Cerebrospinal Fluid (CSF)

Location
Ventricular system Subarachnoid space (including cysternal system)

Function
Protect the CNS from mechanical insult (as a cushion) Maintain the equilibrium of neuronal and glial Remove the waste products of neuronal metabolism Determine pulmonary ventilation and CBF according to its acidity

CSF
Aim of its examination
Diagnostic Treatment evaluation or follow up Prognostic

Formation
Rate 0.35 mL/minute ~ 500 mL/day Formed by : Choroid plexuses at :

Floor of each lateral ventricles (largest and most important) Roofs of the third and fourth ventricles (smaller)

Capillary beds that supply the pia and arachnoid (smaller) Ependyma and adjacent glial elements (smaller)

CSF

Formation (ctnd)
A complex process : Active transport (expenditure of energy) Passive diffusion Active transport Cuboid epithelial cells (in choroid pelxus) secrete Na ion Positive potential attracts negative ion especially Cl Many of ionic solutes increase osmotic pressure Water and other solutes follow in maintaining osmotic equilibrium

Passive diffusion Continual diffusion occurs at : Ependyma and vascular beds

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CSF
Dynamic
Total volume of CSF : 75 100 mL ( 15-40 mL at ventricular system) Rate of production 0.35 mL/min ~ 500 mL/day Daily turn over 4-5 times Circulation Lateral ventricles Monro foramenThird ventricle Sylvii aqueductFourth ventricle Luschka and Magendie foramina Subarachnoid space (cysternal system) superior and lateral convexity of brain hemispheres Arachnoid villi venous sinuses (venous blood flow)

CSF
Absorption
Mainly at Arachnoid villi (Arachnoid granulation or Pacchionian bodies) Others (smaller) : veins and capillary of piamatter Unidirectional (valve)

Mechanism - Depends on : Hydrostatic pressure (high to low) Colloid osmotic pressure (low to high) Active transport by cells forming the walls of the arachnoid villi

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CSF
Composition
Water Small amount of protein Gases in solution (O2 and CO2) + + 2+, Mg2+, Cl-, Glucose Na , K , Ca A few white cell Organic constituents

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CSF
Normal values
Color Pressure Cell Glucose Protein -globulin Osmolaritas pH Natrium Kalium Chloride Magnesium Clear, colorless 70-200 mmH2O 0-5/mm3 (lymphocyte or mononuclear cell) 45-80 mg% 5-15 mg% (ventricles) 10-25 mg% (cysternal) 15-45 mg% (lumbar) 5-22 % total protein 295 mOsmol/L 7.31 142-150 mEq/L 2.2-3.3 mEq/L 120-130 mEq/L 2.7 mEq/L

CO2

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CSF
Color
Clear, colorless Change in color : Cell > 200 / mm3 (RBC > 1000 red color) Traumatic puncture : 3-tubes test

clear blood More pale xanthochrom

Unchange

blood

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CSF
Pressure
Depends on : Rate of formation and absorption Flow disturbance Measurement : Manometer while Lumbar or Cysternal puncture Position : Lateral decubitus Sitting

: Normal pressure 70-200 mmH2O : 280 mmH2O

Normally slight increase in case of Coughing or straining Change in heart beat and respiratory cycle Pressure on abdomen
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Pressure Change in flow disturbance Queckenstedt Test press on jugular veins result in normally increase CSF pressure and return to normal limit in 10 CSF obstruction nothing or slightly increase CSF pressure

CSF

Cell : Leucocytes or PMN means pathologic I.e infection of

bacterial, fungal, viral, chemical agents, tumor

Protein : higher than normal limit means pathologic condition Glucose

: two third of blood glucose; below 40 mg% abnormal (i.e in pyogenic infection, tuberculous/fungal meningitis)

Electrolytes : low chloride concentration meningitis (but

not specific)
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CSF
Osmolality : similar to blood plasma Acidity (pH) : Lower than blood pCO2 : Higher than blood
In subacute or chronic metabolic acidosis : CSF acidity relatively un-changed

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CSF
Disorders of CSF
Flow disurbance Accompany other diseases
Flow disturbance Obstruction occurs in CSF flow in ventricular system or subarachnoid space Result in Hydrocephalus

Non-communicating :
Common in children Caused by aqueduct stenosis, over-growth of foramina Luschka and Magendie
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CSF
Disorders of CSF

Communicating hydrocephalus
Common in adult Free communicating between ventricles and subarachnoid space Obstruction at subarachnoid space Caused by inflammation, subarachnoid bleeding, tumor growth

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CSF|LP
LUMBAL PUNCTURE
Indication : Measure CSF pressure Obtain sample for cell count, chemical work-up, bacteriology Intrathecal treatment/procedure : spinal anesthesia, antitumors, antibiotics Diagnostic procedure : pneumoencephalography, myelography, scintigraphic cysternography

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CSF|LP
Indications: Suspect meningitis Suspect encephalitis Diagnose meningeal carcinomatosis Diagnose tertiary syphilis Diagnose meningeal leukemia Staging of lymphomas; Follow up therapy for meningitis Evaluation of dementia Evaluation for Guillain-Barre Treat pseudotumor cerebri Evaluation for multiple sclerosis R/O subarachnoid hemorrhage (after neg. head CT) Instillation of drugs, anesthetics, or radiographic media into CNS
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CSF|LP
Technique
Preparation : Take blood sample for glucose 15 before LP Explain the procedure to patient Obtain informed consent Exclude possibility of increased ICP or CNS mass lesion (eye exam/ head CT). Position : Lateral decubitus in full flexion posture At the bed side Small cushion on head or knee (if needed)

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CSF|LP
Technique
Site of puncture Inter-vertebral space at vertebra L3 L4 Imaginary line connecting iliac crests Other site (if failed) : L2-L3 or L4-L5 Infant/children at L4-L5

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CSF|LP
Technique
Sitting position if failed in recumbent (2-3 times) Measure (opening) pressure Patient preparation Aseptic technique : Clean the area using iodine 10% application in round move starting from the center Change glove once Use sterile covering/towel

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CSF|LP
Technique
Insertion : All tools available : spinal needle (18,19,20), manometer, sterile bottles (3) Local anesthetic (lidocaine 1-2%) : 0.1-0.2 mL subcutaneous and 0.2-0.5 mL deeper Introduce spinal needle, with bevel turned up, into interspace, in a horizontal direction, with slightly cephalad inclination ("aim for the belly button"). Always have stylish in place when maneuvering needle in interspace.
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CSF|LP
Measure opening pressure (normal is 100-250 mmHg): If pressure elevated, ask pt to relax and ensure that there is no abdominal compression or breath holding (straining and abdominal pressure can increase ICP). If pressure markedly elevated, remove only 5 cc of spinal fluid and remove needle immediately. Else, collect 15-20 cc in four collection tubes (2 cc per tube), and remove needle (with styled in place). Can send extra fluid in tube #3, or in extra red-top (#5). Instruct pt to lie flat for approx. 4 hrs to minimize post LP headache (caused by CSF leakage).
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CSF|LP

Contraindications: Infection at intended site of LP Anticoagulation; Increased intra-cranial pressure Severe hemorrhagic diathesis CNS mass lesion in posterior fossa Suspect venous sinus occlusion

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CSF|LP

Complication Headache Backache Intracranial subdural hematoma Infection CSF leak Herniation

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