Chapter 9 CSF

What is the normal range of WBCs in children's CSF?

0-10 cells/uL

How many mLs can be taken out if the pressure is less than or greater than normal?

1 to 2 mL should be removed

What causes pleocytosis ?

Associated with a white blood cell count greater than 200 cell/uL OR a red blood cell count exceeding 400 cells/uL

An unknown fluid can be positively identified as CSF by determining the A. lactate concentration. B. albumin concentration. C. presence of oligoclonal banding on electrophoresis. D. presence of carbohydrate-deficient transferrin on electrophoresis.

D. presence of carbohydrate-deficient transferrin on electrophoresis.

The most common causes of meningitis are what?

Haemophilus influenzae, Neisseria meningitidis, and Strep. pneumoniae.

A pink supernatant after centrifugation results from what?

Oxyhemoglobin

Why would you scan the entire slide using a low-power objective?

This scan will provide an overview of the cellularity of the specimen and will aid in detecting abnormalities (plasma cells, macrophages, hemosiderin-laden macrophages, malignant cell, or cell clumps that can be few in number)

Microbiological examination: what is a Wright's stain used for?

ameba Naegleria fowleri

In adult CSF, what is the normal range for WBCs? What would you most likely find?

0 - 5 cell/uL Lymphocytes and Monocytes

A typical reference interval for the IgG index is what?

0.30 to 0.70 Values greater than this range are associated with increased intrathecal production of IgG Values less than this range indicate a compromised blood brain barrier

What is the normal range for neonates

10 - 60 mL

What is the "closing" CSF pressure after the CSF has been removed and before the spinal needle has been withdrawn?

10 to 30 mm Hg, less than the opening pressure.

What are the normal ranges of total protein in CSF?

15 to 45 mg/dL (150 to 450 mg/L)

CSF formation, circulation, and reabsorption into the blood make up a dynamic process that constantly turns over how many mLs each hour?

20

If the CSF pressure is normal, how many mLs can be taken from the patient?

20mL

What is the normal CSF pressure for an adult in a lateral recumbent position?

50 to 180 mm Hg

what is the normal range of CSF in adults

85 - 150 mL

An orange supernatant results from what?

A combination of oxyhemoglobin and bilirubin

How many leukocytes are normally present in the CSF obtained from an adult? A. 0 to 5 cells/μL B. 0 to 10 cells/μL C. 0 to 20 cells/μL D. 0 to 30 cells/μL

A. 0 to 5 cells/μL

Which of the following proteins in the CSF is used to monitor the integrity of the blood-brain barrier? A. Albumin B. Transthyretin C. Transferrin D. Immunoglobulin G

A. Albumin

Which of the following statements regarding CSF is true? A. Cerebrospinal fluid is constantly produced. B. Cerebrospinal fluid is reabsorbed into the blood at the choroid plexus. C. Cerebrospinal fluid is essentially composed of diluted plasma. D. Cerebrospinal fluid circulates through the brain and spinal cord because of active and passive diffusion processes.

A. Cerebrospinal fluid is constantly produced.

Which of the following statements about CSF glucose is false? A. Increased CSF glucose values are diagnostically significant. B. Glucose enters the CSF by active transport and simple diffusion. C. Decreased CSF glucose values reflect a defective blood-brain barrier and increased glycolysis. D. CSF glucose values reflect the plasma glucose concentration 30 to 90 minutes preceding collection.

A. Increased CSF glucose values are diagnostically significant.

Which of the following cell types predominate in CSF during a classic case of viral meningitis? A. Lymphocytes B. Macrophages C. Monocytes D. Neutrophils

A. Lymphocytes

Pleocytosis is a term used to describe A. an increased number of cells in the CSF. B. a pink, orange, or yellow CSF specimen. C. an increased protein content in the CSF caused by cellular lysis. D. inflammation and sloughing of cells from the choroid plexus.

A. an increased number of cells in the CSF.

During a lumbar puncture procedure, the first collection tube of CSF removed should be used for A. chemistry tests. B. cytologic studies. C. hematologic tests. D. microbiological studies.

A. chemistry tests.

An immunoglobulin G index greater than 0.70 indicates A. intrathecal synthesis of immunoglobulin G. B. a compromised blood-brain barrier. C. active demyelination of neural proteins. D. increased transport of immunoglobulin G from plasma into the CSF.

A. intrathecal synthesis of immunoglobulin G.

Study Questions: Cerebrospinal fluid (CSF) is produced primarily from A. secretions by the choroid plexus. B. diffusion from plasma into the central nervous system. C. ultrafiltration of plasma in the ventricles of the brain. D. excretions from ependymal cells lining the brain and spinal cord.

A. secretions by the choroid plexus.

What would cause an increase of the CSF IgG index?

About 90% of patients with multiple sclerosis have an IgG index greater than 0.70 (also increased in inflammatory disorders of CNS)

Why does Tube #1 go to chemistry/immunologic testing?

Any minimal blood contamination resulting from vessel injury during the initial tap normally doesn't affect these results.

Which of the following cells can be present in small numbers in normal CSF? A. Erythrocytes B. Lymphocytes C. Macrophages D. Plasma cells

B. Lymphocytes

Which of the following statements about oligoclonal bands is false? A. In the CSF, these bands indicate increased intrathecal concentrations of immunoglobulin G. B. The bands usually correlate with the stage of disease and can be used to predict disease progression. C. The bands are often present in the CSF and serum of individuals with a lymphoproliferative disease. D. The bands are often present in the CSF but not in the serum of individuals with multiple sclerosis.

B. The bands usually correlate with the stage of disease and can be used to predict disease progression.

Which of the following is not an analytical concern when the processing and testing of CSF are delayed? A. The viability of microorganisms B. The lability of the immunoglobulins C. The lysis of leukocytes and erythrocytes D. Alterations in the chemical composition

B. The lability of the immunoglobulins

Cerebrospinal fluid is found between the A. arachnoid and dura mater. B. arachnoid and pia mater. C. pia mater and dura mater. D. pia mater and choroid plexus.

B. arachnoid and pia mater.

All of the following proteins are normally present in the CSF except A. albumin. B. fibrinogen. C. transthyretin. D. transferrin.

B. fibrinogen.

India ink preparations and microbial antigen tests on CSF can aid in the diagnosis of A. bacterial meningitis. B. fungal meningitis. C. tuberculous meningitis. D. viral meningitis.

B. fungal meningitis.

Microbiological examinations: What is a gram stain used for?

Bacteria and fungi

A yellow supernatant results from what?

Bilirubin

Which of the following procedures frequently provides a rapid presumptive diagnosis of bacterial meningitis? A. A blood culture B. A CSF culture C. A CSF Gram stain D. Immunologic tests on CSF for microbial antigens

C. A CSF Gram stain

In CSF, which of the following findings indicates a traumatic puncture? A. The presence of erythrophagocytic cells in the CSF B. Hemosiderin granules within macrophages in the CSF sediment C. An uneven distribution of blood in the CSF collection tubes D. A xanthochromic supernatant after CSF centrifugation

C. An uneven distribution of blood in the CSF collection tubes

Which of the following events does not result in an increased CSF total protein? A. A traumatic puncture procedure B. Alterations in the blood-brain barrier C. Trauma to the central nervous system, resulting in fluid loss D. Decreased reabsorption of CSF into the peripheral blood

C. Trauma to the central nervous system, resulting in fluid loss

When choroid plexus cells and ependymal cells are present in CSF, they A. are often clinically significant. B. represent the demyelination of nerve tissue. C. can closely resemble clusters of malignant cells. D. indicate breakdown of the blood-brain barrier.

C. can closely resemble clusters of malignant cells.

All of the following can cause xanthochromia in CSF except A. high concentrations of protein. B. high concentrations of bilirubin. C. increased numbers of leukocytes. D. erythrocytes from a traumatic tap.

C. increased numbers of leukocytes.

what happens if the flow path between production and reabsorption of CSF into the blood is obstructed ?

CSF accumulates, producing hydrocephalus; intracranial pressure can increase, causing brain damage, intellectual and developmental disabilities or death if left untreated.

subarachnoid space

CSF flows in the space between the arachnoidea mater and the pia mater, what is it called?

When using a hemacytometer, what should you do if the number of cells in the nine squares exceeds 200 or is crowded (overlapping)?

CSF should be diluted with saline

The clarity or turbidity of CSF depends on its what?

Cellularity

Under physical examination: what color is CSF? what is its clarity?

Colorless; clear

Microbiological examination: What is the India ink used for?

Cryptococcus neoformans

Several techniques are available, but what is the preferred and most widely used method?

Cytocentrifugation "cytospin

Which of the following substances does not normally pass through the blood-brain barrier? A. Po2 B. Albumin C. Glucose D. Fibrinogen

D. Fibrinogen

Which of the following cell types predominate in CSF during a classic case of bacterial meningitis? A. Lymphocytes B. Macrophages C. Monocytes D. Neutrophils

D. Neutrophils

Normal CSF lactate levels (less than 25 mg/dL) are commonly found in patients with A. bacterial meningitis. B. fungal meningitis. C. tuberculous meningitis. D. viral meningitis.

D. viral meningitis.

Delay in testing can cause inaccurate results such as what?

Falsely low cell count caused by the lysis of white blood cells or falsely high lactate levels caused by glycolysis.

What is most commonly used to identify microorganisms in CSF?

Gram-stain

After CSF has been collected, when should you label the specimen?

Handled and labeled at patient bedside

What are the indications for lumbar puncture and CSF examination

Infections Hemorrhage Neurologic disease malignancy Tumor Treatments

What are the contraindications for lumbar puncture and CSF examination

Infections Septicemia Systemic infection Localized lumbar infection

Where is CSF made? What is the function of meninges?

Meninges surrounds the brain and spinal cord. CSF --> 70% is made in the choroid plexus and is deposited into the 4 ventricles of the brain

What are the infectious causes of neutrophils in CSF?

Meningitis: *bacterial *early viral, tuberculous, fungal *amebic encephalomyelitis Cerebral abscess

What are the infectious causes of monocytes in CSF?

Meningitis: Tuberculous, fungal

What are the infectious causes of lymphocytes in CSF?

Meningitis: Viral, tuberculous, fungal, syphilitic HIV infections and AIDS Partially treated bacterial meningitis Parasitic infestations

A brownish supernatant results from what?

Methemoglobin formation. (what forms hemoglobin in the RBCs)

Tube #2 (in CSF) is used for what?

Microbial testing (can be at Room temp)

Tube #3 (in CSF) is used for what?

Microscopic examination of cellular components. (Cell count, cytology studies) (can be refrigerated)

Oligoclonal bands

Multiple discrete bands in the γ region noted during electrophoresis of plasma or other body fluids

Pia mater

Out of the meninges, which one is the innermost membrane, which also adheres to the surface of the neural tissues?

arachnoid mater

Out of the meninges, which one is the middle layer, and derives its name from its visual resemblance to a spider web?

What are the infectious causes of eosinophils in CSF?

Parasitic infestations Coccidioides immitis Fungal infections Idiopathic eosinophilic meningitis

What is the function of CSF

Protects, supports the brain and spinal cord and provides a medium for the transport and exchange of nutrients and metabolic waste

Why would RBC's be present in CSF?

RBCs most often represent CSF contamination with peripheral blood during the lumbar puncture procedure. Rarely, RBCs are present because of a recent subarachnoid or cerebral hemorrhage

What are the infectious causes of plasma cells in CSF?

Same disorders associated with increased lymphocytes, particularly tuberculous and syphilitic meningitis

Tau Protein

Second band of transferrin; exclusively synthesized in the CSF; A protein unique to CSF; its presence is an unknown fluid; can be positively ID it as CSF; especially useful for head trauma patients

Microbiological examinations: What is an acid fast used for?

TB meningitis

what does protein electrophoresis reveal?

The composition and distribution of proteins in CSF

What power objective is used when doing the differential cell count?

The differential cell count is performed using a 50x or a 100x oil objective.

When a differential cell count is performed using a cytospin or concentrated smear, what power objective should be used first? How should you scan the slide?

The entire slide should be scanned first using a low-power objective (10x)

All substance that enter and leave the CSF must pass through what?

The membranes and cytoplasm of the capillary endothelial cells.

Blood-brain barrier

The physiologic interface between the vascular system and cerebrospinal fluid. Changes in the blood-brain barrier can result in changes in the normal chemical and cellular composition of the cerebrospinal fluid.

Xanthochromia

The pink, orange, or yellowish discoloration of supernatant cerebrospinal fluid after centrifugation. (always document what color it is you see)

Pleocytosis

The presence of a greater-than-normal number of cells in cerebrospinal fluid.

Microbiological examinations: what is a culture used for?

To detect bacterial cause

Why should a locally infected site be avoided?

To prevent introduction of the infection into the central nervous system.

Electrophoresis, after concentrating CSF (80 to 100 times), normally reveal only the presence of what?

Transthyretin, albumin, and transferrin

Four protein bands predominate in a normal CSF pattern, what are they?

Transthyretin, albumin, and two distinct transferrin bands.

Most often, clot formation is associated with what?

Traumatic puncture, in which blood and plasma proteins contaminated the CSF

True or False: A traumatic tap can result in significant false elevation of the CSF total protein.

True

True or False: Cerebrospinal fluid (CSF) bathes the brain and spinal cord. CSF is produced primarily (70%) from secretions into the four ventricles of the brain by the highly vascular choroid plexus (vascular fringe-like folds in the pia mater).

True

True or False: Cerebrospinal fluid flows in the space between the arachnoidea mater and the pia mater, called the subarachnoid space, where it bathes and protects the delicate tissues of the central nervous system.

True

What are the infectious causes of macrophages in CSF?

Tuberculous meningitis Fungal meningitis

Tube #1 (in CSF) is used for what?

Used for chemical and immunologic testing (can be Frozen)

Where does the physician perform the lumbar puncture?

Usually in the third or fourth lumbar interspace (or lower) in adults. And in the fourth and fifth interspace in children.

What is the normal range of WBCs in healthy neonates CSF?

neonates can have up to 30 WBCs/uL, with monocytes predominating

Dura mater

out of the three meninges, which one is tough, next to the bone, and is the outermost layer