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LCS

Pengantar Praktikum
Cerebrospinal Fluid (CSF)

•  Komposisi dan formasi


•  Cairan tubuh terbanyak ke 3
•  Dewasa volume 90-150 mL
•  Neonatus volume 10-60 mL
Cerebrospinal Fluid (CSF)
•  Diproduksi di Pleksus choroideus dari 4 ventrikel,
berasal dari sel efendimal yang termodifikasi
•  20 ml / jam (dewasa)

•  Mengalir dalam spasian


subarachnoid
•  volume rata-rata 90 – 150 ml
(dewasa)
•  Reabsorbsi di villus arachnoid
•  Akhirnya tereabsorbsi ke dalam
darah
Cerebrospinal Fluid (CSF)

•  Blood Brain Barrier


•  Terjadi karena deretan erat sel-sel endothelial untuk
mencegah filtrasi molekul besar
•  Mengontrol/menahan/menyaring komponen darah
•  Menjaga CSF tidak seperti darah
Cerebrospinal Fluid (CSF)

•  Blood Brain Barrier


•  Essential to protect the brain
•  Blocks chemicals, harmful substances
•  Antibodies and medications also blocked

•  Tests for those substances normally blocked can


indicate level of disruption by diseases: ie
meningitis and multiple sclerosis.
Cerebrospinal Fluid (CSF)

•  Fungsi:
•  Suplai nutrisi ke jaringan otak
•  Membuang metabolit tidak bermanfaat
(sampah)
•  Melindungi dari trauma
Cerebrospinal Fluid (CSF)

•  Empat kategori penyakit:


•  Meningeal infections
•  Subarachnoid hemorrhage
•  CNS malignancy
•  Demyelinating disease
Cerebrospinal Fluid (CSF)

•  Indikasi analisis:
•  Konfirmasi diagnosis meningitis
•  Evaluasi perdarahan intrakranial
•  Diagnosis malignansi dan leukemia
•  Investigasi nervous system disorders
Cerebrospinal Fluid (CSF)

•  Specimen collection and handling

•  Routinely collected via lumbar puncture


between 3rd & 4th, or 4th & 5th lumbar vertebrae
under sterile conditions

•  Intracranial pressure measurement taken


before fluid is withdrawn.
Cerebrospinal Fluid (CSF)
• Spesimen:
• Tube 1 – chemistries and serology
• Tube 2 – microbiology cultures
• Tube 3 – hematology
• Handling:
• Tube 1 (chem-sero) frozen
• Tube 2 (micro) room temp
• Tube 3 (hemo) refrigerated

• Pemeriksan secara STAT
• Spesimen berpotensi infeksius
Cerebrospinal Fluid (CSF)
• Penampilan fisik
• Normal - Jernih, tidak berwarna
• Beberapa kondisi– hazy, cloudy, turbid, milky, bloody,
xanthrochromic
• Tidak jernih: mungkin karena lipid, protein, sel atau bakteri
• Clots menunjukkan trauma saat pengambilan
• Milky – peningkatan lipids
• Oily – kontaminasi


Cerebrospinal Fluid (CSF)
•  Fisik
•  Xanthrochromic – Diskolorisasi kekuningan
pada supernatant (bisa juga pink atau oranye)
•  Paling sering karena adanya perdarahan
•  Sebab lain: peningkatan bilirubin, karoten, protein,
melanoma
Cerebrospinal Fluid (CSF)
•  Fisik
•  Clots – menunjukkan peningkatan fibrinogen, biasanya karena trauma
pengambilan, tatapi bisa juga menunjukkan kerusakan BBB.


Traumatic collection vs
cerebral hemorrhage
•  Perdarahan serebral
•  Distribusi merata dalam sampel
•  Dapat terbentuk Clot formation (lebih sering pada
trauma)
•  Xanthrochromic supernatan
•  Eritrosit sudah di dalam sampel minimal 2 jam
•  Microscopic : adanya erythrophages, siderophages,
Hemosiderin granul
RBCs

Always send tube #1 and #4 for cell count and


compare RBCs
Traumatic tap: Elev RBC in tube 1, nl in tube 4
•  1000 RBC : 1 WBC to adjust WBC count in bloody tap
SAH or HSV: Elev RBC in tube 1 AND tube 4
•  “Crenated RBCs” and xanthochromia (yellow
supernatant after centrifuge)
•  Seen in hyperbilirubinemia (ESLD), old SAH, old blood
from prior traumatic LP or bleed
Cerebrospinal Fluid (CSF)

•  Normal tidak ada eritrosit


•  WBC:
•  Dewasa – up to 5 mononuclear WBCs/uL
•  Newborn – up to 30 mononuclear WBCs/uL
•  Children (1-4) - up to 20 mononuclear /uL
•  Children (5+) – up to 10 mononuclear / uL
•  Increased numbers = Pleocytosis
Cerebrospinal Fluid (CSF) - protein
•  Normal 15 – 45 mg/dL .
•  Albumin fraction. If IgG – from damaged BBB, or CNS produced,
electrophoresis to evaluate oligoclonal / malignant bands.
•  Decreased levels not significant
•  Increases levels
•  Damaged B-B (as in meningitis or hemorrhage)
•  Production of immunoglobulins within CNS (MS)
•  Degeneration of neural tissue
•  Dye-binding methods – preferred
•  Alkaline biuret
•  Coomassie brilliant blue - a blue color produced is proportional to
the amount of protein present (Beers Law)
Cerebrospinal Fluid (CSF) - glucose

•  Selectively transported across blood-brain barrier


•  Normal values: 60-70% of blood glucose
•  STAT procedure, glycolysis reduces level quickly.
•  Procedure performed as for blood specimen
•  Decreased levels seen in bacterial & fungal meningitis
•  Hypoglycemia
•  Brain tumors
•  Leukemias
•  Damage to CNS
Glucose

Normal
•  Viral infection
Low glucose
•  Bacterial meningitis, TB, fungal
Really low
•  <18 is strongly suggestive of bacterial
meningitis
Cerebrospinal Fluid (CSF)
•  CSF Lactate
•  Normal values = 11-22 mg/dL
•  Increase as result of hypoxia
•  Bacterial meningitis. Head injury
•  CSF Glutamine
•  Normal 8-18 mg/dL
•  Increased levels associated with increases in ammonia (toxin)
•  CSF Enzymes
•  Lactate dehydrogenase (LDH or LD)
•  5 isoenzyme types; LD1&LD2 are in brain tissue
•  Creatine kinase (CPK or CK)
•  Isoenzyme CK3/ CK-BB from brain tissue
•  Following cardiac arrest, patients with CSF levels <17 mg/dL have
favorable outcome.
Cerebrospinal Fluid (CSF)

•  Serology
•  VDRL (Veneral Disease Research Laboratory)
•  For detection of neurosyphilis
•  On CSF test low sensitivity, but great specificity
•  FTA-Abs also used on CSF, more sensitive, but must
prevent blood contamination.
Typical Viral Meningitis

•  CSF WBC elevated, but <250 (first PMNs,


then lymphocytes)
•  CSF protein elevated, but <150
•  Glucose > 50% of serum concentration
Typical Bacterial Meningitis

•  CSF WBC >1000, PMN predominance


•  CSF protein >500mg/dl
•  CSF glucose <45 mg/dl
Differential Diagnosis of Meningitis
by Laboratory Results
Bacterial Viral Tubercular Fungal
Increased WBC count Increased WBC count Increased WBC count Increased WBC count

Neutrophils Lymphs Lymps & Monos Lymphs & Monos


Marked ↑ protein Mod. ↑ protein Mod-Marked ↑ protein Mod-Marked ↑ protein

Marked ↓ glucose ↔ normal glucose ↓ glucose Normal to ↓ glucose



Lactate > 35 mg/dL Lactate normal Lactate > 25 mg/dL Lactate > 25 mg/dL

+ gram stains Pellicle formation + India ink with


Cryptococcus
neoformans
+ bacterial antigen + immunological test
tests for C. neo.
Transudat - Eksudat
•  ETIOLOGI EFUSI PLEURA
•  INFEKSI
•  TUBERKULOSIS
•  NON TUBERKULOSIS
o  Pneumonia ( para pneumonia efusi )
o  Jamur
o  Parasit
o  Virus
•  NON INFEKSI
•  Hipoproteinemia
•  Neoplasma
•  Kelainan sirkulasi/ gagal jantung
•  Emboli paru
•  Atelektasis
•  TRAUMATIK ( HEMOTORAX )
Macam-macam bentuk cairan pleura;
A.  Exudat
B.  Transudat
C.  Darah ( hematotorak )
D.  Pus ( empiema )
E.  Xilotorak
Macam-macam sifat cairan pleura

A. EKSUDAT:
•  Peningkatan permeabilitas vaskuler sehingga
akan terjadi perem besan cairan dan protein ke
pleura
•  Infeksi TB
•  Infeksi NON TB ( pneumonia, jamur, virus )
•  Keganasan ( Primer , Metastase)

Macam-macam sifat cairan pleura

B. TRANSUDAT :
•  Perembesan cairan yg tidak/sedikit disertai
perembesan protein
•  Mekanisme ada 3
•  Peningkatan tekanan hidrostatik kapiler
•  Penurunan tekanan koloid osmotik kapiler
•  Penurunan tekanan intra pleura
Terbentuknya cairan bisa ok satu atau lebih mekanisme ini
•  etiologi
•  Gagal jantung
•  Sirosis hepatis à Asites
•  Atelektasis
•  Sindrome nefrotik
•  Meigs syndrome
•  Keganasan efek secara tidaklangsung oleh proses keganasan
seperti hipoalbumin

Transudative vs Exudative

—  Transudative —  Exudative
¡  CHF ~36% ¡  Pneumonia ~ 22%

¡  Nephrotic syndrome ¡  Malignancy ~14%

¡  Hypoalbuminemia ¡  PE ~11%

¡  Hepatic hydrothorax ¡  Inflammatory (pancreatitis,

¡  Atelectasis ARDS, uremic pleurisy etc.)


~7%
¡  Connective tissue disease
Lights Criteria

—  Pleural effusion is exudative if one or more of the


following:
¡  Ratio of pleural fluid protein level to serum protein level >
0.5
¡  Ratio of pleural fluid LDH level to serum LDH level > 0.6

¡  Pleural fluid LDH level > 2/3 the upper limit of normal for
serum LDH level.
—  98% sensitive and 83% specific for exudative
effusion using Lights criteria.
—  Absence of all 3 criteria = transudative
Pleural Fluid Evaluation – Cell count with diff
Pemeriksaan mikroskopis cairan otak
Jumlah sel :
Isap lart Turk pekat dlm pipet lekosit sp tanda 1
Isap cairan otak sampai tanda 11
Tetesan pertama dibuang
Hitung dg kamar hitung ( pd 9 kotak) = N
Jumlah sel cairan otak = N x 5/4
Bedakan : sel polimorfonuklear (%)
sel mononuklear (%)

Interpretasi : Normal : 0 – 5 sel/mmk


Batas abnormal : 6 – 10 sel/mmk
Abnormal : > 10 sel/mmk
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Pemeriksaan KIMIAWI
Tes PANDY
Prinsip : Globulin + Albumin + r PANDY
à mengendap
Cara :
1 ml r. PANDY + 1 tetes cairan otak

kekeruhan

Interpretasi :
– tidak keruh
+ opalescent (berkabut)
++ keruh
+++ sangat keruh
++++ keruh spt susu + endapan
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Pemeriksaan KIMIAWI
Tes NONNE
Prinsip : Globulin + reagen NONNE (NH4)2SO4
à terbentuk cincin putih
Cara : Masukkan dlm tabung
0,5 ml r. NONNE + 0,5 ml cairan otak scr
hati2 à 2 lapisan
Tunggu 3 menit à lihat cincin putih di
antara 2 lapisan
Interpretasi :
– tidak ada cincin
+ cincin tipis
++ cincin agak jelas, dikocok à cairan berkabut
+++ cincin jelas, dikocok à cairan keruh
++++ cincin jelas, dikocok à cairan sangat keruh
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Cara test RIVALTA
Masukkan 1 tetes cairan
peritoneal / pleura

Hasil Test
Rivalta (+) : keruh + presipitat
(–) : jernih
5 ml r.
RIVALTA

Reagen RIVALTA :
100 ml aquadest + 0,1 ml as. Cuka glasial 37