(7) Csf Semester VI 2013 FK Unud

8/16/2019 (7) Csf Semester VI 2013 FK Unud

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CEREBROSPINAL FLUIDCEREBROSPINAL FLUIDANALYSISANALYSIS

I Nyoman WandeI Nyoman Wande

Clinical Pathology DepartmentClinical Pathology Department

Medical Facultyof Udayana UniversityMedical Facultyof Udayana University

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Overview:Overview:

• Production of CSFProduction of CSF

• Indications of LPIndications of LP

• Contraindications of LPContraindications of LP• Routine of CSF analysisRoutine of CSF analysis

• CSF analysis in several diseaseCSF analysis in several disease

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PPRODUCE OFRODUCE OF CSFCSF

Produced atProduced at choroidchoroid plexplexusus ofof ventriventriccelel wallswalls (±70%)(±70%)

ependependyymmal cellsal cells ofof ventriventriccelel !!

cere"ral su"arachnoidcere"ral su"arachnoid

#00 m$ of C& is formed'day#00 m$ of C& is formed'day althoughalthoughonly 0*#0 ml is present in the system at anyonly 0*#0 ml is present in the system at anytime+time+

,ea"sorption of C& occurs at the arachnoid,ea"sorption of C& occurs at the arachnoidvillivilli

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CCOMPOSIOMPOSITTIION OFON OF CSFCSF

• Protein (Protein (----)) . *#/# mg'd$. *#/# mg'd$

• luluccososee (-)(-) .. 1020%1020% of "loodof "lood glugluccoseose• 3344 Ca Ca4444 PhosphatPhosphat ul ulphphat (-)at (-)

• 5a5a44 Cl Cl .*0*#% higher than "lood.*0*#% higher than "lood

"y active secretion of choroid"y active secretion of choroidplexusplexus

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FUNFUNCTION OFCTION OF CSFCSF

•MECHANICAL FUNCTIONMECHANICAL FUNCTION – SShock absorbenhock absorben – – pprevent to shakyrevent to shaky

– LLubbricantubbricant bet!een brain"sku##$ bet!een brain"sku##$ %e&u##aspina#is%e&u##aspina#is" co#u%na" co#u%navertebravertebraee

•CONT'OL TO (OLUME )CONT'OL TO (OLUME )*'O+U*'O+UCTION,CTION, – As the -i##er o- space &ue to atrophic re.ionAs the -i##er o- space &ue to atrophic re.ion

– or &ecrease vo#u%e pro&uction i-or &ecrease vo#u%e pro&uction i- space occupyin. #essionspace occupyin. #ession happene&happene&

•

T'ANS*O'TT'ANS*O'T FUNCTIONFUNCTION – To c#ean/!ash the brain -ro% %etabo#ite 0 to1ic a.entTo c#ean/!ash the brain -ro% %etabo#ite 0 to1ic a.ent

→

an&an& than e1crete&than e1crete&

– Transport -oo& to ce##s o- CSFTransport -oo& to ce##s o- CSF


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ensitivity'specificity DiseasesHigh sensitivity highs!ecificity

"acterial tu#erculous andfungal $eningitis

High sensitivity $oderate

s!ecificity

%iral $eningitis su#arachnoid

he$orrhage $ulti!le sclerosisC&S sy!hilis infectious!olyneuritis !aras!inal a#cess

Moderate sensitivity high

s!ecifisity

Meningeal $alignancy

Moderate sensitivity$oderate s!ecificity

Intracranial he$orrhage viralence!halitis su#duralhe$ato$a

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'a#el( )iseases detected #y la#oratory e*a$ination

of CSF


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INDIINDICATIONCATION FORFOR LLUMBALUMBALPUNCTUREPUNCTURE

• +ia.nosis o- CNS in-ection+ia.nosis o- CNS in-ection

• +ia.nosis o- subarachnoi& he%orrha.e+ia.nosis o- subarachnoi& he%orrha.e

• +ia.nosis o- %enin.ea# %a#i.nancy+ia.nosis o- %enin.ea# %a#i.nancy

• +ia.nosis o- &e%ye#inatin. &isease+ia.nosis o- &e%ye#inatin. &isease

• +ia.nosis o- CNS vascu#itis+ia.nosis o- CNS vascu#itis

• Intratheca# treat%ent o- %enin.ea# %a#i.nancyIntratheca# treat%ent o- %enin.ea# %a#i.nancy

• Intratheca# treat%ent o- -un.a# %enin.itisIntratheca# treat%ent o- -un.a# %enin.itis


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ABSOLUTE CONTAINDICATION OFABSOLUTE CONTAINDICATION OFLUMBAR PUNCTURELUMBAR PUNCTURE

• Increase& intracrania# pressureIncrease& intracrania# pressure

• Skin in-ection in the #u%ba# re.ionSkin in-ection in the #u%ba# re.ion


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S!eci$en CollectionS!eci$en Collection

Lu$#ar !unctureLu$#ar !uncture +LP, is the insertion of a needle into+LP, is the insertion of a needle intothe su#arachnoid s!ace +the area under the $e$#ranethe su#arachnoid s!ace +the area under the $e$#ranethat surrounds the #rain and s!inal cord, of the lu$#arthat surrounds the #rain and s!inal cord, of the lu$#ar+lower #ac-, region for diagnostic or thera!eutic !ur!oses(+lower #ac-, region for diagnostic or thera!eutic !ur!oses(

'his allows access to the cere#ros!inal fluid +CSF, in'his allows access to the cere#ros!inal fluid +CSF, inwhich the #rain and s!inal cord float(which the #rain and s!inal cord float(

.lthough the su#arachnoid s!ace can #e accessed fro$ .lthough the su#arachnoid s!ace can #e accessed fro$other levels the lu$#ar region is $ost often used as itother levels the lu$#ar region is $ost often used as it

allows the needle to #e inserted #elow the end of theallows the needle to #e inserted #elow the end of thes!inal cord(s!inal cord(

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PPosition & site of LPosition & site of LP

S/.'/) POSI'IO& L0I&1 POSI'IO&


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CSF S'OR.1/CSF S'OR.1/

C& should "e analysed immediately (less than 1 h)

after collection+

6f storage is reuired for later investigation this can "e

done at /829C (short term) or at :;09C (long term)+


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CSF .&.L0SISCSF .&.L0SIS

• Macrosco!icMacrosco!ic

• Microsco!icMicrosco!ic

• Micro#iologyMicro#iology• Che$istriesChe$istries

• SerologySerology

• PCRPCR

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Recommended Lao!ato!y TestRecommended Lao!ato!y Teston CSFon CSF

'outine'outine

Openin. CSF *ressureOpenin. CSF *ressure

Tota# ce## countTota# ce## count

+i--erentia# ce## count )staine& s%ear,+i--erentia# ce## count )staine& s%ear,

2#ucose )CSF/p#as%a ratio,2#ucose )CSF/p#as%a ratio,

*rotein*rotein

Use-u# in certain circu%stancesUse-u# in certain circu%stances

Cu#tures )bacteria -un.i viruses Mycobacteriu% tubercu#osis,Cu#tures )bacteria -un.i viruses Mycobacteriu% tubercu#osis,

Stains )2ra%3s stain aci&"-ast stain,Stains )2ra%3s stain aci&"-ast stain,

Fun.a# an& bacteria# anti.ensFun.a# an& bacteria# anti.ens *o#y%erase chain reaction )T4 viruses,*o#y%erase chain reaction )T4 viruses,

Cyto#o.yCyto#o.y

*rotein e#ectrophoresis*rotein e#ectrophoresis

(+'L test -or syphi#is(+'L test -or syphi#is

Fibrin"&erivative +"&i%erFibrin"&erivative +"&i%er


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CSF Macrosco!icCSF Macrosco!ic

5656 Turbi&ity / c#ou&yTurbi&ity / c#ou&y

7676 pHpH

8686 Speci-ic 2ravity )S2,Speci-ic 2ravity )S2,9696 Co#oCo#orr

:6:6 Se&i%entSe&i%ent

;6;6 *e##ic#e*e##ic#e

7.7. Pressure Pressure

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CSF color and a!!earance

&or$al CSF is crystal clear with the

a!!earance and viscosity of water(

.#nor$al CSF $ay a!!ear ha2y cloudys$o-y or #loody

Clotting of CSF is a#nor$al and indicates

increased !rotein or fi#rinogen levels


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TURBIDITY / CLOUDY TURBIDITY / CLOUDY ::

Opa#escentOpa#escent

Turbi&Turbi&

5656 He%orrha.eHe%orrha.e

7676 *resent o- in-#a%ation ce##s bacteria or -un.i*resent o- in-#a%ation ce##s bacteria or -un.i

∑

Ce##sCe##s )9


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pHpH : normal : alkalis: normal : alkalisSGSG : !""# $ !""%: !""# $ !""%COLORCOLOR :: &l'ar ( &olorl'ss&l'ar ( &olorl'ss

5656 ==anthoanthocchro%hro%ia>ia>

subarachnoi& he%orrha.esubarachnoi& he%orrha.e

trau%atic L*trau%atic L*

&e#aye& processin. o- sa%p#e&e#aye& processin. o- sa%p#e

?aun&ice )especia##y bi#irubin @ 9 %./&L, ?aun&ice )especia##y bi#irubin @ 9 %./&L,

protein @ 5:< %./&Lprotein @ 5:< %./&L

presence o- carotene pi.%entpresence o- carotene pi.%ent

7676 'e&'e& >> arti-icia#arti-icia# b#ee&in.b#ee&in. subarachnoi& subarachnoi& b#ee&in.b#ee&in.

8686 4ro!n4ro!n > #on. ti%e b#ee&in.> #on. ti%e b#ee&in. he% he%o#ysiso#ysis

9696 22rayray >> ∑

#euko#eukocytecyte↑

)puru#ent)puru#ent in-#a%ationin-#a%ation,,

:6:6 2reen2reen >> %enin.itis %enin.ococcen%enin.itis %enin.ococcen


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PELPELLICELLICEL

Nor%a##y > -or%e& i- CSF a##o! 79 hours atroo% te%perature

)'nin*i+isp,r,l'n+a )'nin*i+is TBC

*e##ice# -ast -or%e&%inute " 5 hour bi.-or% coarse#y

*e##ice# -or%e& a-ter57"79 hours -or% #ikespi&er nest


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CSF Microsco!icCSF Microsco!ic

/*a$ination of cells: 'otal cell count/*a$ination of cells: 'otal cell countdifferential cell countdifferential cell count

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CELL COUNTCELL COUNT

5656 Fuchs"'osentha#Fuchs"'osentha# cha%bercha%ber )9=9=


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DIFFERENTIAL CELLS COUNTDIFFERENTIAL CELLS COUNT

5656 +i--erentiate&+i--erentiate& toto *MN*MN 00 MNMN

*MN @ MN > puru#ent a*MN @ MN > puru#ent acutecute

MN @ *MN > serousMN @ *MN > serous chronischronis // reconva#esencereconva#esence

7676 +i--6+i--6 Count &o in s%ear o-Count &o in s%ear o- CSFCSF !ith!ithri.htri.ht stainin.stainin. / %et/ %ethy#ene b#uehy#ene b#ue

8686 Count o-Count o- 5


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)iCROBIOLOGY)iCROBIOLOGY E-A)INATIONE-A)INATION

5656 +irect s%ear+irect s%ear

7676 Cu#ture 0 Sensitivity testCu#ture 0 Sensitivity test

8686 ((irira#a# iso#ationiso#ation

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CHE)ISTRIES ANALYSISCHE)ISTRIES ANALYSIS

5656 *rotein*rotein ua#itativeua#itativeNone Ape#t )'ose"ones,None Ape#t )'ose"ones,

*an&y*an&y

7676 *rotein*rotein uantitativeuantitative

SSASSA %etho&%etho&

4iuret4iuret %etho&%etho&

86 2#ucosa86 2#ucosa

2O+"*A*2O+"*A*

He1okinaseHe1okinase

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CHE)ICAL ANALYSISCHE)ICAL ANALYSIS.,ali+a+i' p.,ali+a+i' pro+'inro+'in

None Ape#t )'ose"ones,None Ape#t )'ose"ones,

To kno! e#evation o-To kno! e#evation o- .#obu#in.#obu#in concentrationconcentration

*rin*rinccipip#e o- the test#e o- the test >>

.#obu#in.#obu#in se&i%ente&se&i%ente& in saturate&in saturate& )NH9,7SO9)NH9,7SO9 so#utionso#utionIn to reaction tubeIn to reaction tube J K%% 5%#J K%% 5%# saturate&saturate& )NH9,7SO9)NH9,7SO9 so#6so#6

An& than a&&An& than a&&


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INTERPRETINTERPRET TION OF TION OF NONE APELTNONE APELT TEST TEST

" >" > No appearin. o- 'No appearin. o- '

> > ' s#i.ht#y %i1in.' s#i.ht#y %i1in. ' #ess' #ess

7 >7 > ' ' c#earc#ear %i1in.%i1in. opa#escentopa#escent8 >8 > ' ' %ore c#ear%ore c#ear %i1in.%i1in. turbi&turbi&

9 >9 > ' ' very c#earvery c#ear %i1in.%i1in. very turbi&very turbi&

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CHE)ICAL ANALYSISCHE)ICAL ANALYSIS.,ali+a+i' pro+'in.,ali+a+i' pro+'in

*AN+*AN+ TESTTEST

To kno! e#evation o-To kno! e#evation o- .#obu#in.#obu#in an&an& a#bu%ina#bu%in concentrationconcentration

*rin*rinccipip#e o- the test#e o- the test>>

proteinprotein se&i%ente& in saturate& pheno#se&i%ente& in saturate& pheno#

so#ution in !aterso#ution in !ater

To a !atch .#assTo a !atch .#ass 5 %# *an&y 5 %# *an&y rea.enrea.enA&&A&& 55 &rop o-&rop o- CSFCSF

c#ou&iness a.aints a b#ack bac.roun& in&icatesc#ou&iness a.aints a b#ack bac.roun& in&icates

increase& a%ount o- .#obu#inincrease& a%ount o- .#obu#in05/25/16 31


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INTERPRETAINTERPRETA TION OF TION OF PANDYPANDY TEST TEST

" >" > c#ear 0 co#or#essc#ear 0 co#or#ess

> Opa#escent > Opa#escent : C#ou&yC#ou&y 5


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CSF S/ROLO10CSF S/ROLO10

Serology test for sifilis +%)RL,Serology test for sifilis +%)RL,

CSF i$$unoglo#ulinsCSF i$$unoglo#ulins

S!ecific anti#odies +$easles ru#ella HS% HI%CM%S!ecific anti#odies +$easles ru#ella HS% HI%CM%

'o*o!las$a,'o*o!las$a,

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=verage and ,ange of=verage and ,ange ofCere"rospinal &luid ProteinCere"rospinal &luid Protein

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C& Parameters in someC& Parameters in some


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C& Parameters in someC& Parameters in some5eurological Disease5eurological Disease

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> i l C " i l &l id &i di> i l C " i l &l id &i di


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>ypical Cere"rospinal &luid &inding>ypical Cere"rospinal &luid &indingin ?arious >ypes of @eningitisin ?arious >ypes of @eningitis

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ConclusionConclusion

• CSF analysisCSF analysis High sens and high s!ecHigh sens and high s!ecfor the diagnosis $eningitis: #acterialfor the diagnosis $eningitis: #acterialtu#erculous and fungal(tu#erculous and fungal(

• Routine CSF analysis:Routine CSF analysis: – Openin. CSF *ressureOpenin. CSF *ressure

– ce## countce## count

– +i--erentia# ce## count )staine& s%ear,+i--erentia# ce## count )staine& s%ear,

– 2#ucose )CSF/p#as%a ratio,2#ucose )CSF/p#as%a ratio,

– *rotein*rotein

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Learning 'as-Learning 'as-

• >rigger scenario.>rigger scenario.

• . #oy 3 years old ca$e to e$ergency de!art$ent with chief . #oy 3 years old ca$e to e$ergency de!art$ent with chiefco$!lained sei2ure dan fever( History of !revious illness she wasco$!lained sei2ure dan fever( History of !revious illness she wassuffering fro$ !roductive cough and rhinitis since si* days a go(suffering fro$ !roductive cough and rhinitis since si* days a go(

• $earning tasA.$earning tasA.

• Mention the -ind of CSF test should #e done4Mention the -ind of CSF test should #e done4

• )escri#ed the location of CSF !uncture in this !atient4)escri#ed the location of CSF !uncture in this !atient4

• Mention and descri#ed theMention and descri#ed the $acrosco!ic e*a$ination of CSF should #e$acrosco!ic e*a$ination of CSF should #e

done5done5• )escri#ed of 6ualitative !rotein analysis of CSF()escri#ed of 6ualitative !rotein analysis of CSF(

• 7hat are the CSF findings in #acterial $eningitis57hat are the CSF findings in #acterial $eningitis5

• Mention the differential diagnosis of this !atient4Mention the differential diagnosis of this !atient4


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elf assessment.elf assessment.

8(8( How is CSF !roduct 5How is CSF !roduct 5

9(9( 7hat is the indication and contraindication of lu$#ar7hat is the indication and contraindication of lu$#ar!uncture 5!uncture 5

(( How to inter!rete the result of each test 5How to inter!rete the result of each test 53(3( How to differentiate the red colour of CSF due to theHow to differentiate the red colour of CSF due to the

artificial #leeding and the su#arachnoidal #leeding 5artificial #leeding and the su#arachnoidal #leeding 5

;(;( Procedure collection of CSF5Procedure collection of CSF5

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(7) Csf Semester VI 2013 FK Unud