Lumbar Puncture and CSF Analysis: Katherine Pesalbo

LUMBAR PUNCTURE AND
CSF ANALYSIS
KATHERINE PESALBO
 CSF is an invaluable diagnostic aid in the evaluation of inflammatory conditions, infectious or non -
infectious, involving the brain, spinal cord, and meninges, and CT - negative subarachnoidal hemorrhage
and in leptomeningeal metastases
LUMBAR PUNCTURE
CONTRAINDICATIONS
 Infected skin
 Coagulation defect
 Platelet Count, INR, PTT
 Platelet count of <20,000 uL – contrainidication
 Platelet count of >40 ,000 uL – prior to LP
 Platelet count of >50, 000 and INR of <1.5 – bleeding rarely ocuurs
ASRA GUIDELINES FOR PATIENTS RECEIVING ANTICOAGULANT
AND ANTIPLATELET
 Unfractionated Heparin (UFH), Therapeutic Dosing - discontinuing UFH 2–4 h

 Low-Molecular-Weight Heparin (LMWH), Therapeutic Dose – stopped for at least 24 h prior
 Warfarin – contraindication, stopped 4–5 days prior to the LP
 Aspirin and Nonsteroidal Anti-inflammatory Drugs - unlikely to cause bleeding
COMPLICATIONS
MAJOR MINOR
 Cerebral herniation  Backache

 Injury to the spinal cord or  post-LP headache
nerve roots  Radicular pain or numbness
 Hemorrhage (spinal
hematoma)
 Infection
IMAGING AND LABORATORY PRIOR TO LP
 For patients who have an altered level of consciousness, a focal neurologic deficit, new-onset seizure, papilledema.
 Should rule out focal mass lesion or spinal cord compression
 Meningitis
ANALGESIA
 Lorazepam 1–2 mg given PO 30 min prior or IV 5 min prior

 Lidocaine 4% - applied 30 min prior to the procedure
POSITIONING
 The patient is asked to lie on his or her side, facing away from the
examiner, and to “roll up into a ball.” The neck is gently ante-flexed and
the thighs pulled up toward the abdomen; the shoulders and pelvis
should be vertically aligned without forward or backward tilt’
 LP is therefore performed at or below the L3–L4 interspace
 Anatomic guide is a line drawn between the posterior superior iliac
crests, which corresponds closely to the level of the L3–L4 interspace.
 Can be done in seating position but the opening pressure will not be
accurate
TECHNIQUE
 1. Identify desired site for needle insertion

 6. Inject 1% licocaine 3–5 mL into the subcutaneous
 2. Put on sterile gloves
tissue
 3. Cleanse the skin with povidone-iodine or similar
 7. Insert LP needle (20- to 22-gauge) in the midline,
disinfectant
midway between two spinous processes
 4. Drape the area with a sterile cloth
 8. Once the SAS is reached, attach manometer to the
 5. Blot dry the needle insertion site using a sterile needle and measure the opening pressure
gauze pad
TECHNIQUE
CSF Analysis:
 (1) cell count with differential
 (2) protein and glucose concentrations
 9. CSF is allowed to drip into collection tubes; it should  (3) culture (bacterial, fungal, mycobacterial, viral)
not be withdrawn with a syringe
 (4) Gram’s and acid-fast stained smears
 10. Prior to removing the LP needle, the stylet is
reinserted to avoid the possibility of entrapment of a  (5) latex agglutination
nerve root in the dura as the needle is being withdrawn  (6) PCR amplification of DNA or RNA
 (7) antibody levels against microorganisms
 (8) immunoelectrophoresis for determination of γ-
globulin level and oligoclonal banding
 (9) cytology
BLOODY TAP
 Clear CSF after centrifugation – bloody tap

 Xanthochromic CSF after centrifugation - suggests SAH
 Also present in patients with liver disease and markedly elevated CSF protein concentration
POSTDURAL-PUNCTURE HEADACHE
 Occurs in 10–30% of patients

 Caused by drop in the CSF pressure due to leakage at the LP site where the needle entered the SAS
 Begins within 48 h but may be delayed for up to 12 days
 Nausea and stiff neck often accompany headache, sometimes, patients report blurred vision, photophobia, tinnitus,
and vertigo
 Resolves without specific treatment
 Supportive analgesics and antiemetics
 Position: head-down Trendelenburg, lateral decubitus position
 Persistent pain (Epidural blood patch): injection of 15 mL of autologous whole blood directed at the epidural
space at the level of the initial LP.
ATRAUMATIC VS TRAUMATIC NEEDLES
 “Atraumatic” needle has its opening on the top surface of the needle, a
design intended to reduce the chance of cutting dural fibers
NORMAL VALUES
 <5 lymphocytes and monocyte per uL

 PMN and RBC are not found in normal CSF
 In traumatic tap RBC number decreases as additional CSF is
collected
 CSF Glucose concentration of <2.2 mmol/L (<40 mg/dL) is
abnormal
 Normal CSF Protien concentration is >50 mg/dL
CSF GLUCOSE CONCENTRATION & CSF:SERUM GLUCOSE RATIO
 Glucose is actively transported across the blood – brain barrier

 CSF glucose levels are directly proportional to the plasma levels and simultaneous measurement in CSF and blood
is required during LP
 Normal CSF glucose concentration is 50 – 60% of serum values
 CSF/serum glucose ratio <0.4 – 0.5 is considered to be pathological
 A high CSF glucose concentration has no specific diagnostic importance when related to an elevated blood
glucose concentration, in diabetics.
CSF LACTATE & CSF GLUCOSE
 CSF lactate is independent of blood concentration

 The normal value is considered to be < 2.8– 3.5 mmol/l
 CSF lactate correlates inversely with CSF/serum glucose ratio… Except in mitochondrial disease
 Decreased CSF/serum glucose ratio or increased CSF lactate indicates bacterial and fungal infections or
leptomeningeal metastases
TOTAL PROTEIN
 Integrity of the CSF barrier determine the protein content of the CSF
 Elevated CSF protein concentrations can be found in the majority of patients with bacterial (0.4 – 4.4 g/l), cryptococcal (0.3 – 3.1 g/l), tuberculous
(0.2 – 1.5 g/l) meningitis and neuroborreliosis
 A concentration of > 1.5 g/l is specific (99%), but insensitive (55%) for bacterial meningitis compared to other inflammatory diseases
 In viral neuroinfections, CSF protein concentrations are raised to a lesser degree (usually < 0.95 g/l)
 In herpes simplex virus encephalitis CSF protein concentration is normal in half of the patients during the first week of illness
 Non - infectious causes for an increased CSF protein and sometimes with an increased cell count include:
 Subarachnoid hemorrhage
 Central nervous system (CNS) vasculitis
 CNS neoplasm
 Elevated total protein concentration with normal CSF cell count is a hallmark in acute and chronic inflammatory demyelinating polyneuropathies
 Total CSF protein is elevated in 80% of patients with leptomeningeal metastases
QUALITATIVE (OLIGOCLONAL) INTRATHECAL IGG SYNTHESIS
 Used to assist in the diagnosis of autoimmune disorders of the CNS, such as paraneoplastic disorders and CNS
infections
 Intrathecal oligoclonal IgG in the CSF is one of the laboratory criteria supporting the clinical diagnosis of Multiple
Sclerosis
CYTOLOGY
 Lymphocytes and monocytes at the resting phase and occasionally ependymal cells are found in normal CSF
 Increased number of neutrophilic granulocytes can be found in bacterial and acute viral CNS infections
 Macrophages containing haematoidin (crystallized bilirubin) degraded from haemoglobin may appear about 2 weeks after
bleeding and are a sign of a previous subarachnoid bleeding
 Spectrophotometry of CSF - recommended method of choice for CT – negative subarachnoid bleeding up to 2 weeks after onset
 Presence of macrophages without detectable intracellular material is a non - specific finding, occurring in: disc herniation,
malignant meningealinfi ltration, spinal tumours, head trauma, stroke, MS, vasculitis, infections, and subarachnoid
hemorrhage
 Presence of >10 or more eosinophils/μl in CSF or eosinophilia of at least 10% of the total CSF leukocyte count is
associated with parasitic infections and coccidioiodomycosis
 Malignant CSF cells indicate leptomeningeal metastases.
 False - positive results occur when infl amatory cells are mistaken for tumour cells or from contamination of the peripheral blood

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LUMBAR PUNCTURE AND

 Unfractionated Heparin (UFH), Therapeutic Dosing - discontinuing UFH 2–4 h

 Cerebral herniation  Backache

 Lorazepam 1–2 mg given PO 30 min prior or IV 5 min prior

 1. Identify desired site for needle insertion

 Clear CSF after centrifugation – bloody tap

 Occurs in 10–30% of patients

 <5 lymphocytes and monocyte per uL

 Glucose is actively transported across the blood – brain barrier

 CSF lactate is independent of blood concentration

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