BRAIN AND MIND BRAIN AND MIND SYSTEMSYSTEM

KELAINAN CAIRAN OTAKKELAINAN CAIRAN OTAK

Dept. Patologi Klinik FK USUDept. Patologi Klinik FK USU

dr. Tapisari Tambunan SpPK (K)dr. Tapisari Tambunan SpPK (K)

dr. Ozar Sanuddin SpPK (K)dr. Ozar Sanuddin SpPK (K)

PhysiologyPhysiologyCerebrospinal Fluid (CSF) :Cerebrospinal Fluid (CSF) :

** Hasil Hasil produk aktifitas ventricular choroi produk aktifitas ventricular choroidd plexuses plexuses * * BBereredaredar melalui ventricles dan subarachnoid melalui ventricles dan subarachnoid spaces spaces

* * DDiabsorbsi oleh arachnoid villi iabsorbsi oleh arachnoid villi venous sinuses venous sinuses aliran darah aliran darah

Fungsi CSFFungsi CSF* Fungsi utama : proteksi, memberi bantalan untuk * Fungsi utama : proteksi, memberi bantalan untuk

brain dan spinal brain dan spinal

• Blood Brain Barrier : Blood Brain Barrier :

- bekerja dgn proses metabolik- bekerja dgn proses metabolik aktif -aktif - menjaga menjaga

kons sbgn besar substansi dlm CSF dlm kadar yg kons sbgn besar substansi dlm CSF dlm kadar yg

berbeda dari dlm darah, dgn rentang kadar yang berbeda dari dlm darah, dgn rentang kadar yang

sempitsempit

Pengambilan spesimenPengambilan spesimen Lumbal punksiLumbal punksi

Indikasi LP: Indikasi LP:

1. Suspek 1. Suspek ::- Meningitis, Meningitis, - Encephalitis,Encephalitis,- Brain abscess, Brain abscess, - SSubarachnoid hemorrageubarachnoid hemorrage

2. DD2. DD/:/:

- C- Cerebral infark dgn cerebralerebral infark dgn cerebral hemorrhage (80%) hemorrhage (80%)

3. Pemberian anestesi, media kontras, 3. Pemberian anestesi, media kontras,

obat-obat obat-obat

4. Treatment pada bbrp pasien dgn hipertensi 4. Treatment pada bbrp pasien dgn hipertensi intracranial benigna intracranial benigna

Komplikasi LP: Komplikasi LP:

- Pada Tekanan Intracranial meninggi - Pada Tekanan Intracranial meninggi Herniasi, mortalitas meningkatHerniasi, mortalitas meningkat

- Paresis - Paresis s/ds/d paralisis (spinal cord tumor) paralisis (spinal cord tumor)

- Pada gangguan koagulasi - Pada gangguan koagulasi Extradural @ Extradural @

Subdural hematomaSubdural hematoma

Pelaksanaan LPPelaksanaan LP : : - - PPagi dan puasa 1agi dan puasa 1 malam malam - - Lokasi Lokasi dewasa : L3-L4 dewasa : L3-L4 anak : L4-L5 anak : L4-L5 - Ditaruh pada - Ditaruh pada 44 tube sentrifus steril tube sentrifus steril.. tube tube pertama pertama tdk digunakan tdk digunakan ok ok

bebercampur darah dari trauma punksircampur darah dari trauma punksi -Tube 1 :Serologi dan Kimia klinik (k-Tube 1 :Serologi dan Kimia klinik (kadar adar

Protein, Ca, GlukosaProtein, Ca, Glukosa, kadar, kadar bervariasi bervariasi tergantung tergantung lokasi lokasi spesimen diambil spesimen diambil (ventricle, cisterna magna, lumbar spinal (ventricle, cisterna magna, lumbar spinal area)area)

- T- Tube ube 22 : kultur : kultur - T- Tube ube 33 : : hitung/jenis hitung/jenis selsel hematologi hematologi

Composition of Normal Spinal FluidComposition of Normal Spinal Fluid

Amount Amount : 90-150 ml : 90-150 ml Color Color : colorless, like water : colorless, like water Transparency Transparency : clear, like water : clear, like water Specific Gravity Specific Gravity : 1.006-1.008: 1.006-1.008 Glucose Glucose : 45-100 mg/100ml : 45-100 mg/100ml (60-70% KGD)(60-70% KGD) Urea Urea : 8-28 mg/100ml : 8-28 mg/100ml Sodium Sodium : 117-137 mEq/L : 117-137 mEq/L Pottasium Pottasium : 2.33-4,59 mEq/L : 2.33-4,59 mEq/L

Acid-base balance :Acid-base balance : pH pH : 7.31: 7.31 PcoPco2 2 : 47.9 mmHg: 47.9 mmHg

HCOHCO33 : 22.9 mEq/L: 22.9 mEq/L

Uric acid Uric acid : 0.07- 2.8 mEq/L: 0.07- 2.8 mEq/L Total protein Total protein : 20-40 mg/100ml: 20-40 mg/100ml

Lumbar Lumbar : 20-40 mg/100ml: 20-40 mg/100ml Cisternal Cisternal : 15-25 mg/100ml: 15-25 mg/100ml Ventricular Ventricular : 5-10 mg/100ml: 5-10 mg/100ml

Electrophoretic separation of lumbar fluid, mean Electrophoretic separation of lumbar fluid, mean values :values : Prealbumin Prealbumin : 4.6 ± 13%: 4.6 ± 13% Albumin Albumin : 49.5 ± 6.5 %: 49.5 ± 6.5 % αα11-globulin -globulin : 6.7 ± 2.0 %: 6.7 ± 2.0 % αα2- 2- globulin globulin : 8.3 ± 2.1%: 8.3 ± 2.1% ΒΒ- and - and ττ- globulin - globulin : 18.5 ± 4.8 %: 18.5 ± 4.8 % γγ-globulin -globulin : 11.2 ± 2.7 %: 11.2 ± 2.7 %

Calcium (lumbar) Calcium (lumbar) : 2.32 mEq/L: 2.32 mEq/L Magnesium Magnesium : 2.20 mEq/L : 2.20 mEq/L Creatinine Creatinine : 0.4 – 1.5 mg/100ml: 0.4 – 1.5 mg/100ml Lactic dehydrogenase : 8-50 units Lactic dehydrogenase : 8-50 units CellCell : 1-5 cells/mm: 1-5 cells/mm3 3 (lymphocytes)(lymphocytes)

Pemeriksaan LabPemeriksaan Lab

Makroskopis Makroskopis MikroskopisMikroskopis Analisa Kimia Analisa Kimia Imunologi Imunologi MikrobiologiMikrobiologi

MakroskopisMakroskopis Jernih, tidak berwarna Jernih, tidak berwarna Darah : - merahDarah : - merah * gross * gross abaikan pem. Kimia abaikan pem. Kimia * koreksi perhitungan lekosit : * koreksi perhitungan lekosit : jlh lekosit = jlh leko terhitung – a jlh lekosit = jlh leko terhitung – a a = a = jlh eri dlm darahjlh eri dlm darah x leko dlm darah x leko dlm darah jlh eri dlm CSFjlh eri dlm CSF - Bloody tap (traumatic tap) :- Bloody tap (traumatic tap) : * Cedera pembuluh darah pada tindakan LP* Cedera pembuluh darah pada tindakan LP * Tube 1, 2, 3 berturut-turut jlh darah makin kurang, * Tube 1, 2, 3 berturut-turut jlh darah makin kurang, * Jk ragu, bandingkan hitung sel tube 1 dan ke 3 * Jk ragu, bandingkan hitung sel tube 1 dan ke 3 * Supernatan setelah disentrifus : jernih, tak berwarna * Supernatan setelah disentrifus : jernih, tak berwarna - Hemorrhage : - Hemorrhage : * Darah pada tube 1,2 dan 3 sama banyak * Darah pada tube 1,2 dan 3 sama banyak * Supernatan kekuningan * Supernatan kekuningan * Eritrosit crenated* Eritrosit crenated * Jk darah banyak, bisa terlihat clot * Jk darah banyak, bisa terlihat clot * Pada intracerebral hemorrage bisa terlihat jernih * Pada intracerebral hemorrage bisa terlihat jernih

Xanthochromia : Xanthochromia : - Kekuningan- Kekuningan - Bisa warna bilirubin (jk jaundice berat, kronis, @ - Bisa warna bilirubin (jk jaundice berat, kronis, @ prematur), derivat Hb, lipidlike substance karenaprematur), derivat Hb, lipidlike substance karena destruksi jar. otak destruksi jar. otak - Jk mengandung banyak protein dan clot, indikasi adanya - Jk mengandung banyak protein dan clot, indikasi adanya obstruksi,obstruksi, mis. tumor mis. tumor Transparansi : Transparansi : - > - > 200 lekosit : cloudy (berawan)200 lekosit : cloudy (berawan) 200 – 500 lekosit : keruh200 – 500 lekosit : keruh > 500 : turbid> 500 : turbid - acute meningitis : bervariasi berawan s/d spt pus- acute meningitis : bervariasi berawan s/d spt pus - encephalitis, tuberculous meningitis : jernih- encephalitis, tuberculous meningitis : jernih Sedimen : Normal tdk ada Sedimen : Normal tdk ada Clot : adanya fibrinogen Clot : adanya fibrinogen

MikroskopisMikroskopis Diperiksa pada sedimen Diperiksa pada sedimen Total lekosit normal - dewasa : 0 - 6 mononuclear /mm3Total lekosit normal - dewasa : 0 - 6 mononuclear /mm3

- neonati : 0 – 30 - neonati : 0 – 30 Eritrosit : bedakan dulu trauma atau tidakEritrosit : bedakan dulu trauma atau tidak Hitung jenis :Hitung jenis :

- - NNetrofil tinggi : infeksi bakteri, etrofil tinggi : infeksi bakteri, viral viral masa dini (1-2 hari), masa dini (1-2 hari),

TB TB dan dan jamurjamur

- - LLimfosit meninggi : Viralimfosit meninggi : Viral,, TB, jamur, Syphilic TB, jamur, Syphilic

- - PPlasma sel meninggi : multiple sclerosislasma sel meninggi : multiple sclerosis

- - EEosinofil meninggi : non infeksi : vaksinasi rabies, alergiosinofil meninggi : non infeksi : vaksinasi rabies, alergi

Kimia KlinikKimia Klinik Total Protein Total Protein Glukosa : Normal : 60 – 70 % KGD (seimbang 2-4 jam) Glukosa : Normal : 60 – 70 % KGD (seimbang 2-4 jam) Meninggi : hiperglikemiaMeninggi : hiperglikemia Menurun : - hipoglikemiaMenurun : - hipoglikemia - pemakaian meningkat oleh CNS, - pemakaian meningkat oleh CNS, lekosit, eritrosit, jar, mikro organisme lekosit, eritrosit, jar, mikro organisme - gangguan transport dari plasma ke - gangguan transport dari plasma ke CSFCSF LDH : - normal 5 – 10 % kadar plasma LDH : - normal 5 – 10 % kadar plasma - DD bacterial @ viral meningitis- DD bacterial @ viral meningitis - Prognose encephalitis : jelek jk LDH tinggi- Prognose encephalitis : jelek jk LDH tinggi

Lain-lainLain-lain

Serologis : sifilis, VDRL, FTA (fluorescent treponemal Serologis : sifilis, VDRL, FTA (fluorescent treponemal antibodyantibody

ElektrolitElektrolit MikrobiologiMikrobiologi

Strassingger.SK, 2008

Strassingger.SK, 2008

Strassingger.SK, 2008

Cerebrospinal fluid in diseaseCerebrospinal fluid in diseaseDiseaseDisease Preasure Preasure

(mm (mm water)water)

AppearanceAppearance ClotClot No & Type of CellNo & Type of Cell Protein Protein

(mg/100ml)(mg/100ml)

SugarSugar

(mg/(mg/100ml)100ml)

ChloridesChlorides

(mEq/L)(mEq/L)

RemarksRemarks

NormalNormal 100-200100-200 Clear, Clear, colorlesscolorless

00 0-5 lymphocytes0-5 lymphocytes 20-4020-40 45-10045-100 113-127113-127

Meningitis Meningitis PyogenicPyogenic TuberculousTuberculous

Lymphocytic Lymphocytic choroimeningitischoroimeningitis

3+3+

3+3+

2+2+

CloudyCloudy

Clear or Clear or slightly turbidslightly turbid

Clear or Clear or opalescentopalescent

LargeLarge

WebWeb

00

3+ PMN3+ PMN

2+ lymphocytes2+ lymphocytes

50-2000 lymphocytes50-2000 lymphocytes

3+3+

2+2+

++

D(0)D(0)

20-4020-40

20-4020-40

Slightly DSlightly D

D<100D<100

NN

Tubercle bacilliTubercle bacilli

Cord TumorCord Tumor NN Clear & deep Clear & deep yellowyellow

MassMass N to + lymphocytesN to + lymphocytes 3+3+ NN NN

Brain AbscessBrain Abscess 1+ to 3+1+ to 3+ Clear or Clear or turbidturbid

±± + PMN+ PMN + to 2++ to 2+ NN N to slightly N to slightly DD

Brain TumorBrain Tumor 3+3+ Clear yellowClear yellow ±± N lymphocytesN lymphocytes ± to 2+± to 2+ NN NN

PoliomyelitisPoliomyelitis NN Clear or Clear or opalescentopalescent

00 50-2000 PMN early50-2000 PMN early

lymphocyteslymphocytes

leterleter

++ NN N to slightly N to slightly DD

Filtrable virusFiltrable virus

EncephalitisEncephalitis N toN to Clear, Clear, colorlesscolorless

00 N to + lymphocytesN to + lymphocytes ±± NN NN Filtrable virusFiltrable virus

Subarachnoid Subarachnoid hemorrhagehemorrhage

1+ to 2+1+ to 2+ Bloody yellowBloody yellow 00 BloodBlood 3+3+ NN NN

NeurosyphilisNeurosyphilis MeningovascularMeningovascular

TabesTabes ParesisParesis

++

++

++

Clear, Clear, colorlesscolorless

RareRare

RareRare

Many, Many, smallsmall

20-100 PMN early, 20-100 PMN early, lymphocytes leterlymphocytes leter

25-75 lymphocytes25-75 lymphocytes

25-50 lymphocytes25-50 lymphocytes

+ to 2++ to 2+

++

++

NN

NN

NN

NN

NN

NN

Serologic test for Serologic test for syphilis nearly always syphilis nearly always reactivereactive

80% reactive80% reactive

100% reactive100% reactive

Cerebrospinal fluid in diseaseCerebrospinal fluid in diseaseDiseaseDisease Preasure Preasure

(mm (mm water)water)

AppearanceAppearance ClotClot No & Type of CellNo & Type of Cell Protein Protein

(mg/100ml)(mg/100ml)

SugarSugar

(mg/(mg/100ml)100ml)

ChloridesChlorides

(mEq/L)(mEq/L)

RemarksRemarks

NormalNormal 100-200100-200 Clear, Clear, colorlesscolorless

00 0-5 lymphocytes0-5 lymphocytes 20-4020-40 45-10045-100 113-127113-127

Meningitis Meningitis PyogenicPyogenic TuberculousTuberculous

Lymphocytic Lymphocytic choroimeningitischoroimeningitis

3+3+

3+3+

2+2+

CloudyCloudy

Clear or Clear or slightly turbidslightly turbid

Clear or Clear or opalescentopalescent

LargeLarge

WebWeb

00

3+ PMN3+ PMN

2+ lymphocytes2+ lymphocytes

50-2000 lymphocytes50-2000 lymphocytes

3+3+

2+2+

++

D(0)D(0)

20-4020-40

20-4020-40

Slightly DSlightly D

D<100D<100

NN

Tubercle bacilliTubercle bacilli

Cord TumorCord Tumor NN Clear & deep Clear & deep yellowyellow

MassMass N to + lymphocytesN to + lymphocytes 3+3+ NN NN

Brain AbscessBrain Abscess 1+ to 3+1+ to 3+ Clear or Clear or turbidturbid

±± + PMN+ PMN + to 2++ to 2+ NN N to slightly N to slightly DD

Brain TumorBrain Tumor 3+3+ Clear yellowClear yellow ±± N lymphocytesN lymphocytes ± to 2+± to 2+ NN NN

Cerebrospinal fluid in diseaseCerebrospinal fluid in disease

DiseaseDisease Preasure Preasure

(mm water)(mm water)

AppearanceAppearance ClotClot No & Type of CellNo & Type of Cell Protein Protein

(mg/100ml)(mg/100ml)

SugarSugar

(mg/100ml)(mg/100ml)

ChloridesChlorides

(mEq/L)(mEq/L)

RemarksRemarks

PoliomyelitisPoliomyelitis NN Clear or Clear or opalescentopalescent

00 50-2000 PMN early50-2000 PMN early

lymphocyteslymphocytes

leterleter

++ NN N to slightly N to slightly DD

Filtrable virusFiltrable virus

EncephalitisEncephalitis N toN to Clear, Clear, colorlesscolorless

00 N to + lymphocytesN to + lymphocytes ±± NN NN Filtrable virusFiltrable virus

Subarachnoid Subarachnoid hemorrhagehemorrhage

1+ to 2+1+ to 2+ Bloody yellowBloody yellow 00 BloodBlood 3+3+ NN NN

NeurosyphilisNeurosyphilis MeningovascularMeningovascular

TabesTabes ParesisParesis

++

++

++

Clear, Clear, colorlesscolorless

RareRare

RareRare

Many, Many, smallsmall

20-100 PMN early, 20-100 PMN early, lymphocytes leterlymphocytes leter

25-75 lymphocytes25-75 lymphocytes

25-50 lymphocytes25-50 lymphocytes

+ to 2++ to 2+

++

++

NN

NN

NN

NN

NN

NN

Serologic test for Serologic test for syphilis nearly syphilis nearly always reactivealways reactive

80% reactive80% reactive

100% reactive100% reactive