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DR.RITTU CHANDEL
MD BIOCHEMISTRY (SECOND YR)
GRANT GOVT MEDICAL COLLEGE, BYCULLA, MUMBAI –
400008
29 – 10 -2013
Cerebrospinal fluid

Total volumes:
– Adults: 140 - 170 ml
– Children:
29-Oct-13

cerebral ventricles – 30ml
subarachnoid space - 120 ml

10 - 60 ml
Dr.Rittu Chandel

2
hydrocephalus

29-Oct-13

Dr.Rittu Chandel

3
Functions of CSF
Buoyancy
2. Protective effect
3. Metabolic
4. homeostasis
1.

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Dr.Rittu Chandel

4
Specimen collection

Cisternal (occipital)
In paralysis
Ventricular puncture
(lateral occipital)
For infants
29-Oct-13

Dr.Rittu Chandel

5
CSF analysis
CSF

Gross

microbiology
29-Oct-13

pathology

Dr.Rittu Chandel

biochemistry
6
Polypropylene tubes

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Dr.Rittu Chandel

7
composition
•
•
•
•
•
•
•
•

Colour
- Colourless
PH
- 7.28 – 7.32
Appearance
- Clear
Sp. Gravity
- 1.003 – 1.004
No clot formation on standing
Proteins
- 10 – 45 mg/dl
Glucose
- 45 – 100 mg/dl
Chlorides
- 120 -130 mEq/l

29-Oct-13

Dr.Rittu Chandel

8








Urea
Uric acid
Creatinine
Cholesterol
Ammonia
A:G ratio
Serum:CSF protein

29-Oct-13

Dr.Rittu Chandel

- 6.0 - 16 mg/dL
- 0.5 - 3.0 mg/dL
- 0.6 - 1.2 mg/dL
- 0.2 - 0.6 mg/dL
- 10 – 35 μg/dL
- 3:1
– 200:1
9
Gross examination
 Appearance

Normal – crystal clear, colourless and no coagulum
1.Colour
Any change in colour is always pathological
Red
Yellow

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Dr.Rittu Chandel

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xanthochromia
 Pale pink to yellow colour in supernatant of CSF

Froin’s syndrome
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Dr.Rittu Chandel

11
D/D of bloody CSF
 Traumatic tap - hemorrhagic fluid clears between

first and third tubes; remains uniform in SAH
 Pathological
- RBC have crenated appearance
 Xanthochromia, erythrophagocytosis and hemosedrin

laden macrophages indicate a subarachnoid bleed in
absence of prior trauma

29-Oct-13

Dr.Rittu Chandel

12
Gross examination(contd)
 2. Turbidity
o WBC >200 cell/μl
o RBC >400 cell/μl
o Microorganisms, radiographic contrasts, aspirated

epidural fat
o Protein > 150 mg/dl
 Clot formation
 Viscous CSF

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Dr.Rittu Chandel

13
Pressure of CSF
Normal
Adults – 90 – 180 mm water
Infants and children – 10 – 100 mm water

>250 mm water
Intracranial hypertension
Tumors

Decreased pressure
Dehydration
Circulatory collapse
CSF leakage
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Dr.Rittu Chandel

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Biochemical analysis of
CSF
 1. Glucose

Normal – 45 – 100 mg/100 ml
decreased – coccal meningitis
TB meningitis
intrathecal streptomycin
Increased – diabetic hyperglycemia

In assessing response to treatment
29-Oct-13

Dr.Rittu Chandel

15
 2.Proteins

Normal – 15 – 45 mg/dl
Term infants – 90 – 150 mg/dl
Pre term - 115 – 170 mg/dl
 Increased CSF protein
I. Increased permeability of blood brain barrier
II. Increased intrathecal IgG secretion

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electrophoresis

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Permeability of blood brain
barrier
CSF/serum albumin index
index

permeability

<9

intact barrier

9 – 14

slight impairment

14 – 30

moderate impairment

>30

severe impairment

Index slightly elevated in infants up to 6 months of age
29-Oct-13

Dr.Rittu Chandel

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CSF serum immunoglobulin
ratio

 Increases in multiple sclerosis

 Increased CSF IgM and kappa light chains – marker of

multiple sclerosis
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Dr.Rittu Chandel

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CSF proteins and CNS
diseases
proteins

Diseases or disorders

Α2 - macroglobulin

Subdural hemorrhage, bacterial meningitis

Β – amyloid protein 42 and ζ protein

Alzheimer’s disease

Β 2 - microglobulin

Leukemia/lymphoma, bechets syndrome

C- reactive protein

Bacterial and viral meningitis

fibronectin

Lymphoblastic leukemia, AIDS, meningitis

methemoglobin

Mild subarachnoid/subdural hemorrhage

Mylein basic protein

Multiple sclerosis, tumors

Protein 14- 3 -3
29-Oct-13

Dr.Rittu Chandel

Creutzfeldt – jacob disease

21
CSF leak (rhinorrhea)

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Dr.Rittu Chandel

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CSF lactate
 CSF and blood lactate are largely independent
 Normal

newborn – 10 – 60 mg/dl
Child and adult – 9 – 26 mg/dl
Differentiating meningitis

CSF lactate
(mg/dl)

meningitis

< 25 mg/dl
Almost always less
than 35 mg/dl

viral

>35 mg/dl

bacterial

Persistently elevated - poor prognosis in patients with severe
head injury
29-Oct-13

Dr.Rittu Chandel

23
CSF phenylalanine
CSF copper

 Total cell count –

Normal - 0 – 5 cells/ μl
Neonate – 0 -30 cells/ μl
No RBC
 Differential count
Lymphocytes: monocytes = 70:30
Neutrophils – 7%
29-Oct-13

Dr.Rittu Chandel

24
Lumbar puncture findings
test

bacterial

viral

fungal

tuberculous

Opening
pressure

elevated

Usually normal

variable

variable

Leukocyte count > Or =1000/μl

<100/μl

variable

variable

Differential
count

Mainly
neutrophils

Mainly
lymphocytes

Mainly
lymphocytes

Mainly
lymphocytes

protein

Mid – marked
increase

Normal – mild
increase

increased

increased

glucose

< or = 40 mg/dl

normal

decreased

Decreased ;<45
mg/dl

CSF/serum
glucose ratio

Normal –
marked
decrease

Usually normal

low

low

29-Oct-13

Dr.Rittu Chandel

25
CSF enzymes
CSF enzymes

disease

Adenosine deaminase

Tubercular meningitis

Creatine kinase ( CK – BB )

Hydrocephalus, cerebral infarction,
primary brain tumors, subarachnoid
hemorrhage

LDH

CNS leukaemia, lymphoma, metastatic
carcinoma, bacterial meningitis, SAH

lysozyme

Bacterial and tuberculous meningitis

Aspartate transaminase

Cerebral abscess, cerebral hemorrhage,
primary or metastatic malignancy

Placental alkaline phosphatase

Germ cell tumor

29-Oct-13

Dr.Rittu Chandel

26
CSF tumor markers
Carcinoembryonic antigen

Metastatic carcinoma of leptomeninges

Human chorionic gonadotropin

Choriocarcinoma, malignant germ cell
tumors

Alpha feto protein

Germ cell tumors

CSF ferritin

CNS malignancy

29-Oct-13

Dr.Rittu Chandel

27
Synovial fluid

29-Oct-13

Dr.Rittu Chandel

28
resilience
Surrounded by shell of water
molecules
A slippery consistency
Compressed – occupy smaller
volume
Relaxed – occupy

29-Oct-13

Dr.Rittu Chandel

29
functions
 Reduce friction between bones
 Lubricates joints
 Fluid provides nutrients to cartilage
 Lessens shock of walking and jogging impact

29-Oct-13

Dr.Rittu Chandel

30
Composition
Volume
Color
Clarity

<3.5 mL
pale yellow
clear

Neutrophils
<20% of diff.
Lymphocytes
<15 % of diff.
Monocytes & macrophages
65% of diff.
Crystals
NONE
Glucose
<10 mg/dL (serum synovial
difference)
Lactate
<250 mg/dL
Total protein
<3 g/dL
Uric acid
= blood value
29-Oct-13

Dr.Rittu Chandel

31
collection
*Avoid all powdered anticoagulants – interfere
with crystal analysis
 Fluid verification


29-Oct-13

Mucin clot test Add fluid to dilute acetic acid 
turbidity (clot formation) due to
hyaluronate
Dr.Rittu Chandel

32
examination
Synovial
fluid

Gross

microbiology
29-Oct-13

pathology

Dr.Rittu Chandel

biochemistry
33
Gross examination
 Total volume – recorded at bedside
 Normal= 3.5 mL
 Diseased / inflamed = up to 25

mL

 Colour – colourless

xanthochromia
red brown
 Clarity –transparent
opaque
oily
floating rice bodies
ground pepper appearance
29-Oct-13

Dr.Rittu Chandel

34
Biochemical analysis
 Mucin clot test

Non specific finding
 Glucose
Serum synovial difference < 10 mg/dl
Septic arthritis – difference 20 – 60 mg/dl
 Protein
Normal – 1-3 g/dl
Increased in inflammation
 Uric acid
 RF
 ANA
29-Oct-13

Dr.Rittu Chandel

35
Cell count
 Total count

Normal – 150 – 200 / μl
abnormal >10,000/ μl
 DLC
Normal - Neutrophils – 20%
Gout >50%
Acute bacterial arthritis – 75%

29-Oct-13

Dr.Rittu Chandel

36
Differential count






Normal
Neutrophils – 20%
Lymphocytes – 15%
Monocytes and macrophages – 65%
Abnormal
Reiters cell
Eosinophilia >2%

 Microscopic examination
29-Oct-13

Dr.Rittu Chandel

37
Uric acid crystals

29-Oct-13

Dr.Rittu Chandel

38
crystals

29-Oct-13

Dr.Rittu Chandel

39
lymph
 The lymphatic system is an extensive vascular network
 responsible for the transport of fluid , immune cells ,

proteins and lipids .
 The failure to transport lymph fluid results in a
number of disorders and diseases .
 Lymphedema , for example , is a pathology
characterized by the retention of fluid in limbs
creating extreme discomfort , reduced mobility.

29-Oct-13

Dr.Rittu Chandel

40
 slightly basic fluid
 Resembles plasma in its content
 Protein content varies widely from 2% to 8%

29-Oct-13

Dr.Rittu Chandel

41
bibliography
Harrisons internal medicine
Ranna shinde
Vasudevan
Henrys clinical diagnosis

THANK YOU
29-Oct-13

Dr.Rittu Chandel

42

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