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- 1. DR.RITTU CHANDEL MD BIOCHEMISTRY (SECOND YR) GRANT GOVT MEDICAL COLLEGE, BYCULLA, MUMBAI – 400008 29 – 10 -2013
- 2. 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
- 4. Functions of CSF Buoyancy 2. Protective effect 3. Metabolic 4. homeostasis 1. 29-Oct-13 Dr.Rittu Chandel 4
- 5. Specimen collection Cisternal (occipital) In paralysis Ventricular puncture (lateral occipital) For infants 29-Oct-13 Dr.Rittu Chandel 5
- 8. 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
- 9. 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
- 10. Gross examination Appearance Normal – crystal clear, colourless and no coagulum 1.Colour Any change in colour is always pathological Red Yellow 29-Oct-13 Dr.Rittu Chandel 10
- 11. xanthochromia Pale pink to yellow colour in supernatant of CSF Froin’s syndrome 29-Oct-13 Dr.Rittu Chandel 11
- 12. 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
- 13. 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 29-Oct-13 Dr.Rittu Chandel 13
- 14. 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 29-Oct-13 Dr.Rittu Chandel 14
- 15. 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
- 16. 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 29-Oct-13 Dr.Rittu Chandel 16
- 19. 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 19
- 20. CSF serum immunoglobulin ratio Increases in multiple sclerosis Increased CSF IgM and kappa light chains – marker of multiple sclerosis 29-Oct-13 Dr.Rittu Chandel 20
- 21. 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
- 22. CSF leak (rhinorrhea) 29-Oct-13 Dr.Rittu Chandel 22
- 23. 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
- 24. 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
- 25. 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
- 26. 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
- 27. 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
- 29. resilience Surrounded by shell of water molecules A slippery consistency Compressed – occupy smaller volume Relaxed – occupy 29-Oct-13 Dr.Rittu Chandel 29
- 30. 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
- 31. 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
- 32. 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
- 33. examination Synovial fluid Gross microbiology 29-Oct-13 pathology Dr.Rittu Chandel biochemistry 33
- 34. 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
- 35. 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
- 36. 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
- 37. 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
- 38. Uric acid crystals 29-Oct-13 Dr.Rittu Chandel 38
- 40. 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
- 41. slightly basic fluid Resembles plasma in its content Protein content varies widely from 2% to 8% 29-Oct-13 Dr.Rittu Chandel 41
- 42. bibliography Harrisons internal medicine Ranna shinde Vasudevan Henrys clinical diagnosis THANK YOU 29-Oct-13 Dr.Rittu Chandel 42