CEREBROSPINAL FLUID

Mila Amor V. Reyes, MD, FPSP

Anatomic and Clinical Pathologist
 CSFultrafiltrate of plasma, clear, has a low
density, contains Na+, K+ , and Cl ions but
very little protein, and normally very sparse
lymphocytes

Formed at the choroid plexuses of ventricles

Exits the ventricular system through foramina of
Luschka and Magendie
Circulates over the surface of the cerebral
hemispheres and downward over the central canal
of the spinal cord, and subarachnoid space
Resorbed primarily by arachnoid villi in the dural
sinuses
 Lumbar puncturemethod for collecting CSF
for analysis

Indicated in patients suspected of having neurologic

disordersmeningitis, encephalitis, SAH, CNS
leukemia and other neoplastic disorders; and as a
technique to introduce chemotherapeutic drugs or
radiographic contrast material

Complicationspostpuncture headache resulting

from leakage of CSF from the subarachnoid space;
precipitation of tonsillar herniation in patients with
increased ICP; introduction of infectious agents; or
progression of paralysis in patients with SC tumors
 Carries a 0.3% mortality rate in the
presence of papilledema

Specimen is collected into 3-4 sterile

tubes:
Tube 1chemistry and immunology studies
Tube 2microbiologic examination
Tube 3cell count and differential count
Tube 4cytology, if malignancy is suspected
 CSF ANALYSIS
Visual Interpretation of CSF

1. Bloodmay color CSF red, pink, yellow, or

grossly bloody

CHARACTERISTICS DISTINGUISHING TRAUMATIC PUNCTURE

FROM SUBARACHNOID HEMORRHAGE
Traumatic Lumbar Puncture Subarachnoid Hemorrhage

Progressively less blood in tubes Uniformly bloody in all tubes as

as collected collected
CSF usually clots on standing CSF does not clot on standing
Xanthochromia absent Xanthochromia may be present
2. Colorcolorless; pathologic colorations are
best appreciated by observing a sample of
CSF against a white background alongside a
tube of distilled water

Xanthochromiapale pink to pale orange color; may

also appear if normal CSF is not examined within 1
hour of collection
Orange xanthochromiausually due to oxyhemoglobin,
seen in 90% of patients with SAH
Yellow xanthochromiaoccurs with increased CSF
protein and hyperbilirubinemia

Substances that may color CSF: methemoglobin,

melanin in metastatic melanoma, contamination
with thimerosal, carotene, and rifampin
3. Clarityclear as distilled water

Turbid (opalescent, milky, purulent) CSF may result

from:
Erythrocytes (at least 400 cells/uL)
Leukocytes (at least 200 cells/uL)
Microorganisms, radiographic contrast material,
epidural fat

CSF that contains cells in numbers < those needed

to produce turbidity can be detected by the Tyndall
effectobservation of specimens in direct bright
light viewed against a dark background reveal a
characteristic "snowy" or sparkling appearance
when the specimen tube is lightly tapped
4. Clotting normal CSF, with very low
fibrinogen, does not clot

Clotting may occur: after a traumatic puncture,

markedly elevated CSF protein (>1000 mg/dL),
and tuberculous meningitis
Laboratory Assays

1. CELL COUNTS AND CYTOLOGYRBC count,

total and differential WBC count should be
performed within 1 hour of collection
o Normal CSF <5 mononuclear leukocytes/cu mm
(newbornsup to 18-20/cu mm)
o Presence of granulocyte is abnormal

o Lymphocytes, monocytes, and other mononuclear

cells (e.g., pia arachnoid cells, ependymal cells)
may be identified
 PLEIOCYTOSISpathologic increase in the
number of CSF leukocytes

o Neutrophilic pleiocytosisusually due to bacterial

meningitis caused by pyogenic microbes; may result
in CSF WBC counts of 1,000-20,000 cells/cu mm

o Lymphocytic pleiocytosispredominance of
lymphocytes, usually with some plasma cells
infectious causes: viral, syphilitic, tuberculous or fungal
meningitis, parasitic CNS disease, SSPE, partially
treated bacterial meningitis, and bacterial meningitis
due to unusual organisms (e.g., Leptospira and
Listeria)
non-infectious causes: MS and other demyelinating
disorders, chemical meningitis, sarcoidosis, and
vasculitis
o Eosinophilic pleiocytosisoccurs most commonly with
parasitic CNS diseases, coccidioidomycosis
also, rabies vaccination, rickettsia infections, intrathecal
injections of foreign protein, sarcoidosis, bronchial
asthma and other allergic disorders, ventricular shunt
infections, and CNS leukemia

o Mixed cellularity pleiocytosisneutrophils,

lymphocytes, monocytes, plasma cells, and pia
arachnoid mesothelial cells
associated with tuberculous and fungal meningitis,
chronic or atypical bacterial meningitis, aseptic
meningitis, various types of meningoencephalitis,
demyelinating disorders, and ruptured brain abscess

o Abnormal cells in CSF: leukemic leukocytes or other

neoplastic cells, fungal organisms (Cryptococcus
neoformans), amebae (Naegleria fowleri,
Acanthamoeba)
2. CHEMISTRY DETERMINATIONS

Proteinalways present, due to

combination of transport across the BBB
and synthesis within the CNS

o NV= 15-45 mg/dL (<1% of the plasma level),

higher concentration in infants and in older
adults

o All serum protein fractions + "prealbumin"

fraction are demonstrated in CSF
 3 types of protein determinations:

1. Semiquantitative screening tests (e.g., Pandy's

test)

2. Quantitative turbidimetric, colorimetric, or

spectrophotometric tests

3. Immunologic or "fractionation" tests (e.g.,

electrophoresis)
Indicated in MSoften with increase in CSF IgG levels,
with prominent oligoclonal bands due to increased Ig
production in areas of demyelination (75-95% of cases)
 Decreased proteinmay be due to leakage of
CSF (eg, previous lumbar puncture, CSF
rhinorrhea)

Increased proteinincreased permeability of

the BBB, increased local production, or
decreased reabsorption by the arachnoid villi;
also, following traumatic lumbar puncture;
usually with CSF pleiocytosis
 CONDITIONS ASSOCIATED WITH INCREASED CSF PROTEIN
CONCENTRATIONS

Meningitides Subarachnoid or intracerebral

hemorrhage
Meningoencephalitides Degenerative CNS disease

Polyneuritis Aseptic meningeal reactions

Brain abscess Brain and spinal cord tumors

Parameningeal infections Diabetic neuropathy

Intoxication states
 Albuminocytologic dissociationincreased CSF
protein concentration and normal or nearly
normal total cell count
Classically seen with Guillain-Barre syndrome;
also, brain tumors, MS, cerebrovascular
thrombosis, subarachnoid block, neurovascular Sy,
polyneuritis, or chronic CNS infections

Froin's syndromeCSF changes associated with

complete subrachnoid block at or below the
level of the foramen magnum
markedly increased total protein, (often 1,000
mg/dL), xanthochromia, moderate pleiocytosis,
and spontaneous clotting
 Glucosederived solely from plasma
through active transport and passive
diffusion
o NV= 50-80 mg/dL (60-80% of the plasma
level)
o changes in plasma glucose level can take 1-3

hours to appear as changes in the CSF level

CSF and plasma glucose levels should be
obtained simultaneously, if possible; and should
be performed at least 3 hours after oral or
parenteral intake of glucose, if feasible
o Increased glucoseevidence of hyperglycemia
occurring 1-3 hours prior to lumbar puncture

o HypoglycorrhachiaCSF glucose
concentration lower than normal (<40 mg/dL);
results from impaired glucose transport and/or
increased glucose utilization by CNS tissues,
leukocytes, or microbes
 CONDITIONS ASSOCIATED WITH DECREASED CSF
GLUCOSE
Systemic hypoglycemia Subarachnoid hemorrhage

Bacterial, fungal, and Sarcoidosis of the CNS

tuberculous meningitis
Viral meningoencephalitis
Meningeal irritation due to
neoplasms
 CalciumCa levels parallel those of serum ionized calcium

Electrolyte, pH, pCO2, p02indicated in cases of coma or

traumatic brain injury

Glutamineshown to correlate with the degree of hepatic

encephalopathy

Lactic acidused in the evaluation of meningitis

C-reactive Proteinuseful in distinguishing between bacterial

and other forms of meningitis

EnzymesCK, LD, ACE, ADA; clinical utility of these tests has

not yet been clarified
3. MICROBIOLOGIC TECHNIQUES
Include direct CSF exam, culture isolation and identification of
microbes, identification of antigen by immunologic technique
(e.g., latex particle agglutination), nucleic acid probes and
amplification techniques (PCR, RFLP)

Gram/acid fast-stained smear of CSFexcellent test for rapid

diagnosis; sensitivity is 70-90%

India ink examfungal meningitis due to C. neoformans

(budding, encapsulated yeast)

Wet mount exam of CSFPAM (motile trophozoites)

If few organisms are present, centrifuge the CSF (cytospin) and
examine the sediment

Positive identification of microbes, rests on culture isolation

Most commonly performed CSF serologic test for Sy is VDRL/RPR

Key Points:

1. CSF is an important body fluid specimen that

should be examined dynamically, grossly,
chemically, microscopically for cellular content,
and at times for evidence of microorganisms
when CNS disease occurs.

2. CNS syphilis must be confirmed by examination

of CSF for evidence of antibody production.

3. CSF exam is crucial to the diagnosis and

management of microbial diseases of the CNS.
 CEREBROSPINAL FLUID FINDINGS
Disorder Opening Color Clarity Total Cell Differential Protein Glucose Remarks
Pressure Count Cell Count (mg/dL) mg/dL)
(mm Hg) (cells/uL)

Normal 70-180 Colorless Clear 0-5 Mononuclear 15-45 50-80 -

cells only

Bacterial 200-750+ Faint Opalescent or 500-20,000 Neutrophilic 50-1500 0-45 Direct smears,
meningitis xanthochromia purulent pleiocytosis culture

Tuberculosis 150-750+ Faint Opalescent 25-500 Lymphocytic 45-500 0-45 Direct smears,
meningitis xanthochromia pleiocytosis culture

Aseptic 130-750+ May be Clear, cloudy, 5-5000 Mixed or 20-200+ Usually N Marked
meningitis xanthochromic or turbid lymphocytic changes with
pleiocytosis abscess

Neurosyphilis N-300+ Colorless Clear 10-150 Lymphocytic 45-150 Usually N May vary with
pleiocytosis activity of
disease

Viral meningo- N-450 Colorless Clear 10-150 Lymphocytic 15-110 50-110 -

encephalitis pleiocytosis

Traumatic N-low Colorless Variable, Variable Erythrocyte N N Usually less

puncture supernatant bloody predominate blood in each
tube collected

Cerebral N-200 Colorless Clear 0-10 Usually N-100 50-100 Changes are
thrombosis mononuclear usually
unremarkable

Cerebral 100-1100 Xanthochromic Bloody Variable Erythrocytic or 20-2000 50-100 Pleiocytosis

hemorrhage mixed with non-
bloody fluid
CEREBROSPINAL FLUID FINDINGS

Disorder Opening Color Clarity Total Cell Different Cell Protein Glucose Remarks
Pressure Count Count (mg/dL) mg/dL)
(mm Hg) (cells/uL)

Subarachnoid 110-700+ Xanthochromic Uniformly Variable Erythrocytes 20-1000 50-100 Xanthochromia

hemorrhage supernatant bloody predominate depends on
time of
puncture

Brain tumor 150-800+ Occasional Clear N-25 Lymphocytic 20-500 50-100+ Variable
xanthochromia pleiocytosis findings
depending on
location

Spinal cord N-low Colorless or Clear, with clot N-100 Lymphocytic 35-3500 50-100+ Variable
tumor xanthochromia pleiocytosis findings
depending on
location

Multiple N Xanthochromia Clear N-40 Lymphocytic N-130 50-90 Immunological

sclerosis Colorless pleiocytosis protein tests
useful