[slide ajar] materi pk 3.5 (asisten 2012)

7/26/2019 [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

-

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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