Download - [SLIDE AJAR] Materi PK 3.5 (Asisten 2012)
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PATOLOGI KLINIK 3.5CEREBROSPINAL FLUID EXAMINATION
ASISTEN 2012
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INTRODUCTIONCerebrospina !"i# $CS%& is a bo#i' !"i# ()a( *an be
!o"n# in ()e en(ire *erebra+spine *a,i('.
Cerebrospina !"i# )as a (o(a ,o"-e o! aro"n# 0/
150 - in a#"( ()a( resi#es -os(' in ()e s"bara*)noi#$aro"n# 125-&
Cerebrospina !"i# is aso !o"n# in ()e neona(es as
-"*) as 10/0 -
S"prisin' in e,er' 5/ )o"rs (o(a CS% ,o"-e isrepa*e#.
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INTRODUCTION
CS% is !or-e# in ()e ,en(ri*"ar *)oroi# pe4"s b' a
*o-bine# pro*ess o! a*(i,e se*re(ion an#
"(ra!i(ra(ion !ro- pas-a.
CS% ea,es ()e ,en(ri*"ar s's(e- ()ro") ()e
-e#ia an# a(era !ora-ina !oin o,er ()e brain
an# spina *or# s"r!a*e i()in s"bara*)noi# spa*e .
CS% resorp(ion o**"rs a( ara*)noi# ,ii.CS% !or-a(ion ra(e in a#"( is abo"( 500-+#a' or
20-+)o"r
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Provides physical support Protective efect againts sudden change in
acute venous(respiratory and postural) and
arterial blood pressure impact pressure Provides excretory waste unctionTransported hypothalamus-releasing actor
to the cells o median eminence
Mantains central nervous system ionichomeostasis
FUNCTION OF CSF
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C! may be obtained by " #umbar puncture Cisterna puncture
#ateral cervical puncture $entricular cannulas%shunt
but the most common used is lumbar
puncture
SPECIMEN COLLECTION
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Meningealinection
Primary ormetastatic
malignancy
ubarachnoidhemorrhage
&emyelinatingdisease
'&'CT'* !*+#,M+ P,CT,+.
Indication of Lumbar Puncture: 4 major disease category (American College of Physician,1!"#
The most important role o C! examination is in diagnosiso bacterial/ ungal/ mycobacterial/ and amoebicmeningitis0
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'ntracranial lesion " lumbar puncture willhigher the ris1 o transtentorial hernia
#ocal inection in lumbar area
Coagulopathy $ertebral lesion
CONTRAINDICATION OF LUMBARPUNCTURE
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#,M+ P,CT,+.#umbar puncture is usually done in #2-#3 or #3-
#4
#umbar puncture is perormed with patient in thelateral recumbent position or sitting upright0 The
lateral recumbent position is preerred because itallows accurate measurement o the openingpressure0
The patient is instructed to remain in the etalposition with the nec1/ bac1/ and limbs held in5exion
Correct patient positioning is an importantdeterminant o success in obtaining C!0
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C*MP#'CT'*The most common complication is
headache0 6ydration and use o a 78 or 74gauge needle have been recommended aspreventive measures0
+are complication is extradural/subdural/ orsubarachnoid spinal hematoma withparaplegia/ in patient with bleedingtendency due to thrombocytopenia or
anticoagulant0
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CSF EXAMINATION
1. Gross Examination
2. Microscopic Examination
- Total Cell Count- The Differential Count
3. Chemical Examination
- Globulin- Glucose Test
- rotein
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GROSS EXAMINATIONCSF a!!earance
Nor"al# crystal clear $a!!earance an% &iscosit' co"!arable to (ater)
Clou%' or turbi% CSF # "a' be cause% b' *
- leu+oc'te $,cells/"icro0)
- er'throc'te $,1 cells/"icro0)
- "icroor2anis" $bacteria fun2ia"oeba)
- as!iration of e!i%ural fat %urin2 lu"bar !uncture
- contrast "e%ia/ ra%io2ra!hic contrast "e%ia
4iscous CSF
Ma' be encountere% in !atient (ith "etastatic "ucin !ro%ucin2 a%enocarcino"a cr'!tococcal
"enin2itis %ue to ca!sular !ol'sacchari%e or li5ui% nucleus !ul!osus resultin2 fro" nee%le
in6ur' to annulus fibrosus.
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GROSS EXAMINATION Clot for"ation
"a' occur %ue to an increase of fibrinogen $ associate% (ith con%ition such as trau"atic ta!subarachnoi% bloc+ su!!urati&e "enin2itis an% tuberculous "enin2itis
ellicle -, &er' fine clots
"a' be %etecte% b' obser&in2 the surface of CSF after 12 to 24 hours refrigerated
in+-re% CSF
In%icates the !resence of bloo% an% is 2rossl' bloo%' (hen 78C count e9cee%s :"icro0. It
"a' ori2inate fro" subarachnoi%al he"orrha2e intracerebral he"orrha2e or cerebral infarct or
fro" trau"atic s!inal ta!
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Microscopic Examination1. Total Cell Count
Procedure
. Total cell count are performed on undiluted
CSF sample in manual counting chamber ( Fuch-Rosenthal chamber or ImprovedNeubauer chamber) without staining
. Total Cells are counted n 1! lar"e s#uare ( 1 mm$ each %th depth &.' mm ) n Fuch-Rosenthal chamber
. or n nne 1mm' s#uares of &.1 depth n Improved Neubauer hemoctometer.
Normal ran"e for leuocte C*F
+dult , &- cells (lmphocte and monocte)mcro/
Neonates , &-$& mononuclear cells mcro/
. The leuocte count should be made as a routne test and must be made %thn the firsthalf hour after %thdra%al of C*F sample.
. No R0Cs should be present n normal C*F. If numerous patholo"c process s probable suchas trauma mal"nanc nfarct hemorrha"e.
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. The Differential Count
if total cell count is hi2h $,; cells/ cu."".) 'ear < 3 l'"!hoc'tes>-1 'ear < l'"!hoc'tes
; 'ear- !ubert' < > leu+oc'tes
In a%ult nor"al CSF contain s"all nu"ber of l'"!hoc'tes an% "onoc'tes in
a!!ro9i"ate @ < 3 ratio S"all nu"ber of neutro!hils $MNs) "a' also be seen in nor"al CSF
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Pleocytosis (increase cell count) 2
- 3ue to an rrtatve or nflammator leson of bran spnal cord ormenn"es.
- 4ore common n cerebral tumour than n chronc encephalts- 4ost of the cells have ther or"n n menn"es
- +cute process %ll tend to have a predomnance of se"mentedgranulocytes( especall po"enc nfecton)
- Chronc nfecton and non bacteral acute reactons (to5c) usuallhave predomnance lymphocytes.
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Moderate increase in cells (98-988%cubic milimeter) with lymphocyte predominating/is
ound in "
.arly tuberculous meningitis
ll orm o neurosyphillis nterior poliomyelitis
.ncephalitis lethargica
Multiple sclerosis/ etc0
'ncrease in cells to 9888%cubic milimeter with lymphocyte predominating/ is ound in " #ate tuberculous meningitis
Poliomyelitis
cute syphillic meningitis
:reat increase in cells (;9888%cubic milimeter) with segmented granulocytespredominating
is ound in "
Pyogenic meningitides
'n5uen
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C6.M'C# .>M'T'*
90 :lobulin
globulin test should be made on all body 5uids0Anyamount of bloodwill be interered the test
a) Pandy?s TestTo 9 ml o a saturated a@ueous solution o phenol (4-98A)
in small test-tubes/ add 9 drop o spinal 5uid0 bluish$hite ringis immediately ormed i an excess o globulinis present0 This test is more sensitive than +oss-Bones Test
b) +oss-Bones Modication o onnecs pelt Test
*verlay 9 ml o spinal 5uis on 7 ml p a saturated solution
o ammonium sulphate0 $hite or gray ring at point
contact indicates an excess o globulin0
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70 :lucose Test (:*&-PP Method)*bDective " To determine glucose concentration in C!
Principle " :lucose concentration is determine ater en
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REAGENTSPhosphate bufer Ph H04 748 mmol%#
Phenol4 mmol%#
3-minoantipyrine 804 mmol%#
:lucose *xidase (:*&) 98 1,%#
Peroxidase (P*&) 9 1,%#tandard " 988 mg%dl (4/44 mmol%#
STORAGE INSTRUCTION & REAGENTS STABILITY
The reagent is stable up to the end i the indicated expired date/ i stored at 7-IoC
/ protected rom light and avoided rom contamination0 &o not ree
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PROCEDURE
CALCULATION
:lucose ( mg%&l) N absorbance ample > Concentrationtandard%Cal (mg%d#)
absorbance std%cal
CONVERSION FACTOR
:lucose (mg%d#) x 8/84449 N :lucose (mmol%#)
NORMAL RANGE
!asting 24-48 mg%d#
Blank Sample or Standard
ample or tandard
&istilled water+eagent
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98 micro#9888 micro#
98 micro#
-9888 micro#
Mix/ incubate 78 minutes/ at 78-74oC/ +ead the absorbance againtsthe blan1 within L8
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&ecrease acterial/ tuberculous/ and ungal meningitis
Meningeal involvement by malignant tumor
arcoidosis/ cysticercosis/ trichinosis/ ameba
cute syphillitic meningitis
'ntrathecal administration o radioionated serum albumin ubarachnoid hemorrhage
ymptoatic hypoglycemia
+heumatoid meningitis
'ncreaseo clinical signicance
Traumatic tap may also cause a spurious increase in C! glucose
INTERPRETATION
2 P t i
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20 Protein
PrincipleProtein orms a purple coloured complex with cupric ions in al1aline solution0 The
reaction ta1es its name rom the simple compound biuret which reacts in the same
way0The intensity o the purple colour is measured at 438 nm% yellow green lter and
compared with a standard o 1nown protein concentration 0
Test Principle
The principle o this total protein assay is by biuret reaction0'n al1aline solution/
cupric
ions react with all compounds with two amide or peptide bonds lin1ed either
directly or
through an intermediate carbon atom to orm a violet colored complex0 Theintensity o
this colored complex is directly proportional to the protein concentration in the
sample0
Reagent Reagent !
odium 6ydroxide odium 6ydroxide
Potassium sodium Tartrate Potassium odium Tartrate
Potassium 'odide
Copper ulphate
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P"pette "ntote#t t$%e
Blank Std&Cal Sample
ample/ td%Cal - 78 78
&ist =ater 78 - -
+eagent 9888 9888 9888
Mix/ incubate or 4 min/ at 78-74%HH *C+ead absorbance againts reagent blan1 within L8 min
Proced$re
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+eerrence range
dult " 94-34 mg%d#
.levated 'ncrease permeability o the blood brain barrier &ecreased resorption a arachnoid villi
Mechanical obstruction o C! due to spinal bloc1 above thepuncture site
'ncrease intrathecal immunoglobulin ('g) synthesi
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C.+.+*P'# !#,'& !'&': '
M.':'T'
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C.+.+*P'#!#,'&!'&':
rain Tumorppearance " Clear and colorless/ or xantochromia (pale pin1 to
yellow color in supernatant o centriugated C!)
pinal 5uid present " may be elevated
Protein level " may be increased
:lucose level " normalCell Count " ormal or slightly elevated lymphocyte
ubdural 6ematoma
C! ndings vary depending on whether the hematoma is recentor several days old0 'n recent subdural (within H days o inDury)/C! is usually bloody or xanthochromic0 'n late cases C! is clear0
The classic C! triad " elevated protein level/ xanthochromic/relatively normal cell count present in 48A patient
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