ANALYSIS
I Nyoman Wande
Clinical Pathology Department
PRODUCE OF CSF
Produced at
choroid plexus of ventricel walls (70%) ,
ependymal cells of ventricel &
cerebral subarachnoid
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COMPOSITION OF CSF
Protein (<<) : 15-45 mg/dL
Glucose (<) : 60-80% of blood glucose
K+, Ca++, Phosphat, Sulphat (<)
Na+, Cl-, :10-15% higher than blood
FUNCTION OF CSF
MECHANICAL FUNCTION
Shock absorben prevent to shaky
Lubbricant, between brain-skull; medullaspinalis- columna
vertebrae
TRANSPORT FUNCTION
To clean/wash the brain from metabolite & toxic agent & than
excreted
Transport food to cells of CSF
INDICATION OF LP
Always check the papilledema before attempting lumbar
puncture (funduscopie)
Diagnosis
Convulsion, Paresis / Paralyse, Coma
Great Fontanel : bulging
Neck stiffnes + altered consciousness
Milliary TB , Leukemia
Intra cranial pressure (ICP) increased
Therapy
To increased ICP (Hydrocephallus)
Direct Th/. intratecal
Follow up th/.
CONTRA INDICATION of LP
ICP : brain tumor (angulus pontocerebeller,
infratentorial, V. III)
Danger herniated brain to foramen magnum
before LP funduscopie.
Infection at location of LP
Intracranial bleeding Hemorrhagic stroke
Brain abscess
Septic conditons
Specimen Collection
Lumbar puncture (LP) is the insertion of a needle into
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SEATED POSITION
LYING POSITION
CSF STORAGE
CSF should be analysed immediately (i.e. <1 h)
after collection.
If storage is required for later investigation this can be
done at 48C (short term) or at 20C (long term).
Only protein components and RNA
(after
appropriate preparation) can be analysed from stored
CSF (Good Practice Point).
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CSF ANALYSIS
Macroscopic
Microscopic
Microbiology
Chemistries
Serology
PCR
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Routine
CSF Macroscopic
1. Turbidity / cloudy
2. pH
3. Specific Gravity (SG)
4. Color
5. Sediment
6. Pellicle
7. Pressure
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TURBIDITY / CLOUDY :
Opalescent
Turbid
1. Hemorrhage
2. Present of inflamation cells, bacteria, or fungi
Cells (400-600/cmm pleocytosis)
4. Pleocytosis in clear CSF
Meningitis TBC
Tabes dorsalis
Poliomyelitis
Meningitis luetica
pH : normal : alkalis
SG : 1.003 1.008
COLOR : clear & colorless
1.
Xanthochromia:
2.
subarachnoid hemorrhage,
traumatic LP,
delayed processing of sample,
jaundice (especially bilirubin > 4 mg/dL),
protein > 150 mg/dL,
presence of carotene pigment
Red : artificial bleeding, subarachnoid bleeding
3.
4.
5.
Green
: meningitis meningococcen
PELLICEL
Normally : formed if CSF allow 24 hours at
room temperature
Meningitis
purulenta
Pellicel fast formed
minute - 1 hour, big
form, coarsely
Meningitis TBC
Pellicel formed after
12-24 hours, form like
spider nest
CSF Microscopic
Examination of cells, Total cell count,
differential cell count
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CELL COUNT
1. Fuchs-Rosenthal chamber (4X4X0,2cmm)
2. Improved Neubauer chamber (3X3X0,1cmm)
3. Dilution: 10/9X (turk reagent)
4. Formula
Fuchs-Rosenthal
Improved Neubauer
= 1/3N cell/cmm
= 5/4N cell/cmm
5. Normally = 0-5/cmm
Child < 5thn: N < 20/cmm)
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MiCROBIOLOGY EXAMINATION
1.
2.
3.
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Direct smear
Culture & Sensitivity test
Viral isolation
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CHEMISTRIES ANALYSIS
1. Protein Qualitative
None Apelt (Rose-Jones)
Pandy
2. Protein Quantitative
SSA method
Biuret method
4. Glukosa
Autoanalyzer
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CHEMICAL ANALYSIS
qualitative protein
None Apelt (Rose-Jones)
To know elevation of globulin concentration
Principle of the test :
globulin sedimented in saturated (NH4)2SO4 solution
In to reaction tube 7mm + 1ml saturated (NH4)2SO4 sol.
And than add 0,5 ml CSF
Allow for 3 minute
+ WHITE RING appearing at the juncture of the liquid
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CHEMICAL ANALYSIS
qualitative protein
PANDY TEST
To know elevation of globulin and albumin
concentration
Principle of the test:
protein sedimented in saturated phenol
solution in water
To a watch glass + 1 ml Pandy reagen,
Add 1 drop of CSF
cloudiness againts a black bacground indicates
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CSF SEROLOGY
Serology test for sifilis (VDRL)
CSF immunoglobulins
Specific antibodies (measles, rubella, HSV, HIV,CMV,
Toxoplasma)
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Learning Task
Trigger scenario:
A boy two years old taken by his mother to emergency
department with chief complained fever and convulsion.
His mother also complained cough since 4 days.
Learning task:
1. Mention the kind of CSF test should be done!
2. Described the location of CSF puncture in this patient!
3. What are the CSF findings in bacterial meningitis?
4. What are the CSF findings in tuberculous meningitis?
5. Mention the differential diagnosis of this patient!
Self assessment:
1. How is CSF product ?
2. What is the indication and contraindication of lumbar
puncture ?
3. How to interprete the result of each test ?
4. How to differentiate the red colour of CSF due to the
artificial bleeding and the subarachnoidal bleeding ?
5. How to make 5X dilution of CSF with sodium chloride
0.9%?
6. Procedure collection of CSF?
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