CERBROSPINAL FLUID
EXAMINATION
DR ASMA MANZUR
DEMONSTRATOR
PATHOLOGY DEPT
CERBROSPINAL FLUID EXAMINATION
•The cerebrospinal Fluid [CSF] is a
clear, colourless transparent fluid
present in the cerebral ventricles,
spinal canal, and subarachnoid
spaces.
COLLECTION AND TRANSPORT OF CSF
• Fluid collected from the
arachnoid space.
• needle is inserted
between L3 andL4 and
the c.s.f. is allowed to
drip into a dry sterile
container.
• A ventricular puncture is
sometimes performed to
collect c.s.f. from infants.
COLLECTION OF CSF
1. Take two sterile, dry, screw-
capped containers and label one
No. 1(FOR culture) and other No.2
(for investigation)
2. Collect about 1 ml of c.s.f. in
container No. 1 and about 2–3 ml
in container No. 2.
3. Immediately deliver the samples
with a request form to the
laboratory.
LABORATORY EXAMINATION OF
C.S.F.
• Day 1
• 1 Report the appearance of
the c.s.f.
– clear/turbid/cloudy
– purulent (looking like pus),
– contains blood,
– contains clots.
• Normal c.s.f. Appears clear
and colourless.
2. Test the c.s.f.
• Depending on the
appearance of the c.s.f.,
proceed as follows:
• Purulent or cloudy c.s.f.
Suspect pyogenic meningitis
and test the c.s.f. as follows:
• Immediately make and
examine a Gram stained
smear for bacteria and
polymorphonuclear
neutrophils (pus cells). Issue
the report without delay.
• Culture the c.s.f.
• Slightly cloudy or clear c.s.f.
• Perform a cell count and note whether the cells
are mainly pus cells or lymphocytes.
• When cells predominantly lymphocytes:
– This could indicate viral meningitis, tuberculous
meningitis, cryptococcal meningitis, trypanosomiasis
encephalitis,
• Measure the concentration of protein
• Measure the concentration of glucose.
• Examine a wet preparation for encapsulated
yeast cells
• Examine a wet preparation for trypanosomes and
a Giemsa stained smear
BIOCHEMICAL TESTING OF C.S.F.
• Biochemical c.s.f. tests which may be required
include the measurement of protein and
glucose.
• Measurement of c.s.f. glucose
Normal c.s.f. glucose 2.5–4.0 mmol/1 (45–72
mg%).
c.s.f remains Normal in viral
infection
Raised c.s.f. glucose hyperglycemia
Low c.s.f. glucose pyogenic bacterial meningitis
• Measurement of c.s.f. total protein
• Normal c.s.f. protein
Total c.s.f. protein is normally 0.15–0.40
g/l (15–40 mg%)
• Increased c.s.f. total protein
– amoebic
– trypanosomiasis meningoencephalitis,
– Cerebral malaria,
– brain tumours,
– cerebral injury,
– spinal cord compression,
– poliomyelitis, the Guillain-Barré syndrome
• Ziehl-Neelsen smear when tuberculous
meningitis is suspected
• India ink preparation when cryptococcal
meningitis is suspected
• Wet preparation and Giemsa smear when
trypanosomiasis meningoencephalitis is
suspected
• Report the c.s.f. as ‘Normal’: when it appears
• clear, contains no more than 5 WBC 106/1,
and the protein concentration is not raised (or
Pandy’s test is negative).
• Note: A c.s.f. begins to appear turbid when it
contains about 200 WBC 106/1.
GRAM SMEAR
• A Gram smear is required when the c.s.f.
contains pus cells (neutrophils).
• A Gram smear may also provide useful
information when a c.s.f. is unsuitable for cell
counting or biochemical testing (e.g. when it is
heavily blood stained or contains clots
Examining a c.s.f. Gram smear
• Examine the smear microscopically for pus cells and
bacteria using the 40 and 100 objectives.
• Pus cells:
• Bacteria:Look in well stained (not too thick) areas
for:
Gram negative intracellular N. meningitidis
diplococci
Gram positive diplococci S. pneumoniae
Gram negative rods H. influenzae
Gram negative rods E. coli or other coliforms
• Unevenly stained irregular in size yeast cells
(some showing budding), suggestive of C.
neoformans
CSF showing gram positive
organism
CELL COUNT
• A white cell count with
an indication whether
the cells are pus cells or
lymphocytes, is
required when the c.s.f.
appears slightly cloudy
or clear or when the
Gram smear does not
indicate pyogenic
bacterial meningitis.
Method;
1. Using a fine bore Pasteur
pipette or capillary tube,
carefully fill the counting
chamber with the well-mixed
diluted c.s.f. The fluid must
not overflow into the
channels on each side of the
chamber.
2. Wait about 2 minutes for the
cells to settle. Count the cells
microscopically.
Calculation:Number of cells counted x 10
9
(as neubauer’s chamber has a depth of
0.1 mm and total counting area is 9 sq.
mm.)
: Cells are
Fuch’s rosenthal chamber
counted in five large squares.
Calculation = no. of cells counted x
10
5x2
(depth is 0.2 mm. and total counting
area is 16 sq.mm.)
Cell
Counts
●“Normal” adult CSF 0-5 cells/ml
● Lymphocytes.
●RBC count is of limited use, but can
be used to correct CSF leukocyte
counts* & CSF protein values of a
traumatic tap CSF.
W* = WBCf - WBCb x RBCf
RBCb
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Important points
• Cells in CSF should be counted
immediately with out delay to prevent
degeneration of cells which will give false
low counts.
• Bloody/ traumatic tap adds approximately
1-2 WBC per 1000 RBCs. Hence in the
estimation of total leucocytes count a
deduction is made equivalent to 1 WBC for
every 700 erythrocytes counted.
CULTURING C.S.F.
• Culture the c.s.f. when bacteria are seen in
the Gram smear and, or, cells are present, or
the protein concentration is raised.
Day 2 and Onwards
Examine and report the cultures
Chocolate agar and blood agar
cultures Look especially for
colonies that could be:
1. Neisseria meningitidis (growing on
chocolate agar and blood agar,
oxidase positive
2. Streptococcus pneumoniae
(sensitive to optochin)
3. Haemophilus influenzae (growing
only on chocolate agar)
4. Cryptococcus neoformans (Gram
stain the colonies)
• MacConkey agar culture
Look especially for colonies
that could be:
• Escherichia coli or other
coliform.
• Streptococcus agalactiae.
• Listeria monocytogenes.
• bacteria that cause neonatal
meningitis
