Cerebrospinal fluid
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Transcript of Cerebrospinal fluid
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CEREBROSPINAL FLUIDCSF
DR. U. RATHNA KUMARIMD – Post Graduate
IPEM
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Liquor cerebrospinalis
• A clear, colorless fluid that surrounds and permeates the CNS.
• Offers support, protection and nourishment.
• In essence, the brain "floats" in it.
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• 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.
• 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.
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Functions of CSF
• Protects, lubricates the brain• Provides nutrients, removes waste 90-150 ml adult 10-60 ml in newborn• Modulates pressure changes (Buoyancy) • Serves as a chemical buffer to maintain
constant ionic environment• Serves as a transport medium for
nutrients and metabolites, endocrine substances and even neurotransmitters
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Location of CSF
• Two lateral ventricles
• Third ventricle
• Fourth ventricle
• Spinal cord central canal
• Subarachnoid space
• Continuous with extracellular fluid of brain parenchyma
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• CSF flows through the subarachnoid space between the arachnoid and pia mater
• 20 ml of fluid produced every hr in choroids plexus and reabsorbed by arachnoid villi
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Formation of CSF
• Choroid plexuses of lateral, third and fourth ventricles
• Ependymal lining of ventricular system• Pia-glial membrane• Blood vessels• 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.
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Circulation of CSFLateral ventricles
interventricular foramen of Monroe
third ventricle
mesencephalic aqueduct (aqueduct of Sylvius)
fourth ventricle
spinal cord central canal; also, out the lateral apertures to the subarachnoid space
to the venous system
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• foramina of Magendie (Median aperture) and foramina of Luschka(Lateral apertures);
Circulates,
• Due to pulsation of blood in choroid plexus
• Due to pulsation of ependymal cells
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Circulation of CSF
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Absorption of CSF
1. Through the arachnoid villi, a protrusion of arachnoid membrane into the central venous sinus and other sinuses
• A valve opens when CSF pressure exceeds venous pressure
2. Absorption by veins and capillaries of CNS
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arachnoid granulation
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• It is suggested that CSF flow along the cranial nerves and spinal nerve roots allow it into the lymphatic channels.
• plays a substantial role in CSF reabsorbtion, in the neonate, where arachnoid granulations are sparsely distributed.
Absorption of CSF
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Composition of CSF
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Normal CSF
• Thin, colourless, clear fluid• Pressure 90-180mm WATER (10-100 neonates)• 0-5 WBC’s /mm3 (neonates 0-30/ mm3 ) (Lymphocytes & monocytes)• Occasional ependymal or choroid plexus cells• Protein 15-45mg/dl• Glucose 50-80mg/dl• Chloride 113-130 mEq/L• Sterile
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CSF GLUCOSE
• Glucose enters the CSF by selective transport across the blood-brain barrier.
• normal value 60 – 70 percent that of the plasma glucose.
• The diagnostic significance. low CSF glucose can be considerable
diagnostic value in determining the causative agents in meningitis.
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Clinical significance of elevated protein values
• Elevated total protein values are most frequently seen in pathologic conditions.
• elevated CSF protein due to damage to the blood brain barrier.
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CSF GLUTAMINE
• Glutamine is produced in the CNS by the brain cells from ammonia and alpha-ketoglutarate.
• removes the toxic metabolic waste product ammonia from the CNS.
• Normal concentration of ammonia is 8-18 mg/dl.
• Elevated levels associated with liver disorders.
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CSF LACTATE
• Aid in the diagnosis and management of meningitis cases
• Destruction of tissue within the CNS owing to oxygen deprivation (hypoxia) causes the production of increased CSF lactic acid levels.
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Blood-Brain Barrier (BBB)
• physiological barrier to flow of substances from blood to brain tissue
• The BBB functions to preserve a stable environment for neurons of the CNS
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Blood-Brain Barrier (BBB)
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Brain capillary
• Tight junctions• Surrounded by astrocytes• Carrier mediated transport of glucose and amino
acids
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Blood-Brain Barrier
• Lipid soluble molecules will cross easily.
• High CO2/low O2 produce vasodilation and decrease resistance of BBB
• Injury or inflammation
decreases the resistance of BBB (allows some antibiotics to be used for treatment)
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Circumventricular organs (CVO)
• Selected brain areas are not protected by the BBB – the circumventricular organs (CVO) bordering on the 3rd and 4th ventricles– parts of the hypothalamus - median eminence– neurohypophysis– pineal gland– area postrema– subfornical organ– subcommissural organ
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Hydrocephalus
• An abnormal increase in the volume of CSF
• Symptoms: sleep changes, spastic paresis, papilledema, bulging of skull in young, seizures, cranial nerve deficits, depression.
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Hydrocephalus
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CAUSES OF HYDROCEPHALUS
• Meningitis: pneumococcal, TB
• Intrauterine infections
• IVH
• Lesions, Tumors or malformations of the posterior fossa
PATHOLOGY• AQUEDUCTAL STENOSIS:
– Abnormally narrow aqueductus of sylvius.
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Hydrocephalus
• Communicating
– due to excessive formation of CSF or lack of absorption
•Non-communicating – due to obstruction of flow through ventricle system
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Ventriculo-peritoneal shunts
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Jugular compression maneuver (Queckenstedt maneuver)
• Compress jugular veins in neck - increases CSF pressure at the cerebellomedullary cistern and the lumbar cistern (normal)
• Decreased pressure at lumbar cistern indicates blockage of spinal central canal
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Lumbar puncture
• a lumbar puncture (or LP, and colloquially known as a spinal tap)
• is a diagnostic procedure that is performed in order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis
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lumbar puncture
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Spinal cord terminates at L1; needle entry must occur distal to this location
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Proper angle of entry through the L3-L4 interspace
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full flexion
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Level of entry
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Spinal needle
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Spinal needle
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Under strict aseptic precautions.,
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Lp - layers
1- Skin2- Facia and SC fat3- Surpaspinous ligament4- Interspinous ligament5- Ligamentum flavum6- Epidural space (epidural anesthesia needle stops here)7- Dura8- arachnoid
Right after that the needle pops into the subarachnoid space where the CSF is.
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The opening pressure
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Collecting the CSF
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Appearance of CSF
• clear and colourless (normal); • bright red - This indicates the presence of blood.
The appearance of fresh blood in all three tubes supports the diagnosis of a subarachnoid hemorrhage.
• xanthochromic (yellow) - jaundice • xanthochromic (yellow) - suggests a
subarachnoid hemorrhage has recently occurred • turbid - This indicates the presence of white cells
and is suggestive of a CNS infection.
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Cell counts
• increased neutrophils - This indicates a bacterial meningitis, cerebral abscess,
• increased lymphocytes - This indicates a viral meningitis, tuberculosis, syphilis, fungal and parasitic infections.
• Degenerative diseases of the CNS, such as multiple sclerosis, will also generate elevated lymphocyte counts.
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