Cerebrospinal Fluid
Analysis
Pavel Štourač
Department of Neurology
University Hospital Brno
Cerebrospinal fluid analysis
 lumbar puncture
 inflammation of CNS
(meningoencephalitis)
 bleeding (intracerebral hemorrhage,
subarachnoid hemorrhage)
 tumours of CNS (primary tumours,
metastases)
Contraindication of lumbar puncture
 intracranial hypertension: occipital and
temporal brain herniation
 skin inflammation in area of lumbar
puncture
 coagulation abnormalities and
anticoagulant therapy
 severe spondylosis of lumbar area
Analysis of cerebrospinal fluid
 macroscopic appearance - clear,cloudy,
xanthochromatic, hemorrhagic
 protein content
 cytology quantitatively and differential
cell count including the presence of
bacteria
 lactate
 glucose
Standard CSF analysis
Macroscopic appearance:
 protein content
 cytology, differential cell count
 lactate and glucose in CSF
 albumin, IgG,IgA,IgM in CSF and serum
 oligoclonal IgG bands in CSF and serum
 specific antibody indices (AI - IgG class)
 MRZ reaction (M-measles, R-rubeolla, Zvaricella
zoster)
 erythrocytes and haemoglobin
Enlarged CSF analysis
 PCR - polymerase chain reaction-HSV
encefalitidu
 tumour markers-carcinoembryonal
antigen
 specific CNS proteins - neuron specific
enolase in CSF and serum
 tau protein, fosforylated tau protein
 beta-amyloid 1-42 in cerebrospinal fluid
 beta trace protein-liquorrhea (CSF
leakage, nose, ear)
Cytological analysis of CSF
cell number and differential cell count
70% lymphocytes, 30% monocytes
Fuchs Rosenthal chamber
pleocytosis: >5 cells/1µl
 inflammatory syndrome
 pathological bleeding(phagocytes)
 non-specific irritative syndrome
 malignant cells-infiltration of meninges
Diagnostical markers
 oligoclonal IgG bands
 MRZ
 neurofilaments of neuronal and glial
cytoskeleton-longitudinal follow-up
 repeated lumbar punctures
 tau protein, fosforylated tau protein, betaamyloid-triplet
(dementia diagnosis)
Oligoclonal IgG
 Methods: isoelectric focusing, immunobloting,
imunoenzymatic staining
 5 patterns of oligoclonal IgG in parallel
investigation of CSF and serum
 normal polyclonal IgG in CSF and serum
 oligoclonal IgG only in CSF (sclerosis multiplex)
 oligoclonal IgG in CSF and serum (more IgG
bands in CSF comparing IgG bands in serum)
 monoclonal IgG bands in CSF and serum
(myeloma, monoclonal gammapathy)
MRZ reaction
 intrathecal antiviral antibody synthesis
 M-measles, R-rubella, Z-varicella zoster
viruses
 MRZ-biomarker of chronic autoimmune
inflammatory process
 MRZ sensitivity in multiple sclerosis:84-
92 %
 frequency and value of antibody indices
increase in parallel with general
intrathecal IgG synthesis
Polyspecific immune reaction in CNS
and antibody indices
 Antibody index
 antibody index -AI reflects pathological,
intrathecally produced fraction of specific
antibodies in CSF
 reference range AI = 0.7-1.3
 patological values AI >1.4
Neurological diseases with
autoimmune pathogenesis
 Paraneoplastic autoimmune neurological
syndromes
anti-Hu, anti-Yo, anti-Ri, anti-Ta/Ma2,antiCV2,
anti-amphiphysin, NMDAR
 NMO - neuromyelitis optica Devic
demyelinating disease with specific IgG
antibodies (NMO)-IgG (anti-AQP-4)
immunobloting, immunohistochemistry
Neurological diseases with
autoimmune pathogenesis
 Systemic autoimmune diseases with CNS
involvment
 lupus erythematodes, Sjögren´s
syndrome, Wegener´s granulomatosis MRZ
reaction
 AIDP - Guillain-Barré syndrome
 Qalb > 6.5 x 10-3
 normal CSF cytology
 intrathecal Ig synthesis negative
Neuroborreliosis
 Dominant IgM intrathecal synthesis
 disease related pattern: IgM>IgA>IgG
 B-activated lymphocytes
(intracytoplasmatic IgM)
 disturbance of blood-CSF barrier, i.e. Qalb
> 6.5
 IgG OB-70% positive-monophasic course
 positive specific antibody synthesis (AI
Bb >1.4)
 cytological finding - mixed cell pleocytose