Cerebrospinal Fluid

Francis F. Demetera, MD, DPSP

CD B: Lab D Decrease CSF pressure
decrease CSF pressure Herniation or Spinal block- no further
after 1-2 mL collection fluid should be withdrawn
CEREBROSPINAL FLUID
CSF leakage
Production: dehydration
- 500 mL per day, at the rate of 0.3-0.4 mL per min spinal-subarachnoid block
- 70% ultrafiltration and secretion through choroid plexus circulation collapse
- 30% from ventricular ependymal lining and cerebral
subarachnoid space Increase Opening Pressure
more than 250 mm intracranial HPN may be due to
Adult Volume: - meningitis
- 90-150 mL - hemorrhage
- 25 mL in the ventricles others in the subarachnoid space - tumors
- replaced every 5-7 hours - SVC syndrome
- CHF
Neonate Volume: - tense/straining
- 10-60 mL - cerebral edema
- mass lesios
Major Functions: - hypoosmolality
- physical support - conditions inhibiting CSF absorption
- protective effect - cryptococcal meningitis- may be the
- excretory waste function only abnormality seen
- transport of hypothalamus releasing factor - pseudotumor cerebri- may be the only
- CNS ionic homeostasis abnormality seen
H, K, Ca, Mg transport systems Idiopathic intracranial hypertension
Glucose, urea and creatinine diffuse freely (2 or more hours to - obese women during childbearing
equilibrate years

CSF COLLECTION Diseases Detected by Laboratory Examination of CSF:

- may be obtained by lumbar (at or below L3-L4), cisternal, or Moderate specificity High specificity
lateral cervical puncture Intracranial hemorrhage
- respiratory compromise may occur in infants if head is flexed Moderate
Viral encephalitis Meningeal

- varies with postural changes, blood pressure, venous return, sensitivity
Subdural hematoma
malignancy

valsalva maneuvers, factors that alter cerebral blood flow Viral meningitis
- Adults: position should be lateral decubitus with legs and neck in Subarachnoid

a neutral position, may be slightly higher if patient is sitting up, hemorrhage Bacterial
varies up to 10 mm with respiration High
MS Tuberculous
- Adult range attained at 6-8 years sensitivity
CNS syphilis
Fungal meningitis
- collect a max volume of 20 mL Infectious polyneuritis

- more than 200 mm: collect only 2 mL Paraspinal abscess

Indication:
- meningeal infection (particularly bacterial): most important Tubes for CSF collection:
Tube 1 Chemistry and immunology
indication of CSF exam
- subarachnoid hemorrhage Tube 2 Microbiological studies
- primary or metastatic malignancy Tube 3 Cell count/ Differential
- demyelinating disease Tube 4 Cytology- only if malignancy is suspected

Contraindications: * Tube 1: never used for microbiology possible contamination of

- local skin infections over proposed puncture site (absolute CI) skin bacteria; delivered to lab and processed quickly
- raise ICP; exception: pseudotumor cerebri * If tube 1 is hemorrhagic due to traumatic puncture do not use
- suspected spinal cord mass or intracranial mass lesion (based on when protein studies are the most important aspect of the analysis
sateralizing neurological findings or papilledema) (in suspected MS)
- uncontrolled bleeding diathesis * Tube 3 should be examined for the major purpose of CSF
- spinal column deformities (may require fluoroscopic assistance) collection
- lack of patient cooperation * Glass tubes should be avoided because of cell adhesion to glass
affects cell count and differential
Normal Opening Pressure * Should be delivered to the laboratory and processed quickly to
Adults 90-180 mm of water minimize cellular degradation (begins 1 hour after collection)
Obese 250 mm of water * Refrigeration: contraindicated for culture specimens because
fastidious organisms will not survive (H. influenza, N. meningitidis)
Infants/ Young children 10-100 mm of water

CD B Lab D: CSF Page 1 of 5

 Recommended CSF laboratory tests Xanthochromia
- to detect, CSF should be centrifuged and supernatant fluid
- opening CSF pressure compared with a tube of distilled water
- Total cell count (WBC and RBC) pale pink, pink, orange or yellow CSF after centrifugation
Routine - Differential cell count (stained smear) - RBC lysis, subarachnoid hemorrhage
- Glucose (CSF/plasma ration) pale pink to orange:
- Total protein - release oxyhemoglobin
- Cultures (bacteria, fungi, viruses, - 2-4 or even up to 12 hours after subarachnoid bleed
mycobacterium tuberculosis) - peak: 24-36 hours; disappear in 4-8 days
- gram stain, acid fast stain yellow
- fungal and bacterial antigens - bilirubin (bilirhachia)
- enzymes (LD, ADA, CK-BB) - 12 hours after bleed
- lactate - peak: 2-4 days; persists for 2-4 weeks
Useful under -
PCR (TB, viruses)
certain - cytology CSF supernatant
conditions - Associated diseased/disorders
electrophoresis (protein immunofixation) color
- proteins (C-reactive, 14-3-3, T, B-amyloid, Pink - RBC lysis/Hgb breakdown products
transferrin) - RBC lysis/Hgb breakdown products
- VDRL test for syphilis Yellow - Hyperbilirubinemia
- Fibrin derivative D-dimer - CSF protein >150 mg/dL (1.5 g/L)
- Tuberculostearic acid - RBC lysis/Hgb breakdown products
Orange - Hypervitaminosis A (carotenoids)
Yellow-green - Hyperbilirubinmia (biliverdin)
GROSS EXAMINATION Brown - Meningeal metastatic melanoma
Normal Gross Exam
Color Crystal clear and colourless Other causes of visible CSF xanthochromia:
- Artifactual red cell lysis d/t detergent contamination of needle of
Viscosity similar to that of water
collecting tube
Abnormal Gross Exam - Delay in processing for more than 1 hour without refrigeration
Turbid/Cloudy >200 WBC/uL - CSF protein levels over 150 mg/dL, in bloody traumatic taps
>400 RBC/uL
(>100,000 RBCs/uL), or in pathologic states: such as complete
Microorganisms
spinal block, polyneuritis, and meningitis
Radiographic contrast - Merthiolate disinfectant contamination
Epidural fat - Carotenoids (orange) in hypercarotinemia (hypervitaminosis A)
Protein >150 mg/dL (>1.5 g/L) - Melanin (brownish) from meningeal metastatic melanoma
Cell count <50 cells/uL may be observed by - Rifampin therapy (red-orange)
Tyndall effect by experienced observers
Grossly bloody - >6,000 RBC/uL
- grossly bloody Spectrophotometry: can help to differentiate hemoglobin-dervied
- may originate from subarachnoid substances from other xanthochromic pigments with different
maximal absorption peaks
hemorrhage, intracerebral hemorrhage,
cerebral infarct or from a traumatic spinal tap
- traumatic taps Differential Diagnosis of Bloody CSF:
Clot formation
- complete spinal block (Froins syndrome) Traumatic tap Pathologic hemorrhage
- suppurative or tuberculous meningitis Fluid clears between 1st-3rd Color of fluid is uniform in 3
*not seen in patients with subarachnoid tubes tubes
hemorrhage No xanthochromia, Xanthochromia,
fine surface pellicles: may be observed after ertythrophagocytosis or erythrophagocytosis or
refrigeration for 12-24 hours hemosiderin laden hemosiderin- laden
- may interfere with cell count accuracy by macrophages (no prior tap) macrophages (no prior tap)
entrapping inflammatory cells D-dimer negative D dimer positive
Viscous CFS - metastatic mucin- producing *false positive: DIC, trauma
adenocarcnomas from repeated lumbar
- cryptococcal meningitis due to capsular puncture, fibrinolysis
polysaccharide
- liquid nucleus pulposus resulting from needle
injury to the annulus fibrosus

Tyndall effect: direct sunlight directed on tube at a 90-degree angle

from observe will impart a sparkling or snowy appearance as
suspended particles scatter the light

CD B Lab D: CSF Page 2 of 5

 Increased CSF neutrophils Increased CSF Lymphocytes
MICROSCOPIC EXAMINATION (lymphocytosis)
Cell and Differential count: a. Meningitis a. Meningitis
Normal Leukocyte Count - bacterial meningitis - viral meningitis
Neonates 0-30/uL - early viral - tuberculous meningitis
Adults 0-5/uL meningoencephalitis - fungal meningitis
Normal Erythrocyte Count - early tuberculous meningitis - syphilitic meningoencephalitis
no RBC should be present - early mycotic meningitis - leptospiral meningitis
limited diagnostic value - amebic encephalomyelitis - bacterial due to uncommon
Clue for trauma, malignancy, infarct or haemorrhage organisms
b. Other infections - early bacterial meningitis
- cerebral abscess where leukocyte counts are
Corrected WBC count: - subdural empyema relatively low
- AIDS-related CMV - parasitic infestations
WBCcorr = WBCobs - WBCadded
radiculopathy (cysticercosis, trichinosis,
where:
WBCadded = WBCBLD x RBCCSF/RBCBLD toxoplasmosis)
- aseptic meningitis due to
To correct added total protein: septic focus adjacent to
meninges
TPadded= [TPserum X (1-HCT)] X RBCCSF/RBCBLD
c. Following seizures b. Degenerative disorders
- subacute sclerosing
CSF reference for differential cytocentrifuge counts: d. Following CNS haemorrhage panencephalitis
- subarachnoid - MS
Adults Neonate - intracerebral - drug abuse encephalopathy
Lymphocytes 62 + 34 20 + 18 - GBS
Monocytes 36 + 20 72 + 22 e. Following CNS infarct - Acute disseminated
Neutrophils 2+5 3+5 encephalomyelitis
f. Reaction to repeated lumbar
Histiocytes Rare 5+4
punctures
Ependymal cells Rare Rare
Eosinophils Rare Rare g. Injection of foreign material in c. Other inflammatory disorders
subarachnoid space - Handl syndrome (headache
Eosinophilic Pleocytosis (methotrexate, contrast media) with neurologic deficits and
Commonly associated with: Infrequently associated with: CSF lymphocytosis)
- acute polyneuritis - bacterial meningitis h. metastatic tumor in contrast - sarcoidosis
with CSF - polyneuritis
- CNS reaction to foreign - CNS periarteritis
- leukemia/lymphoma
material (drugs, shunts)
- fungal infections - myeloproliferative disorders CHEMICAL ANALYSIS: TOTAL PROTEIN
- idiopathic eosinophilic - 80% from plasma
- neurosarcoidosis
meningitis - reference range (15-45 mg/dL)
- idiopathic
- primary brain tumors CSF, mg/L Plasma/CSF ratio
hypereosinophilic
Prealbumin 17.3 14
syndrome
Albumin 155.0 236
- parasitic infections: most - tuberculous Transferrin 14.4 142
common meningoencephalitis Ceruloplasmin 1.0 366
Immunoglobulin 12.3 802
- viral meningitis Ig(G)
IgA 1.3 1346
eosinophilic meningitis: 10% in cell count a2-microglobulin 2.0 1111
Fibrinogen 0.6 4940
IgM 0.6 1167
Inflammatory and infectious causes of CSF Plasmocytosis B-lipoprotein 0.6 6213
- Acute viral infections
- GBS
- MS
- Parasitic CNS manifestations
- Sarcoidosis
- Subacute sclerosing panencephalitits
- Tuberculous meningitis

CD B Lab D: CSF Page 3 of 5

Increase CSF total protein - Normal CSF/Plasma Glucose Ratio- 0.3-0.9
Traumatic spinal puncture
Increased blood- CSF permeability Hypoglycorrachia
Arachnoiditis (ex: following methotrexate therapy) - below 40 mg/dL or 2.2 mmol/L or ratio below 0.3
Meningitis (bacterial, viral, fungal, tuberculous) - bacterial, fungal and tuberculous meningitis
Hemorrhage (subarachnoid, intracerebral) - useful parameter in assessing response to treatment in meningitis
- returns to normal level before protein and cell count
Endocrine/ metabolic disorders
- Milk-alkali syndrome with hypercalcemia
- Diabetic neuropahty Other analytes:
- hereditary neuropahties and myelopathies a. Lactate
- decreased endocrine function (thyroid, parathyroid) - viral versus bacterial meningitis
- other disorders (uremia, dehydration) - viral: <25 mg/dL, Bacterial >35 mg/dL
- Head injury- poor prognosis if persistently elevated
Drug toxicity
- Ethanol b. CK
- Phenothiazines - CK-BB (90%), CKmt (10%)
- Phenytoin - CK-BB- more specific than CK
- increased 6 hours after schema or anoxic insult
CSF circulation defects
- Mechanical obstruction (tumor, abscess, herniated disk) 5 U/L upper normal level
- Loculated CSF effusion <5 U/L minimal damage
5-20 U/L mild to moderate injury
Increased immunoglobulin IgG synthesis
- MS 21-50 U/L correlated with death
Neurosyphilis c. Glutamine
- subacute sclerosing panencephalitis - ammonia + glutamic acid= glutamine
Increased IgG synthesis and blood CSF permeability 20 mg/dL upper reference level
- GBS >35 mg/dL hepatic encephalopathy
- collagen vascular diseases (lupus, periarteritis)
- chronic inflammatory demyelinating radiculopathy
MICROBIOLOGICAL EXAMINATION
Protein: BBB permeability
Normal Bacterial Viral Fungal Tubercul
CSF/Serum albumin index= CSF albumin (mg/dL)
ous
Serum albumin (g/dL)
<9 Intact BBB
9-14 slight impairment Opening 90-180 usually variable variable
15-30 moderate impairment pressure mm H20 normal
>30 severe impairment
Leukocyte 0-5/uL > 1000/uL <100/ uL variable variable
count
Protein: Immunoglobulin G synthesis
CSF/ Serum IgG ratio= CSF IgG (mg/dL) Cell Mainly mainly mainly mainly
Serum IgG (g/dL) differentia Neutro Lympho Lympho Lympho
Normal ratio 1:390 or 0.003 l
impaired BBB increased ratio in MS Protein 15-45 mild- normal-
mg/dL marked mild
Other proteins
Protein Disease/Disorder Glucose 50-80 usually normal : may be
mg/dL < 40 mg/ <45 mg/
Myelin Basic Surrogate disease marker for acute MS
dL dL
Protein
2 macroglobulin Subdural hemorrhage or BBB breakdown CSF-to- 0.3-0.9 normal- usually Low Low
B2 marker for neuro-Behcets syndrome serum marked normal
macroglobulin glucose
Screening test for bacterial (high) versus viral ratio
CRP
meningitis Lactic 9-26 mg/ mild- usually Mild- Mild-
Fibronectin High levels= poor prognosis for ALL patients acid dL marked normal- moderate moderate
B amyloid and T Alzheimers disease mild
protein
Protein 14-3-3 CJD
Bacterial meningitis
B2 transferrin CSF leakage (otorrhea, rhinorrhea)
- mainstay in the diagnosis: gram stain and culture
Bilirubin Subarachnoid hemorrhage
newborn to 1 month E.coli, other gram negative bacilli
neonates Group B streptococci
Glucose:
- diffuse freely through BBB 3 months and older S. pneumonia
- requires 2 hours or more to equilibrate N. meningitides
- 60% of plasma values H. influenza (up to 18)
- Reference range: 50-80 mg/dL or 2.8-4.4 mmol/L

CD B Lab D: CSF Page 4 of 5

Spirochetes meningitis
- neurosyphilis
- Diagnosis: CSF parameters and serological tests
- Tests:
Non-treponema: VDRL
Treponema: FTA-ABS (may give false positive)
Reactive VDRL neurosyphilis is likely

Reactive CSF FTA-ABS neurosyphilis is likely

Non-reactive serum FTA-ABS rules out neurosyphilis

Reactive serum FTA-ABS, rules out neurosyphilis

Non-reactive CSF FTA-ABS

Viral meningitis:
- Enteroviruses
Echoviruses
Coxsackieviruses
Poliovirus
- Arbovirus
- Reverse transcriptase- PCR
- Cryptococcus neoformans
most frequently isolated organism
india ink or nigrosin stains
capsular halo
25% sensitivity, 53% with multiple lumbar puncture
- Latex Agglutination test (Calas)
detects cryptococcal antigen
CSF or serum as sample

Tuberculous meningitis:
- AFB: 10-12% sensitivity (>50% in another study)
- PCR nucleic acid amplification
- negative result does not rule out TB meningitis

Primary amebic meningoencephalitis

a. Naegleria fowleri- wet mount (light or phase-contrast
microscopy)
b. Acanthamoeba spp.- Granulomatous meningitis
c. Balamuthia mandrillaris- Increase neutrophils and protein;
decrease glucose and RBC

CYTOLOGY
- smears are processed by medical technologists and diagnosis is
made by pathologists
- at least 1 mL
- moderate sensitivity
Leukemia: highest at 70%, ALL> AML (>5 cells/uL with
lymphoblasts)
- Metastatic carcinoma- 20-60%
- Primary CNS malignancies- 30%
- High specificity (97-98%)

CD B Lab D: CSF Page 5 of 5