Neurological data interpretation, Cerebrospinal fluid analysis, Lumber Puncture, Normal results of CSF, Abnormal Results of CSF(Bacterial Meningitis, Viral Meningitis, Tuberculous Meningitis, Subarachnoid Hemorrhage, Guillian Barre Syndrome), CT scan, MRI, Electroencephalogram(EEG)..

1. Neurological
Data

2. Cerebrospinal
fluid analysis

3. Cerebrospinal fluid
• Cerebrospinal fluid is an ultra filtrate of plasma, present in both
intracranial and spinal compartments. It is continuously being
secreted by the choroid plexus at a constant rate inside the
ventricles of the brain and circulates in the subarachnoid space
of the brain and spinal cord through CSF pathways.
• Functions of the CSF:
1. Protection of the CNS
2. Nourishment
3. Waste removal

4. Lumbar
Puncture
Also called (spinal tap), Is a
medical procedure in which a
needle is inserted into the spinal
canal, most commonly to collect
cerebrospinal fluid for diagnostic
testing.

5. Normal results of CSF

6. Normal range
Color Clear
Specific gravity
pH
1.006–1.007
7.4
pressure 50–200 mm H2O
RBCs count Nil
WBC count 0–5 (upto 30 in neonates)
WBC types Lymphocytes
CSF Proteins 15–40 mg/dL
CSF lactate 1–3 mmol/ L
CSF glucose 50–80 mg/dL (two thirds of blood glucose)
Microbial examination No microorganism

7. Interpretation of abnormal
results

8. Appearance: cloudy and turbid
Pressure: elevated (>25 cm H₂O)
WBC: elevated >100 cell/µL (primarily polymorphonuclear leukocytes (>90%))
Glucose level: low (<40% of serum glucose)
Protein level: elevated (>50 mg/dL)
Bacterial Meningitis

9. Appearance: clear
Pressure: normal or elevated
WBC: elevated (50 – 1000 cells/µL, primarily lymphocytes, can be PMN early on)
Glucose level: normal (>60% serum glucose, however, may be low in HSV infection)
Protein level: elevated (>50 mg/dL)
Viral (Aseptic) Meningitis

10. Appearance: opaque, if left to settle it forms a fibrin web
Pressure: elevated
WBC: elevated (10 – 1000 cells/µL, mononuclear)
Glucose level: low
Protein level: elevated (1-5 g/L)
Tuberculous Meningitis

11. Appearance: blood-stained initially, then xanthochromia (yellowish) >12 hours later
Pressure: elevated
WBC: elevated (WBC to RBC ratio of approx 1:1000)
RBC: elevated
Glucose level: normal
Protein level: elevated
Subarachnoid Hemorrhage

12. Appearance: clear or xanthochromia
Pressure: normal or elevated
WBC: normal
Glucose level: normal
Protein level: elevated (>5.5 g/L)
Guillain Barre Syndrome

13. An 8-year-old male presents with a 12-hour history of high fever, severe headache,
confusion, photophobia and neck stiffness.
CSF results
Appearance: cloudy
Opening pressure: 30 cm H₂O
WBC: 936 cells/µL (>95% PMN cells)
Glucose level: < 40% of serum glucose
Protein level: 3 g/L
What is the most likely diagnosis? bacterial meningitis

14. An 8-year-old female presents with 24 hours of headache, photophobia and mild neck
stiffness, in addition to coryzal symptoms. She is fully orientated and her observations are
stable.
CSF results
Appearance: clear
Opening pressure: 23 cm H₂O
WBC: 150 cells /µL (primarily lymphocytes)
Glucose level: normal
Protein level: 90 mg/dL
What is the most likely diagnosis? viral meningitis.

15. A 12-year-old male presents to A&E with history of a sudden onset severe headache which
occurred suddenly Since the headache, he has been feeling nauseated, but he is otherwise
well and fully orientated. Examination is appear to have some mild neck stiffness.
CSF results
Appearance: yellowish
Opening pressure: 23 cm H₂O
WBC: normal
Red cell count: raised
Glucose level: normal
Protein level: 80 mg/dL
Xanthochromia: positive
What is the most likely diagnosis? subarachnoid hemorrhage (SAH)

16. CT scan

17. Computed tomography (CT) scan
Facts
• Each CT scan without
contrast = 300 xray
• Each CT with contrast
= 500 xray
Definition :
• A CT of the brain is
a noninvasive
diagnostic imaging
procedure that uses
special x-ray
measurements to
produce horizontal,
or axial, images
(often called slices)
of the brain.

18. Indications
0
1
0
2
0
4
0
3
Headache NV , Seizure ,
papilledema (sign of high ICP)
Before doing LP
A CT brain is ordered to look at the
structures of the brain and evaluate for
the presence of pathology such as:
1. Mass/tumor
2. Fluid collection (such as an abscess)
ischemic processes (such as a stroke)
3. Hemorrhage
4. Trauma and fracture to the skull
hydrocephalus

19. Interpretation
• Site/brain
• View/axial
• Native or contrast
enhanced
• Showing what/ lesion
• Location of the lesion /right
or left....etc...
Mnemonic : Blood Can Be Very
Bad!!
B: Blood
C: Cisterns
B: Brain
V: Ventricles
B: Bone

20. Density
Hyperdense =
white
Hypodense =
black
1.Air
2. Fat
3. Fluid
Infarction
5 tumor
1. Metallic fb
2.Bone structure
3. Calcification
4. Hemorrhage
5. Contrast
substanc

23. Types of intracranial hemorrhage

24. Types of
intracranial
hemorrhage

26. Epidural
hemorrhage

27. Subdural
hemorrhage

28. Intracerebral
hemorrhage with
surrounding
edema

30. Subarachnoid
hemorrhage: cisterns
Other sites: fissures,
circle of Willis...

32. Intraventricular
hemorrhage

33. Hydrocephalus

34. Ischemic stroke
in MCA region

35. Brain MRI

36. Brain MRI
MRI uses a strong magnetic field
and radio waves to create
images.

37. Brain MRI
• Takes longer time
(30-45 mins).
• May need sedation.
• Claustrophobic.
Cons
Pros
• No radiation.
• Better resolution
(soft tissue).

38. Sedation in MRI
Drug options
• Chloral hydrate
• Sodium pentobarbital
• Propofol
HR, RR, BP and O2 sat. should be
monitored during sedation.
• Infants should take nothing by mouth for
at least 4 hours before deep sedation
• Older children take nothing by mouth for
at least 6 hours

39. MRI compatible incubator

40. Brain maturation and MRI

41. Brain maturation and MRI

42. Myelination
Begins before birth
On imaging:
• T1 matures by 8 mo
• T2 matures by 2 yr
• Inferior to superior
• Posterior to anterior
• Central to peripheral
• Matures by 2 years

44. MRI sequences of brain
DWI
Diffusion weighted
image
01
T1WI
T1 weighted image
02
DTI
Diffusion tensor
imaging
05
Fluid attenuation
inversion recovery
FLAIR
04
T2WI
03
T2 weighted image

45. Brain Infographics
04
White > Hyper intense
01
Grey (black) > Hypo intense

46. DWI
● Only brain tissue
● Detection of early acute infarction → Hyperintense

47. T1WI
● White matter → Hyperintense (white)
● Grey matter → Hypointense (grey)

48. T2WI
• White matter → Hypointense (grey)
• CSF → Hyperintense (white)

49. FLAIR
• White matter → Hypointense (grey)
• CSF → Hypointense (black)

50. CT
(bone is white)
MRI
(bone is black)

51. Infarction of brain BY MRI …..
• By DWI hyper intense
• By T1W hypo intense
• By T2W hyper intense
• By FLAIR hyper intense
Brain hemorrhage …..
• DWI not benefit in brain hemorrhage its used only for recent infarction
• T1W, T2W, FLAIR hemorrhage appear hyper
intense in all sequence
T2 FLAIR DWI T1

52. Electroencephalography
(EEG)

53. ● Graphic recording of the time variations of electrical
activity of the brain (almost exclusively “of the brain
cortex”)
● Done by placing small electrodes on the patent’s scalp
● The origin of the electrical activity is likely to be
postsynaptic potentials in the dendrites of the cortical
neurons.
What is EEG

54. EEG
Graphic recording of the brain’s
electrical activity

56. Indications of EEG
• Unprovoked seizures: to support Dx of epilepsy, classify and
localize it, and Follow up of epilepsy (to determine whether to
stop Rx or not)
• Localizing a brain tumor
• Cases of brain damage (toxicity, hypoxia, encephalitis)
• Determining cortical activity in cases of Developmental delay,
encephalopathy, and Coma
• Sleep disorders
• Declaring brain death

57. Types of EEG waveforms
Classified according to their :
• Shape
• Frequency
• Amplitude

58. EEG waveforms: frequency based

59. Types of EEG waveforms
Brain activity is recorded as:
• Background activity
• Transient events

60. Sharp waves >
70msc
Spikes < 70msc
Epileptiform Discharges

61. Simple partial
(focal with
preserved
consciousness)
EEG in Epilepsy
Spikes and Sharp
waves on the
Contralateral
side

62. Rolandic epilepsy
EEG in Epilepsy
Repetitive spikes
in Rolandic
Area

63. Typical Absence
seizure
EEG in Epilepsy
Generalized spike
and wave
pattern at 3 Hz
frequency

64. (Juvenile)
myoclonic
epilepsy
EEG in Epilepsy
Irregular spikes at
4-6 Hz frequency

65. Infantile spasms
EEG in Epilepsy
Hypsarrhythmia
(Chaos) pattern

66. Generalized tonic
clonic seizure
(ictal phase)
EEG in Epilepsy
Generalized
polyspikes

67. Generalized tonic
clonic seizure
(ictal phase)
EEG in Epilepsy
Generalized
polyspikes

68. Herpes encephalitis
Periodic Sharp
waves

69. Thanks