Cerebrospinal Fluid Examination

BASIC CEREBROSPINAL FLUID TESTS

Pressure

Normal cerebrospinal fluid (CSF) pressure = 100-200 mm H2 O. Attach the end of drip set to LP needle. Do LP with this needle. Keep the drip set in vertical position. CSF clims though the set. Measure the height of the CSF column

Elevation is due to increased intracranial pressure.

most common causes of elevated CSF pressure

meningitis and subarachnoid hemorrhage.

Brain tumor and brain abscess cause increased intracranial pressure after a period of days or weeks.

The CSF pressure varies directly with venous pressure

has no relationship to arterial pressure.

The Queckenstedt sign = increased venous pressure via jugular vein compression increases CSF pressure at the lumbar region,

a subarachnoid obstruction above the lumbar area prevents this effect.

Appearance

Normal CSF is clear and colorless.

may be pink or red if red blood cells (RBCs) are present

white and cloudy if there are white blood cells (WBCs) or high protein content.

there must be more than 400 WBCs/mm³ before the CSF becomes cloudy.

When blood is present in the CSF for more than 4 hours = xanthochromia (yellow color) occusr due to hemoglobin pigment from lysed RBCs.

Protein levels of more than 150 mg/100 ml (1.5g/L) may produce a faint yellowish color -can simulate xanthochromia of RBC origin.

Severe jaundice may also simulate xanthochromia.

Glucose

45 mg/100 ml or higher

in normal persons it is rare to find values below 45 mg/100 ml.

The CSF glucose level is 60% of the serum glucose value

In newborns, the CSF level is about 80% of the serum glucose level.

It takes 30 min to 2 hours for a change to occur in CSF values after a change in serum glucose.

CSF glucose level fall –

meningitis due to bacteria, tuberculosis, and fungi.

very early infection the initial CSF glucose value may be normal,

later it begins to decrease.

only 60%-80% of children with acute bacterial meningitis have CSF glucose levels below normal

elevated blood glucose levels may mask a decrease in CSF values

So determine the blood glucose level at the same time that the CSF specimen is obtained, if intravenous (IV) glucose therapy is being given.

a low CSF glucose level may be due to peripheral blood hypoglycemia,

Other causes of hypoglycorrhachia

metastatic carcinoma

Subarachnoid hemorrhage,

leptospiral meningitis

primary amebic meningoencephalitis,

aseptic meningitis or in meningoencephalitis due to mumps, enteroviruses, lymphocytic choriomeningitis

viral meningitis, encephalitis, brain abscess, syphilis, and brain tumor, CSF glucose levels typically are normal

Protein

The normal protein concentration of CSF is considered to be 15-45 mg/100 ml

Newborn values are different

From birth to day 30, the range is 75-150 mg/100 ml

From day 90 to 6 months of age, the range is 15-50 mg/100 ml

Values reach adult levels by 6 months of age.

increased protein concentration is proportional to the degree of leukocytosis in the CSF.

protein concentration is increased by the presence of blood.

mild to moderate protein concentration increase seen with slight leukocytosis; in

cerebral trauma

brain or spinal cord tumor

brain abscess

cerebral infarct or hemorrhage (CVA

systemic lupus,

uremia, myxedema, multiple sclerosis (MS),

hereditary neuropathy,

chronic CNS infections

Blood in the CSF introduces 1 mg of protein/1,000 RBCs.

when the RBCs begin to lyse, the protein level may appear disproportionate to the number of RBCs.

In acute bacterial meningitis, the CSF protein is elevated in about 94% of cases

A marked protein elevation without a corresponding CSF cell increase is known as "albuminocytologic dissociation."

This has been associated with the Guillain-Barre syndrome (acute idiopathic polyneuritis) or with temporal (giant cell) arteritis

20% of Guillain-Barre syndrome have normal CSF protein levels,

Pandy's test, CSF is added to a few drops of saturated phenol agent. This agent reacts with all protein, more with globulin. Chronic infections such as (tertiary) syphilis or MS tend to accentuate globulin elevation and thus may give positive Pandy test results even though the total CSF protein level may not be greatly increased.

increased CSF gamma-globulin levels occur in – MS

Cell count

Normal CSF contains up to five cells/mm3 , all are lymphocytes.

In newborns 0-30 cells/cu mm, majority being neutrophils.

conditions that affect the meninges will cause CSF leukocytosis

degree of leukocytosis depend on the type of irritation, its duration, and its intensity.

high WBC counts are found in acute meningeal infections.

very early stage, leukocytosis may be minimal

100% of patients with acute bacterial infection have elevated cell counts

normal count may be misleading.

in bacterial infections, polymorphonuclear neutrophils are the predominating cell

 in viral infections, chronic nervous system diseases, =, lymphocytes or mononuclears predominate.

tuberculous meningitis, is a bacterial and a chronic type of infection. - the cells are lymphocytes

coxsackie virus and echovirus infections may have a of neutrophils

Uremia produce a lymphocytosis

Partial treatment of bacterial meningitis may cause lymphocytosis.

After therapy is started, WBC values decrease.

with Haemophilus influenzae infection and pneumococcal infection may take 2 to 14 days for count to become normal

 Fungal infections = elevated neutrophils

Nocardia meningitis or brain abscess, show persistent neutrophilia

subarachnoid hemorrhage or traumatic spinal fluid taps, approximately 1 WBC is added to every 700 RBCs

Neonatal CSF

Neonates have higher CSF ranges for protein, glucose, and cell count than adults

Cell counts 1-7 days after birth average about 5-20/mm3 - 60% neutrophils.

Glucose is about 75%-80% of the blood glucose level.

Culture

The diagnosis of acute bacterial meningitis often depends on the isolation of the

New borns=

streptococci

Escherichia coli.

Listeria monocytogenes

enteric gram-negative bacteria

age 3 months to 6 years

H. influenzae

Meningococcus

Pneumococcus

In adults, Meningococcus and Pneumococcus

Staphylococci in  CNS operations (e.g., shunt procedures), septicemia, or endocarditis.

if any particular organism is suspected, the laboratory should be informed so that special media can be used if necessary. = meningococci grow best in a high carbon dioxide atmosphere, and H. influenzae should be planted on media provided with a Staphylococcus streak. Culture detects about 85%

Cell : Glucose

POLYMORPHONUCLEAR with LOW GLUCOSE

Acute bacterial meningitis

POLYMORPHONUCLEAR  with LOW OR NORMAL GLUCOSE

Some cases of early phase acute bacterial meningitis

Primary amebic (Naegleria species) meningoencephalitis

Early phase Leptospira meningitis

POLYMORPHONUCLEAR: with NORMAL GLUCOSE

Brain abscess

Early phase coxsackievirus and echovirus meningitis

Acute bacterial meningitis with IV glucose therapy

Listeria (about 20% of cases)

LYMPHOCYTIC with LOW GLUCOSE

Tuberculosis meningitis

Cryptococcal (Torula) meningitis

Mumps meningoencephalitis (some cases)

Meningeal carcinomatosis (some cases)

Meningeal sarcoidosis (some cases)

Listeria (about 15% of cases)

LYMPHOCYTIC with NORMAL GLUCOSE

Viral meningitis

Viral encephalitis

Postinfectious encephalitis

Lead encephalopathy

CNS syphilis (majority of patients)

Brain tumor (occasionally)

Leptospira meningitis (after the early phase)

Listeria (about 15% of cases)

Gram stain

70% positive results in culture-proved acute bacterial meningitis cases.

a negative Gram stain result does not rule out acute bacterial meningitis

Latex agglutination tests for bacterial antigens

slide latex agglutination (LA) tests have become available for detection of pneumococcal, meningococcal,H. influenzae type B, and streptococcal group B bacterial antigen in CSF

several different strains of meningococci may produce infection, and it is necessary to have an antibody against each one that it is desired to detect.

the LA kits are expensive per patient

Cerebrospinal fluid lactate

acute bacterial, tuberculous, and fungal meningitis have elevated CSF lactate values,

normal persons and in viral ("aseptic") meningitis do not.

CSF lactate may remain elevated 2-3 days after the start of antibiotic therapy.

Xanthochromia increases CSF lactate levels

CSF lactate is not specific for bacterial infection,

it is not elevated in all cases of bacterial meningitis,

CSF lactate assay is useful in

patients with symptoms of meningitis +

CSF Gram stain results are negative +

LA test results are also negative.

Such patients could have tuberculous

fungal meningitis

partially treated bacterial meningitis,

meningitis due to other organisms.

Increased CSF lactic acid levels, especially if more than twice upper limit, suggest that further investigation is essential.

A normal lactate level is not reliable in excluding bacterial meningitis.

MYCOBACTERIAL MENINGITIS

Mycobacterial meningitis is most common in children between the ages of 6 months and 5 years

Chest x-ray film = show hilar adenopathy in 50%-90%

normal chest findings are more

Purified protein derivative skin test result is negative in 5%-50%

moderate anemia

erythrocyte sedimentation rate is elevated in 80%

CSF findings typically show

moderate WBC elevation (usually <500/mm3 and almost always <1,000),

the majority being lymphocytes.

in the early stages, a majority of neutrophil

Protein level is mildly or moderately elevated

Glucose level is decreased in 50%-85%

acid-fast smear

culture

exclusion of other etiologies

evidence of tuberculosis elsewhere,

clinical suspicion.

Acid-fast smears on CSF are positive in about 20%-40%

When findings are atypical, a nucleic acid probe with polymerase chain reaction (PCR) amplification on CSF can be helpful if it is available.

� \ s o � � onsideration should be given to performing surgical soft tissue procedures that reduce muscle spasm around the hip girdle, including an adductor tenotomy or psoas transfer and release.
 

A rhizotomy procedure in which the roots of the spinal nerves are divided has produced considerable improvement in selected patients with severe spastic diplegia. A tight heel cord in a child with spastic hemiplegia may be treated surgically by tenotomy of the Achilles tendon.

Quadriplegia is managed with motorized wheelchairs, special feeding devices, modified typewriters, and customized seating arrangements.

7. Communication skills may be enhanced by the use of Bliss symbols, talking typewriters, and specially adapted computers including artificial intelligence computers to augment motor and language function.
   
   
8. Behavior problems interfere with the development of a child with CP; assistance of a psychologist or psychiatrist.
9. Learning and attention deficit disorders and mental retardation managed by a psychologist and educator.
10. Strabismus, nystagmus, and optic atrophy –consult with  ophthalmologist - in the initial assessment.
11. Lower urinary tract dysfunction should receive prompt assessment and treatment.
12. Several drugs have been used to treat Spasticity, including dantrolene sodium, the benzodiazepines, and baclofen.

            Intrathecal baclofen - used - in selected children with severe spasticity.

            Botulinum toxin - management of spasticity in specific muscle groups, - positive response in - patients studied.

            Patients with incapacitating athetosis occasionally respond to levodopa, and       children with dystonia may benefit from carbamazepine or trihexyphenidyl.

n><� n < � � class=MsoNormal style='tab-stops:10.2pt'> 

Palpation

Applying the palm of the hand to the chest

Thrills

increased precordial pulsation (apical in left ventricular hypertrophy and basal and right sided in right ventricular hypertrophy)

diastolic shock (in the pulmonary area in pulmonary hypertension)

The apex beat, normally in the fourth or fifth intercostal space within the mid-clavicular line

pulse wrist (radial) or inguinal region (femoral).

Sinus arrhythmia (increase in rate on inspiration with decrease on expiration)

bounding pulse

weak pulse

collapsing (

femoral pulses may be absent, or delayed

Percussion

right cardiac border does not extend beyond the right sternal edge

the upper border is at the level of the second intercostal space

determine cardiac size

Diminished or absent cardiac dullness is found in emphysema and pneumothorax.

Auscultaition

The ranges for heart rate in infancy and childhood are:

Newborn          70/120  

Infant               80/160              

Preschool child 75/120  

School child 70/110

Auscultate areas -

Mitral

Tricuspid

Pulmonary

Aortic

3^rd & 4^th left intercostal spaces,below left clavicle.

Auscultatory assessment

cardiac rhythm

heart sounds

murmurs.

Third heart sound

ejection click

intensity of heart sounds

Description of murmurs should include

1)   site,

2)   intensity (graded 0—6) with point of maximum intensity,

3)   timing (systolic: pan, early or late; or diastolic: early diastolic, mid-diastolic or presystolic,

4)   propagation (mitral systolic murmurs radiate to the left axilla, aortic systolic to the neck, aortic regurgitant down the left sternal edge) and

5)   variation with position. Coarctation of the aorta may produce a murmur audible over the back.

6)  Variation with respiration

venous hum

pericardial friction rub

to his ear.

other systems, e.g. by hepatic enlargement in cardiac failure.