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Cerebrospinal Fluid Analysis

ZEESHAN YOUSUF

Anatomy and Physiology


Produced by choroid plexus & ultrafiltration Approximately 500 ml/day Bathes CNS while it collects waste and provides nutrients Total volumes:
Adults: Children: 140 - 170 mL 10 - 60 mL

Collection and Processing


Lumbar puncture, cisternal puncture, lateral cervical puncture, shunts & cannulas Opening pressure = 90 - 180 mm H2O (+/-) Approximately 15 - 20 cc fluid collected Process within 1 hour without refrigeration - STAT Three tube set-up:
Tube 1: Chemistry and Immunology (Frozen) Tube 2: Microbiology (Room temperature) Tube 3: Cell count, differential, cytology (Refrigerated)

Indications
Meningeal infection* Subarachnoid hemorrhage (SAH) CNS malignancy Demyelinating diseases

Diagnosis by CSF
High sensitivity, high specificity
Bacterial, TB, and fungal meningitis

High sensitivity, moderate specificity


Viral meningitis, SAH, MS, CNS syphilis, abcess

Moderate sensitivity, high specificity


Meningeal malignancy

Moderate sensitivity, moderate specificity


Intracranial hemorrhage, viral encephalitis, subdural hematoma

Gross Examination
Normal CSF is clear, colorless Viscosity equal to water Clot seen in traumatic tap, not SAH Viscous CSF with increased protein exudate Turbidity:
WBC > 200 cells/uL RBC > 400 cells/uL Microorganisms, increased protein

Routine Lab Tests


Required Opening CSF pressure Total cell count and differential (stained) Glucose (CSF/plasma ratio) Protein Optional Cultures, gram stain, antigens, cytology Protein electrophoresis, VDRL, D-dimers

Xanthochromia
Pink, orange, or yellow discoloration RBC lysis or hemoglobin breakdown May be seen within hours of LP Peak intensity at 24 - 36 hours RBC > 6000/uL (SAH, ICH, infarct, traumatic) Oxyhemoglobin, bilirubin, increased protein Carotinoids, melanin, rifampin therapy

Differential Dx of Bloody CSF


Traumatic tap - blood clears between tubes Xanthochromia - pink tinge, RBCs SAH - blood does not clear or clot

Microscopic Exam of CSF


Total Cell Count WBCcorr = WBCobs - WBC added WBC added = WBCBLD - RBCCSF / RBCBLD Differential Cell Count Centrifuge method Filtration methods Sedimentation methods Ependymal cells, chondrocytes, and choroid plexus cells may be seen rarely

Reference Intervals for CSF


Cell type Adults(%) Neonates(%)

Lymphocytes Monocytes Neutrophils Histiocytes Ependymal Eosinophils

62 36 2 Rare Rare Rare

20 72 3 5 Rare Rare

Increased Neutrophils in CSF


Meningitis (bacterial, early TB, viral, fungal) Other infections Following seizures Following CNS hemorrhage Following CNS infarct Reaction to repeated LP Foreign materials Metastatic tumor

Increased Lymphocytes in CSF


Meningitis (aseptic, L monocytogenes) Parasitic infections Degenerative disorders
SSPE, MS, encephalopathy due to drugs, GBS

Other inflammatory conditions


Sarcoidosis, polyneuritis, periarteritis involving the CNS

Plasmacytosis in CSF
TB meningitis Syphilitic meningitis MS Parasitic infections SSPE GBS Sarcoidosis Acute viral infections

Eosinophilic pleocytosis in CSF


Commonly associated with Parasitic infections Fungal infections Reaction to foreign material Infrequently associated with Bacterial or tuberculous meningitis Viral, rickettsial infection, lymphoma, sarcoidosis

Chemical Analysis
Total protein non-specific marker of disease Turbidimetric methods based on TCA or SSA & sodium sulfate for precipitation Simple, rapid, no special instrumentation 300 different proteins have been isolated from CSF using two-dimensional electrophoresis and silver staining

Conditions Associated with Increased CSF Total Protein


Increased blood-CSF permeability
Meningitis (bacterial, fungal, TB) Hemorrhage (SAH, ICH) Endocrine disorders Mechanical obstruction (tumor, disc, abcess) Neurosypilis, MS, SSPE, GBS, CVD

Electrophoresis
Identification of oligoclonal bands 2 or more discrete bands in the gamma region absent or of lesser intensity in concurrently run patients serum Silver stain more sensitive than paragon violet IFE better resolution and more specific Sensitivity = 83 - 94%

Bacterial Meningitis
0 - 1m: Group B strept & E. coli (GNR) 1m - 5y: H. influenzae 5 - 29y: N. meningitidis >29y: S. pneumoniae Listeria monocytogenes common in newborns, elderly, and other immunocompromised hosts

Bacterial Meningitis
Grams stain sensitivity = 60 - 90% Depends on organism, experience, # Culture sensitivity = 80 - 90% Latex agglutination becoming more widely used due to simplicity and accuracy

Bacterial Meningitis

Neurosyphilis
Darkfield microscopy for spirochetes CSF FTA-ABS 100% sensitive Negative test rules out diagnosis VDRL nearly 100% specific Positive test rules in neurosyphilis RPR unsuitable for CSF (higher FP than VDRL)

Neurosyphilis

Viral Meningitis
Enteroviruses (echoviruses, coxsachie, polio viruses) account for 80% cases Diagnosis of exclusion, rarely use cultures Viral inclusions for CMV, HSV PCR for HSV available Usually requires brain biopsy

HIV
Wide variety of abnormalities with or without neurological disease Lymphocytic pleocytosis, elevated IgG, and oligoclonal bands ID of opportunistic (fungal) infections main reason for examining CSF

Fungal Meningitis
India ink for cryptococcal capsular halos 50% sensitivity LA and CF antibodies now available Sensitivity as high as 96%

Tuberculous Meningitis
Early diagnosis extremely difficult Sensitivity for acid-fast stains 10% Large volumes of CSF recommended Higher levels of adenosine deaminase ELISA and PCR now available Sensitivity = 50 - 82% Specificity = 90 - 100%

Primary Amebic Meningoencephalitis (PAM)


Rare disease caused by free-living ameba Naegleria fowleri or Acanthamoeba species Motile Naegleria trophozoites may be seen with light microscope Acridine orange stain can differentiate ameba (brick red) from leukocytes (bright green)

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