Cerebrospinal Fluid Analysis

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1

cerebrospinal fluid

selective secretion of plasma, not an ultrafiltrate

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sodium, chloride and magnesium

contained in higher levels in CSF than in plasma

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potassium calcium and protein

contained in lower levels in CSF than in plasma

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meninges

the three membranes surrounding the brain and spinal cord

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dura mater

outer layer next to the bone

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arachnoid mater

middle layer resembling a spider web

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pia mater

innermost layer adhering to the surface of neural tissue

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subarachnoid space

the space between arachnoid mater and pia mater where CSF is held

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bathe and protect brain and spinal cord

purpose of CSF

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hydrocephalus

the build up of CSF if reabsorption process is blocked

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85-150 mL

normal adult volume of spinal fluid

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10-60 mL

neonate normal volume of spinal fluid

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blood-brain barrier

interface between blood and CSF only allowing certain substances to cross

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protein glucose and lactate, microorganism cultures, and antigen presence

routinely measured tests for CSF analysis

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aseptic lumbar puncture in third or fourth lumbar interspace with local anesthesia

cerebrospinal fluid specimen collection

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1-2 mL

amount of CSF that should be removed if CSF pressure is less than or greater than normal

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chemistry, serology, immunology

CSF #1

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microbiology

CSF #2

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cell counts and cytology

CSF #3

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stat

examination and testing timing of CSF

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falsely low cell count, falsely high lactate caused by glycolysis

inaccurate results caused by delated testing

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clear, colorless and viscosity like water

three physical characteristics of normal CSF

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pleocytosis

increased number of cells in CSF

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cloudy CSF

associated with white blood cells greater than 200 cells/mL or red blood cells greater than 400 cells/mL

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cloudy CSF

associated with microorganisms or increased protein

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xanthochromia

abnormal color of CSF, usually yellow, orange, or pink due to various conditions

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traumatic tap

greatest amount of blood in tube 1, least in tube 3; colorless supernatant after centrifugation

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hemorrhage

consistent amount of blood in all three tubes; xanthochromic supernatant after centrifugation; macrophages with phagocytized RBCs which stain positive for hemosiderin and may include hematoidin crystals

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0-5 WBC/uL, no RBC presence

normal cell count for CSF

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hemacytometer

used to perform cell counts on CSF

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normal saline

used if a dilution is needed to perform microscopic examination

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RBC count

performed to aid in the differentiation of a recent hemorrhage from a traumatic tap experience

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WBC count

performed to diagnose CNS disease and variety of other conditions

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2% acetic acid

used to lyse RBCs and enhance visualization of WBC nuclei

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lymphocytes and monocytes

predominate white blood cells in CSF

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neutrophils

present in bacterial meningitis, early viral, fungal, TB, or parasitic infections, and some noninfectious conditions

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lymphocytes

increased in viral, TB, fungal, or syphilitic meningitis particularly in later stages

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plasma cells

abnormal when seen in MS and acute viral and chronic inflammatory conditions

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monocytes

may be increased in a mixed cell pattern such as TB or fungal meningitis, chronic bacterial meningitis, or rupture of cerebral abscess

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eosinophils

>10% presence in parasitic, fungal, or allergic reactions (sometimes caused by malfunctioning shunt)

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macrophages

often found after hemorrhage because of phagocytic ability

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other cells

need to be distinguished between malignant cells and others

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15-45 mg/dL

normal CSF total protein

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increased protein

in CSF caused from contamination with blood during tap, change in blood-brain barrier, decreased reabsorption into venous blood, and increased synthesis in CNS

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increased protein

seen in disorders such as bacterial, viral, and other meningitis, cerebral infarction, hemorrhage, endocrine disorders, MS, obstruction of CSF flow, and trauma

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decreased protein

seen in increased reabsorption because of increased intracranial pressure and loss of fluid because of trauma or invasive procedures

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CSF/serum albumin index

used to assess permeability of blood-brain barrier; <9 normal, 9-14 minimal impairment, and 15-100 moderate to severe, >100 complete breakdown of barrier

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0.30 to 0.70

CSF to IgG Index reference range

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greater than .70

CSF/IgG Index associated with increased intrathecal production of IgG

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less than .30

CSF/IgG Index that indicates compromised blood brain barrier

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MS

most patients (90%) have IgG index greater than .70

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tau protein

second band of transferrin specific for CSF

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electrophoresis

performed to identify oligoclonal bands that are present in CSF but absent in serum in MS

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myelin basic protein

surrounds axons of nerves and is necessary for proper nerve conduction; may be seen in MS and other demyelinating diseases

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glucose

values reflect plasma value 30-90 minutes before CSF collection (60-70% of plasma concentration)

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50-80 mg/dL

normal glucose range in CSF

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decreased glucose

associated with many conditions including meningitis hypoglycemic states, and metastatic or primary tumors

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increased glucose

has no clinical significance

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lactate

increased in conditions impairing blood supply or transport of oxygen to CNS (anaerobic conditions)

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10-22 mg/dL

normal lactate range in CSF

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increased lactate

cerebral infarction, intracranial hemorrhage, hydrocephalus, traumatic brain injury, and meningitis

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viral meningitis

lactate level rarely exceeds 25-30 mg/dL

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bacterial meningitis

lactate levels greater than 35 mg/dL and decreased glucose

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gram stain

look for bacteria and fungi

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india ink

for Cryptococcus neoformans

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acid-fast stain

for TB meningitis

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Wright's stain

for ameba Naegleria fowleri

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culture

to detect bacterial cause

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detection of microbial antigens

to assist in identifying bacterial and fungal antigens in CSF