Lumbar puncture (LP) carries a certain risk if the CSF pressure

is very high (evidenced by headache and papilledema), for it increases

the possibility of a fatal cerebellar or transtentorial herniation.
The risk is considerable when papilledema is due to an intracranial
mass, but it is much lower in patients with subarachnoid
hemorrhage or pseudotumor cerebri, conditions in which repeated
LPs have actually been employed as a therapeutic measure

Kecuali bila curiga karena infeksi, LP should be preceded

by computed tomography (CT) or MRI whenever an elevation of
intracranial pressure is suspected. If radiologic procedures do disclose
a mass lesion that is causing displacement of brain tissue
toward the tentorial opening or into the foramen magnum (the presence
of a mass alone is of less concern) and if it is considered
absolutely essential to have the information yielded by CSF examination,
the LP maybe performedwith certain precautions. A
fine-bore (no. 22 or 24) needle should be used, and if the pressure
proves to be very highover 400 mmH2Oone should obtain
the necessary sample of fluid and then, according to the suspected
disease and patients condition, administer mannitol (or urea) and
observe a fall in pressure on the manometer. Dexamethasone or an
equivalent corticosteroid may also be given, in an initial intravenous
dose of 10 mg, followed by doses of 4 to 6 mg every 6 h in
order to produce a sustained reduction in intracranial pressure.

There are few serious complications of LP (beyond the slight

risk of inducing brain herniation in the circumstances described
above). The most common is headache, which has been estimated
to occur in one-third of patients, but in severe form in far fewer

Pemeriksaan CSF mengambil 3 tabung: tabung pertama utk pemeriksaan kimiawi dan immunoglobulin, tabung
kedua untk gram dan kultur, tabung tiga utk cell count dan differential

Pemeriksaan: gross, kimiawi, gram, kultur, cell count, differential, pressure

GROSS EXAM

Normal: bening. Terjadi perubahan warna menjadi keruh kalau cell count >200 atau merah kalau RBC >400

Atau xantochromic. Xantochromic ada 2 macam, kuning dan pink:

Perjalanannya, bila ada RBC lisis, awalnya dia akan menjadi pink xanthochromia, lalu menjadi oranye, lalu menjadi
kuning akibat berubah RBCnya jadi bilirubin.
 Pale pink to orange xanthochromic

Detected 2-4 hours and peak at 24-36 hours after the onset of subarachnoid
bleeding, then gradually decrease for 4-8 days

Yellow xanthochromia

Derived from bilirubin

Develops about 12 hours after subarachnoid bleeding

Peaks at 2-4 days, persist for 2-4 weeks

Pink terjadi akibat lisis dari RBC

Oranye juga akibat lisis RBC (dan juga bisa merupakan perjalanan dari xanthochromia)

Kuning adalah akibar dari bilirubin

Minor degrees of color change are best detected
by comparing tubes of CSF and water against a white background
(by daylight rather than fluorescent illumination) or by
looking down into the tubes from above.

A traumatic tap (in which blood from the epidural venous

plexus has been introduced into the spinal fluid) may seriously
confuse the diagnosis if it is incorrectly interpreted to indicate a

pre-existent subarachnoid hemorrhage. To distinguish between

these two types:
1. two or three serial samples of fluid
should be taken at the time of the LP. With a traumatic tap, there
is usually a decreasing number of RBC in the second and third
tubes.
2. Also with a traumatic tap, the CSF pressure is usually normal,
3. In traumatic tap a large amount of blood is mixed with the fluid, it will
clot or form fibrinous webs. These are not seen with pre-existent
hemorrhage because the blood has been greatly diluted with CSF
and defibrinated.
4. With subarachnoid hemorrhage, the RBC begin
to hemolyze within a few hours, imparting a pink-red discoloration
(erythrochromia) to the supernatant fluid;allowed to stand for a
day or more, the fluid becomes yellow-brown (xanthocromia).
Prompt centrifugation of bloody fluid from a traumatic tap will
yield a colorless supernatant;only with large amounts of blood
(RBC over 100,000/mm3) will the supernatant fluid be faintly xanthochromic
due to contamination with serum bilirubin and lipochromes.

CELL CONT & DIFF

Normal 0-5 wbc, ga ada rbc

Persistent neutrophilic meningitis (>1 week) may be noninfectious or due to less common pathogens such
as Nocardia, Actinomyces, Aspergillus, and the Zygomycetes

DIFF Count

Biasanya sih Cuma dibedain MN atau PMN aja. Ga sampai detail. Tapi kalau detail ya bagus sih

Normalnya tidak ada predominasi. Tapi ada yg bilang semua limfosit andaikata ada
Nah kalo ditemukan cell count yang tinggi (sangat tinggi, biasanya 500-ribuan) biasanya itu bacteria. Kalau
meningkat tapi ga tinggi, biasanya itu viral,tuberculous,fungal,dll

Soal predominasi:

Neutrophilia ditemukan di infeksi bacterial atau viral/TB/fungal awal. Viral/TB/fungal nanti bakal jadi dominansi limfosit
setelah beberapa saat. Bisa juga ditemukan di SAH/intracranial hemorrhage, setelah seizure, setelah infark CNS

Limfositosis ditemukan di infeksi virus/TB/fungal/parasit/aseptic. Dan juga GBS/Multiple sclerosis

Eosinofilik (10% eosinofil) muncul di infestasi parasit

Di table bisa diliat dasyatnya

PROTEIN DAN GLUKOSA

Sebaiknya diambil kadar serum protein dan glukosa dulu biar ga positif palsu naik atau turun

Protein CSF biasanya <1% protein darah. Glukosa CSF/serum rasionya dari 0,3-09 (biasanya yg dipake o,6)

Nilai normal protein CSF= 15-45 mg/dl

Meningkat kalau ada:

1. Meningkatnya permeabilitas BBB misalnya saat perdarahan (bocor) dan inflamasi (gap membesar)
2. Blok CSF

Values of protein 1000 mg/dL or more usually indicate loculation of

the lumbar CSF (CSF block ) atau spinal meningtis;the fluid is then deeply yellow and
clots readily because of the presence of fibrinogen;a combination
called Froin syndrome
3. IgG meningkat (GBS/MS)

Glukosa normalnya 35-50 mg/dl

Menurun bila ada infeksi bakteri/TB/fungal/

Virus nggak turun!

Meningkat: kalau glukosa darah juga meningkat. Traumatic tap juga bisa meningkatkan.

GRAM

Gram dan AFB bisa positif

As a rule, viral infections of the meninges and

brain do not lower the CSF glucose