CEREBROSPINAL FLUID [CSF]

CEREBROSPINAL FLUID

The cerebrospinal Fluid [CSF] is a clear,

colorless transparent, tissue fluid present in
the cerebral ventricles, spinal canal, and
subarachnoid spaces.
CEREBROSPINAL FLUID
CEREBROSPINAL FLUID
 CEREBROSPINAL FLUID [FORMATION]

CSF is largely formed by the choroid plexus of the lateral

ventricle and remainder in the third and fourth ventricles.

About 30% of the CSF is also formed from the ependymal

cells lining the ventricles and other brain capillaries.

The choroid plexus of the ventricles actively secrete

cerebrospinal fluid.

The choroid plexuses are highly vascular tufts covered by

ependyma.
FORMATION & CIRCULATION OF CSF
 MECHANISM OF FORMATION OF CSF
CSF is formed primarily by secretion and also by filtration
from the net works of capillaries and ependymal cells in
the ventricles called choroid plexus.

Various components of the choroid plexus from a blood-

cerebrospinal fluid barrier that permits certain substances
to enter the fluid, but prohibits others.

Such a barrier protects the brain and spinal cord from

harmful substances.
 MECHANISM OF FORMATION OF CSF

The entire cerebral cavity enclosing the brain and spinal

cord has a capacity of about 1600 to 1700 milliliters

About 150 milliliters of this capacity is occupied by

cerebrospinal fluid and the remainder by the brain and
cord.
 MECHANISM OF FORMATION OF CSF
Rate of formation:

About 20-25 ml/hour

550 ml/day in adults. Turns over 3.7 times a day

Total quantity: 150 ml:

30-40 ml within the ventricles

About 110-120 ml in the subarachnoid space [of which

75-80 ml in spinal part and 25-30 ml in the cranial part].
 MECHANISM OF FORMATION
CSF is formed at a rate of about 550 milliliters each day,.
About two thirds or more of this fluid originates as
secretion from the choroid plexuses in the four ventricles,
mainly in the two lateral ventricles.

Additional small amount of fluid is secreted by the

ependymal surfaces of all the ventricles and by the
arachnoidal membranes

Small quantity comes from the brain itself through the

perivascular spaces that surround the blood vessels
passing through the brain.
 MECHANISM OF FORMATION
Secretion by the Choroid Plexus. The choroid plexus, is
a cauliflower-like growth of blood vessels covered by a thin
layer of epithelial cells.
Secretion of fluid by the choroid plexus depends mainly on
active transport of sodium ions through the epithelial cells
lining the outside of the plexus.
The sodium ions in turn pull along large amounts of chloride
ions because the positive charge of the sodium ion attracts
the chloride ion's negative charge. The two of these together
increase the quantity of osmotically active sodium chloride
in the cerebrospinal fluid, which then causes almost
immediate osmosis of water through the membrane, thus
providing the fluid secretion.
 MECHANISM OF FORMATION

Less important transport processes move small amount of

glucose into the cerebrospinal fluid and both potassium and
bicarbonate ions out of the cerebrospinal fluid into the
capillaries.

The resulting characteristics of the CSF are:

Osmotic pressure approximately equal to that of plasma sodium
ion concentration
Approximately equal to that of plasma chloride ion
About 15 per cent greater than in plasma potassium ion
approximately 40 per cent less glucose
 ABSORPTION OF CSF THROUGH
ARACHNOID VILLI

The arachnoidal villi are fingerlike inward projections of the

arachnoidal membrane through the walls into venous sinuses.

villi form arachnoidal granulations can protruding into the

sinuses.

The endothelial cells covering the villi have vesicular passages

directly through the bodies of the cells large enough to allow
relatively free flow of (1) cerebrospinal fluid, (2) dissolved
protein molecules, and (3) even particles as large as red and
white blood cells into the venous blood.
 COMPOSITION OF CSF

Proteins = 20-40 mg/100 ml

Glucose = 50-65 mg/100 ml
Cholesterol = 0.2 mg/100 ml
Na+ = 147 meq/Kg H2O
Ca+ = 2.3 meq/kg H2O
Urea = 12.0 mg/100 ml
Creatinine = 1.5 mg/100 ml
Lactic acid = 18.0 mg/100 ml
 CHARACTERISTICS OF CSF

Nature:
Colour = Clear, transparent fluid
Specific gravity = 1.004-1.007
Reaction = Alkaline and does not
coagulate
Cells = 0-3/ cmm
Pressure = 60-150 mm of H2O

The pressure of CSF is increased in standing, coughing,

sneezing, crying, compression of internal Jugular vein
(Queckenstedt’s sign
 CIRCULATION OF CSF

Circulation: CSF is mainly formed in choroid pleaxus of the

lateral ventricle.
CSF passes from the lateral ventricle to the third ventricle
through the interventricular foramen (foramen of Monro).
From third ventricle it passes to the fourth ventricle through
the cerebrol aqueduct. The circulation is aided by the arterial
pulsations of the chroid plexuses.
From the fourth ventricle (CSF) passes to the sub arachnoid
space around the brain and spinal cord through the foramen
of magendie and foramina of luschka.
 CIRCULATION OF CSF
Lateral ventricle

Foramen of Monro [Interventricular foramen]

Third ventricle:
Cerebral aqueduct

Fourth ventricle:

Foramen of megendie and formen of luschka

Subarachnoid space of Brain and Spinal cord

 CIRCULATION OF CSF

Circulation: CSF slowly moves cerebromedullary

cistern and pontine cisterns and flows superiorly
through the interval in the tentorium cerebelli to
reach the inferior surface of the cerebrum. It moves
superiority over the lateral aspect of each cerebrol
hemisphere.
 FUNCTIONS OF CSF

A shock absorber
A mechanical buffer
Act as cushion between the brain and cranium
Act as a reservoir and regulates the contents of the cranium
Serves as a medium for nutritional exchange in CNS
Transport hormones and hormone releasing factors
Removes the metabolic waste products through absorption
 CSF AND INFLAMMATION
Increased inflammatory cells [pleocytosis] may be
caused by infectious and noninfectious processes.

Polymorphonuclear pleocytosis indicates acute

suppurative meningitis.

Mononuclear cells are seen in viral infections

(meningoencephalitis, aseptic meningitis), syphilis,
neuroborreliosis, tuberculous meningitis, multiple
sclerosis, brain abscess and brain tumors.
 CSF AND INFLAMMATION
Increased inflammatory cells [pleocytosis] may be
caused by infectious and noninfectious processes.

Polymorphonuclear pleocytosis indicates acute

suppurative meningitis.

Mononuclear cells are seen in viral infections

(meningoencephalitis, aseptic meningitis), syphilis,
neuroborreliosis, tuberculous meningitis, multiple
sclerosis, brain abscess and brain tumors.
 CSF AND PROTEINS

Increased protein: CSF protein may rise to 500 mg/dl in

bacterial meningitis.

A more moderate increase (150-200 mg/dl) occurs in

inflammatory diseases of meninges (meningitis,
encephalitis), intracranial tumors, subarachnoid
hemorrhage, and cerebral infarction.

A more severe increase occurs in the Guillain-Barré

syndrome and acoustic and spinal schwannoma.
 CSF AND PROTEINS

Multiple sclerosis: CSF protein is normal or mildly

increased.
Increased IgG in CSF, but not in serum [IgG/albumin index
normally 10:1].
90% of MS patients have oligoclonal IgG bands in the CSF.
Oligoclonal bands occur in the CSF only not in the serum.
The CSF in MS often contains myelin fragments and myelin
basic protein (MBP).
MBP can be detected by radioimmunoassay. MBP is not
specific for MS. It can appear in any condition causing
brain necrosis, including infarcts.
 CSF & LOW GLUCOSE
Low glucose in CSF:
This condition is seen in suppurative tuberculosis

Fungal infections

Sarcoidosis

Meningeal dissemination of tumors.

Glucose is consumed by leukocytes and tumor cells.

 BLOOD IN CSF

Blood: Blood may be spilled into the CSF by accidental

puncture of a leptomeningeal vein during entry of the LP
needle.

Such blood stains the fluid that is drawn initially and

clears gradually. If it does not clear, blood indicates
subarachnoid hemorrhage.

Erythrocytes from subarachnoid hemorrhage are cleared

in 3 to 7 days. A few neutrophils and mononuclear cells
may also be present as a result of meningeal irritation.
Leukemia Cells in CSF
CSF AND XZNTHOCHROMIA

Xanthochromia [blonde color] of the CSF following

subarachnoid hemorrhage is due to oxyhemoglobin
which appears in 4 to 6 hours and bilirubin which
appears in two days.

Xanthochromia may also be seen with hemorrhagic

infarcts, brain tumors, and jaundice.
 CSF AND TUMOUR CELLS

Tumor cells indicate dissemination of metastatic or

primary brain tumors in the subarachnoid space.

The most common among the latter is medulloblastoma.

They can be best detected by cytological examination.

A mononuclear inflammatory reaction is often seen in

addition to the tumor cells.
 INDICATIONS OF CSF EXAMINATION

Infections: meningitis, encephalitis

Inflammatory conditions: Sarcoidosis, neuro syphilis,
SLE
Infiltrstive conditions:Leukamia, lymphoma,
carcinomatous - meningitis
Administration of drugs in CSF
(Therapeutic aim)

 Antibiotics: (In case of meningitis)

 Antimitotics
 Diagnostic aim: Myelography,
Cisternography
 Anaesthetics are also given through the
lumbar Puncture.
 CONTRA-INDICATIONS FOR LP

•Local skin infections over proposed puncture site

(absolute contraindication)

•Raised intracranial pressure (ICP); exception is

pseudotumor cerebri

•Suspected spinal cord mass or intracranial mass lesion

(based on lateralizing neurological findings or papilledema)
Cont’d.
• Uncontrolled bleeding diathesis

• Spinal column deformities (may require

fluoroscopic assistance)

• Lack of patient cooperation

 LUMBAR PUNCTURE

A lumbar puncture also called a spinal tap is a

procedure where a sample of cerebrospinal fluid is
taken for examination.

CSF is mainly used to diagnose meningitis [an

infection of the meninges].

It is also used to diagnose some other conditions

of the brain and spinal cord.
 PRECAUTIONS FOR LUMBAR PUNCTURE

 Asked to sign a consent form

 Ask about taking any medicines

 Are allergic to any medicines

 Have / had any bleeding problems

 Ask about medications such as aspirin or warfarin

 Ask the female patient might be pregnant

 Empty the bladder before the procedure

LUMBAR PUNCTURE

1. Material for sterile technique [gloves and mask

are necessary]
2. Spinal Needle, 20 and 22-gauge
3. Manometer
4. Three-way stopcock
5. Sterile drapes
6. 1% lidocaine without epinephrine in a 5-cc
syringe with a 22 and 25-gauge needles
7. Material for skin sterilization
8. Adhesive dressing
9. Sponges - 10 X 10 cm
 LUMBAR PUNCTURE [Complications]

Post lumbar puncture headache occurs in 10% to 30% of

patients within 1 to 3 days and lasts 2 to 7 days.

The pain is relieved by lying flat.

Treatment consists of bed rest and fluid with simple

analgesics.
 LUMBAR PUNCTURE [Complications]

Headache following a lumbar puncture is a common and

often debilitating syndrome.
Continued leakage of cerebrospinal fluid from a puncture
site decreases intracranial pressure, which leads to
traction on pain-sensitive intracranial structures.
The headache is characteristically postural, often
associated with nausea and optic, vestibular, or otic
symptoms. Although usually self-limited after a few days,
severe postural pain can incapacitate the patient.
Management is mainly symptomatic, but definitive
treatment with the epidural blood patching technique is
safe and effective when done by an expert operator.
 LUMBAR PUNCTURE

Patient usually lie on a bed on side with knees pulled

up against the chest.
It may also done with sitting up and leaning forward on
some pillows. Sterilize the area.
push a needle through the skin and tissues between
two vertebra into the space around the spinal cord
which is filled with CSF.
CSF leaks back through the needle and is collected in a
sterile container.
As soon as the required amount of fluid is collected the
needle is taken out and a plaster is put over the site of
needle entry.
 LUMBAR PUNCTURE

Sent the sample to lab to be examined under

the microscope to look for bacteria.
It is also 'cultured' for any bacterial growth
The fluid can also be tested for protein, sugar
and other chemicals if necessary.
Sometimes also measure the pressure of the
fluid. This is done by attaching a special tube to
the needle which can measure the pressure of
the fluid coming out.
LUMBAR PUNCTURE
CEREBROSPINAL FLUID
CEREBROSPINAL FLUID
CEREBROSPINAL FLUID
CEREBROSPINAL FLUID
CEREBROSPINAL FLUID
CEREBROSPINAL FLUID
LUMBAR PUNCTURE
 LUMBAR PUNCTURE

Place the patient in the lateral decubitus position lying on

the edge of the bed and facing away from operator.
Place the patient in a knee-chest position with the neck
flexed.
The patient's head should rest on a pillow, so that the
entire cranio-spinal axis is parallel to the bed.
Sitting position is the second choice because there may be
a greater risk of herniation and CSF pressure cannot be
measured
 LUMBAR PUNCTURE

Find the posterior iliac crest and palpate the L4 spinous

process, and mark the spot with a fingernail.

Prepare the skin by starting at the puncture site.

Anesthetize the skin using the 1% lidocaine in the 5 mL

syringe with the 25-gauge needle. Change to 22-gauge
needle before anesthetizing between the spinous process.

Insert in the midline with the needle parallel to the floor

and the point directed toward the patient's umbilicus
 LUMBAR PUNCTURE

Advance slowly about 2 cm or until a "pop'' (piercing a

membrane of the dura) is heard.

Then withdraw the stylet in every 2- to 3-mm advance of

the needle to check for CSF return.

If the needle meets the bone or if blood returns (hitting

the venous plexus anterior to the spinal canal), withdraw
to the skin and redirect the needle.

If CSF return cannot be obtained, try one disk space

down
 HYDROCEPHALUS

Hydrocephalus" means excess water in the cranial vault.

This condition is frequently divided into communicating

hydrocephalus and noncommunicating hydrocephalus.

In communicating hydrocephalus fluid flows readily from

the ventricular system into the subarachnoid space,

in noncommunicating hydrocephalus fluid flow out of one

or more of the ventricles is blocked.
HYDROCEPHALUS
 CSF analysis of various
conditions
GBS MS Bacterial Viral TB SAH
meningiti meningiti
s s
Appearance N N Cloudy N N or Blood
slightly stained
cloudy
White cells N Increased Increased Raised Increased N
lymphocytes neutrophills lymphocyte lymphocyte
s s
Red cells N N N N N Very high

Protein High (only High High or N or high High or N or high

after one very high very high
week
Glucose N or low N Very low N or low N or low N or low