CEREBROSPINAL FLUID

[CSF]

Edited by
Liniyanti D.Oswari.MD.MNS.MSc.
For block 8
Medical School, University of Sriwijaya

CEREBRAL CIRCULATION
The Circle of Willis is
the joining area of
several arteries at
the bottom (inferior)
side of the brain. At
the Circle of Willis,
the internal carotid
arteries branch into
smaller arteries that
supply oxygenated
blood over 80% of
the cerebrum.

CEREBROSPINAL FLUID

CEREBROSPINAL FLUID

The intracranial compartment is a rigid

container and consists of three components
a. brain-80% of total volume
b. blood-10% of total volume
c. CSF-10% of total volume

CEREBROSPINAL FLUID [FORMATION]

CSF is largely formed by the choroid plexus of the
lateral ventricle and remainder in the third and
fourth ventricles.
About 30% of the CSF is also formed from the
ependymal cells lining the ventricles and other brain
capillaries.
The choroid plexus of the ventricles actively secrete
cerebrospinal fluid.
The choroid plexuses are highly vascular tufts
covered by ependyma.

FORMATION & CIRCULATION OF CSF

MECHANISM OF FORMATION OF CSF

CSF is formed primarily by secretion and also by

filtration from the net works of capillaries and
ependymal cells in the ventricles called choroid
plexus.

Various components of the choroid plexus from a

blood-cerebrospinal fluid barrier that permits
certain substances to enter the fluid, but prohibits
others.
Such a barrier protects the brain and spinal cord

MECHANISM OF FORMATION OF CSF

The entire cerebral cavity enclosing the brain and
spinal cord has a capacity of about 1600 to 1700
milliliters
About 150 milliliters of this capacity is occupied by
cerebrospinal fluid and the remainder by the brain
and cord.
Rate of formation:
About 20-25 ml/hour
550 ml/day in adults. Turns over 3.7 times a day
Total quantity: 150 ml:
30-40 ml within the ventricles
About 110-120 ml in the subarachnoid space [of
which 75-80 ml in spinal part and 25-30 ml in the
cranial part].

MECHANISM OF FORMATION
CSF is formed at a rate of about 550 milliliters each
day,. About two thirds or more of this fluid
originates as secretion from the choroid plexuses in
the four ventricles, mainly in the two lateral
ventricles.
Additional small amount of fluid is secreted by the
ependymal surfaces of all the ventricles and by the
arachnoidal membranes
Small quantity comes from the brain itself through
the perivascular spaces that surround the blood
vessels passing through the brain.

MECHANISM OF FORMATION
Secretion by the Choroid Plexus. The choroid
plexus, is a cauliflower-like growth of blood vessels
covered by a thin layer of epithelial cells.
Secretion of fluid by the choroid plexus depends
mainly on active transport of sodium ions through
the epithelial cells lining the outside of the plexus.
The sodium ions in turn pull along large amounts of
chloride ions because the positive charge of the
sodium ion attracts the chloride ion's negative
charge. The two of these together increase the
quantity of osmotically active sodium chloride in the
cerebrospinal fluid, which then causes almost
immediate osmosis of water through the membrane,

MECHANISM OF FORMATION
Less important transport processes move small amount of
glucose into the cerebrospinal fluid and both potassium and
bicarbonate ions out of the cerebrospinal fluid into the
capillaries.
The resulting characteristics of the CSF are:
Osmotic pressure approximately equal to that of plasma sodium
ion concentration
Approximately equal to that of plasma chloride ion
About 15 per cent greater than in plasma potassium ion
approximately 40 per cent less glucose

ABSORPTION OF CSF THROUGH

ARACHNOID VILLI
The arachnoidal villi are fingerlike inward projections of
the arachnoidal membrane through the walls into
venous sinuses.
villi form arachnoidal granulations can protruding into
the sinuses.
The endothelial cells covering the villi have vesicular
passages directly through the bodies of the cells large
enough to allow relatively free flow of (1) cerebrospinal
fluid, (2) dissolved protein molecules, and (3) even
particles as large as red and white blood cells into the
venous blood.

COMPOSITION OF CSF
Proteins
Glucose
Cholesterol
Na+
Ca+
Urea
Creatinine
Lactic acid

=
=
=
=
=
=
=
=

20-40 mg/100 ml
50-65 mg/100 ml
0.2 mg/100 ml
147 meq/Kg H2O
2.3 meq/kg H2O
12.0 mg/100 ml
1.5 mg/100 ml
18.0 mg/100 ml

CHARACTERISTICS OF CSF
Nature:
Colour
=
Clear, transparent
fluid
Specific gravity =
1.004-1.007
Reaction
=
Alkaline and does not
coagulate
Cells
=
0-3/ cmm
Pressure
=
60-150 mm of H2O
The pressure of CSF is increased in standing,
coughing, sneezing, crying, compression of
internal Jugular vein (Queckenstedts sign

CIRCULATION OF CSF
Circulation: CSF is mainly formed in choroid pleaxus
of the lateral ventricle.
CSF passes from the lateral ventricle to the third
ventricle through the interventricular foramen
(foramen of Monro).
From third ventricle it passes to the fourth ventricle
through the cerebrol aqueduct. The circulation is
aided by the arterial pulsations of the chroid plexuses.
From the fourth ventricle (CSF) passes to the sub
arachnoid space around the brain and spinal cord
through the foramen of magendie and foramina of
luschka.

CIRCULATION OF CSF
Lateral ventricle
Foramen of Monro [Interventricular foramen]
Third ventricle:
Cerebral aqueduct
Fourth ventricle:
Foramen of megendie and formen of luschka
Subarachnoid space of Brain and Spinal cord

CIRCULATION OF CSF
Circulation: CSF slowly moves
cerebromedullary cistern and pontine cisterns
and flows superiorly through the interval in
the tentorium cerebelli to reach the inferior
surface of the cerebrum. It moves superiority
over the lateral aspect of each cerebrol
hemisphere.

FUNCTIONS OF CSF
A shock absorber
A mechanical buffer
Act as cushion between the brain and cranium
Act as a reservoir and regulates the contents of the
cranium
Serves as a medium for nutritional exchange in CNS
Transport hormones and hormone releasing factors
Removes the metabolic waste products through
absorption

Causes of an increased
CSF

Conditions Increasing CSF Volume

increased production(Ch plexus
papilloma)
decreased reabsorption of CSF
(meningitis, SAH)
Obstruction to flow of CSF (e.g. aq
stenosis)

CSF AND INFLAMMATION

Increased inflammatory cells [pleocytosis]
may be caused by infectious and noninfectious
processes.
Polymorphonuclear pleocytosis indicates acute
suppurative meningitis.
Mononuclear cells are seen in viral infections
(meningoencephalitis, aseptic meningitis),
syphilis, neuroborreliosis, tuberculous meningitis,
multiple sclerosis, brain abscess and brain
tumors.

CSF AND INFLAMMATION

Increased inflammatory cells [pleocytosis]
may be caused by infectious and noninfectious
processes.
Polymorphonuclear pleocytosis indicates acute
suppurative meningitis.
Mononuclear cells are seen in viral infections
(meningoencephalitis, aseptic meningitis),
syphilis, neuroborreliosis, tuberculous meningitis,
multiple sclerosis, brain abscess and brain
tumors.

CSF AND PROTEINS

Increased protein: CSF protein may rise to 500
mg/dl in bacterial meningitis.
A more moderate increase (150-200 mg/dl) occurs
in inflammatory diseases of meninges (meningitis,
encephalitis), intracranial tumors, subarachnoid
hemorrhage, and cerebral infarction.
A more severe increase occurs in the Guillain-Barr
syndrome and acoustic and spinal schwannoma.

CSF AND PROTEINS

Multiple sclerosis: CSF protein is normal or mildly
increased.
Increased IgG in CSF, but not in serum [IgG/albumin
index normally 10:1].
90% of MS patients have oligoclonal IgG bands in
the CSF.
Oligoclonal bands occur in the CSF only not in the
serum.
The CSF in MS often contains myelin fragments and
myelin basic protein (MBP).
MBP can be detected by radioimmunoassay. MBP is
not specific for MS. It can appear in any condition
causing brain necrosis, including infarcts.

CSF & LOW GLUCOSE

Low glucose in CSF:
This condition is seen in suppurative
tuberculosis
Fungal infections
Sarcoidosis
Meningeal dissemination of tumors.
Glucose is consumed by leukocytes and tumor
cells.

BLOOD IN CSF
Blood: Blood may be spilled into the CSF by
accidental puncture of a leptomeningeal vein
during entry of the LP needle.
Such blood stains the fluid that is drawn initially
and clears gradually. If it does not clear, blood
indicates subarachnoid hemorrhage.
Erythrocytes from subarachnoid hemorrhage are
cleared in 3 to 7 days. A few neutrophils and
mononuclear cells may also be present as a result
of meningeal irritation.

Leukemia Cells in CSF

CSF AND XZNTHOCHROMIA

Xanthochromia [blonde color] of the CSF
following subarachnoid hemorrhage is due to
oxyhemoglobin which appears in 4 to 6 hours
and bilirubin which appears in two days.
Xanthochromia may also be seen with
hemorrhagic infarcts, brain tumors, and
jaundice.

CSF AND TUMOUR CELLS

Tumor cells indicate dissemination of metastatic
or primary brain tumors in the subarachnoid
space.
The most common among the latter is
medulloblastoma.
They can be best detected by cytological
examination.
A mononuclear inflammatory reaction is often
seen in addition to the tumor cells.

INDICATIONS OF CSF EXAMINATION

Infections:
meningitis, encephalitis
Inflammatory conditions:Sarcoidosis, neuro
syphilis, SLE
Infiltrstive conditions:Leukamia, lymphoma,
carcinomatous - meningitis
Administration of drugs in CSF (Therapeutic aim)
Antibiotics:
(In case of meningitis)Antimitotics
Diagnostic aim: Myelography, Cisternography
Anaesthetics are also given through the lumbar
puncture

LUMBAR PUNCTURE
A lumbar puncture also called a spinal tap is
a procedure where a sample of
cerebrospinal fluid is taken for examination.
CSF is mainly used to diagnose meningitis
[an infection of the meninges].
It is also used to diagnose some other
conditions of the brain and spinal cord.

CONTRA-INDICATIONS FOR LP
Local skin infections over proposed puncture site
(absolute contraindication)
Raised intracranial pressure (ICP); exception is
pseudotumor cerebri
Suspected spinal cord mass or intracranial mass
lesion (based on lateralizing neurological
findings or papilledema)
Uncontrolled bleeding diathesis
Spinal column deformities (may require
fluoroscopic assistance)
Lack of patient cooperation

PRECAUTIONS FOR LUMBAR PUNCTURE

Asked to sign a consent form
Ask about taking any medicines
Are allergic to any medicines
Have / had any bleeding problems
Ask about medications such as aspirin or
warfarin
Ask the female patient might be pregnant

LUMBAR PUNCTURE
1. Material for sterile technique [gloves and
mask are necessary]
2. Spinal Needle, 20 and 22-gauge
3. Manometer
4. Three-way stopcock
5. Sterile drapes
6. 1% lidocaine without epinephrine in a 5cc syringe with a 22 and 25-gauge needles
7. Material for skin sterilization
8. Adhesive dressing
9. Sponges - 10 X 10 cm

LUMBAR PUNCTURE [Complications]

Post lumbar puncture headache occurs in 10% to
30% of patients within 1 to 3 days and lasts 2 to 7
days.
The pain is relieved by lying flat.
Treatment consists of bed rest and fluid with
simple analgesics.

LUMBAR PUNCTURE [Complications]

Headache following a lumbar puncture is a
common and often debilitating syndrome.
Continued leakage of cerebrospinal fluid from a
puncture site decreases intracranial pressure,
which leads to traction on pain-sensitive
intracranial structures.
The headache is characteristically postural, often
associated with nausea and optic, vestibular, or
otic symptoms. Although usually self-limited after a
few days, severe postural pain can incapacitate
the patient. Management is mainly symptomatic,
but definitive treatment with the epidural blood
patching technique is safe and effective when
done by an expert operator.

LUMBAR PUNCTURE
Patient usually lie on a bed on side with knees
pulled up against the chest.
It may also done with sitting up and leaning
forward on some pillows. Sterilize the area.
push a needle through the skin and tissues
between two vertebra into the space around the
spinal cord which is filled with CSF.
CSF leaks back through the needle and is
collected in a sterile container.
As soon as the required amount of fluid is
collected the needle is taken out and a plaster is
put over the site of needle entry.

LUMBAR PUNCTURE
Sent the sample to lab to be examined
under the microscope to look for bacteria.
It is also 'cultured' for any bacterial
growth
The fluid can also be tested for protein,
sugar and other chemicals if necessary.
Sometimes also measure the pressure of
the fluid. This is done by attaching a
special tube to the needle which can
measure the pressure of the fluid coming
out.

LUMBAR PUNCTURE

CEREBROSPINAL FLUID

CEREBROSPINAL FLUID

CEREBROSPINAL FLUID

CEREBROSPINAL FLUID

CEREBROSPINAL FLUID

LUMBAR PUNCTURE

LUMBAR PUNCTURE
Place the patient in the lateral decubitus position
lying on the edge of the bed and facing away from
operator.
Place the patient in a knee-chest position with the
neck flexed.
The patient's head should rest on a pillow, so that
the entire cranio-spinal axis is parallel to the bed.
Sitting position is the second choice because there
may be a greater risk of herniation and CSF
pressure cannot be measured

LUMBAR PUNCTURE
Find the posterior iliac crest and palpate the L4
spinous process, and mark the spot with a
fingernail.
Prepare the skin by starting at the puncture site.
Anesthetize the skin using the 1% lidocaine in the
5 mL syringe with the 25-gauge needle. Change to
22-gauge needle before anesthetizing between the
spinous process.
Insert in the midline with the needle parallel to the
floor and the point directed toward the patient's
umbilicus

LUMBAR PUNCTURE
Advance slowly about 2 cm or until a "pop''
(piercing a membrane of the dura) is heard.
Then withdraw the stylet in every 2- to 3-mm
advance of the needle to check for CSF return.
If the needle meets the bone or if blood returns
(hitting the venous plexus anterior to the spinal
canal), withdraw to the skin and redirect the
needle.
If CSF return cannot be obtained, try one disk
space down

HYDROCEPHALUSL
Hydrocephalus" means excess water in the cranial
vault.
This condition is frequently divided into
communicating hydrocephalus and
noncommunicating hydrocephalus.
In communicating hydrocephalus fluid flows
readily from the ventricular system into the
subarachnoid space,
in noncommunicating hydrocephalus fluid flow out
of one or more of the ventricles is blocked.

HYDROCEPHALUS