CSF Flashcards by Kyra Catedral

Function
• Cushions the brain and spinal cord
• Provides a system to supply nutrients and removes waste

CSF

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• In adults, approximately_____ of CSF is produced every hour

• Total volume:______ ml in adults;
_______in neonates

20 ml

90-150 ml

10-60 ml

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Formation
• Produced in the______

• Located in the ______and the _____&______ventricles

• Minor amounts are produced by the________ and ______

choroid plexus

2 lateral ventricles

3rd and 4th

ependymal cells and arachnoid membranes

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• Capillary networks in the pia mater that form CSF from plasma by selective filtration under hydrostatic pressure and active transport

Choroid Plexes

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• Note: CSF is NOT an ultrafiltrate of plasma

• CSF has higher (3) and lower (2) levels than plasma

sodium, chloride, and magnesium

potassium and calcium

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Cerebrospinal Fluid
1.The CSF passes from the lateral ventricles to the third ventricle through the interventricular foramen (or the foramen of Monro).

From the third ventricle, the CSF flows through the cerebral aqueduct (or the aqueduct of Sylvius) to the fourth ventricle.
From the fourth ventricle, the majority of CSF passes through the apertures of the fourth ventricle: the median aperture (or the foramen of Magendie) and two lateral apertures (or the foramen of Luschka). Via these openings, the CSF enters the cisterna magna and prepontine cisterns, respectively.
From there, the CSF flows through the subarachnoid space of the brain and spinal cord.

5.It is finally reabsorbed through arachnoid granulations.

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• Excess fluid in the cranial vault that causes increased intracranial pressure

Hydrocephalus

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Hydrocephalus

• Two main classifications:
•____________
• caused by blockage of fluid flow in the subarachnoid spaces or by blockage of the arachnoid villi/granulations

•__________
“ caused by a block in the aqueduct of Sylvius, resulting from atresia (Closure) before birth in many babies or from blockage by a brain tumor at any age

Communicating or non-obstructive

Non-communicating or obstructive

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• Aseptic technique with local anesthetic

• Collected by lumbar puncture between the 3rd, 4th, or 5th vertebra (bet. L3-L4 for adults and L4-L5 for children)

Lumbar puncture

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Lumbar Puncture

• Measurement of ‘opening’ and ‘closing’ pressure is essential

• Using a_____ attached to the spinal needle and performed after the dura mater has been entered

• Normal opening pressure for an adult in a lateral recumbent position: _______

• May collect______ml of CSF

• If the pressure is less or more than the normal range, collect only_____ml

• Normal closing pressure is______ less than the opening pressure

manometer

50-180 mm Hg

20 ml

1-2 ml

10-30 mm Hg

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• 3 sterile tubes

• Tube 1: for…
• Tube 2: for…
• Tube 3: for…
• Tube 4 is…

chemical and serologic tests (frozen: -15 to -30C)

microbiology (RT: 19-26C)

cell count (refrigerated: 2-8C)

optional for microbiology or for additional serology tests

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If only 1 tube is collected…

• NOTE: Assess each tube for color, clarity, and volume!

Micro> Hema > Chem/Sero

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Physical Examination

• Normal appearance:______

• Cloudy or turbid: may be due to…

•_______: general term applied to a spectrum of CSF discolorations

crystal clear/colorless

high proteins, high lipids, or pleocytosis (increased cell number)

Xanthochromia

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•______: oxyhemoglobin

•_____: bilirubin

•______: combination of oxyhemoglobin and bilirubin, carotene

•_____: methemoglobin

Pink

Yellow

Orange

Brown

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intracranial hemorrhage (IH) or blood vessel puncture during lumbar puncture/traumatic tap (TT)

• Uneven blood distribution: even distribution of blood in the 3 tubes (_____); heaviest blood concentration on Tube 1 (______)

• Clot formation: present in_____; blood from____ does not contain enough fibrinogen to form clots

IH; TT

TT; IH

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• Note: If CSF is refrigerated for at least____ hours, the formation of a web-like pellicle is seen in pxs with______

tuberculous meningitis

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Xanthochromia
• Centrifuge CS in a microhematocrit tube and examine supernatant against a white background

• Xanthochromic supernatant is more likely present in______ than _______ (RBCs in CSF need_____ to lyse)

• Note: A very recent hemorrhage would produce a______ supernatant

intracranial hemorrhage than traumatic tap

1-2 hours

clear

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• Microscopic examination: presence of macrophages with ingested RBCs or hemosiderin granules indicates…

• D-dimer test →…

• D-dimer is a product of fibrin degradation

• Detectable_____ hours after its formation

intracranial hemorrhage
→IH

→IH

2hrs

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Amount of blood decreases or clears progressively from first to last collection tube

Streaking of blood in CSF during collection

CSF may clot

Usually no xanthochromia

No hemosiderin present

Traumatic Tap

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Amount of blood the same in all collection tubes

Blood evenly dispersed during
collection

CSF does not clot owing to defibrination in vivo

Xanthochromia present

Presence of hemosiderin-laden macrophages (siderophage)

Hemorrhage

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Microscopic Examination

• CSF_____ count: routinely performed

• Performed immediately because WBCs lyse within____

• RBCs are lysed using_____

• Normal adult CSF contains_____ WBC

•_____ count has little diagnostic significance

• May aid in the determination of the cause of a red CSF

WBC count

1 hour

3% glacial acetic acid

0-5 WBCs/microliter

RBC

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Microscopic Examination

•_____ differential count is performed using a stained concentrated specimen

• Methods of concentration

•______: commonly used (centrifuge for 5-10 minutes and then stain sediment with Wright’s stain)
• _____,_______,______

• Count 100 WBCs

• If______ WBCs, report only the numbers of cell types seen

WBC

Centrifugation

Cytocentrifugation, sedimentation, and filtration

<100

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Microscopic Examination

• (3) are the normal WBCs in CSF

• Adults:______ ratio
• Children:______ ratio

Study These Flashcards

Lymphocytes, monocytes, and occasional neutrophils

70:30 L/M

30:70 L/M

• High WBC count with mostly neutrophil:________ • Moderately elevated WBC count with mostly L/M:________

bacterial meningitis other types of meningitis

Microscopic Examination •_______ • May contain ***phagocytized bacteria*** • ***Granules are less prominent*** than in blood • If with pyknotic nuclei (nuclear shrinkage): degenerating WBCs that resemble NBCs (inflammatory and neoplastic disorders)

Neutrophils

• Parasites, fungi (C. immitis), foreign material (medications, shunts)

Eosinophils

Microscopic Examination • Lymphocytes and monocytes __________: increased ***dark blue cytoplasm and clumped chromatin*** • Seen in ***viral infections*** • If with elevated WBC count, in multiple sclerosis and other degenerative neurological disorders

• Reactive lymphocytes

• Remove cellular debris and foreign objects like RBCS • Seen following repeated taps and after a hemorrhage • may contain ***hemosiderin and hamatoidin***

• Macrophages (erythrophagocytic)

Microscopic Examination • Malignant cells • Hematologic origin: ***lymphoblasts, myeloblasts, and monoblasts*** in leukemia complications, and lymphoma cells from lymphoid tissues • Nonhematologic origin: ***lung, breast, renal, and Gl malignancy; CNS tumors (astrocytoma, retinoblastoma, medulloblastoma)***

• Non-pathologic significant cells • Seen after neurologic medical procedures •________ •________: lining of the ventricles and neural canal •________: lining of the arachnoid

Choroidal cells Ependymal cells Spindle-shaped cells

Chemical Examination • CSF Protein • From the transport of plasma proteins in the choroid plexus and meninges, and intrathecal synthesis • Normal CS proteins: (3), with trace amounts of____

transthyretin, albumin, and transferrin IgG

• used to assess the ***integrity of the blood-brain barrier*** and to ***indicate pathologic conditions of the central nervous system***

• Total protein

CSF Total Protein • Causes of **¥increased CSF protein***

• CSF contamination with peripheral blood during the puncture procedure • altered capillary endothelial exchange (change in the blood-brain barrier) • decreased reabsorption into the venous blood • increased synthesis by cells in the central nervous system (meningitis)

CSF Total Protein • Causes of ***decreased CSF protein***

• increased reabsorption through the arachnoid villi because of increased intracranial pressure • loss of fluid because of trauma (e.g., a dural tear) or invasive procedures

in CS results from passage across the blood- brain barrier, assuming no contamination occurs during the puncture procedure

CSF Albumin/ • All albumin

•_______ can be used as a reference protein to monitor the permeability of the blood-brain barrier

albumin

measures BBB permeability

• CSF serum/albumin index:

• CSF/serum albumin index =

Albumin in CSF (mg/dL) / Albumin in Serum (g/dL)

CSF Serum/Albumin Index • Result Interpretation: •: normal •: minimal impairment of BBB •: moderate to severe damage •: complete breakdown of BBB

< 9 9-14 15-100 > 100

C5F IgG • IgG is normally present in small amounts in CSF (1 mg/dl) • Typical reference interval:______ •>_____: increased intrathecal production, multiple sclerosis (diagnostically sensitive)

0.30 to 0.70 > 0.70

• reveals the composition and distribution of proteins in CSF

CSF Protein Electrophoresis

• 4 distinct protein bands • The second transferrin band is also known as______

• Transthyretin • Albumin • 2 bands of transferrin (tau transferrin)

• synthesized almost exclusively in the CNS

Tau

• If present in CSF and absent in serum: indicative/hallmark of multiple sclerosis; single most consistent laboratory abnormality (95% of patients)

• Oligoclonal bands

CSF Myelin Basic Protein •______, a primarily lipid substance (70%), surrounds the axons of nerves and is necessary for proper nerve conduction • In multiple sclerosis and other demyelinating diseases, the myelin sheaths undergo degradation and release_______ into the CSF • _______determinations are used primarily to follow the course of disease or to identify those individuals with ***multiple sclerosis who do not show oligoclonal banding***

Myelin myelin basic protein Myelin basic protein

Demyelinating Disorders _________ • Autoimmune disorder (antibodies against the myelin sheath) • Initiated by T-helper cells that react against self myelin antigens and secrete cytokines •______ cells secrete ***interferon-gamma which activates macrophages*** •_____ cells promote ***recruitment of leukocytes***

• Multiple sclerosis TH1 TH17

• Immune-mediated demyelinating neuropathy usually preceded by an acute, flu-like illness • molecular mimicry of the carbohydrate sequences of Campylobacter jju, CMV, EBY, and M. pneumoniae

• Guillain-Barre syndrome

• 'ascending paralysis'

• Guillain-Barre syndrome

• Multiple sclerosis TH1 TH17

CSF Glucose • Normally, CSF glucose ranges from________, which is approximately 60% to 70% of the plasma concentration • Increased CSF glucose levels: ***hyperglycemia and traumatic puncture procedures*** (because of peripheral blood contamination) but have no diagnostic significance

50 to 80 mg/dL (2.75 to 4.40 mmol/L)

• Low CS glucose values (______) or______: hypoglycemic states, meningitis, and infiltration of the meninges with metastatic or primary tumor • decreased or defective transport across the blood-brain barrier, and increased glycolysis within the central nervous system

< 40 mg/dL hypoglycorrhachia

CSF Lactate • Normally present in CSF at concentrations ranging from_____ • ***Increased CSF lactate levels:*** anaerobic metabolism within the central nervous system because of decreased oxygenation of the brain • ***In viral meningitis,*** the lactate level rarely exceeds_____; in contrast, other forms of meningitis, especially bacterial meningitis, usually produce CSF lactate levels greater than______

10 to 22 mg/dL (1.1 to 2.4 mmol/L) 25 to 30 mg/dL 35 mg/dL.

Microbiological Examination • Performed to identify the causative agent of meningitis • Grown in culture from____ hours (bacterial) to____ (tubercular) • Procedures • Gram stain • Acid fast stain • India ink preparation • Latex agglutination tests

24; 6 weeks

Microbiological Examination •_____: routinely performed from all suspected cases of meningitis • Smears and cultures must be performed on_____ specimen (centrifuge for 15 minutes) • Organisms commonly encountered: ***SHEN*** • (2) in newborns • Note: GS and CSF culture may be negative so blood cultures should also be taken

Gram stain concentrated S. pneumoniae, H. influenzae, E. coli, N. meningitidis S. agalactiae and L. monocytogenes

• Acid-fast or fluorescent antibody stains are not routinely performed unless______ is suspected

tuberculous meningitis

Microbiological Examination • For fungal meningitis: Gram stain and India ink to detect_______ (3) also cause fungal meningitis) • Note: classic______ pattern in Gram stain

C. neoformans (C. immitis and C. albicans ) starburst

• Lateral flow assay/latex agglutination test for______: antibodies against cryptococcal polysaccharide capsule (must be confirmed by culture and India ink due to false-positive reactions) • Cytocentrifuged CSF smear stained with Wright's stain: may detect motile______

C. neoformans N. fowleri

Immunologic Methods • Mainly used to detect microbial antigens in the CSF using polyclonal antibodies • Latex slide agglutination test for______ • High sensitivity and specificity • Good prognostic indicator

Cryptococcus neoformans

CSF Flashcards

(59 cards)