Fluid (CSF)

AKA
Liquor Cerebrospinalis (LCS)

Location

Ventricular system Subarachnoid space (including cysternal system)

Function

Protect CNS from mechanical insult (as a cushion) Maintain the equilibrium of neuronal and glial cells Remove waste products of neuronal metabolism

Anatomy

CSF

Formation
Rate 0.35 mL/minute ~ 500 mL/day Formed by :

CSF

Choroid plexuses at :
Floor of each lateral ventricles (largest and most important) Roofs of the third and fourth ventricles (smaller)

Capillary beds that supply the pia and arachnoid (smaller) Ependyma and subjacent glial elements (smaller)
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Anatomy (site of CSF formation)

CSF

Formation (cont.)
A complex process : Active transport (expenditure of energy) Passive diffusion

CSF

Active transport Cuboid epithelial cells (in choroid plexus) secrete Na ion Positive potential attracts negative ion especially Cl Many of ionic solutes increase osmotic pressure Water and other solutes follow in maintaining osmotic equilibrium Passive diffusion Continual diffusion occurs at Ependym and vascular beds
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Circulation
Lateral ventricles Monroe foramina Third ventricle Sylvii aqueduct Fourth ventricle Luschka and Magendie foramina Subarachnoid space (cysternal system) Superior and lateral convexity of brain

CSF

hemispheres Arachnoid villi Venous sinuses Venous blood flow to the heart

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Absorption
Mainly at Arachnoid villi (Arachnoid granulation or Pacchionian bodies) Others (smaller) : veins and capillary of piamatter Unidirectional (valve)

CSF

Mechanism Depends on : Hydrostatic pressure (high to low) Colloid osmotic pressure (low to high) Active transport by cells forming the walls of the arachnoid villi
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Site of Absorption

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Dynamics

CSF

Total volume of CSF : 75 100 mL ( 1540 mL at ventricular system) Rate of production 0.35 mL/min ~ 500 mL/day Daily turn over 4-5 times

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Composition
Water (main component) Small amount of protein Ions: Na, K, Ca, Mg, Cl Glucose A few white cell ( < 5/mm3 is normal ) Organic constituents Dispersed gases (O2 and CO2)

CSF

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Normal values

CSF

Color Clear, colorless Opening Pressure 70-200 mmH2O Cell 0-5/mm3 (lymphocyte or MN cell) Glucose 45-80 mg% Protein 5-15 mg% (intraventricular) 10-25 mg% (cysternal) 15-45 mg% (lumbar) -globulin 5-22 % of total protein Osmolarity 295 mOsmol/L pH 7.31 Sodium (Natrium) 142-150 mEq/L Potassium (Kalium) 2.2-3.3 mEq/L Chloride 120-130 mEq/L Magnesium 2.7 mEq/L CO2 25
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CSF
Color
Clear, colorless Change in color : Cell > 200 / mm3 (RBC > 1000 red color) Traumatic puncture : 3-tubes test

clear

blood
Get paler xanthochromic blood
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remain unchanged

CSF
Opening Pressure
Depends on : Rate of formation and absorption Patency of ventricular and subarachnoid system Measurement : Manometer during lumbar or cysternal puncture

Position : Lateral decubitus Sitting

: Normal pressure 70-200 mmH2O : 280 mmH2O

Slightly increased in several condition: Coughing or straining Pressure on abdomen

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CSF
Opening Pressure
(cont.)

Fluctuative changes in heart beat and respiratory cycle

Change in flow disturbance Queckenstedt Test pressure on both jugular veins results in increase CSF pressure that returns to normal within 10 sec. CSF obstruction no or slight increase of CSF pressure

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Cell

Leucocytes or PMN means pathologic i.e. infection of bacterial, fungal, viral, chemical agents, tumor higher than normal limit means pathologic condition two third of blood glucose; below 40 mg% abnormal (i.e in pyogenic infection, tuberculous/fungal meningitis) low chloride concentration meningitis (but not specific)
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Protein

Glucose

Electrolytes

Disorders of CSF
~ Flow disturbance Several causes of flow disturbance:

CSF

Tumor Infection Subarachnoid bleeding Aqueductal stenosis

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CSF

Flow disturbance: Obstruction of ventricular system or subarachnoid space results in hydrocephalus 2 kinds of hydrocephalus: Communicating Non communicating
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Disorders of CSF (cont.)

Communicating hydrocephalus
Common in adult Free communication between ventricles and subarachnoid space Obstruction at subarachnoid space Caused by inflammation, subarachnoid bleeding, tumor growth

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Disorders of CSF (cont.)

Non-communicating hydrocephalus :
Common in children Caused by aqueduct stenosis, overgrowth of Luschka and Magendie foramina

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Lumbar Puncture
Indication :

CSF

Measure CSF pressure Obtain sample for cell count, chemical work-up, bacteriology Intrathecal treatment/procedure : spinal anesthesia chemotherapies for cancer antibiotics Other diagnostic procedure : myelography, pneumoencephalography, scintigraphic cysternography
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Lumbar Puncture
Contraindications:

CSF

Infection at the site of LP (low back region) Use of anticoagulants Increased intra-cranial pressure Severe hemorrhagic diathesis CNS mass lesion in posterior fossa Suspect venous sinus occlusion
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CSF

Some conditions that require LP

When we suspect meningitis or encephalitis To diagnose meningeal carcinomatosis To diagnose tertiary syphilis To diagnose meningeal leukemia To diagnose staging of lymphomas Follow up therapy for meningitis

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CSF

Some conditions that require LP

Evaluation of dementia Evaluation for Guillain-Barre Treatment of pseudotumor cerebri Evaluation for multiple sclerosis Rule out subarachnoid hemorrhage (after neg. head CT) Instillation of drugs, anesthetics, or radiographic media into CNS

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CSF|LP
Technique
Preparation : Explain the procedure to patient Obtain informed consent Exclude possibility of increased ICP or CNS mass lesion (eye exam/ head CT) Take blood sample for glucose 15 before LP Positioning of the patient determine its success!! Lateral decubitus in full flexion posture At the bed side Small cushion on head or knee (if needed)
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CSF|LP
Technique
Site of puncture Inter-vertebral space at vertebra L3 L4 Imaginary line connecting iliac crests Other site (if failed) : L2-L3 or L4-L5 Infant/children at L4-L5

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CSF|LP
Technique
Sitting position if failed in recumbent (2-3 times) Measure (opening) pressure Patient preparation Aseptic technique : Clean the area using iodine 10% application in round movement starting from the center Change glove once Use sterile covering/towel

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CSF|LP
Technique
Insertion : All tools available : spinal needle (18,19,20), manometer, sterile bottles (3) Local anesthetic (lidocaine 1-2%) : 0.1-0.2 mL subcutaneous and 0.2-0.5 mL deeper Introduce spinal needle, with bevel facing up, into interspace, in a horizontal direction, with slightly cephalad inclination ("aim for the belly button"). Always have stylet in place when maneuvering needle in the interspace
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CSF|LP
Measure opening pressure (normal is 100-250 mmHg): If pressure elevated, ask pt to relax and ensure that there is no abdominal compression or breath holding (straining and abdominal pressure can increase ICP). If pressure markedly elevated, remove only 5 cc of spinal fluid and remove needle immediately. Else, collect 15-20 cc in four collection tubes (2 cc per tube), and remove needle (with stylet in place). Can send extra fluid in tube #3, or in extra red-top (#5). Instruct pt to lie flat for approx. 4 hrs to minimize post LP headache (caused by CSF leakage).
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CSF|LP

Complication
Headache Backache Intracranial subdural hematoma Infection CSF leak Herniation

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Tengkyu

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