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Cerebrospinal Fluid Analysis:- Part 1 – Cerebrospinal Fluid (CSF) History and Normal Findings

August 22, 2022CSFLab Tests

Table of Contents

  • Cerebrospinal Fluid Analysis (CSF)
      • History of the cerebrospinal fluid (CSF)
      • Definition of the cerebrospinal fluid (CSF)
      • CSF production:
      • Functions of Cerebrospinal Fluid (CSF):
      • The appearance of CSF:
      • The pressure of CSF:
      • Total cell count in CSF:
      • The glucose level of CSF:
      • The protein level of CSF:
      • Gamma globulin (CSF):
      • Chloride (CSF):
      • LDH (CSF):
      • Bilirubin (CSF):
        • Normal Cerebrospinal Fluid Analysis (CSF) findings and normal range from various sources:
      • Normal CSF summary:

Cerebrospinal Fluid Analysis (CSF)

History of the cerebrospinal fluid (CSF)

  1. Cotugno recognized it in 1794; CSF is the third major body fluid.
  2. CSF provides a physiologic system to supply nutrients to the nervous tissue.
  3. It removes metabolic wastes.
  4. It provides a cushion to the brain and spinal cord against trauma.
  5. The brain and spinal cord are lined by meninges, which consist of:
    1. The Dura mater is the outer layer.
    2. The Arachnoid mater is in between the outer and inner layers.
    3. The Pia mater is the inner layer.
  6. CSF flows through the arachnoidal space between the arachnoid and pia mater.
  7. 20 mL of CSF is produced every hour in the choroid plexus and reabsorbed by the arachnoid villi to maintain a total volume of 140 to 170 mL in adults and 10 to 60 mL in neonates.
CSF flow in arachnoidal space

CSF flow in arachnoidal space

Definition of the cerebrospinal fluid (CSF)

  1. It is a clear, colorless fluid similar to blood plasma and interstitial fluid.
  2. Approximately 600 mL of CSF is produced daily.
  3. Around 125 to 150 mL of CSF circulates in the ventricles and subarachnoid space.
  4. The choroid plexus in the lateral, third, and fourth ventricles produce a major portion of the CSF.
  5. CSF does not accumulate but is reabsorbed into venous circulation through arachnoid villi.
  6. The blood forms CSF, and after circulating throughout the CNS, it returns to the blood.
Cerebrospinal fluid (CSF)

Cerebrospinal fluid (CSF)

CSF production:

  1. CSF is secreted by the choroid plexus, around the cerebral vessels, and along the walls of the ventricles of the brain.
  2. It fills:
    1. Ventricle and cisternae.
    2. Bath the spinal cord.
    3. It is reabsorbed into the blood through the arachnoid villi.
    4. CSF turnover is rapid, exchanging about four times/day.
    5. >80% of the CSF protein contents originate from plasma by ultrafiltration and pinocytosis.
    6. The rest is from the intrathecal synthesis.
    7. As the CSF passes down the lumbar region of the spinal space, the protein concentration increases.
CSF circulation in brain and spinal canal

CSF circulation in the brain and spinal canal

Functions of Cerebrospinal Fluid (CSF):

  1. The intracranial and the spinal cord float in the CSF and are protected from blows and jolts.
  2. The buoyant properties of the CSF prevent the brain from tugging on meninges, Nerve roots, and blood vessels.
  3. Its primary function is to protect the brain and spinal cord from injury.
  4. It transports the substances through the central nervous system.
  5. CSF is the ultrafiltrate of the plasma.

The appearance of CSF:

  1. Normal CSF Is clear and colorless.
    1. This clear CSF circulates in the subarachnoid space.
    2. No clot is seen.

The pressure of CSF:

  1. It is 70 to 180 mm H2O or 5 to 14 mm Hg (another reference = 100 to 200 mm H2O).
  2. This pressure is when the person is lying down and doubles up when the person sits up.

Total cell count in CSF:

  1. In adults, normal CSF contains 0 to 5 cells/cmm.
    1. These are mononuclear cells and lymphocytes.
    2. In newborns, the CSF cell count is 0 to 30/cmm, mostly neutrophils.
  2. Infants are 0 to 20 cells/cmm.
  3. No RBC is seen.

The glucose level of CSF:

  1. It is 45 to 80 mg /dL . The reference value is 45 mg/dL (2.5 mmol/L) or higher.
    1. In a normal person, it is rare to find glucose below 45 mg/dL.
    2. CSF glucose is 20 mg /dL lower than the blood glucose level.
    3. CSF glucose level is around 60% of the serum glucose level.
    4. In newborns, the CSF glucose level is 80% of the serum glucose level.
    5. The CSF glucose decrease is important to diagnose the various types of meningitis.
  2. Ventricular glucose is 5 to 10 mg higher than the lumbar CSF.

The protein level of CSF:

  1. Normal CSF protein is 15 to 45 mg/dL in lumbar CSF.
  2. It is 15 to 25 mg/dL in the cisternal fluid.
  3. It is 5 to 15 mg/dL in the ventricular fluid.
  4. In the newborn, the values are different and more uncertain.
    1. At the time of birth is 30 mg/dL and the range is 75 to 150 mg/dL.
    2. In infants from 30 days to 90 days, CSF protein is 20 to 100 mg/dL.
    3. The range from 90 days to 6 months is 15 to 50 mg/dL. The values slowly decline and reach the adult level by six months of age.
Age of the patient Amount of total protein
Infants 30 to 200 mg/dL
Child 14 to 45 mg/dL
Adult 15 to 45 mg/dL
Elderly 15 to 60 mg/dL

Gamma globulin (CSF):

  1. It is 3 to 12 % of the total protein.

Chloride (CSF):

  1. It is from 120 to 130 meq/L.
  2. It is 20 meq higher than the serum.

LDH (CSF):

  1. It is 15 to 17 units/L

Bilirubin (CSF):

  1. It is negative.

Normal Cerebrospinal Fluid Analysis (CSF) findings and normal range from various sources:

Lab findings Source 2 Source 1 Source 4
Volume
  1.  Adult 90 to 150 mL
  2. Child = 60 to 100 mL
Pressure <20 cm H2O
  1.  50 to 180  mm H2O
  2. If the pressure is >180 mm H2O.
  3. Then do not take more than 1 to 2 ml of CSF)
  1. Adult = 90 to 180 mm H2O
  2. Child (<8 years) = 10 to 100 mm H2O
Appearance Clear and colorless, no clot  Crystal clear and colorless Clear and colorless
Blood  Nil  Negative  Nil
White cell count
  1. Neonates = 0 to 30 cell/µL
  2. 1 to 5 years = 0 to 20 cells/ µL
  3. 6 to 18 years = 0 to 10 cells/  µL
  4. Adult = 0 to 5 cells/ µL
  1.  0 to 30 cells
  2.  0 to 5 cells
  1. Adult = 0 to 5 WBC/µL
  2. Newborn = 0 to 30 WBC/µL
  3. Child = 0 to 15 WBC/µL
Differential count
 Neutrophils 0 to 6%
  1.  Adult = 0 to 6%
  2. Newborn = 0 to 8%
  1. Adult = 0 to 6%
  2. Newborn = 0 to 8%
 Lymphocytes 40 to 80%
  1.  Adult = 40 to 80%
  2. Newborn = 5 to 35%
  1. Adult = 40 to 80%
  2. Newborn = 5 to 35%
 Monocytes 15 to 45%
  1.  Adult = 15 to 45%
  2. Newborn = 50 to 90%
  1. Adult = 15 to 45%
  2. Newborn = 50 to 90%
 Protein
  1.  15 to 45 mg/dL
  2. It is high in elders and children up to 70 mg/dL
  1. Adult = 15 to 45 mg/dL = lumbar
  2. 15 to 25 mg/dL = Cisternal
  3. 5 to 15 mg/dL = Ventricular
  4. Neonates = 15 to 100 mg/dL
  5. Adults >60 years = 15 to 60 mg/dL

 

  Lumbar  area
  1. Adult = 15 to 45 mg/dL
  2. Neonates = 15 to 100 mg/dL
  3. >60 years = 15 to 60 mg/dL
Adult = 15 to 45 mg/dL 
  Cisternal area 15 to 25 mg/dL Adult = 15 to 45 mg/dL = lumbar
 Ventricular area 5 to 15 mg/dL Adult = 5 to 15 mg/dL 
Electrophoresis
Prealbumin 2 to 7% 2 to 7%
Albumin 56 to 76%  10 to 35 mg/dL 56 to 76%
Alpha1 globulin 2 to 7% 2 to 7%
Alpha2 globulin 4 to 12% 4 to 12%
Beta globulin 8 to 18% 8 to 18%
Gamma globulin 3 to 12% 3 to 12%
IgG 0 to 4.5 mg/dL <4.0 mg/dL
Oligoclonal band Negative Negative
Biochemical estimation
Glucose 50 to 75 mg/dL (60 to 70% of blood glucose)
  1.  Infant, child = 60 to 80  mg/dL
  2. Adult = 40 to 70 mg?dL
  1. Adult = 40 to 70 mg/dL
  2. Child = 60 to 80 mg/dL
  3. CSF/plasma glucose ratio = <0.5
  4. CSF glucose levels are 60 to 70% of the blood
pH
  1. Lumbar area= 7.28 to 7.32
  2. Cisternal area = 7.32 to 7.34
Sodium  135 to 160 meq/L
Potassium  2.6 to 3.0 meq/L
Chloride 700 to 750 mg/dL  115 to 130 meq/L
  1.  Infant = 110 to 130 meq/L
  2. Adult = 118 to 132 meq/L
LDH <2 to 7.2 units/mL <20 U/L Adult = <20 U/L (around 10% of serum)
Lactic acid 10 to 25 mg/dL  10 to 24 mg/dL
  1. Adult = 10 to 22 mg/dL
  2. Newborn = 10 to 60 mg/dL
Glutamine 6 to 15 mg/dL
  1.  Neonates = 10.34 ± 3.6 mg/dL
  2. 3 months to 2 year = 7.27 ± 1.3 mg/dL
  3. 2 to 10 years = 6.76 ± 1.20 mg/dL
  4. Adult = 8.61 ± 0.50 mg/dL
Urea nitrogen 6 to 16 mg/dL
Phosphorus 1.2 to 2.0 mg/dL
Creatinine 0.5 to 1.2 mg/dL
Uric acid 0.5 to 4.5 mg/dL
Bilirubin Negative
Ammonia 10 to 35 µg/dL
Syphilis serology Negative  Negative Negative
CSF cytology for malignancy Negative Negative Negative

Normal CSF summary:

Characteristics Normal values
Volume
  1. Adult = 90 to 150 mL
  2. Neonates = 10 to 60 mL
Appearance
  1. Clear, colorless, and no clot seen
  2. Xanthochromasia = Negative
Total cell count
Adult and children 0 to 6/cmm, all are mononuclear
Infants <19 /cmm
Neonates <30/cmm
Chemistry
Glucose (Lumbar area)
  1. Lumbar area = 45 to 80 mg/dL (20 mg/dL < blood glucose)
  2. Ventricular area = 5 to 10 mg/dL>lumbar fluid
Total protein
Lumbar area
  1. Neonates =≤150 mg/dL
  2. 2 to 3 weeks = 20 to 80 mg/dL
  3. 3 months to 60 years = 15 to 45 mg/dL
  4. >60 years  = 15 to 60 mg/dL
Ventricular area 5 to 15 mg/dL
Cisternal area 15 to 25 mg/dL
IgG <4.0 mg/dL (<10% of total CSF proteins)
Chloride 120 to 130 m eq/L (20 meq/L > than serum value)
Sodium 142 to 150 meq/L
Potassium 2.2 to 3.3 meq/L
CO2 25 meq/L
pH 7.35 to 7.40
AST (SGOT) 7 to 49 units
Urea nitrogen 5 to 25 mg/dL
Bilirubin Negative
Creatine kinase (CK) 0 to 5 IU/L
Lactate dehydrogenase (LDH) ∼10% of the serum level
CSF electrophoresis
Oligoclonal band Negative
Proteins
  1. Prealbumin = 2% to 7%
  2. Albumin = 56% to 76%
  3. Alpha-1- globulin = 2% to 7%
  4. Alpha-2- globulin = 4% to 12%
  5. Beta- globulin = 8% to 18%
  6. Gamma globulins = 3% to 12%
IgG <4.0 mg/dL (<10% of the total CSF proteins)
Possible References Used
Go Back to CSF

Comments

Mehboob Fatteh Reply
October 2, 2021

These lab summares are excellent. Thank you for providing refresher information. Very informative and helpful.

Dr. Riaz Reply
October 3, 2021

Thanks for the encouraging comments.

Dr Rk Reply
October 21, 2021

sir please elaborate how to process sample for cytology.

Dr. Riaz Reply
October 22, 2021

Please let me know what sample of cytology you want to process.
In summary, CSF fluid needs to be centrifuged, and then you can fix the sediment smear with alcohol or other commercial fixatives. Now you can do gram stain, Giemsa stain, or hematoxylin/eosin stain.

Dr Rk Reply
December 26, 2021

Thanks sir
sir i want to process csf cytology and cell counts at my lab, with limited resources.
few queries:
1) can i use leishman stain / pap stain
2) for cell counts can i use improved neubauer cahmber/ hematology analyzer

Dr. Riaz Reply
December 26, 2021

Dear
You can use Leishman stain (or Giemsa) on the centrifuged sediment of the CSF. For CSF cell count, it depends upon the number of cells. You can use the Neubauer chamber. You can try a Hematology analyzer; compare the count with the Neubauer chamber.

Dr Rk Reply
December 27, 2021

thank you sir

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