Cytopathology of Cerebrospinal Fluid Genevi è ve Warner Learmonth Histopathologist /Cytopathologist. Royal Free Hospital, ...
Diagnostic Cytopathology <ul><li>Cytopathology is a complementary  diagnostic tool. </li></ul><ul><li>Correlation with oth...
Cytopathology Laboratory <ul><li>Communicate with Laboratory Staff  </li></ul><ul><li>Check laboratory facilities </li></u...
What is Cerebrospinal Fluid?  Where does it come from?  Where does it go? <ul><li>THE NORMAL CSF  obtained at lumbar punct...
Safety procedures  Infective specimens <ul><li>Tuberculosis  </li></ul><ul><li>HIV </li></ul><ul><li>Hepatitis </li></ul><...
Processing Cerebrospinal Fluid Specimen  ---  Cytospin Technique Is there enough fluid for processing? 2-10ml usually rece...
Processing Cerebrospinal fluid Cytospin method
Staining the cells <ul><li>May Grunwald Giemsa  (  MGG)  air dried </li></ul><ul><li>Papanicolaou  stain  </li></ul><ul><l...
Check the origin of “CSF “ specimen <ul><li>Is it really  lumbar puncture CSF? </li></ul><ul><li>Is it from an ventricular...
Microscopy <ul><li>Cytopathologist needs the  best quality microscope. </li></ul><ul><li>No oil immersion used! </li></ul>...
“  Normal CSF” and “Abnormal CSF” <ul><li>NORMAL </li></ul><ul><li>Acellular ---- check that this is a  clear  fluid speci...
Abnormal CSF <ul><li>ABNORMAL </li></ul><ul><li>Very cellular </li></ul><ul><li>Mixed Inflammatory exudate </li></ul><ul><...
Background -- very very important <ul><li>Children on a safe  happy holiday in Namibia   </li></ul>Bloodstained fluid – in...
Specimens from Neurology/  Neurosurgery / HIV/AIDS Clinic, A&E <ul><li>Neurology:  often non specific symptoms and signs -...
Acute Inflammation Meningitis High power view Polymorphs Low power view polymorphs DR Bryan Knight Vancouver
Lymphoid Cells
Mixed Inflammatory Infiltrate Camouflage !
What are these small round structures?
Mixed Plasma cells and Lymphocytes and small round structures with concentric rings
Special stain – mucicarmine. Cryptococci Mucin stain ( PAS for glycogen stains cells and talc granules too)
Sputum from same patient when reviewed showed Cryptococci
  This patient was a fit healthy man. Admitted with severe dyspnoea. Sputum: ?abnormal cells, TB bacilli, Sputum NAD  TB c...
Tuberculosis in CSF <ul><li>Cytological  appearances are  not  specific,  </li></ul><ul><li>maybe lymphocytic or mixed inf...
Tuberculosis and HIV/AIDS The “Terrible Twins” <ul><li>Ziehl Neehlsen stain for acid fast TB  bacilli </li></ul>
Examine Papanicolaou stained slide under Fluorescent light at 450  μ m TB bacilli are fluorescent !
“ CSF” received from a five  year old  sheep farmer’s daughter  <ul><li>CSF was actually from the orbit ! </li></ul><ul><l...
Hydatid disease presents as a cyst in  any tissue of the body. Clear fluid  is aspirated . Hooklets seen. Sometines scolic...
Hydatid Disease ( Echinococcus granulosus) Histology of Cyst wall laminated membrane Cyst wall & daughter cysts
Abnormal Cells in CSF <ul><li>Lymphoma /Leukaemia </li></ul><ul><li>Metastatic tumours  </li></ul><ul><li>Childhood tumour...
  Lymphoma/ Leukaemia  AIDS patients develop cerebral and other extranodal B-cell lymphomas due to loss of the surveillanc...
Metastatic  Malignant Melanoma with Macronucleoli --- “Big Mac” Cell types: Small “lymphoid”, Binucleate, Multinucleate, B...
Metastatic neoplasms Breast, lung, ovary, testis  Breast Ovarian squamous ca Choriocarcinoma
Metastatic Retinoblastoma
Medulloblastoma
Retinoblastoma and ?pinealoblastoma
Craniopharyngioma Cyst Or ? squamous carcinoma
Capillary Haemangionblastoma Intraoperative smears
Primary Brain Tumours Intra operative smears
Pitfalls and Mimicry in Cytology <ul><li>Oogpister or “Eye pisser” in the Namib desert mimics a lizard </li></ul>Pollen gr...
Report on  what  you see,  not what you expect to see.  Scan, look for the “odd man out”.  Be aware of odd/ unusual appear...
This is a giraffe in Etosha, Namibia White bone in mouth ! Giraffes are herbivorous!  Lack of calcium in leaves of local a...
Remember ! There is more to Cytology than meets the Eye .   So keep an eye out !
Further Reading <ul><li>J. Bell, J.Clin Pathol, 1994; 47 :573-378  </li></ul><ul><li>Update on Central nervous System. Cer...
Dedication <ul><li>This presentation is dedicated to the memory of  </li></ul><ul><li>The late Mr Patrick Carey , Neurosur...
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Cytopathology Of Cerebrospinal Fluid[1]Power Point

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Cytopathology Of Cerebrospinal Fluid[1]Power Point

  1. 1. Cytopathology of Cerebrospinal Fluid Genevi è ve Warner Learmonth Histopathologist /Cytopathologist. Royal Free Hospital, London and Groote Schuur Hospital, University of Cape Town
  2. 2. Diagnostic Cytopathology <ul><li>Cytopathology is a complementary diagnostic tool. </li></ul><ul><li>Correlation with other other diagnostic modalities: </li></ul><ul><li>1. Clinical information: Age, gender, previous illness, check database results. </li></ul><ul><li>2. Ultrasound, MRI, CTscan. </li></ul><ul><li>3. Communicate with the clinical team. </li></ul>
  3. 3. Cytopathology Laboratory <ul><li>Communicate with Laboratory Staff </li></ul><ul><li>Check laboratory facilities </li></ul><ul><li>Discuss difficulties </li></ul><ul><li>Availability of special stains </li></ul><ul><li>Residual specimen </li></ul><ul><li>for Flow Cytometry </li></ul>
  4. 4. What is Cerebrospinal Fluid? Where does it come from? Where does it go? <ul><li>THE NORMAL CSF obtained at lumbar puncture: </li></ul><ul><li>The cerebrospinal fluid (CSF) is clear fluid, produced from arterial blood by the choroid plexuses of the lateral and fourth ventricles by a combined process of diffusion, active transfer. </li></ul><ul><li>The choroid plexus consists of tufts of capillaries with thin fenestrated endothelial cells. </li></ul><ul><li>VOLUME: 140 ml. The volume of the ventricles is about 25 ml. CSF is produced at a rate of 0.2 - 0.7 ml per minute or 600-700 ml per day. </li></ul><ul><li>Circulation of CSF is aided by the pulsations of the CSF acts as a cushion that protects the brain from shocks and supports the venous sinuses. </li></ul><ul><li>Chemistry :CSF from the lumbar region contains 15 to 45 mg/dl protein and 50-80 mg/dl glucose (two-thirds of blood glucose). </li></ul><ul><li>Cellularity: Normal CSF contains 0-5 mononuclear cells . </li></ul><ul><li>The CSF pressure: lumbar puncture (LP), 8-15 mm Hg with the patient lying on the side, twice that value with the patient sitting up. </li></ul>
  5. 5. Safety procedures Infective specimens <ul><li>Tuberculosis </li></ul><ul><li>HIV </li></ul><ul><li>Hepatitis </li></ul><ul><li>Septic meningitis </li></ul><ul><li>Viral meningitis </li></ul>
  6. 6. Processing Cerebrospinal Fluid Specimen --- Cytospin Technique Is there enough fluid for processing? 2-10ml usually received Colour of fluid ? /clear/cloudy/bloodstained Xanthochromia”( blonde colour) seen in SAH Consistency? (Mucoid)
  7. 7. Processing Cerebrospinal fluid Cytospin method
  8. 8. Staining the cells <ul><li>May Grunwald Giemsa ( MGG) air dried </li></ul><ul><li>Papanicolaou stain </li></ul><ul><li>alcohol fixed </li></ul>Blue pink magenta purple &quot;Rainbow&quot; stain, emphasises nuclear details
  9. 9. Check the origin of “CSF “ specimen <ul><li>Is it really lumbar puncture CSF? </li></ul><ul><li>Is it from an ventricular drain ? </li></ul><ul><li>( hydrocephalic patient) </li></ul><ul><li>Is it from a cystic brain lesion? </li></ul><ul><li>Is it an intra –operative fluid specimen? </li></ul><ul><li>Is it a smear from an intra operative procedure? </li></ul>
  10. 10. Microscopy <ul><li>Cytopathologist needs the best quality microscope. </li></ul><ul><li>No oil immersion used! </li></ul><ul><li>Examine at low power first. x40, x100, x400 </li></ul><ul><li>Check the background </li></ul><ul><li>Before issuing report Check all clinical details again. </li></ul>
  11. 11. “ Normal CSF” and “Abnormal CSF” <ul><li>NORMAL </li></ul><ul><li>Acellular ---- check that this is a clear fluid specimen </li></ul><ul><li>?Problems with preparation </li></ul><ul><li>Scanty cells </li></ul>
  12. 12. Abnormal CSF <ul><li>ABNORMAL </li></ul><ul><li>Very cellular </li></ul><ul><li>Mixed Inflammatory exudate </li></ul><ul><li>Lymphocytic cells </li></ul><ul><li>Clusters of cells </li></ul><ul><li>Abnormal cells </li></ul><ul><li>Background </li></ul><ul><li>Bacteria </li></ul><ul><li>Pigment </li></ul><ul><li>Fungi </li></ul><ul><li>“ mucoid” material </li></ul><ul><li>Contaminants </li></ul>
  13. 13. Background -- very very important <ul><li>Children on a safe happy holiday in Namibia </li></ul>Bloodstained fluid – intact erythrocytes –
  14. 14. Specimens from Neurology/ Neurosurgery / HIV/AIDS Clinic, A&E <ul><li>Neurology: often non specific symptoms and signs ---- MS, ME, sarcoidosis, Parkinsons, Alzheimers. </li></ul><ul><li>Lymphoid cells, plasma cells, macrophages </li></ul><ul><li>Neurosurgery ---- surgery for subarachnoid haemorrhage, tumours of brain tissue, pituitary tissue, cystic lesions of brain, metastatic neoplasms. </li></ul><ul><li>Macrophages, Neoplastic cells, “foreign cells, </li></ul><ul><li>HIV/AIDS --- Cerebral deterioration, ? lymphoma ? Tuberculosis ? Fungal infection </li></ul><ul><li>A & E ---- acute meningitis, meningococcal, streptococcal, “stroke”, SAH </li></ul>
  15. 15. Acute Inflammation Meningitis High power view Polymorphs Low power view polymorphs DR Bryan Knight Vancouver
  16. 16. Lymphoid Cells
  17. 17. Mixed Inflammatory Infiltrate Camouflage !
  18. 18. What are these small round structures?
  19. 19. Mixed Plasma cells and Lymphocytes and small round structures with concentric rings
  20. 20. Special stain – mucicarmine. Cryptococci Mucin stain ( PAS for glycogen stains cells and talc granules too)
  21. 21. Sputum from same patient when reviewed showed Cryptococci
  22. 22. This patient was a fit healthy man. Admitted with severe dyspnoea. Sputum: ?abnormal cells, TB bacilli, Sputum NAD TB culture negative. Patient developed severe headaches ? Miliary Tuberculosis CSF showed cryptococci. Hobby: exploring caves. Cryptococcal infection is usually an opportunistic organism in patients with HIV/AIDS or immunosuppression .
  23. 23. Tuberculosis in CSF <ul><li>Cytological appearances are not specific, </li></ul><ul><li>maybe lymphocytic or mixed inflammatory cells </li></ul><ul><li>Maybe cloudy fluid, with necrotic background </li></ul><ul><li>Area of endemic TB/ “at risk” person </li></ul><ul><li>Clinical Suspicion </li></ul><ul><li>HIV/AIDS </li></ul><ul><li>Immunosuppression </li></ul><ul><li>History of previous/current TB </li></ul>
  24. 24. Tuberculosis and HIV/AIDS The “Terrible Twins” <ul><li>Ziehl Neehlsen stain for acid fast TB bacilli </li></ul>
  25. 25. Examine Papanicolaou stained slide under Fluorescent light at 450 μ m TB bacilli are fluorescent !
  26. 26. “ CSF” received from a five year old sheep farmer’s daughter <ul><li>CSF was actually from the orbit ! </li></ul><ul><li>Refractile hooklets from Echinococcus granulosus </li></ul><ul><li>Hydatid disease spread by the black - backed jackal to sheep and sheep dogs. </li></ul>
  27. 27. Hydatid disease presents as a cyst in any tissue of the body. Clear fluid is aspirated . Hooklets seen. Sometines scolices and the laminated membrane brain cyst cytology specimen autopsy specimen rostellum hooklets
  28. 28. Hydatid Disease ( Echinococcus granulosus) Histology of Cyst wall laminated membrane Cyst wall & daughter cysts
  29. 29. Abnormal Cells in CSF <ul><li>Lymphoma /Leukaemia </li></ul><ul><li>Metastatic tumours </li></ul><ul><li>Childhood tumours </li></ul><ul><li>Primary Intracranial “Tumours” /Cysts </li></ul><ul><li>Primary Intracerebral Tumours </li></ul><ul><li>Patients are often in Oncology Clinic </li></ul>
  30. 30. Lymphoma/ Leukaemia AIDS patients develop cerebral and other extranodal B-cell lymphomas due to loss of the surveillance function of T-cells . Pap Papanicolaou stain MGG /Giemsa stain Dr Bryan Knight
  31. 31. Metastatic Malignant Melanoma with Macronucleoli --- “Big Mac” Cell types: Small “lymphoid”, Binucleate, Multinucleate, Balloon. ** Prominent macronucleoli ( L.Koss)
  32. 32. Metastatic neoplasms Breast, lung, ovary, testis Breast Ovarian squamous ca Choriocarcinoma
  33. 33. Metastatic Retinoblastoma
  34. 34. Medulloblastoma
  35. 35. Retinoblastoma and ?pinealoblastoma
  36. 36. Craniopharyngioma Cyst Or ? squamous carcinoma
  37. 37. Capillary Haemangionblastoma Intraoperative smears
  38. 38. Primary Brain Tumours Intra operative smears
  39. 39. Pitfalls and Mimicry in Cytology <ul><li>Oogpister or “Eye pisser” in the Namib desert mimics a lizard </li></ul>Pollen grain which can be mistaken for parasitic remnants
  40. 40. Report on what you see, not what you expect to see. Scan, look for the “odd man out”. Be aware of odd/ unusual appearances, Avoid complacency !
  41. 41. This is a giraffe in Etosha, Namibia White bone in mouth ! Giraffes are herbivorous! Lack of calcium in leaves of local acacia trees. Giraffes suck bones to avoid osteoporosis !! Look carefully!
  42. 42. Remember ! There is more to Cytology than meets the Eye . So keep an eye out !
  43. 43. Further Reading <ul><li>J. Bell, J.Clin Pathol, 1994; 47 :573-378 </li></ul><ul><li>Update on Central nervous System. Cerebrospinal Fluid. </li></ul><ul><li>Website : Neuropathology, Dimitri P. Agamonolis, Akron Childrens’ Hospital, N.E Ohio, University Colleges of Medicine. ( excellent images, videos, discussions). </li></ul>
  44. 44. Dedication <ul><li>This presentation is dedicated to the memory of </li></ul><ul><li>The late Mr Patrick Carey , Neurosurgeon, RCSI, Dublin. </li></ul><ul><li>and </li></ul><ul><li>The late Professor P.J. Bofin, Neuropathologist, RCSI, Dublin. </li></ul>

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