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Cerebrospinal fluid

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Cerebrospinal fluid

  1. 1. CEREBROSPINAL FLUID CSF DR. U. RATHNA KUMARI MD – Post Graduate IPEM
  2. 2. Liquor cerebrospinalis <ul><li>A clear, colorless fluid that surrounds and permeates the CNS. </li></ul><ul><li>Offers support, protection and nourishment. </li></ul><ul><li>In essence, the brain &quot;floats&quot; in it. </li></ul>
  3. 3. <ul><li>Cerebrospinal fluid (CSF) is a clear fluid present in the ventricles of the brain, the central canal of the spinal cord, and the subarachnoid space. </li></ul><ul><li>CSF is produced in the brain by modified  ependymal cells in the  choroid plexus  (approx. 50-70%), and the remainder is formed around blood vessels and along ventricular walls.  </li></ul>
  4. 4. Functions of CSF <ul><li>Protects, lubricates the brain </li></ul><ul><li>Provides nutrients, removes waste </li></ul><ul><li>90-150 ml adult </li></ul><ul><li>10-60 ml in newborn </li></ul><ul><li>Modulates pressure changes ( Buoyancy) </li></ul><ul><li>Serves as a chemical buffer to maintain constant ionic environment </li></ul><ul><li>Serves as a transport medium for nutrients and metabolites, endocrine substances and even neurotransmitters </li></ul>
  5. 6. Location of CSF <ul><li>Two lateral ventricles </li></ul><ul><li>Third ventricle </li></ul><ul><li>Fourth ventricle </li></ul><ul><li>Spinal cord central canal </li></ul><ul><li>Subarachnoid space </li></ul><ul><li>Continuous with extracellular fluid of brain parenchyma </li></ul>
  6. 7. <ul><li>CSF flows through the subarachnoid space between the arachnoid and pia mater </li></ul><ul><li>20 ml of fluid produced every hr in choroids plexus and reabsorbed by arachnoid villi </li></ul>
  7. 9. Formation of CSF <ul><li>Choroid plexuses of lateral, third and fourth ventricles </li></ul><ul><li>Ependymal lining of ventricular system </li></ul><ul><li>Pia-glial membrane </li></ul><ul><li>Blood vessels </li></ul><ul><li>Cells are believed to actively secrete Na + into the ventricular system in exchange for K + . Sodium ions electrically attract Cl - and osmotically draw water from the blood vascular system to constitute the CSF. </li></ul>
  8. 11. Circulation of CSF <ul><li>Lateral ventricles </li></ul><ul><li>interventricular foramen of Monroe </li></ul><ul><li>third ventricle </li></ul><ul><li>mesencephalic aqueduct </li></ul><ul><li>(aqueduct of Sylvius) </li></ul><ul><li>fourth ventricle </li></ul><ul><li>spinal cord central canal; </li></ul><ul><li>also, out the lateral apertures to the subarachnoid space to the venous system </li></ul>
  9. 12. <ul><li>foramina of Magendie  (Median aperture) and  foramina of Luschka (Lateral apertures); </li></ul><ul><li>Circulates, </li></ul><ul><li>Due to pulsation of blood in choroid plexus </li></ul><ul><li>Due to pulsation of ependymal cells </li></ul>
  10. 13. Circulation of CSF
  11. 14. Absorption of CSF <ul><li>Through the arachnoid villi, a protrusion of arachnoid membrane into the central venous sinus and other sinuses </li></ul><ul><li>A valve opens when CSF pressure exceeds venous pressure </li></ul><ul><li>Absorption by veins and capillaries of CNS </li></ul>
  12. 15. arachnoid granulation
  13. 16. <ul><li>It is suggested that CSF flow along the  cranial nerves  and spinal nerve roots allow it into the lymphatic channels. </li></ul><ul><li>plays a substantial role in CSF reabsorbtion, in the  neonate , where arachnoid granulations are sparsely distributed. </li></ul>Absorption of CSF
  14. 17. Composition of CSF
  15. 18. Normal CSF <ul><li>Thin, colourless, clear fluid </li></ul><ul><li>Pressure 90-180mm WATER (10-100 neonates) </li></ul><ul><li>0-5 WBC’s /mm 3 (neonates 0-30/ mm 3 ) </li></ul><ul><li>(Lymphocytes & monocytes) </li></ul><ul><li>Occasional ependymal or choroid plexus cells </li></ul><ul><li>Protein 15-45mg/dl </li></ul><ul><li>Glucose 50-80mg/dl </li></ul><ul><li>Chloride 113-130 mEq/L </li></ul><ul><li>Sterile </li></ul>
  16. 19. CSF GLUCOSE <ul><li>Glucose enters the CSF by selective transport across the blood-brain barrier. </li></ul><ul><li>normal value 60 – 70 percent that of the plasma glucose. </li></ul><ul><li>The diagnostic significance. </li></ul><ul><li>low CSF glucose can be considerable diagnostic value in determining the causative agents in meningitis. </li></ul>
  17. 20. Clinical significance of elevated protein values <ul><li>Elevated total protein values are most frequently seen in pathologic conditions. </li></ul><ul><li>elevated CSF protein due to damage to the blood brain barrier. </li></ul>
  18. 21. <ul><li>CSF GLUTAMINE </li></ul><ul><li>Glutamine is produced in the CNS by the brain cells from ammonia and alpha-ketoglutarate. </li></ul><ul><li>removes the toxic metabolic waste product ammonia from the CNS. </li></ul><ul><li>Normal concentration of ammonia is 8-18 mg/dl. </li></ul><ul><li>Elevated levels associated with liver disorders. </li></ul>
  19. 22. <ul><li>CSF LACTATE </li></ul><ul><li>Aid in the diagnosis and management of meningitis cases </li></ul><ul><li>Destruction of tissue within the CNS owing to oxygen deprivation (hypoxia) causes the production of increased CSF lactic acid levels. </li></ul>
  20. 23. Blood-Brain Barrier (BBB) <ul><li>physiological barrier to flow of substances from blood to brain tissue </li></ul><ul><li>The BBB functions to preserve a stable environment for neurons of the CNS </li></ul>
  21. 24. Blood-Brain Barrier (BBB)
  22. 25. Brain capillary <ul><li>Tight junctions </li></ul><ul><li>Surrounded by astrocytes </li></ul><ul><li>Carrier mediated transport of glucose and amino acids </li></ul>
  23. 26. Blood-Brain Barrier <ul><li>Lipid soluble molecules will cross easily. </li></ul><ul><li>High CO 2 /low O 2 produce vasodilation and decrease resistance of BBB </li></ul><ul><li>Injury or inflammation </li></ul><ul><li>decreases the resistance of BBB (allows some antibiotics to be used for treatment) </li></ul>
  24. 27. Circumventricular organs (CVO) <ul><li>Selected brain areas are not protected by the BBB – the circumventricular organs (CVO) bordering on the 3 rd and 4 th ventricles </li></ul><ul><ul><li>parts of the hypothalamus - median eminence </li></ul></ul><ul><ul><li>neurohypophysis </li></ul></ul><ul><ul><li>pineal gland </li></ul></ul><ul><ul><li>area postrema </li></ul></ul><ul><ul><li>subfornical organ </li></ul></ul><ul><ul><li>subcommissural organ </li></ul></ul>
  25. 28. Hydrocephalus <ul><li>An abnormal increase in the volume of CSF </li></ul><ul><li>Symptoms: sleep changes, spastic paresis, papilledema, bulging of skull in young, seizures, cranial nerve deficits, depression. </li></ul>
  26. 29. Hydrocephalus
  27. 31. CAUSES OF HYDROCEPHALUS <ul><li>Meningitis: pneumococcal, TB </li></ul><ul><li>Intrauterine infections </li></ul><ul><li>IVH </li></ul><ul><li>Lesions, Tumors or malformations of the posterior fossa </li></ul><ul><li>PATHOLOGY </li></ul><ul><li>AQUEDUCTAL STENOSIS: </li></ul><ul><ul><li>Abnormally narrow aqueductus of sylvius. </li></ul></ul>
  28. 32. Hydrocephalus <ul><li>Communicating </li></ul><ul><li>– due to excessive formation of CSF or lack of absorption </li></ul><ul><li>Non-communicating – due to obstruction of flow through ventricle system </li></ul>
  29. 33. Ventriculo-peritoneal shunts
  30. 34. Jugular compression maneuver (Queckenstedt maneuver) <ul><li>Compress jugular veins in neck - increases CSF pressure at the cerebellomedullary cistern and the lumbar cistern (normal) </li></ul><ul><li>Decreased pressure at lumbar cistern indicates blockage of spinal central canal </li></ul>
  31. 35. Lumbar puncture <ul><li>a  lumbar puncture  (or  LP , and colloquially known as a  spinal tap ) </li></ul><ul><li>is a  diagnostic   procedure that is performed in order to collect a sample of  cerebrospinal fluid  (CSF) for  biochemical , microbiological , and  cytological  analysis </li></ul>
  32. 37. lumbar puncture
  33. 38. <ul><li>Spinal cord terminates at L1; needle entry must occur distal to this location </li></ul>
  34. 39. <ul><li>Proper angle of entry through the L3-L4 interspace </li></ul>
  35. 41. full flexion
  36. 43. Level of entry
  37. 44. Spinal needle
  38. 45. Spinal needle
  39. 46. Under strict aseptic precautions.,
  40. 47. Lp - layers <ul><li>1- Skin 2- Facia and SC fat 3- Surpaspinous ligament 4- Interspinous ligament 5- Ligamentum flavum 6- Epidural space (epidural anesthesia needle stops here) 7- Dura 8- arachnoid </li></ul><ul><li>Right after that the needle pops into the subarachnoid space where the CSF is. </li></ul>
  41. 50. The opening pressure 
  42. 51. Collecting the CSF
  43. 52. Appearance of CSF <ul><li>clear and colourless (normal); </li></ul><ul><li>bright red - This indicates the presence of blood. The appearance of fresh blood in all three tubes supports the diagnosis of a subarachnoid hemorrhage. </li></ul><ul><li>xanthochromic (yellow) - jaundice </li></ul><ul><li>xanthochromic (yellow) - suggests a subarachnoid hemorrhage has recently occurred </li></ul><ul><li>turbid - This indicates the presence of white cells and is suggestive of a CNS infection. </li></ul>
  44. 53. Cell counts <ul><li>increased neutrophils - This indicates a bacterial meningitis, cerebral abscess, </li></ul><ul><li>increased lymphocytes - This indicates a viral meningitis, tuberculosis, syphilis, fungal and parasitic infections. </li></ul><ul><li>Degenerative diseases of the CNS, such as multiple sclerosis, will also generate elevated lymphocyte counts. </li></ul>

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