URINE
&
BODY FLUID
ANALYSIS
CSF ANALYSIS
CONTENTS
INTRO TO CSF
SPECIMEN COLLECTION & STORAGE
PHYSICAL EXAMINATION
MICROSCOPIC EXAMINATION
BACTERIOLOGIC EXAMINATION
CHEMICAL EXAMINATION
IMMUNOLOGIC EXAMINATION
INTRO TO CSF
CNS covered by 3 membranes [meninges].
Outer most membrane dura mater
Center membrane arachnoid mater (“spider-
web like”)
Inner membrane pia mater
CSF between pia and arachnoid maters
• subarachnoid space.
CSF produced by ventricular capillary blood
vessels
• choroid plexuses
Small volume CSF produced by ependymal cells
• line the spaces of the brain and meninges
CSF is a “selective” ultrafiltrate of
plasma.
CSF VOLUMES & FUNCTION
Total CSF volumes:
Adult 85 - 150 ml
Neonate 10 - 60 ml
Adult Rate of Formation 500 ml/day
Turn over = 20 mL/hour
Action:
CNS Protection
CNS Waste Management
CNS Lubrication
CNS Nutrition
SPECIMEN COLLECTION
Lumbar puncture : perform in the 3rd and 4th in adult or 4th
and 5th interspace in children.
Puncture site may vary if an infection present at preferred
site.
Locally infected site must be avoided to prevent
introduction of the infection into the CNS.
Procedures :
o Cleansing the patient skin
o Application of local anesthetic.
o Spinal needle is advanced into the lumbar interspace, and often
a pop is heard on penetration of the Dura mater.
o Physician take the “opening” pressure using the manometer.
Normal pressure for adult : 180 mm Hg.
o If CSF pressure is less than or greater than normal, only 1 to 2
ml should be removed.
o After CSF has been removed, takes “closing” CSF pressure.
o Record both: opening and closing pressure.
SPECIMEN COLLECTION
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
Microbiology
temp.)
y
i str Hem
atol
e m ogy
Ch 2
1 3 • Label 3 / Tube 3 – used for hematology (cell count)
4 ( refrigerated)
Other
• lumbar puncture procedure video -
Yahoo! Search Results.flv
• Video About Lumbar Cerebrospinal
Fluid Drain
Encyclopedia.com.flv
• Medical Videos - Lumbar
Puncture.flv.flv
CSF
Handling and transportation
Bacteria
• Preferably in trans-isolate medium,
pre-warmed to 25-37°C
before inoculation
OR
• Transport at ambient temperature
(relevant pathogens do not survive at
low temperatures)
Viruses
• Transport at 4-8oC (if up to 48hrs or
-70oC for longer duration)
P H Y S I C A L E X A M I N AT I O N
Parameters Observation Inference
Colour Clear, watery and transparent Normal
Red Puncture of blood vessel during collection
Dull red / brownish Intracranial hemorrhage, cranium fracture
Yellow (xanthochromic) Presence of bile pigments (jaundice),
hemorrhage.
Grayish or greenish Due to infection leading to pus formation
Turbidity Clear / transparent Normal
Hazy / ground glass like Presence of cells/ white clots appearance
Cloudy / purulent Increase in protein / lipid conc. , indicate
infection due to presence of WBC.
Red turbid Puncture of blood vessel during collection
Coagulation No coagulation Normal
Coagulation Presence of abnormal amount of proteins
especially fibrinogen in cases of meningitis
Blood (in large quantities) Internal hemorrhage or improper collection.
2
3
5 4
1
1 XANTHACHROMIC
CSF
2 RED TURBID CSF
5 3 DULL RED CSF
4 HAZY CSF
5 CLEAR / NORMAL CSF
M I C R O S C O P I C E X A M I N AT I O N
* Cell counts
* Total
* Leukocyte
* RBC
* Differential
* Cytology
DIFFERENTIAL
• Performed on a
stained* smear made
from CSF.
• It is recommended that • Count 100 cells in
stained smears be consecutive oil-power
made even when the fields.
total cell count is • Report percentage of
within normal limits. each type of cell present.
Normal CSF Differential Cell Count
MICROBIAL TEST
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)
B A C T E R I O L O G I C E X A M I N AT I O N
• Important in identification of the causative agent in meningitis.
• Tests: TESTS PURPOSE
GRAM STAIN & INDIAN INK Suspected cases of meningitis
Detection of bacterial and fungal organisms
ACID FAST STAIN Identification of tuberculosis meningitis
CSF CULTURE For confirmation
LATEX AGGLUTINATION & Latex Agglutination and ELISA provides a rapid
ELISA means for detecting microorganisms in CSF.
• Use second tube because less likely than first tube to contain
organism from puncture site.
• Organisms most frequently encountered in Gram Stain:
S. pneumoniae (gram positive cocci)
H. influenzae ( pleomorphic gram negative rods)
E. coli (gram negative rods)
C HEMICAL E XAM INAT ION
• Protein • Glucose
– 80% plasma derived – Need to know plasma
• LMW value
– Transthyretin – Increased
(prealbumin) • Hyperglycemia
» Albumin • Traumatic tap
– Transferrin
– Decreased
– IgG – very small
amount • Hypoglycemia
– 20% intrathecal synthesis • Meningitis
– Reference range • Tumors
• 15 – 45 mg/dL
Albumin and IgG
IgG sourced from inside
Albumin not made in and outside CNS
CNS ALB used as reference
ALB used to address protein to ID intrathecal
blood-brain barrier source of Ig
integrity CSF IgG index = ratio
Evaluate CSF/serum IgGCSF/IgGserum X ALB
ALB index serum/ALBCSF
Index < 9 = normal Reference range 0.3 – 0.7
9 – 14 minimal • > 0.7 = CNS sourced
impairment • < 0.3 = compromised
> 100 = not intact barrier BBB
ELECTROPHORESIS
• Normal = 4 bands
– ALB
– Transthyretin
– Transferrin
• b1
• t = unique to CSF
– Oligobands ~ multiple
sclerosis
• Myelin basic protein
– Monitoring disease
progression
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 FLUID ENZYMES
• CSF enzyme that usually measured are
the lactic dehydrogenase & creatinine
kinase isoenzymes.
• The LD isoenzymes appear in CSF
following destruction of particular cells,
primarily neutrophils, lymphocytes &
brain cells.
• Measurement of CK enzymes CK BB in
CSF after resuscitation from cardiac
arrest-shown to reliably predict recovery
when levels are below 17 mg/mL.
IMM UNOLOGIC
EX AMINAT ION
Test Cerebrospinal Fluid Immunoglobulin G
Indication Multiple scelerosis
Physiology This immunoglobulin is generally increased in the case of
central nervous system disorders and
inflammations.Radial immunodifussion test is performed
Normal range 5-12%
Interpretation Panic range-values greater than 12% indicate neurologic
disorders
- THE END -
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