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Cerebrospinal Fluid
Examination
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OVERVIEW
1.
2.
3.
4.
5.
6.
7.

8.

9.

10.

11.

Physiology
Functions of CSF
Indications
Recommended laboratory tests
Specimen collection
Opening pressure
Gross examination
Color
Appearance (Clear/clot/cobweb/coagulum)
Viscosity
Microscopic examination
Total count
Differential count
i. Lymphocytes
ii. Neutrophils
iii. Plasma cells
iv. Eosinophils
v. Monocytes and macrophages
vi. Tumor cells
Chemical examination
Proteins
i. Total protein
ii. Albumin
iii. IgG
iv. Other CSF proteins
Glucose
Lactate
F2 isoprostanes
Enzymes
i. Adenosine Deaminase (ADA)
ii. Creatinine Kinase (CK)
iii. Lactate Dehydrogenase (LDH)
iv. Lysozyme
Ammonia, amines and aminoacids
Microbiological examination
Bacterial meningitis
Spirochetal meningitis
Viral meningitis
Fungal meningitis
Tuberculous meningitis
Primary amebic meningoencephalitis
Reference values

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* Physiology
1. CSF is derived from ultrafilteration and secretion through the choroid plexus.
2. CSF resorption occurs at arachnoidal villi predominantly along superior sagittal sinus.

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* Opening pressure
1. Opening pressure can be measured by a manometer before collection of CSF
2. The pressure varies with postural changes, blood pressure, venous return and valsalva
maneuver etc.
3. Pressure should be noted in lateral decubitus position with legs and neck in neutral
position.

manometer tube with graduation from -4 cm to +34 cm and attached to three way tap

Normals
CSF opening pressure

Adult 90-180 mm of water

Children (upto 8 years) 10-100 mm of water

Abnormals
If pressure is elevated more than 200 mm of water, no more than 2 ml should be withdrawn
as it can lead to herniation

1.
2.
3.
4.
5.
6.
7.
8.
9.

Elevated pressure
straining
congestive heart failure
meningitis
superior venacaval syndrome
thrombosis of venous sinuses
cerebral edema
mass lesions
hypoosmolality
Idiopathic intracranial hypertension
(pseudotumor cerebri)

1.
2.
3.
4.

Decreased pressure
spinal-subarachnoid block
dehydration
circulatory collapse
CSF leakage like from cribriform
plate in case of head injury

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B. Appearance
Normal
Appearance

Clear

Abnormals
Turbid/cloudy

Bloody
Clot

Cobweb

Leucocyte count >200 cells/mm3

RBCs >400 cells/ mm3
Microorganisms (bacteria, fungi, amebas)
Radiographic contrast material
Aspirated epidural fat
Protein level greater than 150mg/dl
RBC counts >6000 cells/mm3
Traumatic tap
Complete spinal block (Froins syndrome)
Suppurative or tuberculous meningitis
*Not seen in patients with subarachnoid hemorrhage
Tuberculous meningitis

Cobweb in tuberculous meningitis in CSF

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* Microscopic examination
(A) Total cell count
Methods:
1. Manual count using Neubauers chamber or a Fuchs-Rosenthal type chamber (most
commonly used)
2. Count with an automated cell counter (poor precision)
3. automated flow cytometry of CSF (rapid and reliable, but expensive)
Counting using a neubauers chamber:
1. Sample in tube 3 is used
2. No dilution of CSF is usually required. A diluent (0.05ml CSF + 0.95 ml diluent, 1:20
dilution) is used only if CSF is cloudy and likely to contain increased number of
leucocytes. Diluent mostly used is Turk solution (glacial acetic acid + methylene blue +
distilled water)
3. Put coverslip on chamber.
4. Charge it from sides, take care that no fluid goes into the drain.
5. allow to stand for two minutes, cells will settle down.
6. Cells are counted in four corner WBC counting squares, marked W in the figure.
7. Total count (per/mm3)= No. of cells counted x 10
No. of squares counted

Improved Neubauers chamber

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Counting cells in WBC counting chamber

Normals
Total count

Adults - 0-5 cells/mm3

Children 0-30 cells/mm3
RBCs Zero / hpf

Abnormals
Increased counts

1.
2.
3.
4.
5.

Meningitis and other infections of CNS

Intracranial hemorrhage
Meningeal infiltration by malignancy
Repeated lumbar punctures
Injection of foreign substances (contrast media/drugs) in
subarachnoid space.
6. Multiple sclerosis

Correction for presence of blood in CSF

Presence of blood either due to traumatic tap or subarachnoid hemorrhage artefactually
raises the total count. This needs to be corrected by the following formula Corrected WBC (/mm3) = WBC counted - WBC count in blood x RBC count in CSF
RBC count in blood

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(B) Differential cell count

Methods:
1. counting chamber poor precision, identification of different cell types difficult, not
recommended
2. Direct smears of centrifuged CSF specimen subjected to significant error from
cellular distortion# and fragmentation, but most commonly performed
3. Using a cytocentrifuge recommended method for all body fluids
# cellular distortion can be minimized by adding 2 drops of 22% bovine albumin to the
specimen
Normals:
Cell type
Lymphocytes #
Monocytes
Neutrophils
Histiocytes
Ependymal cells
Eosinophils

Adults (%)
62 +/- 34
36 +/- 20
2 +/- 5
Rare
Rare
Rare

Children (%)
20 +/- 18
72 +/- 22
3 +/- 5
5 +/- 4
Rare
Rare

#Blast like lymphocytes may be seen admixed with small and large lymphocytes in CSF of
neonates
Abnormals:
1. Increased neutrophils
Meningitis
1. Bacterial meningitis # (PMN >60%)
2. Early viral meningoencephalitis (PMN <60%, changes to lymphocytic in 2-3 days)
3. Early tuberculous meningitis
4. Early mycotic meningitis
5. Amebic encephalomyelitis
Other infections
1. Cerebral abscess
2. Subdural empyema
3. AIDS related CMV radiculopathy
Following seizures
Following CNS hemorrhage
1. subarachnoid
2. Intracerebral
Following CNS infarct
Reaction to repeated lumbar punctures
Injection of foreign material in subarachnoid space (e.g. methotrexate, contrast media)
Metastatic tumor in contact with CSF
#A total neutrophil count of >1180 cells/mm3 has 99% predictive value for bacterial meningitis
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(B) Albumin
1.
2.
3.
4.

Albumin is around 56-76% of total proteins in CSF.

Normal CSF albumin (in gm/dl) : serum albumin (in gm/dl) ratio is 1:230.
But this yields a very difficult decimal of 0.004 to deal with.
Hence the permeability of Blood brain barrier is assessed by CSF albumin : serum
albumin index, where value of CSF albumin is taken in mg/dl.
5. A traumatic tap invalidates the calculation.
CSF ALBUMIN / SERUM ALBUMIN ratio = CSF ALBUMIN (g/dl)
Serum albumin (g/dl)

CSF ALBUMIN / SERUM ALBUMIN INDEX = CSF ALBUMIN (mg/dl)

Serum albumin (g/dl)

Normals:
CSF albumin: Serum albumin ratio
CSF albumin:Serum albumin index (mg/gm)
Slightly elevated in infants upto 6 months of
age
Index increases gradually after age 40

0.004
<9
Reflects immaturity of blood brain barrier

Abnormals:
9-14
14-30
>30

Slight impairment
Moderate impairment
Severe impairment

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Glucose
1. CSF glucose levels should be compared with plasma levels, ideally following a 4 hour
fast, for adequate clinical interpretation.
2. CSF glucose levels normalize before protein levels and cell counts following recovery
from meningitis, hence it is a useful parameter in assessing response to treatment.
Normals:
Fasting CSF glucose levels
Normal CSF glucose:Plasma
glucose ratio

60% of plasma level

(50-80 mg/dl)
0.3-0.9

Abnormals:
Decreased CSF fasting glucose (<40mg/dl or
ratio <0.3)
a.k.a. Hypoglycorrhachia
Due to: increased anaerobic glycolysis in
brain tissue and leucocytes
Seen in
1. Bacterial, tuberculous and fungal
meningitis
2. meningeal involvement by malignant
tumor, sarcoidosis, cysticercosis,
trichinosis, ameba, syphilis
3. intrathecal administration of
radioiodinated serum albumin
4. subarachnoid hemorrhage
5. symptomatic hypocglycemia
6. rheumatoid meningitis

Increased CSF fasting glucose values

Due to: No clinical significance

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(B) Creatine Kinase (CK)

1. CK-BB comprises of nearly 90% of brain CK activity, other 10 % being contributed by
mitochondrial CK (CKmt)
2. CK-BB starts rising in CSF after about 6 hours of ischemic insult with peak levels in
about 48 hours.
3. It is also raised following a subarachnoid hemorrhage and predicts chance of
unfavourable outcome.
Abnormals:
FOLLOWING ISCHEMIC INSULT
CK-BB
CK-BB
CK-BB
CK-BB

<5 U/L
5-20 U/L
21-50 U/L
>50 U/L

Minimal neurologic damage

Mild to moderate CNS injury
Correlated with death
Death occurs in all patients

FOLLOWING SUBARACHNOID HEMORRHAGE

CK-BB

>40 U/L

Death

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(D) Fungal Meningitis

Cryptococcus is the most common fungus isolated from CSF
Microbiological Methods:
1. India ink or nigrosin stains for capsule
2. Detection of cryptococcal antigen from CSF using latex agglutination
3. Culture

Cryptococcus in CSF stained with India Ink

Findings in CSF:
Test
Opening pressure
Leucocyte count
Differential count
Protein
Glucose
CSF : serum glucose ratio
Lactic acid

Findings
Variable
Variable
Mainly lymphocytes
Increased
Decreased
Low
Mild to moderate increased

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Test
Opening pressure
Leucocyte count
Differential count
Protein
Glucose

CSF : serum
glucose ratio
Lactic acid

41

Bacterial
meningitis
Elevated
>/= 1000/mm3
Mainly
neutrophils
Mild-moderate
increase
Usually <40
mg/dL

Viral
Meningitis
Usually normal
<100 / mm3
Mainly
lymphocytes
Normal mild
increase
Normal

Fungal
meningitis
Variable
Variable
Mainly
lymphocytes
Increased

Tuberculous
Meningitis
Variable
Variable
Mainly
lymphocytes
Increased

Decreased

Normal /
decreased
Increased

Usually normal

Low

Decreased
(may be <45
mg/dL)
Low

Normal mild
increase

Mild to
moderate
increased

Mild to
moderate
increased

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Test
Opening pressure
Leucocyte count
Differential count
Protein
Glucose

CSF : serum
glucose ratio
Lactic acid

41

Bacterial
meningitis
Elevated
>/= 1000/mm3
Mainly
neutrophils
Mild-moderate
increase
Usually <40
mg/dL

Viral
Meningitis
Usually normal
<100 / mm3
Mainly
lymphocytes
Normal mild
increase
Normal

Fungal
meningitis
Variable
Variable
Mainly
lymphocytes
Increased

Tuberculous
Meningitis
Variable
Variable
Mainly
lymphocytes
Increased

Decreased

Normal /
decreased
Increased

Usually normal

Low

Decreased
(may be <45
mg/dL)
Low

Normal mild
increase

Mild to
moderate
increased

Mild to
moderate
increased

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