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Location
Ventricular system
Subarachnoid space (including cysternal system)
Function
Protect
the CNS from mechanical insult (as a
cushion)
Maintain the equilibrium of neuronal and glial
Remove the waste products of neuronal metabolism
Determine pulmonary ventilation and
CBF according to its acidity

CSF
Aim of its examination
Diagnostic
Treatment evaluation or follow up
Prognostic
Formation
Rate 0.35 mL/minute ~ 500 mL/day
Formed by :
Choroid plexuses at :
Floor of each lateral ventricles (largest and
most important)
Roofs of the third and fourth ventricles (smaller)
Capillary beds that supply the pia and
arachnoid (smaller)
Ependyma and subjacent glial elements (smaller)
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Formation (ctnd)
A complex process :
Active transport (expenditure of energy)
Passive diffusion

CSF

Active transport
Cuboid epithelial cells (in choroid pelxus) secrete Na ion
Positive potential attracts negative ion especially Cl
Many of ionic solutes increase osmotic pressure
Water and other solutes follow in
maintaining osmotic equilibrium
Passive diffusion
Continual diffusion occurs at :
Ependyma and vascular beds
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CSF
Dynamic
Total volume of CSF : 75 100 mL
( 15-40 mL at ventricular system)
Rate of production 0.35 mL/min ~ 500 mL/day
Daily turn over 4-5 times
Circulation
Lateral ventricles Monro foramenThird ventricle
Sylvii aqueductFourth ventricle
Luschka and Magendie foramina
Subarachnoid space (cysternal system)
superior and lateral convexity of brain hemispheres
Arachnoid villi
venous sinuses
(venous blood flow)

CSF
Absorption
Mainly at Arachnoid villi (Arachnoid granulation or
Pacchionian bodies)
Others (smaller) : veins and capillary of piamatter
Unidirectional (valve)
Mechanism - Depends on :
Hydrostatic pressure (high to low)
Colloid osmotic pressure (low to high)
Active transport by cells forming
the walls of the arachnoid villi

CSF
Composition
Water
Small amount of protein
Gases in solution (O and CO )
2
2
Na+, K+, Ca2+, Mg2+, Cl-, Glucose
A few white cell
Organic constituents

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CSF
Normal values
Color
Pressure
Cell
Glucose
Protein

Clear, colorless
70-200 mmH2O
0-5/mm3 (lymphocyte or mononuclear cell)
45-80 mg%
5-15 mg%
(ventricles)
10-25 mg%
(cysternal)
15-45 mg%
(lumbar)
-globulin
5-22 % total protein
Osmolaritas
295 mOsmol/L
pH
7.31
Natrium142-150 mEq/L
Kalium
2.2-3.3 mEq/L
Chloride
120-130 mEq/L
Magnesium
2.7 mEq/L
CO2
25
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Pressure
Depends on :
Rate of formation and absorption
Flow disturbance

CSF

Measurement :
Manometer while Lumbar or Cysternal puncture
Position :
Lateral decubitus
Sitting

: Normal pressure 70-200 mmH2O

: 280 mmH2O

Normally slight increase in case of

Coughing or straining
Change in heart beat and respiratory cycle
Pressure on abdomen

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CSF

Pressure
Change in flow disturbance
Queckenstedt Test press on jugular veins result in
normally increase CSF pressure and return to normal limit in 10
CSF obstruction nothing or slightly increase CSF ressure
Cell

: Leucocytes or PMN means pathologic I.e infection of

bacterial, fungal, viral, chemical agents, tumor

Protein : higher than normal limit means pathologic condition

Glucose

: two third of blood glucose; below 40 mg%

abnormal (i.e in pyogenic infection,
tuberculous/fungal meningitis)

Electrolytes : low chloride concentration meningitis (but not

specific)

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CSF
Osmolality

: similar to blood plasma

Acidity (pH) : Lower than blood

pCO2
: Higher than blood
In subacute or chronic metabolic acidosis :
CSF acidity relatively un-changed

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CSF
Disorders of CSF
Flow disurbance
Accompany other diseases
Flow disturbance
Obstruction occurs in CSF flow in ventricular system or
subarachnoid space
Result in Hydrocephalus
Non-communicating :
Common in children
Caused by aqueduct stenosis, over-growth of foramina
Luschka and Magendie
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CSF
Disorders of CSF

Communicating hydrocephalus

Common in adult
Free communicating between ventricles and subarachnoid space
Obstruction at subarachnoid space
Caused by inflammation, subarachnoid bleeding, tumor growth

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CSF|LP
LUMBAL
Indication :
PUNCTURE

Measure CSF pressure

Obtain sample for cell count, chemical work-up,
bacteriology
Intrathecal treatment/procedure :
spinal anesthesia,
antitumors, antibiotics
Diagnostic procedure : pneumoencephalography,
myelography, scintigraphic cysternography

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Indications:

CSF|LP

Suspect meningitis
Suspect encephalitis
Diagnose meningeal carcinomatosis
Diagnose tertiary syphilis
Diagnose meningeal leukemia
Staging of lymphomas;
Follow up therapy for meningitis
Evaluation of dementia
Evaluation for Guillain-Barre
Treat pseudotumor cerebri
Evaluation for multiple sclerosis
R/O subarachnoid hemorrhage (after neg. head CT)
Instillation of drugs, anesthetics, or radiographic media into CNS

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CSF|LP
Technique
Preparation :
Take blood sample for glucose 15 before LP
Explain the procedure to patient
Obtain informed consent
Exclude possibility of increased ICP or
CNS mass lesion (eye exam/ head CT).
Position :
Lateral decubitus in full flexion posture
At the bed side
Small cushion on head or knee (if needed)

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CSF|LP
Technique
Site of puncture
Inter-vertebral space at vertebra L3 L4
Imaginary line connecting iliac crests
Other site (if failed) : L2-L3 or L4-L5
Infant/children at L4-L5

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CSF|LP
Technique
Sitting position if failed in recumbent (2-3 times)
Measure (opening) pressure
Patient preparation
Aseptic technique :
Clean the area using iodine 10%
application in round move
starting from the center
Change glove once
Use sterile covering/towel

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CSF|LP
Technique
Insertion :
All tools available : spinal needle (18,19,20),
manometer, sterile bottles (3)
Local anesthetic (lidocaine 1-2%) :
0.1-0.2 mL subcutaneous and
0.2-0.5 mL deeper
Introduce spinal needle, with bevel turned up,
into interspace, in a horizontal direction,
with slightly cephalad inclination
("aim for the belly button").
Always have stylet in place when
maneuvering needle in interspace.

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CSF|LP
Measure opening pressure (normal is 100-250 mmHg): If
pressure elevated, ask pt to relax and ensure that there is no
abdominal compression or breath holding (straining and
abdominal pressure can increase ICP).
If pressure markedly elevated, remove only 5 cc of spinal fluid
and remove needle immediately.
Else, collect 15-20 cc in four collection tubes (2 cc per tube),
and remove needle (with stylet in place). Can send extra fluid in
tube #3, or in extra red-top (#5).
Instruct pt to lie flat for approx. 4 hrs to minimize post LP
headache (caused by CSF leakage).

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CSF|LP

Contraindications:
Infection at intended site of LP
Anticoagulation;
Increased intra-cranial pressure
Severe hemorrhagic diathesis
CNS mass lesion in posterior fossa
Suspect venous sinus occlusion

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CSF|LP
Complication
Headache
Backache
Intracranial subdural hematoma
Infection
CSF leak
Herniation

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