Cerebrospinal Fluid Examination

Dr. Aisha Khatoon

Assistant Professor
 CSF Formation

Cerebrospinal fluid (CSF) is the liquid that surrounds the brain &
spinal cord.

• Mechanism of formation:
– Selective ultrafiltration of plasma
– Active secretion by epithelial membranes

Normal blood brain barrier (BBB) is important for the normal

chemistry results of CSF
 Functions of CSF

1- Physical support & protection of the CNS from trauma.

2- Supplying nutrients to the CNS & removal of metabolic wastes

from CNS

3- Intra-cerebral transport
neuroendocrine role i.e. distribution of hypothalamic hormones
within the brain.
 Clinical Indications for CSF Analysis

CSF is performed in cases of suspected:

1- CNS infections (infectious meningitis & encephalitis)

2- CNS malignancy (as malignant infiltrates as in leukemia ..etc)
3- CNS hemorrhages (as subarachnoid hemorrhage)
4- CNS demylineating diseases (as multiple sclerosis)
 Routine Laboratory CSF Analysis
Collection
Lumbar puncture
With complete aseptic techniques

Sampling:
Collected CSF sample is immediately divided into three tubes:
Tube 1: Chemical Investigation
Tube 2: Microbiology Investigation
Tube 3: Microscopic Investigation
 Medicine School of Shandong
2005-5-17
University
 Complications

•Post-lumbar puncture headache: A common

complication that resolves on its own or may require
treatment.

•Infection: Risk of infection at the puncture site,

though rare with proper technique.

•Bleeding: If the needle hits a blood vessel during

the procedure.
 Opening Pressure
• Normal opening pressure in adults is
90~180mmH2O, 10~100mmH2O in children.

Elevated Pressure?? Decreased Pressure??

• Congestive heart failure • Spinal-subarachnoid
• Meningitis block
• Superior vena cava • Dehydration
syndrome
• Circulatory collapse
• Cerebral edema • CSF leakage
• Mass lesion
Medicine School of Shandong
2005-5-17
University
 Normal CSF Analysis
Normal Physical Examination
Appearance & Color Clear ,Colorless
pH 7.4
Daily Secretion 450-500 ml
Specific Gravity 1.006-1.007
Normal Microscopic Examination
Lymphocytes 1-5 /H.P.F
Normal Chemical Examination
Protein 15-45 mg/dl
Glucose 50-80 mg /dl
Chloride 115-130 mmol /L
Calcium 1.0-1.40 mmol/L
Phosphorus 0.4-0.7 mmol/L
Magnesium 1.2-1.5 mmol/L
Potassium 2.6-3.0 mmol/L
Normal Microbiological Examination
No pathogenic microorganisms
 Physical examination of CSF
Normal CSF: Clear & colorless
Viscosity: ~equal to water (increased with increased proteins)
Color and/or turbidity of CSF: observed only in pathological circumstances.

Turbid CSF
Bacteria
WBCs cells or pus cells: suggestive of a CNS infection (menigitis or encephalitis)
Blood : suggestive of hemorrhage: subarachnoid or artifactual traumatic tap

Red & brown color :

Blood

Yellow colour
1- Jaundice (bilirubin in CSF)
2- Xanthochromia (hemoglobin breakdown pigments in CSF)

Xanthochromic CSF suggests that a subarachnoid hemorrhage has recently

occurred.
 Abnormal CSF Appearances

[Link] – traumatic tap or hemorrhage

[Link] (yellow) – SAH, jaundice, high protein
[Link]/viscous – severe meningitis, cryptococcal
infection, mucinous adenocarcinoma
[Link]/cobweb – high protein, TB meningitis, spinal block

Clot Types & Significance

Fine/delicate clot → Tuberculous meningitis
Large clot → Purulent meningitis
Complete spontaneous clot → Spinal block
 Traumatic Tap vs SAH
Feature Traumatic Tap Subarachnoid
Hemorrhage
Gross Bloodier in Uniform blood in
appearance initial tubes all tubes
Clotting on May clot Does not clot
standing
Supernatant Clear Pink/yellow
after spin (xanthochromic)

RBC count Decreases in Uniform in all

later tubes tubes
CSF pressure Normal Increased
CSF protein Normal Increased
 Common Meningitis Pathogens by Age

•0–6 months: Group B Strep, E. coli, Listeria

•6 months–6 years: S. pneumoniae, N. meningitidis, H.
influenzae
•6–60 years: N. meningitidis, Herpes simplex
•>60 years: S. pneumoniae, Listeria
 Microscopic Examination

• Total leukocyte count

• Differential count
• Cytology (malignant cells)
 Microscopic examination of CSF
Differential Count WBCs
Significance Eosinophils ↑ → Parasitic/fungal
WBCs infection, foreign material reaction

Normal Total WBCs count: 0-5 Mixed pattern → TB meningitis,

lymphocytes /HPF chronic bacterial meningitis

Increased neutrophils:
• Bacterial Meningitis
• cerebral abscess RBCs
• subdural empyema Normally CSF is blood free
• CNS hemorrhage
• CNS infarct RBCs in CSF:
Increased lymphocytes: • Subarachnoid hemorrhage
• aseptic and viral meningitis • Malignancy
• Multiple sclerosis
• Artifact: traumatic tap (should
be excluded)
 Malignant Cells in CSF

• Large size, high N:C ratio

• Irregular nuclear membrane, hyperchromasia
• Prominent nucleoli, multinucleation
• Bizarre vacuolization
 Total Leukocyte Count Method
• Dilute CSF 9:1 with diluting fluid (acetic acid +
crystal violet)
• Charge Neubauer chamber
• Count cells in 9 squares
• Calculation: Cells counted × 10/9 = cells/µL
• Alternative: Fuchs-Rosenthal chamber
• Cells in CSF: (1) Many neutrophils in bacterial meningitis, (2) lymphocytes seen in normal CSF
in adults, (3) Many red cells and a small lymphocyte (traumatic tap), (4) Increased monocytes
in CSF, (5) Neutrophils, lymphocytes, and red cells in CSF, (6) Lining cells of pia and arachnoid
in CSF, (7) Blast cells in CSF, (8) a malignant cell in CSF
 Chemical examination of CSF

In addition to the major ions, CSF contains oxygen, sugars

(e.g. glucose, fructose), lactate, proteins (e.g. albumin,
globulins), amino acids, urea, ammonia, glutamine, creatinine,
lipids, hormones (e.g. insulin) and vitamins.
 CSF Glucose
- Normal CSF glucose: 45-80 mg/dl

- The actual CSF glucose concentration may be:

1- Falsely low in the presence of hypoglycemia
Or 2- Incorrectly interpreted as normal when the patient is hyperglycemic

-Accordingly, CSF glucose should always be compared with a

simultaneous plasma glucose that is drawn prior to lumbar puncture.

Normal CSF glucose/ plasma glucose ratio is approximately 0.6-0.7

 CSF Glucose

•Increased: Hyperglycemia, traumatic tap

•Decreased (Hypoglycorrhachia):
• Bacterial/TB/fungal meningitis
• Meningeal carcinomatosis
•Note: Normal in viral meningitis
•Glucose normalizes early during recovery
 CSF Protein

Lumbar CSF protein: 15 - 45 mg/dl (mostly albumin)

➢ The majority of CSF protein is derived from the plasma by

ultrafiltration

➢ An increased CSF protein serves as a useful but nonspecific

indicator of disease
 CAUSES OF ELEVATED CSF PROTEINS
• Increased Capillary Permeability of the Blood-Brain Barrier
Meningitis lead to heightened capillary permeability, allowing
proteins to leak into the CSF.
• Mechanical Obstruction to CSF Circulation
Disorders such as spinal cord tumors cause mechanical
obstructions, resulting in stasis and increased fluid reabsorption,
thereby raising protein levels in the CSF.
• Enhanced Local (Intrathecal) Immunoglobulin (IgG) Production
Diseases such as multiple sclerosis, neurosyphilis
• Combination of Increased Capillary Permeability and Local IgG
Production: Conditions like Guillain-Barré syndrome exhibit both
elevated capillary permeability and enhanced local IgG
production.
• Hemorrhage in the CSF: Traumatic tap and subarachnoid
hemorrhage introduce blood into the CSF, artificially increasing
protein levels.
 Microbiological Examination

•Wet mount: Candida, Cryptococcus, amoebae

•India ink: Cryptococcus capsule
•Gram stain: Bacteria morphology
•AFB stain: Tuberculosis (low sensitivity)
•Culture: Gold standard (~90% sensitivity)
•PCR: Viral CNS infections (high sensitivity)
 Special Tests on CSF

•Culture: For identification of pathogens (bacteria, fungi).

•Polymerase Chain Reaction (PCR): For detecting specific

viral DNA or RNA (e.g., herpes simplex virus, enterovirus).

•Immunologic Tests: To detect antibodies or antigens

(e.g., in cases of autoimmune diseases or infections).

•Cytology: To detect cancer cells, e.g., in cases of CNS

tumors or metastasis.

•Electrophoresis: To detect abnormal proteins (e.g., in

multiple sclerosis or other neurological conditions).
 CSF Findings in Various Conditions

Feature Normal Bacterial Viral TB Fungal Tumor SAH

Appeara
Clear Cloudy Clear Cloudy Clear Clear Xantho
nce

10–
WBC
>500 200 200–500
(cells/µL 0–5 0–5 0–5 0–5
PMN lymph lympho
)
o

Protein N ↑↑ ↑ ↑↑ ↑ ↑ ↑

Glucose N ↓↓ N ↓ ↓ N N

Clot No Large No Fine No No