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Cerebrospinal Fluid
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Cerebrospinal fluid (CSF) is found in the subarachnoid space of the brain (within the ventricles) and spinal canal. It is produced by the choroid plexus in the ventricles of the brain and the cerebral vessels at the rate of 500 ml/day. Production matches reabsorption so at any one time the in an adult the average volume of CSF is about 150 ml.
For information on performing a lumbar puncture and sampling see the Lumbar Puncture article.
- Diagnostic lumbar puncture:
- Infection, e.g. meningitis, viral encephalitis, tuberculosis.
- Demyelinating disorders (including multiple sclerosis).
- Benign intracranial hypertension.
- Subarachnoid haemorrhage.
- Therapeutic lumbar puncture:
- Benign intracranial hypertension.
It is helpful to note the appearance of CSF and the opening pressure (normal 10-20 cm H2O). Samples are usually sent for:
Biochemistry
- Protein - high (>0.4 g/L) levels seen in infection and infiltration disorders (falsely high results are seen if the sample is contaminated with blood).
- Glucose - CSF glucose is usually 60-80% of plasma glucose. A blood sample for glucose should be taken at the same time as the lumbar puncture. Implies there is increased uptake of glucose in the CNS.
Microscopy, culture and sensitivity
- Cell count - white cells with differential (neutrophils and lymphocytes) and red cells. When performing a lumbar puncture, red cells may be present as a result of damage to a blood vessel during the procedure (commonly called a “bloody tap”). To confirm whether this represents a subarachnoid haemorrhage the CSF is centrifuged: clear supernatant fluid confirms a bloody tap, whereas the supernatant fluid is stained yellow in a subarachnoid haemorrhage (known as xanthochromic).
- Gram stain - for bacterial organisms.
- Culture - if appropriate.
Additional investigations
- Xanthochromia - yellow appearance of CSF after centrifugation. This represents breakdown of haemoglobin. Seen in subarachnoid haemorrhage.
- Oligoclonal bands - seen in multiple sclerosis and neurosyphilis.
- Virology.
- Polymerase chain reaction (PCR), e.g. for tuberculosis, viral and partially treated bacterial meningitis.
- Bacterial antigen testing - may be useful if PCR not available and patient partially treated.
- India ink staining for cryptococcus.
| CSF appearance | CSF protein | CSF glucose | CSF cell count | CSF Gram stain | Additional features | |
| Normal | Clear and colourless | 0.2-0.4 g/l (neonate <1.7 g/l) |
60-80% of plasma glucose | Low WCC (higher in neonates) |
No organisms | Opening pressure 10-20 cm H2O |
| Bacterial meningitis | Cloudy and turbid (if severe) | Raised >1.5 g/l | Glucose level is <50% of the plasma level | Cell count is high and mostly neutrophils | May see organisms, e.g. Gram negative diplococci in N. meningitidis | Opening pressure high |
| Viral/aseptic meningitis | Clear | Raised or high end of normal | Glucose level is usually within normal limits. May be reduced in some cases of mumps and herpes simplex |
Cell count is high and mostly lymphocytes | No organisms | PCR or special stains may help identify organism |
| Tuberculous meningitis | Clear or slightly cloudy May have a cobweb appearance |
Raised >1.5 g/l protein is high (much higher than bacterial meningitis) | Glucose level is <50% of the plasma level | Cell count is high with a mixed pleocytosis with mainly lymphocytes | Negative | PCR may help identify TB quickly |
| Subarachnoid haemorrhage | Blood-stained (although not always) |
Raised or high end of normal | Glucose level is usually low | High number of RBCs | No organisms | Uniformly blood-stained ± xanthochromia |
Document ID: 777
Document Version: 24
Document Reference: bgp766
Last Updated: 29 Jul 2009
Planned Review: 29 Jul 2011
The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.
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