CSF Analysis

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1 : Cerebrospinal Fluid Analysis Keith J. Kaplan, MD Department of Pathology Mayo Clinic
2 : Anatomy and Physiology Produced by choroid plexus & ultrafiltration Approximately 500 ml/day Bathes CNS while it collects waste and provides nutrients Total volumes: Adults: 140 - 170 mL Children: 10 - 60 mL
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4 : Collection and Processing Lumbar puncture, cisternal puncture, lateral cervical puncture, shunts & cannulas Opening pressure = 90 - 180 mm H2O (+/-) Approximately 15 - 20 cc fluid collected Process within 1 hour without refrigeration - STAT Three tube set-up: Tube 1: Chemistry and Immunology (Frozen) Tube 2: Microbiology (Room temperature) Tube 3: Cell count, differential, cytology (Refrigerated)
5 : Indications Meningeal infection* Subarachnoid hemorrhage (SAH) CNS malignancy Demyelinating diseases
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8 : Diagnosis by CSF High sensitivity, high specificity Bacterial, TB, and fungal meningitis High sensitivity, moderate specificity Viral meningitis, SAH, MS, CNS syphilis, abcess Moderate sensitivity, high specificity Meningeal malignancy Moderate sensitivity, moderate specificity Intracranial hemorrhage, viral encephalitis, subdural hematoma
9 : Gross Examination Normal CSF is clear, colorless Viscosity equal to water Clot seen in traumatic tap, not SAH Viscous CSF with increased protein exudate Turbidity: WBC > 200 cells/uL RBC > 400 cells/uL Microorganisms, increased protein
10 : Routine Lab Tests Required Opening CSF pressure Total cell count and differential (stained) Glucose (CSF/plasma ratio) Protein Optional Cultures, gram stain, antigens, cytology Protein electrophoresis, VDRL, D-dimers
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12 : Xanthochromia Pink, orange, or yellow discoloration RBC lysis or hemoglobin breakdown May be seen within hours of LP Peak intensity at 24 - 36 hours RBC > 6000/uL (SAH, ICH, infarct, traumatic) Oxyhemoglobin, bilirubin, increased protein Carotinoids, melanin, rifampin therapy
13 : Differential Dx of Bloody CSF Traumatic tap - blood clears between tubes Xanthochromia - pink tinge, RBCs SAH - blood does not clear or clot
14 : Microscopic Exam of CSF Total Cell Count WBCcorr = WBCobs - WBC added WBC added = WBCBLD - RBCCSF / RBCBLD Differential Cell Count Centrifuge method Filtration methods Sedimentation methods Ependymal cells, chondrocytes, and choroid plexus cells may be seen rarely
15 : Reference Intervals for CSF
16 : Increased Neutrophils in CSF Meningitis (bacterial, early TB, viral, fungal) Other infections Following seizures Following CNS hemorrhage Following CNS infarct Reaction to repeated LP Foreign materials Metastatic tumor
17 : Increased Lymphocytes in CSF Meningitis (aseptic, L monocytogenes) Parasitic infections Degenerative disorders SSPE, MS, encephalopathy due to drugs, GBS Other inflammatory conditions Sarcoidosis, polyneuritis, periarteritis involving the CNS
18 : Plasmacytosis in CSF TB meningitis Syphilitic meningitis MS Parasitic infections SSPE GBS Sarcoidosis Acute viral infections
19 : Eosinophilic pleocytosis in CSF Commonly associated with Parasitic infections Fungal infections Reaction to foreign material Infrequently associated with Bacterial or tuberculous meningitis Viral, rickettsial infection, lymphoma, sarcoidosis
20 : Chemical Analysis Total protein non-specific marker of disease Turbidimetric methods based on TCA or SSA & sodium sulfate for precipitation Simple, rapid, no special instrumentation 300 different proteins have been isolated from CSF using two-dimensional electrophoresis and silver staining
21 : Conditions Associated with Increased CSF Total Protein Increased blood-CSF permeability Meningitis (bacterial, fungal, TB) Hemorrhage (SAH, ICH) Endocrine disorders Mechanical obstruction (tumor, disc, abcess) Neurosypilis, MS, SSPE, GBS, CVD
22 : Electrophoresis Identification of oligoclonal bands 2 or more discrete bands in the gamma region absent or of lesser intensity in concurrently run patient’s serum Silver stain more sensitive than paragon violet IFE better resolution and more specific Sensitivity = 83 - 94%
23 : Bacterial Meningitis 0 - 1m: Group B strept & E. coli (GNR) 1m - 5y: H. influenzae 5 - 29y: N. meningitidis >29y: S. pneumoniae Listeria monocytogenes common in newborns, elderly, and other immunocompromised hosts
24 : Bacterial Meningitis Gram’s stain sensitivity = 60 - 90% Depends on organism, experience, # Culture sensitivity = 80 - 90% Latex agglutination becoming more widely used due to simplicity and accuracy
25 : Bacterial Meningitis
26 : Neurosyphilis Darkfield microscopy for spirochetes CSF FTA-ABS 100% sensitive Negative test rules out diagnosis VDRL nearly 100% specific Positive test rules in neurosyphilis RPR unsuitable for CSF (higher FP than VDRL)
27 : Neurosyphilis
28 : Viral Meningitis Enteroviruses (echoviruses, coxsachie, polio viruses) account for 80% cases Diagnosis of exclusion, rarely use cultures Viral inclusions for CMV, HSV PCR for HSV available Usually requires brain biopsy
29 : HIV Wide variety of abnormalities with or without neurological disease Lymphocytic pleocytosis, elevated IgG, and oligoclonal bands ID of opportunistic (fungal) infections main reason for examining CSF
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31 : Fungal Meningitis India ink for cryptococcal capsular halos 50% sensitivity LA and CF antibodies now available Sensitivity as high as 96%
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34 : Tuberculous Meningitis Early diagnosis extremely difficult Sensitivity for acid-fast stains 10% Large volumes of CSF recommended Higher levels of adenosine deaminase ELISA and PCR now available Sensitivity = 50 - 82% Specificity = 90 - 100%
35 : Primary Amebic Meningoencephalitis (PAM) Rare disease caused by free-living ameba Naegleria fowleri or Acanthamoeba species Motile Naegleria trophozoites may be seen with light microscope Acridine orange stain can differentiate ameba (brick red) from leukocytes (bright green)
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