BRAIN AND MIND SYSTEM

KELAINAN CAIRAN OTAK

Dept. Patologi Klinik FK USU dr. Tapisari Tambunan SpPK (K) dr. Ozar Sanuddin SpPK (K)

Physiology
* Cerebrospinal fluid (CSF) : * merupakan produk aktifitas ventricular choroid plexuses * bersirkulasi melalui ventricles dan subarachnoid spaces * diabsorbsi oleh arachnoid villi venous sinuses aliran darah * fungsi utama : proteksi, memberi bantalan untuk brain dan spinal * Blood Brain Barrier bekerja dgn proses metabolik aktif menjaga kons sbgn besar substansi dlm CSF dlm kadar yg berbeda dari dlm darah, dgn rentang kadar yang sempit

Pengambilan spesimen untuk pemeriksaan Biasanya dgn Lumbal punksi Indikasi LP: - Suspek Meningitis, Encephalitis, Brain abscess, subarachnoid hemorrage - DD cerebral infark dgn cerebral hemorrhage (80%) - Pemberian anestesi, media kontras, obat-obat - Treatment pada bbrp pasien dgn hipertensi intracranial benigna Komplikasi LP:

 Komplikasi LP: - Herniasi, mortalitas meningkat (pd tek. Intracranial tinggi) - Paresis sampai paralisis (pd spinal cord tumor) - Extradural @ Subdural hematoma (pd gangguan pembekuan darah) - Perforasi meninges (pd kasus sepsis) - Kematian pada bayi jk tindakan berlebihan (aspiksia, obst trachea) - Infeksi ( tidak aseptik) - Postpuncture headache Pelaksanaan LP:

 Pelaksanaan LP utk pengambilan spesimen : - Sebaiknya pagi hari dan jk dapat setelah puasa 1malam - Dilakukan pada dewasa : L3-L4 anak : L4-L5 - Ditaruh pada 3 tube sentrifus steril yg ditandai dgn no. 1, 2 dan 3. Masing-masing 2-4 ml Spesimen tube 1, biasanya tdk digunakan karena dapat bercampur darah dari trauma punksi Spesimen tube 2 : utk sel & hitung jenis dan pemeriksaan kimia atau imunologi Spesimen tube 3 : kultur Kadar Protein, Ca, Glukosa bervariasi tergantung tempat spesimen diambil (ventricle, cisterna magna, lumbar spinal area)

Composition of Normal Spinal Fluid

Amount : 90-150 ml Color : colorless, like water Transparency : clear, like water Specific Gravity : 1.006-1.008 Glucose : 45-100 mg/100ml (60-70% KGD) Urea : 8-28 mg/100ml Sodium : 117-137 mEq/L Pottasium : 2.33-4,59 mEq/L

 Acid-base balance :
pH : 7.31 Pco2 : 47.9 mmHg HCO3 : 22.9 mEq/L

Uric acid : 0.07- 2.8 mEq/L Total protein : 20-40 mg/100ml

Lumbar : 20-40 mg/100ml Cisternal : 15-25 mg/100ml Ventricular : 5-10 mg/100ml

 Electrophoretic separation of lumbar fluid, mean values :

Prealbumin Albumin 1-globulin 2- globulin - and - globulin -globulin : 4.6 13% : 49.5 6.5 % : 6.7 2.0 % : 8.3 2.1% : 18.5 4.8 % : 11.2 2.7 %

Calcium (lumbar) : 2.32 mEq/L Magnesium : 2.20 mEq/L Creatinine : 0.4 1.5 mg/100ml Lactic dehydrogenase : 8-50 units Cell : 1-5 cells/mm3 (lymphocytes)

Pemeriksaan Lab
Makroskopis Mikroskopis Analisa Kimia Imunologi Mikrobiologi

Makroskopis
Jernih, tidak berwarna Darah : - merah * gross abaikan pem. Kimia * koreksi perhitungan lekosit : jlh lekosit = jlh leko terhitung a a = jlh eri dlm darah x leko dlm darah jlh eri dlm CSF - Bloody tap (traumatic tap) : * Cedera pbl darah pada tindakan LP * Tube 1, 2, 3 berturut-turut jlh darah makin kurang * Jk ragu, bandingkan hitung sel tube 1 dan ke 3 * Supernatan setelah disentrifus : jernih, tak berwarna - Hemorrhage : * Darah pada tube 1,2 dan 3 sama banyak * Supernatan kekuningan * Eritrosit crenated * Jk darah banyak, bisa terlihat clot * Pada intracerebral hemorrage bisa terlihat jernih Xanthochromia :

 Xanthochromia : - Kekuningan - Bisa warna bilirubin (jk jaundice berat, kronis, @ prematur), derivat Hb, lipidlike substance karena destruksi jar. otak - Jk mengandung banyak protein dan clot, indikasi adanya obstruksi, mis. tumor Transparansi : - > 200 lekosit : cloudy 200 500 lekosit : keruh > 500 : turbid - acute meningitis : bervariasi berawan s/d spt pus - encephalitis, tuberculous meningitis : jernih Sedimen : Normal tdk ada Clot : adanya fibrinogen

Mikroskopis
Diperiksa pada sedimen Total lekosit normal - dewasa : 0 - 6 mononuclear /mm3 - neonati : 0 30 Eritrosit : bedakan dulu trauma atau tidak Hitung jenis : - netrofil tinggi : infeksi bakteri, masa dini (1-2 hari) viral, TB, jamur - limfosit meninggi : Viral. TB, jamur, Syphilic - plasma sel meninggi : multiple sclerosis - eosinofil meninggi : non infeksi : vaksinasi rabies, alergi

Kimia Klinik
Total Protein Glukosa : Normal : 60 70 % KGD (seimbang 2-4 jam) Meninggi : hiperglikemia Menurun : - hipoglikemia - pemakaian meningkat oleh CNS, lekosit, eritrosit, jar, mo - gangguan transport dari plasma ke CSF LDH : - normal 5 10 % kadar plasma - DD bacterial @ viral meningitis - Prognose encephalitis :jelek jk LDH tinggi

Lain-lain
Serologis : sifilis, VDRL, FTA (fluorescent treponemal antibody Elektrolit Mikrobiologi

Cerebrospinal fluid in disease

Disease Preasure (mm water) 100-200 Appearance Clot No & Type of Cell Protein (mg/100ml) 20-40 Sugar (mg/1 00ml) 45-100 Chlorides (mEq/L) 113-127 Remarks

Normal Meningitis Pyogenic Tuberculous Lymphocytic choroimeningitis Cord Tumor Brain Abscess Brain Tumor Poliomyelitis

Clear, colorless Cloudy Clear or slightly turbid Clear or opalescent

0-5 lymphocytes

3+ 3+ 2+

Large Web 0

3+ PMN 2+ lymphocytes 50-2000 lymphocytes

3+ 2+ +

D(0) 20-40 20-40

Slightly D D<100 N

Tubercle bacilli

N 1+ to 3+ 3+ N

Clear & deep yellow Clear or turbid Clear yellow Clear or opalescent

Mass 0

N to + lymphocytes + PMN N lymphocytes 50-2000 PMN early lymphocytes leter N to + lymphocytes

3+ + to 2+ to 2+ +

N N N N

N N to slightly D N N to slightly D Filtrable virus

Encephalitis

N to

Clear, colorless Bloody yellow Clear, colorless

Filtrable virus

Subarachnoid hemorrhage Neurosyphilis Meningovascular Tabes Paresis

1+ to 2+

Blood

3+

N Serologic test for syphilis nearly always reactive 80% reactive 100% reactive

+ + +

Rare Rare Many, small

20-100 PMN early, lymphocytes leter 25-75 lymphocytes 25-50 lymphocytes

+ to 2+ + +

N N N

N N N

Cerebrospinal fluid in disease

Disease Preasure (mm water) Appearance Clot No & Type of Cell Protein (mg/100ml) Sugar (mg/1 00ml) Chlorides (mEq/L) Remarks

Normal

100-200

Clear, colorless

0-5 lymphocytes

20-40

45-100

113-127

Meningitis Pyogenic Tuberculous Lymphocytic choroimeningitis

3+ 3+ 2+

Cloudy Clear or slightly turbid Clear or opalescent

Large Web 0

3+ PMN 2+ lymphocytes 50-2000 lymphocytes

3+ 2+ +

D(0) 20-40 20-40

Slightly D D<100 N

Tubercle bacilli

Cord Tumor

Clear & deep yellow

Mass

N to + lymphocytes

3+

Brain Abscess

1+ to 3+

Clear or turbid

+ PMN

+ to 2+

N to slightly D

Brain Tumor

3+

Clear yellow

N lymphocytes

to 2+

Cerebrospinal fluid in disease

Disease Preasure (mm water) Appearance Clot No & Type of Cell Protein (mg/100ml ) Sugar (mg/100ml) Chlorides (mEq/L) Remarks

Poliomyelitis

Clear or opalescent

50-2000 PMN early lymphocytes leter N to + lymphocytes

N to slightly D

Filtrable virus

Encephalitis

N to

Clear, colorless

Filtrable virus

Subarachnoid hemorrhage

1+ to 2+

Bloody yellow

Blood

3+

Neurosyphilis Meningovascular
Tabes Paresis

+ + +

Clear, colorless

Rare Rare Many, small

20-100 PMN early, lymphocytes leter 25-75 lymphocytes 25-50 lymphocytes

+ to 2+ + +

N N N

N N N

Serologic test for syphilis nearly always reactive 80% reactive 100% reactive