1. Cerebrospinal fluid - CSF
Clear and colorless liquid in ventricles, cisterns and subarachnoidal spaces of brain and spinal cord
Main source of substances in CSF – plasma

2. CSF Production – secretion - chorioid. plexus in ventricles
Resorbtion -
subarachnoidal spaces
Circulation –
lat. ventricles,
III. ventricle,
aqueduct, IV. ventricle, cisterna magna, subarachnoidal spaces

4. CSF Daily production 500 ml Total amount – 140 ml Pressure 140 mm H2O
Content - proteins, elements, sugar, chlorides

5. CSF

6. Lumbar punction

7. Lumbar punction

8. Lumbar punction Indications
Inflammatory diseases of brain, spinal cord, meninges, roots, nerves
Bleeding – subarachnoid bleeding
Demyelinating diseases (multiple sclerosis, neuromyelitis optica)
Degenerative diseases of brain, spinal cord, meninges, roots
Meningosis carcinomatosa
Tumors
Paraneoplastic disorders
Autoimunne encephalitis

9. Lumbar punction Contraindication Brain oedema - optic fundus
Trombocytopenia – less than

10. Lumbar punction Queckenstedt test Compression of jugular veins
When increased intracranial pressure is also in spinal canal
+ increased CSL pressure – canal without obstruction
- CSL pressure without change - obstruction of spinal canal
Compression of abdomen - does not show obstruction in Th-, C- part.

11. Lumbar punction General appearance of CSF Colorless – normal CSF
Pink, red (oxyhemoglobin) – bleeding – test of 3 tubes (dif.dg.between SAH and arteficial bleeding)
Xantochromia (yellow color) – increased level of proteins, old bleeding

12. Lumbar punction Queckendstedtova skúška tlak dlaňou na jugulárne vény
či sa zvýšený intrakraniálny tlak prenesie na spinálny kanál
+ stúpnutie likvorového stĺpca - kanál priechodný
- nestúpne likvorový stĺpec - kanál nepriechodný
tlak na brucho - neodhalí obštrukciu Th-, C- obl.

13. Lumbar punction Makroskopický vzhľad
Kvantitatívna a kvalitatívna cytológia
Analýza proteínov vrátane imunoglobulínov
Zastúpenie Ig tried
Stanovenie oligoklonálneho IgG
Proteínové markery pre tumory, deštrukciu mozgového tkaniva, demenciu, hypoxiu

14. Bleeding Subarachnoid b. Normal CSF Clear, colorless
Right
Old bleeding
(bilirubin)
Xantochromia
Left
Normal CSF
Normal CSF
Clear, colorless
Arteficial bleeding
Damage of artery
during LP

15. CSF

16. CSF Bleeding Normal CSF Subarachnoid b. Clear, colorless
Arteficial bleeding
Damage of artery
during LP
Old bleeding
(bilirubin)
Xantochromia

17. CSF

18. Lumbar punction General appearance of CSF
Increased CSF viscosity – marked increased of protein content
Change of color – bacterial meningitis, increased proteins

19. Lumbar punction Measurment of CSF pressure by manometer
Pandy´s test – 3 drops of CSF to Pandy reagens – white color of CSF (+, ++, +++) – increased level of protein
We take CSF for examination – 4-10 ml

20. CSF - examination Basic examination Cell account, type of cells
Level of proteins, Cl, glucose
Special examinations - IgG, IgG/alb. index, oligoclonal bands, IgG, IgA, IgM against B. Burorferi, cultivation, VDRL test for syphilis, PCR - TBC a viral infections, antineuronal antobodies - paraneoplastic sy

21. CSF - elements Increased ammount of cells
More than 1000 /µl. - bacterial inflection
 Ly - viral etiology, at the beginning also granulocytes can be present

22. CSF - elements Increased ammount of cells
Neoplastic elements - TU - ependymoma, plexuspapilloma, meduloblastoma,
Carcinomatous cells – MTS to meninges – breast, bronchial carcinoma, melanoma

23. CSF - examination Acute inflammation - granulocytes
Chronic inflammation - Ly, plazmocytes

24. Viral inflammation - lymfocytes

25. Purulent inflammation - granulocytes

26. Subarachnoid haemorrhage

27. Malignant infiltration

28. CSF - proteins  - inflammatory and noninflammatory diseases
albuminocytological disociation – increased proteins, normal or little increased elements
Guillain - Barre sy (polyradiculoneuritis)
Diabetic neuropathy
Compressive CSF (Froin´s sy)

29. Froin syndrom
The combination of elevated protein, xanthochromia, and hypercoagulation of CSF
Froin’s syndrome - occur with blockage of CSF flow by a spinal cord mass or with meningeal irritation from meningitis.
cerebrospinal fluid (CSF) - xanthochromic,
viscous, and coagulated in the tube
CT myelography - large intradural, extramedullary
lesion at T11–T12, which compress the spinal cord

30. CSF - proteins
 IgG – intrathecal production it means intrathecal inflammation

31. CSF - proteins
Within the gamma region, three patterns of bands may be observed including one clone (monoclonal), many clones (polyclonal) and a few bands (3 to 5, or oligoclonal)
Oligoclonal bands are bands of immunoglobulins that are seen when a patient's blood serum, gained from blood plasma, or CSF is analyzed.
Each band represents a homogeneous protein that is secreted by a single clone of plasma cells

32. Oligoclonal IgG Isoelectroforetic focusation Normal CSF
Oligoclonal IgG in CSF – SM
Oligoclonal IgG in CSF and other bands in CSF and serum – neuroboreliosis
Identical oligoclonal bands in CSF and serum - paraneoplastic syndromes
Monoklonal bands in CSF and serum – myeloma, monoclonal gamapaties

33. Oligoclonal bands SM
Inflammation
/ infection
monoclonal
normal

34. CSF – glucose Glucose in CSF - 60% of plasma glucose concentration
Examine also plasma glucose concentration
Decreased level – bacterial meningitis, TBC meningitis, neurosyphyllis

35. Pathology  B,  elements – acute meningitis, acute encefalitis
 B,  elements - Guillain-Barre, CIDP, tabes dorsalis, meningovascular lues, DM, trombosis of sinuses, brain tumors, gliomatosis, obstruction of CSF circulation

36. Meningeal syndroma Meningeal iritation Stifness of the neck
Kernig sign
Brudzinski´s sign
Opistotonus

37. Meningeal syndrom

38. Meningeal syndrom

39. Meningeal syndrom Meningeal signs on lower extremities
Brudzinski I – anteflexion of the head - flexion of lower extremities
Brudzinski II – pressure on zygomatic bone - grimasing
Brudzinski III – pressure on symphysis – LE flexion
Brudzinski IV – Kernig test - flexion of other LE
Amos sign – support by upper extremities during sitting

40. Intracranial hypertension
Increased intracranial pressure
3 components – brain tissue (80%), blood (10%), CSF (10%)
Signs
Headache
Vomitus
Papilloedema
Brain oedema - CT, MRI
Bradykardia
Increased arterial blood presure

41. Intracranial hypertension
Brain tumor
Brain oedema
Stroke, brain haemorrhage
Infection of CNS
Brain abscess
Hydrocephalus
Trauma

42. Hydrocephalus Increased production Decreased resorbtion
Obstruction in circulation of CSF

43. Tumor plexus chorioideus
Hydrocephalus
Tumor plexus chorioideus
Subarachnoid
heamorrhage
Tumor 3rd ventricle

45. Herniations

46. 1) The brain squeezes under the falx cerebri in cingulate herniation 2)The brainstem herniates caudally
3) The uncus and the hippocampal gyrus herniate into the tentorial notch
4)The cerebellar tonsils herniate through the foramen magnum in tonsillar herniation

47. Subfalcine herniation
The cingulate gyrus is pushed laterally away from the expanding mass and herniates beneath the falx cerebri.

48. Central herniation
occurs when there is downward pressure centrally and can result in bilateral uncal herniation.

49. Transtentorial herniation
Can result from any supratentorial mass lesion, or with severe cerebral edema
Can depend somewhat on individual anatomic variations

50. Transtentorial herniation

51. Uncal herniation occurs when the mass lesion is lateralized
anteromedial portion part of the hippocampus herniates over the edge of the tentorium
secondary effects of tissue necrosis, hemorrhage etc. similar to subfalcine

52. Tonsillar herniation
The cerebellar tonsils herniate downward through the foramen magnum:
Most commonly caused by a posterior fossa mass lesion,
Can be dramatic if a lumbar puncture is done with a undiagnosed mass lesion
The compression of the medulla results in depression of the vital centers for respiration and cardiac rhythm control

53. Tonsillar herniation
Clinical symptoms can be sudden cardiorespiratory arrest or slow progression over a day or two.
The herniated tonsillar tissue is softened (best appreciated after fixation) and the compressed medulla can be swollen and soft or firm depending upon the time course prior to death and the severity of edema

54. Tonsillar herniation

55. Brain herniations
Temporal Occipital