Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino de las Alas Campus
Indang, Cavite
(6346) 4150-010 / 4150-021
www.cvsu.edu.ph

COLLEGE OF NURSING
Department of Medical Technology

Written Report in Analysis of

Urine and
other Body Fluids
(Cerebrospinal Fluid)

Submitted by:
Along, Rhodalyn M.
Andaya, Bless Marie B.
Ao, Christine P.
Bulquerin, Mary Joyce
Castro, Shannen Therese H.
Submiited to:

Isolde M. Quitan, RMT

CEREBROSPINAL FLUID
(Reported by Rhodalyn M. Along)
Definition

The third major fluid of the body

A watery broth, contains less protein and more vitamin C
A clear, colorless body fluid found the brain and spine.
Approximately 20 mL of fluid produces every hour by choroid plexuses and reabsorbed by the
arachnoid villi.
Total volume:
* adult=140-170mL
* neonates=10-60 Ml

Function

Provides physiologic system to supply nutrient to the nervous tissue.

Remove metabolic waste.
Produce mechanical barrier to cushion the brain and spinal cord against trauma.

History

Hippocrates - Discussed water surrounding the brain when describing congenital

hydrocephalus.
Gallen - Referred to excremental liquid in the ventricles of the brain, which he believe was

purged into the nose.

Emmanuel Swedenborg - Referred to CSF as spirituous lymph secreting from the roof of the

fourth ventricle down to medulla oblongata and spinal cord.

Albrecht von Haller - Swiss physician and physiologist, made a note on his book that water
in the brain was secreted into the ventricle and absorbed in the veins, and when secreted in

excess could lead to hydrocephalus.

Francois Magendie - Studied the properties of CSF by vivisection.
- Discovered the foramen magendie, opening in the roof of fourth ventricle.
- Believed that CSF was secreted by the pia mater.
Thomas Willis - Discovered the circle of Willis
-Note that the consistency of the CSF is altered in meningitis.
W. Essex Wynter - Began treating the tubercular meningitis by tapping the subarachnoid

space.
Heinrich Quincke - Popularize lumbar puncture, he advocated for both diagnostic and

therapeutic purposes.

William Mestrezat - Gave first accurate description of the chemical composition of CSF.
Harvey W. Cushing - Published conclusive evidence that the CSF is secreted by the choroid
plexus.

Location

Cerebrospinal fluid originates in the choroid plexus. The choroid plexus is composed of a mass

of tiny blood vessels that are located in the lateral third and fourth ventricle.
The remaining CSF, approximately 30%, is formed in other places like the subarachnoid and
ependymal layer of the ventricles.

Specimen Collection and Handling

Lumbar puncture - specimen usually collected in three sterile tubes labelled as:
o Tube 1 chemical and serological test
o Tube 2 microbiology laboratory
o Tube 3 cell count

STAT basis

Specimen appearance - major terminology used:

o
o
o
o
o
o

Crystal clear normal

Cloudy
Turbid
Milky
Xanthochromic
Helmolyzed/bloody

Cloudy spinal fluid

Xanthochromia - term used to describe CSF supernatant that is pink, orange, or yellow.
Other cause:
1. Increase serum protein
2. Carotene
3. Increase protein concentration
4. Melanoma pigment

Xanthochromia are due to immature liver function and common in infant.

Xanthochromia specimen appearance from pale pink to orange xanthochromia from released
oxyhemoglobin.

A. Traumatic Collection
Grossly bloody CSF indicates intracranial hemorrhage
- Due to the puncture of blood vessel during the spinal tap procedure
Three visual examination of collected specimens result of hemorrhage or a traumatic tap
B. Uneven Distribution of Blood
Blood from cerebral hemorrhage
o Must be evenly distributed throughout the three CSF specimen tubes
o Distribution:
Traumatic tap (Tube 1) heaviest concentration
Tubes 2 and 3 gradually diminishing amounts
Clot Formation

Fluid from traumatic tap form clots owing to the introduction of plasma fibrinogen into
specimen

Bloody CSF (intracranial hemorrhage) does not contain enough fibrinogen to clot

Damaged blood-brain barrier allows increased filtration of protein and coagulation factors also
cause clot formation but do not usually produce bloody fluid

Conditions include: Meningitis, Froin syndrome, blockage of CSF circulation through

subarachnoid space

Classic web-like pellicle associated with tubercular meningitis and can be seen after overnight
refrigeration of the fluid

C. Xanthochromic Supernatant
is the result of blood that has been present longer than that introduced by the traumatic tap
RBCs that remains in the CSF Two hours before noticeable hemolysis begins
HANDLE WITH CARE: A very recent hemorrhage clear supernatant and introduced

serum protein from a traumatic tap = causes the fluid to appear xanthochromic
Examination: Bloody fluid for the presence of xanthochromic
Centrifuge fluid in microhematocrit tube
Supernatant examined against white background
Additional testing Microscopic examination and the D-dimer test

Intracranial hemorrhage

hemosiderin granules
Formation of fibrin at the hemorrhage site detection of fibrin degradation product, D-dimer

macrophages with ingested RBCs (erythrophagocytosis) or

by latex agglutination immunoassay

CELL COUNTING
(Reported by Shannen Therese H. Castro)

In Cerebrospinal Fluid, WBC count or Leukocyte count is the one being used.
Remember:
RBC count is used only for: traumatic tap, correction for leukocytes or protein
RBC count = Total count WBC count

WBC and RBC lyse within 1 hour

40% - leukocytes disintegrate within 2 hours

Refrigerate if specimens cannot be analyzed

Methodology

Normal CSF (adults) 0 to 5 WBCs / L

Increase in children

In newborns 30 mnc / L Clear

Improved Neubauer Counting Chamber used for CSF counting

Advia 120 Hematology System approved by the FDA for additional CSF assay
WBC count all samples
RBC count - <1500 cells / L
Differential count Neutrophils, Lymphocytes, Monocytes

Calculations

To determine the number of cells / L

Number of cells counted x dilution / Number of squares counted x volume of 1 square = cells /

L. This is applicable for both diluted and undiluted

Many varied calculations are available

o
o

Condensations of formula to provide single factors by which to multiply cell count

Purpose: To convert the number of cells counted in a specific amount o fluid to the number
of cells that would be present in 1 L o fluid.

Total Cell Count

Clear specimens undiluted, provided that no overlapping of cells is seen during the

microscopic examination
If dilutions are required: Calibrated automatic pipetting is used. MOUTH PIPETTING IS NOT

ALLOWED!
For total cell count: Dilutions normal saline mixed by inversion and loaded into

Hemocytometer with a Pasteur Pipette

Cells counted in the: Four corner squares and center squares.

WBC count

Lysis of RBCs must be obtained prior to performing the WBC count

If specimens require dilution: Same dilution with total cell count but substitute 3% glacial acetic
acid to lyse the RBCs

Addition of methylene blue stains WBCs, providing better differentiation between neutrophils
and mononuclear cells

Clear specimens (does not require dilution) Four drops of mixed specimen in a clean tube
1. Rinse a Pasteur pipette with 3% glacial acetic acid. Drain thoroughly.
2. Draw four drops of CSF into the rinsed pipette.
3. Allow the pipette to sit for 1 minute.
4. Mix the solution in the pipette and discard the first drop.
5. Load to hemocytometer.

WBCs four corner square and center square

Number multiplied by dilution factor to obtain no. of WBCs / L
Note: If different number of squares is counted, use the Standard Neubauer formula should
be used to obtain the no. of cells / L

Corrections for Contamination

Correction is possible

Determination of the CSF RBC count and blood RBC and WBC count is necessary for
correction

Determine the ratio of WBCs to RBCs in peripheral blood and comparing this ratio with the no.
of contaminating RBCs, the no. of artificially added WBCs can be calculated using this formula:
FORMULA: WBC (added) = WBC (blood) x RBC (CSF) / RBC (blood)

Approximate CSF WBC Count

By subtracting the added WBCs from an actual count

Peripheral blood RBC and WBC counts = normal range

Many laboratories:
Subtract 1 WBC for every 700 RBCs present in the CSF

Quality Control

Liquid commercial controls for spinal fluid RBC and WBC counts are available

Biweekly basis: All diluents must be checked for contamination by exam in a counting chamber
under 4x magnification

If contaminated discard; prepare new solutions

Monthly basis: Speed of cytocentrifuge should be checked with a tachometer, and the timing
should be checked with a stopwatch

If non disposable counting chambers are used must be soaked in a bactericidal solution for at
least 15 minutes and then rinsed thoroughly with water and cleaned with isopropyl alcohol.

DIFFERENTIAL COUNT ON A CSF SPECIMEN

(reported by Christine P. Ao)
Differential Count on a CSF Specimen

Performed on a stained smear and NOT from the cells in the counting chamber.

Specimen should be concentrated before preparing the smear

Methods available for specimen concentration include: sedimentation, filtration, centrifugation,

and cytocentrifugation

Laboratories that do not have a cytocentrifuge concentrate specimens with routine

centrifugation
o

Centrifuge: 5 to 10 minutes

supernatant fluid is removed

suspended sediment are allowed to air dry and are stainedwith Wrights stain.

When the differential count is performed, 100 cells should be counted, classified, and reported
in terms of percentage.

If the cell count is low and finding 100 cells is not possible, report only the numbers of the cell
types seen.

Cytocentrifugation

It is used for retrieving cells or microorganisms from body fluids directly on the microscopic
slides and preparation of monolayer (evenly spread)smear

Fluid is added to the conical chamber

As the specimen is centrifuged, cells present in the fluid are forced into a monolayer within a 6mm diameter circle on the slide.

Fluid is absorbed by the filter paper blotter, producing a more concentrated area of cells.

As little as 0.1 mL of CSF combined with one drop of 30% albumin produces an adequate cell
yield when processed with the cytocentrifuge.

Adding albumin increases the cell yield and decreases the cellular distortion

Cells from both the center and periphery of the slide should be examined because cellular
characteristics may vary between areas of the slide

A daily control slide for bacteria should also be prepared using 0.2 mL saline and two drops of
the 30% albumin currently being used. The slide is stained and examined if bacteria are seen
on a patients slide

CSF Cellular Constituents

Commonly seen cells in CSF are lymphocytes and monocytes

Adults - lymphocytes to monocytes (70:30)

Children - lymphocytes to monocytes (30:70)

Pleocytosis - increased WBC count in CSF. It is considered abnormal, as is the finding of

immature leukocytes, eosinophils, plasma cells, macrophages, increased tissue cells, and
malignant cells.

High CSF WBC count (neutrophils) indicates bacterial meningitis. The CSF differential count is
most frequently associated with its role in providing diagnostic information about the type of
microorganism that is causing an infection of the meninges.

Moderately elevated CSF WBC count (lymphocyte & monocytes) indicates meningitis of viral,
tubercular, fungal, or parasitic origin

a. Neutrophils

Increased neutrophils also are seen in the early stages (1 to 2 days) of viral, fungal, tubercular,
and parasitic meningitis

Neutrophils associated with bacterial meningitis may contain phagocytized bacterias

Neutrophils may be increased following:

CNS hemorrhage

Repeated lumbar punctures

injection of medications or radiographic dye

Neutrophils with pyknotic nuclei indicate degenerating cells (found in approximately 1% of

specimens). They may resemble nucleated red blood cells (NRBCs) but usually have multiple
nuclei.

b. Lymphocytes and Monocytes

Mixture of lymphocytes and monocytes indiactes viral, tubercular, and fungal meningitis

Reactive lymphocytes containing increased dark blue cytoplasm and clumped chromatin = viral
infections in conjunction with normal cells

Increased lymphocytes indiactes asymptomatic HIV infection and AIDS

Moderately elevated WBC count (less than 50 WBCs/m L) with increased normal and reactive
lymphocytes and plasma cells indiactes multiple sclerosis or other degenerative neurologic
disorders.

c. Eosinophils

Increased eosinophils are seen in:

o

parasitic infections

fungal infections (primarily Coccidioides immitis)

introduction of foreign material including medications and shunts into the CNS

d. Macrophages

They function in removing cellular debris and foreign objects such as RBCs

Appear within 2 to 4 hours after RBCs enter the CSF and are frequently seen following repeated
taps

Increased macrophage indicates previous hemorrhage

Further degradation of the phagocytized RBCs results in the appearance of dark blue or black
iron-containing hemosiderin granules

Yellow hematoidin crystals represent further degeneration

Nonpathologically Significant Cells

a. Choroidal cells

These are epithelial lining of the choroid plexus

Commonly seen singularly and in clumps

Nucleoli are usually absent and nuclei have a uniform appearance

b. Ependymal cells

These are lining of the ventricles and neural canal

They have less defined cell membranes

Frequently seen in clusters

Nucleoli are often present

c. Spindle-shaped cells

They represent lining cells from the arachnoid

These are usually seen in clusters

They may be seen with systemic malignancies

Malignant Cells of Hematologic Origin

a. Lymphoblasts, myeloblasts, and monoblasts

These are frequently seen as a serious complication of acute leukemias

Nucleoli are often more prominent than in blood smears

b. Lymphoma cells

Presence of these cells indicate distribution from the lymphoid tissue

They resemble large and small lymphocytes

They sually appear in clusters of large, small, or mixed cells based on the classification of the
lymphoma

Nuclei may appear cleaved, and prominent nucleoli are present

Malignant Cells of Nonhematologic Origin

a. Metastatic carcinoma cells

Cells from lung, breast, renal, and gastrointestinal malignancies

b. Astrocytomas, retinoblastomas, and medulloblastomas

Cells from primary CNS tumors

These are usually appear in clusters

Fusing of cell walls and nuclear irregularities and hyperchromatic nucleoli are seen in clusters of
malignant cells.

Slides containing abnormal cells must be referred to pathology