CSF. Lumbar punction. CSF Cerebrospinal fluid - CSF

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1 CSF Cerebrospinal fluid - CSF Clear and colorless liquid in ventricles, cisterns and subarachnoidal spaces of brain and spinal cord CSF Production secretion chorioid. plexus in ventricles Resorbtion subarachnoid. Spaces Circulation lat. ventricles, III. ventricle, aqueduct, IV. ventricle, cisterna magna, subarachnoidal spaces Daily production 500 ml Total amount 140 ml Pressure mm H2O horizontal position mm H2O sitting position Content - proteins, elements, sugar, chlorides 1

2 Lumbar punction Indications Inflammatory, demyelinating, degenerative diseases of brain, spinal cord, meninges, roots Bleeding Meningosis carcinomatosa Contraindication Brain oedema -optic fundus Trombocytopenia less than General appearance of CSF Colorless normal CSF Pink, red(oxyhemoglobin) bleeding test of 3 tubes (dif.dg.between SAH and arteficial bleeding) Xantochromia (yellow color) increased level of proteins, old bleeding General appearance of CSF Increased CSF viscosity marked increased of protein content Change of color bacterial meningitis, increased proteins 2

3 Measurment of CSF pressure by manometer Pandy s test 3 drops of CSL to Pandy reagens white color of CSF (+, ++, +++) increased level of protein We take CSF for examination 4-10 ml Queckenstedt test Compression of jugular veins When increased intracranial pressure is also in spinal canal + increased CSL pressure canal without obstruction - CSL pressure without change - obstruction of spinal canal Compression of abdomen -does not show obstruction in Th-, C-part. CSF - examination Basic examination Cell account, type of cells Level of proteins, Cl, glucose Special examinations -IgG, IgG/alb. index, oligoclonal bands, IgG, IgA, IgM against B. Burorferi, cultivation, VDRL test for syphilis, PCR -TBC a viral infections, antineuronal antobodies - paraneoplastic sy CSF - elements Increased ammount of cells More than 1000/µl. - bacterial infection Ly -viral etiology, at the beginning also granulocytes can be present CSF - elements Increased ammount of cells Neoplastic elements -TU -ependymoma, plexuspapilloma, meduloblastoma, CSF -examination Acute inflammation - granulocytes Chronic inflammation - Ly, plazmocytes Carcinomatous cells MTS to meninges breast, bronchial carcinoma, melanoma 3

4 Viral infection - lymfocytes Bacterial inflamation - granulocytes Subarachnoid haemorrhage Malignant infiltration CSF - proteins -inflammatory and noninflammatory diseases albuminocytological disociation increased proteins, normal or little increased elements Guillain - Barre sy (polyradiculoneuritis) diabetic neuropathy Compressive CSF (Froin s sy) CSF - proteins IgG intrathecal production it means intrathecal inflammation Isoelectrical focusation 4

5 CSF - proteins Within the gamma region, three patterns of bands may be observed including one clone (monoclonal), many clones (polyclonal) and a few bands (3 to 5, or oligoclonal) Oligoclonal bandsare bands of immunoglobulins that are seen when a patient's blood serum, gained from blood plasma, or CSF is analyzed. Each band represents a homogeneous protein that is secreted by a single clone of plasma cells Oligoclonal IgG Isoelectroforetic focusation Normal CSF Oligoclonal IgG in CSF SM Oligoclonal IgG in CSF and other bands in CSF and serum neuroboreliosis Identical oligoclonal bands in CSF and serum - paraneoplastic syndromes Monoklonal bands in CSF and serum myeloma, monoclonal gamapaties Oligoclonal bands CSL glucose Glucose in CSL -60% of plasma glucose concentration Examine also plasma glucose concentration Decreased level bacterial meningitis, TBC meningitis, neurosyphyllis normal SM Inflammation / infection monoc lonal CSL Pressure Ammount ml osmolarity mosm/l Cl: mmol/l ph -7,31-7, 34 glucose 2,2-3,9 mmol/l > 0,6 CSF/plasma Total proteins mg/l IgG index < 0,65 elements < 4/µl Pathology P, elements acute meningitis, acute encefalitis P, elements -Guillain-Barre, CIDP, tabes dorsalis, meningovascular lues, DM, trombosis of sinuses, brain tumors, gliomatosis, obstruction of CSF circulation 5

6 Meningeal syndroma Meningeal syndrom Stifness of the neck Meningeal signs on lower extremities Kernig sign Meningeal syndrom Kernig flexion of extended LE Meningeal syndrom Meningeal signs on lower extremities Brudzinski I anteflexion of the head -flexion of lower extremities Brudzinski II pressure on zygomatic bone - grimasing Brudzinski III pressure on symphysis LE flexion Brudzinski IV Kernig test -flexion of other LE Amos sign support by upper extremities during sitting Intracranial hypertension Headache Vomitus impresiones gyrorum on skull X-ray papilloedema Brain oedema -CT, MRI Intracranial hypertension Brain tumor Brain oedema Stroke, brain haemorrhage Infection of CNS Brain abscess Hydrocephalus 6

7 Hydrocephalus Tumor plexus chorioideus Tumor of 3rd ventricle Increased production Decreased resorbtion Obstruction in circulation of CSL Brain herniations Temporal Occipital Herniations [1]1) The brain squeezes under the falx cerebriin cingulate herniation 2)The brainstem herniates caudally3) The uncus and the hippocampal gyrus herniate into the tentorial notch 4)The cerebellar tonsils herniate through the foramen magnum in tonsillar herniation 7

8 Subfalcine herniation The cingulate gyrus is pushed laterally away from the expanding mass and herniates beneath the falx cerebri. Central herniation occurs when there is downward pressure centrally and can result in bilateral uncal herniation. Transtentorial herniation Transtentorial herniation Can result from any supratentorial mass lesion, or with severe cerebral edema Can depend somewhat on individual anatomic variations Uncal herniation occurs when the mass lesion is lateralized anteromedial portion part of the hippocampus herniates over the edge of the tentorium secondary effects of tissue necrosis, hemorrhage etc. similar to subfalcine Tonsillar herniation In tonsillar herniation, the cerebellar tonsils herniate downward through the foramen magnum: Most commonly caused by a posterior fossa mass lesion, but can be due to a midline supratentorial mass or as a result of edema Can be dramatic if a lumbar puncture is done with a undiagnosed mass lesion The ensuing compression of the medulla results in depression of the vital centers for respiration and cardiac rhythm control 8

9 Tonsillar herniation Tonsillar herniation Clinical symptoms can be sudden cardiorespiratory arrest or slow progression over a day or two. The herniated tonsillar tissue is softened (best appreciated after fixation) and the compressed medulla can be swollen and soft or firm depending upon the time course prior to death and the severity of edema 9