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ExaminationExamination ofofcerebrospinalcerebrospinal fluidfluid

Marta KalousovInstitute of Clinical Chemistry and Laboratory

Diagnostics,1st Faculty of Medicine and General University

Hospital, Charles University, Prague

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CerebrospinalCerebrospinal fluidfluid

clear colorless fluid

placed in intraventicular and subarachnoidal spaces formed in chorioidal plexi of brain ventricles andsubarachnoidally

circulates round brain and spinal cord

resorbed to venous (80%) and lymphatic (20%)systems

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CerebrospinalCerebrospinal fluidfluid

Volume in adults 120-180 ml Volume in small babies 40-60 ml

daily production 430-580 ml hypooncotic, isoosmolar fluid 40-45% is formed as ultrafiltrate of plasma Density 1006-1009 kg/m3

Pressure in horizontal position 0.59-1.96 kPa Pressure in vertical position 3.92 kPa

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Function of cerebrospinal fluidFunction of cerebrospinal fluid

mechanic protection of brain and spinalcord, protection against microorganisms

transport of biomolecules to the brain

clearance of catabolites (CO2, lactate)

maintenance of constant intracranial

pressure

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Indications to CSFIndications to CSF diagnodiagnossticstics

Neuroinfection

Inflammatory/autoimmune diseases Stroke, trauma, subarachnoidal bleeding

Tumours infiltration of meninges

Defects of BBB Defects of circulation of CSF

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CollectionCollection ofofcerebrospinalcerebrospinal fluidfluid

Lumbar puncture(event. suboccipital orventricular punctures

rare)

simultaneus blood collection!

Lumbar puncture

(event. suboccipital or

ventricular punctures rare)

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ExaminationExamination ofofcerebrospinalcerebrospinal fluidfluidBasic Color

Number of elementsand erythrocytes Total protein Glucose Lactate

Spectrophotometry(360-600 nm)

Others Albumin (CSF,S)

Albumin quotient IgG, IgM (CSF, S) Ig quotient Oligoclonal IgG Specific proteins

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CompositionComposition ofofcerebrospinalcerebrospinal fluidfluid

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SpectrophotometrySpectrophotometry ofof

cerebrospinalcerebrospinal fluidfluid Indication bleeding detection of oxyhemoglobin,

methemoglobin and bilirubin

Oxyhemoglobin fresh bleeding, abs max 415 nm(+smaller peeks at 540 nm and 575 nm)

Methemoglobin encapsulated hematomas, abs max405-408 nm (+smaller peeks at 540 nm, 575 nm, 620-630nm)

Bilirubinnon-conjugated old bleeding, abs max 450-460 nmconjugated - BBB defect, high concentration gradient, absmax 420-430 nm

Cave arteficial bleeding!

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PathologicalPathological findingsfindings in CSFin CSF --

biochemistrybiochemistry

Glucose - in meningitis, mainly purulent, also inbleeding

Lactate - in purulent meningitis, malignantinfiltration of meninges, stroke with severehypoxia, metabolic disesase (mitochondrialencephalopathy)

Total protein - in BBB defects, in intrathecalsynthesis of immunoglobulins Chloride - in TBC meningitis

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PathologicalPathological findingsfindings in CSFin CSF --

cytologycytology

Pleocytosis = increased number of elementspolynuclear pleocytosis purulent meningitismononuclear pleocytosis non-purulentneuroinfectionstumorous pleocytosis

Oligocytosis = normal number of elementsnon-physiological composition of elements

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RelationshipRelationship numbernumber ofofelementselements

totaltotal proteinprotein

Protein-cytologic dissociation increased totalprotein, normal number of elements, present in

tumours and blockade of CSF circulation compresive syndrome, late phase of chronicneuroinfectionsFroins syndrome

Cyto-protein dissociation in early acutephase of meningitides Protein-cytologic association elevation of both

proteins and elements

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AlbuminsAlbumins andand globulinsglobulins in CSFin CSF

in normal CSF, the same relationship as in serum(60% albumin, 40% globulins)

physiological A/G Q 1.5 IgG in inflammation A/G Q

defect BBB without inflammation A/G Q(albumin as small molecule increases faster)

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AlbuminAlbumin andand immunoglobulinimmunoglobulin

quotientsquotients

Albumin quotient

indicator of function

of BBB

Alb CSF x10-3

Qalb

= ---------------Alb serum

Immunoglobulinquotient

indicator of intrathecalsynthesis offimmunoglobulines

IgG CSFQIg = ---------------

IgG serum

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DelpechDelpech--LichtblauLichtblauss quotientquotient

IgGCSF

Alb serum

Q = -------------- . ---------------

AlbCSF IgG serum

>0.65 (0.7) intrathecal synthesis of immunoglobulins

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ReiberReiberss graphgraph

5

4

2

1

Q Alb

QI

g

3

1 normal finding2 isolated defect of BBB

3 defect of BBB andintrathecal synthesis of Ig

4 isolated intrathecalsynthesis of Ig

5 preanalytical oranalytical errors

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IIsoelectricsoelectric focusationfocusation

electrophoresis, in which proteins are divided inpH gradient according to their isoelectric point (pI),performed both in CSF and serumproteins have negative charge in pH > pI and positivecharge in pH< pI, in pI the charge is 0during isoelectric focusation, proteins pass to regions withtheir pI and concentrate there

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I polyclonal IgG corresponding in CSF and serum normalfinding

II oligoclonal IgG in CSF but not in serum local synthesisof IgG inflammatory and autoimmune disease of CSN

III abnormal IgG in CSF more frequent and/or moreintensive than in serum local synthesis of IgG in CNSand production of antibodies in the organism inflammatory and autoimmune disease of CSN

IV mirror pattern abnormal IgG in CSF and serum systemic immune activation without local synthesis of IgGin CNS and defect of BBB

V monoclonal IgG both in CSF and serum - paraprotein

IIsoelectricsoelectric focusationfocusation resultsresultsspecific detection of oligoclonal production of IgG

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OtherOther markersmarkers

Viral and bacterial antigens - Herpes simplex,Mycobacterium tuberculosis, Borrelia burgdorferi

Structural proteins markers of damage S100

protein, NSE (neuron specific enolase), MBP(myelin basic protein) Autoantibodies anti MBP (myelin basic

protein) IgG, anti MAG (myelin associatedglycoprotein) IgM

2-microglobulin hematological malignancies

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PurulentPurulent neuroinfeneuroinfectionctionElements >900/3

Neutrophil granulocytes

Total protein >2 g/l

Glucose in CSF 3,5 mmol/l

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Non-purulent neuroinfectionElements tens-hundreds/3

Lymphocytes

Total protein < 2 g/l or N

Glucose N

Lactate < 3,5 mmol/l

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SubarachnoidSubarachnoidalal bleedingbleedingBloody CSFYellow CSF after

centrifugationSpectrophotometry:

OxyhemoglobinBilirubin

Phagocyted erythrocytes

Total protein Glucose NLactate

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MalignMalignantant infiltrationinfiltration

Elements N - thousands

Malignant elements

Total protein N -

Glucose

Lactate

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ChronicChronic inflammatoryinflammatory diseasedisease MMSSElements tens-hundreds/3

Lymphocytes, plasmatic cells

Total protein N or slightly

Glucose N

Lactate N

IEF 2 oligoclonal IgG

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LiteratureLiterature andand additionaladditional materialmaterial

Zima T.: Laboratory diagnostics. Galn, Praha 2003, p.363-389. in Czech

Glosov L.:Cytological atlas of cerebrospinal fluid. Galn,1998. in Czech

Reiber H., Otto M., Trendelenburg Ch., WormekA.,:Reporting Cerebrospinal Fluid Data: Knowledge Baseand Interpretation Software Clin Chem Lab Med 2001;39(4):324332 2001 by Walter de Gruyter Berlin New York

Biochemical findings: Dr. Mrzov, Institute of ClinicalChemistry and Laboratory Diagnostics, General UniversityHospital, Prague

Case reports: Dr. ern, Department of Pediatrics, GeneralUniversity Hospital, Prague