CSF
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1
Body fluid hierarchy placement of CSF is
3rd major body fluid
2
Three primary functions of Cerebrospinal Fluid (CSF) are
Supply nutrients to the nervous system, remove metabolic waste, produce a mechanical barrier to cushion the brain & spinal cord against trauma
3
Definition and anatomical function of the meninges are
Line the brain and spinal cord
4
Three layers of the meninges in sequence from outermost to innermost are
Dura mater (outer layer), Arachnoid (spiderweb-like), Pia mater (innermost layer)
5
Anatomical location where CSF flows is
Subarachnoid space (below arachnoid)
6
Primary site of CSF production via selective filtration is
Choroid Plexus
7
Hourly rate of CSF production by the choroid plexus is
20 mL/hour
8
Primary anatomical structures responsible for reabsorbing CSF are
Arachnoid Villi / Granulations
9
Primary physiological function of the Blood-Brain Barrier (BBB) is
Protects brain from chemicals & other substances circulating in the blood that can harm the brain tissue
10
Clinical consequences of Blood-Brain Barrier disruption are
Disruption of BBB allows WBCs, proteins & other chemicals to enter the CSF (Ex: Meningitis, M.S.)
11
Anatomical collection sites for lumbar puncture in adults vs infants are
Between L3-L4 (adults) or L4-L5 (infants)
12
Maximum volume of CSF that can be collected using a manometer attached to a spinal needle is
Up to 20 mL
13
Maximum volume of CSF that can be safely removed if CSF pressure is high or low (normal: 50-180 mmHg) is
Only 1-2 mL
14
Standard laboratory department routing for CSF collection Tubes 1, 2, and 3 in 1 tube only
Tube 1: Microbiology
Tube 2: Hema
Tube 3: CC
Tube 2: Hema
Tube 3: CC
15
Sensitivity of CSF collection tubes to tap contamination/introduced cells is
Tube 1 = least affected by blood or bacteria introduced by skin tap; Tube 3 = least likely to contain cells introduced by skin tap
16
Storage temperature parameters for CSF specimens across departments are
Microbiology: 35-37°C; Hematology: Room temperature (up to 4 hours); Chemistry: Refrigeration temperature / Frozen at -70°C for 30 mins
17
Timeframe within which any CSF cell count should be performed to prevent cell lysis is
Performed IMMEDIATELY or within 1 hour (at room temperature)
18
Percentage rate at which WBCs and RBCs disintegrate within 2 hours of collection is
40% WBCs disintegrate within 2 hours
19
Total normal CSF volume in adults vs neonates is
Adults: 90-150 mL; Neonates: 10-60 mL
20
Clinical significance of a Crystal Clear CSF appearance is
Normal
21
Clinical significance of Hazy/Turbid/Milky/Clotted CSF appearance is
Increased WBCs (>200/µL), RBCs (>400/µL), lipids & protein, microorganisms
22
Definition and pigment causes of Xanthochromic CSF appearance are
Pink/Yellow/Orange supernatant; due to hemoglobin degradation products (most common: oxyhemoglobin -> bilirubin), carotene, melanin, protein (>150 mg/dL), rifampin
23
Color supernatant differentiation between Traumatic Tap and Intracranial Hemorrhage is
Traumatic tap = Clear supernatant; Intracranial hemorrhage = Xanthochromic supernatant
24
Distribution of blood across 3 tubes in Traumatic Tap vs Intracranial Hemorrhage is
Traumatic tap = Uneven (1 > 2 > 3); Intracranial hemorrhage = Even (1 = 2 = 3)
25
Clot formation capability in Traumatic Tap vs Intracranial Hemorrhage is
Traumatic tap = Present (due to plasma fibrinogen); Intracranial hemorrhage = Absent
26
Erythrophages and macrophages with ingested RBCs/hemosiderin in CSF indicate
Intracranial hemorrhage (Positive)
27
Clinical condition associated with an Oily CSF appearance is
Radiographic contrast media
28
Clinical condition associated with a Clotted CSF appearance is
Protein & clotting factors; meningitis, Froin syndrome, blockage of CSF circulation
29
Clinical condition associated with a Pellicle CSF appearance is
Tubercular meningitis
30
Normal WBC count reference values in adults vs neonates are
Adults: 0-5 WBCs/µL; Neonates: 0-30 WBCs/µL
31
Calculation formula for total CSF WBC count per µL is
WBC Count (per µL) = (# Cells counted x Dilution) / (Area x Depth factor [0.1])
32
Diluent used for total CSF WBC count to lyse RBCs is
3% Acetic acid with methylene blue
33
Diluent used for total CSF cell count (WBCs + RBCs) is
Normal Saline Solution
34
CSF dilution factor for a Clear sample is
Undiluted (1:1)
35
CSF dilution factor for a Slightly Hazy sample is
1:10
36
CSF dilution factor for a Hazy sample is
1:20
37
CSF dilution factor for a Slightly Cloudy sample is
1:100
38
CSF dilution factor for a Bloody/Turbid sample is
1:200 or 1:1000
39
RBC count correction formula for WBC count in traumatic tap is
Subtract 1 WBC for every 700 RBCs seen
40
Total protein concentration correction formula in traumatic tap is
Subtract 1 mg/dL total protein for every 1,200 RBCs/µL
41
Primary function of cytocentrifugation in CSF differential count preparation is
Forces fluid into conical chamber and cells onto monolayer within 6mm diameter circle on slide; increases cell yield or recovery and decreases cellular distortion (addition of 30% albumin)
42
Normal predominant cell types in adult CSF are
Lymphocytes and Monocytes (70:30 ratio)
43
Normal predominant cell type in neonates (reversed ratio) is
Monocytes (up to 80%)
44
Term defining an increased number of normal cells in the CSF is
Pleocytosis
45
Predominant cell type in Bacterial meningitis, Cerebral hemorrhage, and Intrathecal medications is
Neutrophils
46
Predominant cell type in Viral, TB, & Fungal meningitis and Multiple Sclerosis (M.S.) is
Lymphocytes / Monocytes
47
Clinical condition associated with Eosinophils in CSF is
Parasitic and fungal infections, introducing medications & shunts
48
Microscopic finding of Macrophages in CSF indicates
RBCs in spinal fluid (may contain ingested RBCs appearing as empty vacuoleshost cells, hemosiderin granules & hematoidin crystals)
49
Clinical conditions associated with Blast forms in CSF are
Acute leukemia
50
Clinical conditions associated with Lymphoma cells in CSF are
Disseminated lymphoma
51
Clinical conditions associated with Plasma cells in CSF are
M.S., Guillain-Barré syndrome, Syphilitic meningitis, sarcoidosis
52
Microscopic finding of Ependymal, choroidal, & spindle-shaped cells in CSF indicates
Diagnostic procedures (seen in clusters with distinct cell walls)
53
Microscopic finding of Malignant cells in CSF indicates
Metastatic cancer, 1° CNS carcinoma (seen in clusters w/ fusing of cell borders & nuclei)
54
Normal reference value for total CSF protein in adults is
15-45 mg/dL (<1% or 1/200 that of serum protein)
55
Normal reference value for total CSF protein in infants is
Up to 150 mg/dL
56
Primary cause of increased total CSF protein is
Damage to the BBB (most common)
57
Other causes of increased total CSF protein include
Production of immunoglobulins within the CNS, decreased normal protein clearance from fluid, neural tissue degeneration
58
Causes of decreased total CSF protein include
CSF leakage/trauma, recent puncture, rapid CSF production, CSF intoxication
59
Most prevalent protein fraction in CSF is
Albumin
60
Second most prevalent protein fraction in CSF is
Prealbumin (TTR)
61
Alpha-globulins present in CSF include
Haptoglobin, ceruloplasmin
62
Beta-globulin specific protein variant found in CSF but NOT in serum is
Carbohydrate-deficient transferrin (Tau protein)
63
Gamma-globulins present in CSF include
IgG and some IgA
64
Plasma proteins NOT found in normal CSF are
IgM, Fibrinogen, Lipids
65
Turbidimetric principle used in total CSF protein determination involves
Trichloroacetic acid (TCA) - preferred method; precipitates BOTH albumin & globulins
66
Dye-binding method for total CSF protein determination uses
Coomassie Brilliant Blue (protein binds to dye -> dye turns from red to blue -> ↑ protein = ↑ blue color)
67
Reference values for CSF/Serum Albumin Index indicating BBB integrity are
Normal: 9-14; Slight impairment: 15-30; Moderate impairment: >30; Severe impairment: >100
68
Normal reference value for IgG Index is
0.30 to 0.70 (Old Strasinger: >0.77)
69
Clinical interpretation of an elevated IgG Index (>0.70) is
Indicative of IgG production within the CNS (Ex: Multiple Sclerosis)
70
Diagnostic significance of oligoclonal bands in CSF electrophoresis is
Presence of 2 or more oligoclonal bands in CSF but NOT in serum is valuable for the diagnosis of Multiple Sclerosis
71
Key diagnostic findings in Multiple Sclerosis (MS) include
Demyelinating disorder; (+) Anti-myelin sheath autoantibody, (+) Oligoclonal band in CSF but not in serum, (↑) IgG index, (↑) Myelin basic protein (MBP)
72
Marker used to monitor the clinical course of M.S. during myelin sheath destruction is
Myelin Basic Protein (MBP)
73
Normal reference range for CSF Glucose (GLU) is
50-80 mg/dL (approx. 60-70% of plasma glucose)
74
Specimen draw recommendation prior to spinal tap for CSF glucose evaluation is
Drawn 2 hours prior to spinal tap (to allow time for equilibration between CSF and plasma glucose)
75
Causes of decreased CSF glucose levels are
Bacterial (markedly decreased), tubercular and fungal meningitis (due to alterations in mechanisms of glucose transport across BBB / increased use of glucose by brain cells)
76
Normal CSF glucose level is typically seen in
Viral meningitis
77
Normal reference value for CSF Lactate is
10-24 mg/dL
78
Clinical diagnostic utility of CSF Lactate measurement is
Sensitive method for evaluating the effectiveness of antibiotic therapy; inversely proportional to glucose
79
Diagnostic CSF Lactate level indicative of Bacterial meningitis is
>35 mg/dL
80
Diagnostic CSF Lactate level indicative of Tubercular and Fungal meningitis is
>25 mg/dL
81
Normal CSF Lactate level is seen in
Viral meningitis
82
Normal reference value for CSF Glutamine (GLN) is
8-18 mg/dL
83
Clinical significance of elevated CSF Glutamine levels (>35 mg/dL) is
Indirect test for the presence of excess ammonia in the CSF; associated with disturbance of consciousness (coma) and Reye's syndrome
84
Serological test recommended by CDC for detection of neurosyphilis in CSF is
VDRL
85
Differential findings in Bacterial Meningitis (WBC type, protein, glucose, lactate) are
↑ Neutrophils, ↑↑ Protein, ↓↓ Glucose, ↑↑ Lactate
86
Differential findings in Viral Meningitis (WBC type, protein, glucose, lactate) are
↑ Lymphocytes, Normal/Slight ↑ Protein, Normal Glucose, Normal Lactate
87
Differential findings in Tubercular Meningitis (WBC type, protein, glucose, lactate) are
↑ Lymphocytes/Monocytes, ↑ Protein, ↓ Glucose, ↑ Lactate; (+) Pellicle formation
88
Differential findings in Fungal Meningitis (WBC type, protein, glucose, lactate) are
↑ Lymphocytes/Monocytes, ↑ Protein, ↓ Glucose, ↑ Lactate; (+) India Ink stain / Cryptococcal antigen test
89
Reagent source used in the Limulus Amoebocytes Lysate (LAL) test is
Blood of horseshoe crab
90
Diagnostic target detected by the Limulus Amoebocyte Lysate (LAL) test is
Endotoxin (Gram-negative bacteria)
91
Positive result interpretation for Limulus Amoebocyte Lysate (LAL) test is
Clumping or clot formation (in the presence of endotoxin, amoebocytes release lysate protein)
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