CSF 判讀analysis @ 急診小醫師 - 隨意窩

正常成人CSF 的protein 約23-38 mg/dL. 正常人的極端值約9-58 mg/dL. 早產兒和足月嬰兒的CSF protein 介於20-170 mg/dL. 糖尿病患的CSF protein 會稍微上升. 正常人的CSF ... 急診小醫師https://dictionary.cambridge.org/zht/日誌相簿影音好友名片 201607271111CSF判讀analysis?內科CSF在未檢測前可放置於室溫儲存 https://blog.xuite.net/ymmcc/twblog/586844697 http://emedicine.medscape.com/article/2093316-overview NormalresultsinadultsAppearance:Clear Openingpressure:10-20cmH2O WBCcount:0-5cells/µL(<2polymorphonucleocytes[PMN]);normalcellcountsdonotruleoutmeningitisoranyotherpathologyGlucoselevel:>60%ofserumglucoseProteinlevel:<45mg/dLConsideradditionaltests:CSFculture,othersdependingonclinicalfindings CSF的糖分要與血液中的作比較.如果落差太大.要假設有異常,CSF血糖約為血中的60-70%   下面是uptodate的內容. COMPOSITIONOFTHECSF Xanthochromia—雖然肉眼就可以看出CSF變黃.但最好還是用"Spectrophotometry 分光光度法"檢測.紅血球進入CSF過2-4小時之後就可以看到xanthochromia.所以可以診斷SAH. SAH病患在出血12小時內90%會出現xanthochromia.之後會持續2-4周.  CSF的蛋白質超過150mg/dL或血中的bilirubin過高也會造成xanthochrmia.  Normalcerebrospinalfluid(CSF)isclearandcolorless.BothinfectiousandnoninfectiousprocessescanaltertheappearanceoftheCSF.Asfewas200whitebloodcells(WBCs)/microLor400redbloodcells(RBCs)/microLwillcauseCSFtoappearturbid.CSFwillappeargrosslybloodyif≥6000RBCs/microLarepresent[3]. RedbloodcellsrapidlylyseafterentryintoCSF.Thebreakdownofhemoglobinfirsttooxyhemoglobin(pink)andlatertobilirubin(yellow)leadstoayelloworpinkdiscolorationoftheCSFknownasxanthochromia.Spectrophotometrycanbeusedtoanalyzebloodbreakdownproductsastheyprogressfromoxyhemoglobintomethemoglobinandfinallytobilirubin,therebyrulingouttraumaticblood[11-13].Althoughxanthochromiaisgenerallyconfirmedvisually[14],laboratoryconfirmationwithspectrophotometrymaybemoresensitiveand,ifavailable,isrecommendedbysomeexperts[11,15,16]. XanthochromiacanbedetectedassoonastwotofourhoursafterRBCshaveenteredthesubarachnoidspace,andthereforethisisoftenusedinthediagnosisofsubarachnoidhemorrhage(SAH).Xanthochromiaispresentinover90percentofpatientswithasubarachnoidhemorrhagewithin12hoursoftheonsetofbleeding,anditmaypersistthereafterfortwotofourweeks[11,17-19].  XanthochromiacanalsooccurwithincreasedCSFconcentrationsofprotein(≥150mg/dL)orsystemichyperbilirubinemia(serumbilirubin>10to15mg/dL)[3]. Cells腦脊髓液基本上是沒有細胞的.但5顆以內的RBC及WBC是正常範圍內.成人的CSF超過3顆PMN即為異常.CSF的細胞分析應適當時間內進行.如果抽出超過60分鐘.細胞數可能減少,原因是細胞崩解或黏著在塑膠管壁上.  Normalfindings—TheCSFisnormallyacellular.However,upto5WBCsand5RBCsareconsiderednormalinadultswhentheCSFissampledbylumbarpuncture(LP).Morethan3polymorphonuclearleukocytes(PMNs)/microLareabnormalinadults.TheCSFcellprofilesinneonatesandchildrenarediscussedseparately.  TheCSFcellcountdeterminationshouldbeperformedpromptlysincethecountmaybefalselylowifmeasuredmorethan60minutesaftertheLPisperformed.ThisspuriouslylowcellcountmaybeduetosettlingofthecellsintheCSFovertimeand/oradherenceofRBCsorPMNstoplastictubes. Pleocytosis—腦脊髓液細胞增多.並不只有代表感染.還有很多非感染原因也會造成細胞增多.  AnelevatedCSFWBCconcentrationdoesnotdiagnoseaninfection,sinceincreasesintheCSFWBCconcentrationcanoccurinavarietyofbothinfectiousandnoninfectiousinflammatorystates.Thefollowingtruisms老生常談abouttheinterpretationofCSFcellcountsmaybeuseful: 細菌性腦膜炎很少會出現淋巴細胞為主的表現.而腸病毒腦膜炎在初期2/3病患會以PMN為主.之後12-24小時才轉變為淋巴細胞為主.  ●TheCSFcellcountmustalwaysbecorrelatedwithclinicalfindings.PMNs,forexample,predominateintheCSFofasmanyastwo-thirdsofpatientswithmeningitisduetoenteroviruses;ashifttolymphocyticpredominanceusuallyoccurswithin12to24hours[20,21].Ontheotherhand,lymphocytesrarelypredominateintheearlyphasesofbacterialmeningitis.  CSF的嗜伊紅性細胞無診斷價值.在寄生蟲感染或其他細菌性感染都可以出現.包括結核菌,立克次體,黴菌.非感染性狀況例如淋巴癌.各類型白血病,SAH.阻塞性水腦.  ●ThepresenceofeosinophilsintheCSFhaslimiteddiagnosticutility.CSFeosinophiliamayoccurinparasiticinfestationsbutalsoininfectionsduetoothermicroorganisms,includingMycobacteriumtuberculosis,Mycoplasmapneumoniae,Rickettsiarickettsii,somefungi,andinnoninfectiousconditions,suchaslymphomas,leukemiasofvarioustypes,subarachnoidhemorrhage,andobstructivehydrocephalus. 如何預測外傷性穿刺之後的白血球數量?做腰椎穿刺LP的時候可能刺穿微血管或小靜脈造成出血.使得CSF的RBC和WBC同時增加.如果病患血中的WBC沒有特別高.可以使用RBC增加500-1500.減去一個WBC.來校正WBC數值.  PredictedWBCcountaftertraumatictap—AccidentaltraumatoacapillaryorvenulemayoccurduringperformanceofanLP,increasingthenumberofbothRBCsandWBCsintheCSF.IfatraumaticlumbarpunctureissuspectedandtheperipheralWBCcountisnotabnormallyloworhigh,agoodruleofthumbforestimatingtheadjustedWBCcountistosubtract1WBCforevery500to1500RBCsmeasuredintheCSF.TheformulainthefollowingCalculatorcanalsobeusedtodeterminetheadjustedWBCcountinthepresenceofCSFRBCs(calculator1)[22,23].TheinterpretationofCSFpleocytosisinthesettingofbacterialmeningitisisdiscussedindetailseparately. 如果是頭痛六小時之後才做腰椎穿刺.可藉由xanthochromia來區分是SAH或外傷性穿刺.  ThepresenceorabsenceofotherwiseunexplainedxanthochromiaalsomayhelpdistinguishatraumatictapfromsubarachnoidhemorrhageaslongastheLPisperformedatleastsixhoursaftertheonsetofheadache.  CSF的化學性組成.  Chemicalcomposition—DeterminationofCSFproteinandglucoseconcentrationsareroutinelydoneandmayrevealusefulclinicalinformation. Protein—蛋白質.血中的蛋白質藉由血腦障壁隔絕於CSF.出現在CSF的蛋白質主要藉由微血管內皮細胞的吞飲作用進入CSF.正常成人CSF的protein約23-38mg/dL.正常人的極端值約9-58mg/dL.早產兒和足月嬰兒的CSFprotein介於20-170mg/dL.糖尿病患的CSFprotein會稍微上升.  正常人的CSF蛋白質上下限9-58mg/dL今天遇到一個病患CSFprotein298mg/dL.SAH或腰椎穿刺造成的外傷也會讓protein上升.顯微鏡視野下RBC每增加1000顆,protein上升1mg/dLCSF流動受阻也會造成protein上升.腦膜炎痊癒之後.CSFprotein仍會上升數周至數月. ProteinsarelargelyexcludedfromtheCSFbytheblood-CSFbarrier.ProteinsgainingaccesstotheCSFprimarilyreachtheCSFbytransportwithinpinocytotic吞飲vesiclestraversingcapillaryendothelialcells.ThenormalCSFproteinconcentrationrangesfrom23to38mg/dL(0.23to0.38g/L)inadults[3];inonereport,theextremeupperandlowerCSFproteinconcentrationsinnormalindividualswere58and9mg/dL(0.58and0.09g/L),respectively[19].CSFproteinconcentrationsinprematureandtermneonatesnormallyrangebetween20and170mg/dL(0.2and1.7g/L)[24].TheCSFproteinconcentrationmaybemildlyelevatedinpatientswithdiabetesmellitus. CSFproteincanalsobeelevatedbyasubarachnoidhemorrhageoratraumaticLP.ThepresenceofCSFbleedingresultsinapproximately1mgofprotein/dLper1000RBCs/microL.WhenassessingthepotentialeffectofCSFbleedingonanelevatedCSFproteinconcentration,theCSFproteinconcentrationandRBCcountshouldbeperformedonthesametubeofCSF. ElevationsintheCSFproteinconcentrationcanoccurinbothinfectiousandnoninfectiousconditions,includingconditionsassociatedwithobstructionofCSFflow. CSFproteinelevationsmaypersistforweeksormonthsfollowingrecoveryfrommeningitisandhavelittleutilityinassessingcureortheresponsetotherapy[25].(See'CSFinCNSinfection'below.) Immunoglobulinsandoligoclonalbands—ImmunoglobulinsarealmosttotallyexcludedfromtheCSFinhealthyindividuals.ThebloodtoCSFratioofIgGisnormally500:1ormore.ElevationsinoligoclonallyexpandedimmunoglobulinconcentrationsintheCSF,termedoligoclonalbands,mayoccurinanydisorderthatdisruptstheblood-brainbarrier.OligoclonalbandsmayalsobecausedbyintrathecalproductionofIgG,andthepresenceofsuchbandsisadiagnosticcriterionformultiplesclerosis[26].ExamplesofotherdiseasesthatcancauseoligoclonalbandsintheCSFincludeinfections(eg,nervoussystemLymedisease),autoimmunediseases,braintumors,andlymphoproliferativediseases.GivenhowmanydiseasescanresultinoligoclonalbandsintheCSF,thediagnosticutilityofthisfindingislimited.(See"NervoussystemLymedisease",sectionon'CSFantibodies'and"Evaluationanddiagnosisofmultiplesclerosisinadults",sectionon'CSFanalysisandoligoclonalbands'.) Glucose—CSF糖分下降可能發生於感染性或非感染性狀況.而CSF糖分上升僅發生於高血糖病患.  LowCSFglucoseconcentration(hypoglycorrhachia)mayoccurinavarietyofinfectiousandnoninfectiouspathologicconditions.ElevatedCSFglucoseconcentrationsonlyoccurinthesettingofhyperglycemia. CSF葡萄糖<18mg/dL強烈指向細菌性腦膜炎.包括結核菌.黴漿菌.梅毒螺旋體.黴菌感染.經過治療之後,當細菌性腦膜炎開始恢復.CSF葡萄糖會比細胞和protein先趨向正常化.  ●CSFglucoseconcentrationslessthan18mg/dL(1.0mmol/L)arestronglypredictiveofbacterialmeningitis[25].AbnormallylowCSFglucoseconcentrationscanalsooccurinmycobacterial,mycoplasmal(M.pneumoniae),treponemal,andfungalCNSinfections(table1).Duringrecoveryfrommeningitis,CSFglucoseconcentrationtendstonormalizemorerapidlythantheCSFcellcountandproteinconcentration.  多數病毒性感染.CSFglucose濃度正常.但麻疹腦膜腦炎.淋巴性脈絡叢腦膜炎.泡疹病毒,帶狀泡疹病毒感染也可能造成CSFglucose降低.  Incontrast,theCSFglucoseconcentrationistypicallynormalduringmostviralCNSinfections,althoughlowconcentrationshavebeenreportedinpatientswithmeningoencephalitisduetomumps,enteroviruses,lymphocyticchoriomeningitis(LCM),herpessimplex,andherpeszosterviruses. CSFglucose降低也可發生於非感染性狀況.軟腦膜癌.白血病.CNF淋巴癌.嚴重SAH.神經結節症.  ●LowCSFglucoseconcentrationscanalsooccurinnoninfectiousconditions;patientswithleptomeningealcarcinomatosis,leukemia,CNSlymphoma,severesubarachnoidhemorrhages,orneurosarcoidosismayhavehypoglycorrhachia腦脊髓液糖份過少becauseofcellularorinflammatoryinfiltratesthatdisrupttheactivetransportofglucoseintotheCSF(table1)[27]. 低血糖患者的CSFglucose同樣會下降.  Also,hypoglycemicpatientswhopresentwithCNSsymptomsmayhavelowCSFglucoseconcentrations. 高血糖病患的CSF糖分可能會被誤判.CSF/血清的糖份比例>0.6 血中的糖分要與腦脊髓液糖份平衡可能需要數小時.所以當使用血中糖分校正CSF糖份的時候,要考慮最後一次吃東西的時間.以及施打胰島素或服用降血糖藥物的時間.新生兒的血清/CSF糖分比例變異極大.而且腦室中的CSF與脊椎的CSF糖分也有差異.腦室CSF糖分6-18mg/dL高於脊椎CSF糖分.  高血糖病患的CSF糖分很少超過300mg/dL.  Inthesettingofhyperglycemia,alowCSFglucosemaynotberecognizedifonlytheabsoluteCSFglucoseconcentrationisconsidered.ThenormalCSF-to-serumglucoseratiois>0.6[28].Attemptsto"correct"theCSFglucoseconcentrationforhyperglycemiashouldtakeintoaccountthefactthatittakesseveralhoursfortheserumglucosetoequilibratewiththeCSFglucose;thusthetimingofthelastmealand/oradministrationofinsulinororalhypoglycemicmayberelevant[29].OtherconsiderationsincludethatCSF-to-serumglucoseratiosinneonatesarehighlyvariableandalsothatventricularCSFglucoseconcentrationis6to18mg/dL(0.33to1.0mmol/L)higherthaninthelumbarCSF[30].Inaddition,CSFglucoselevelsrarelyexceed300mg/dL(16.7mmol/L)eveninpatientswithseverehyperglycemia. Lactate—CSF的乳酸濃度是區分細菌性腦膜炎與無菌性腦膜炎最好的指標.優於CSFWBC,glucose,protein濃度.但對於做腰椎穿刺前已經使用抗生素治療的病患,敏感度較差.而其他CNS疾病也可能造成CSF乳酸增加.  DeterminationoftheCSFlactateconcentrationhasbeensuggestedasausefultesttodifferentiatebacterialfromviralmeningitis.Twometa-analysesthatincluded25studies(1692patients)and31studies(1885patients)concludedthatthediagnosticaccuracyofCSFlactatewassuperiortothatofCSFwhitebloodcellcount,glucose,andproteinconcentrationindifferentiatingbacterialfromasepticmeningitis[31,32],althoughsensitivitywaslowerinpatientswhoreceivedantimicrobialtreatmentpriortolumbarpuncture[32],andCSFlactatemaybeelevatedinpatientswithotherCNSdiseases. Cytology—CytologyisoccasionallyusefulforthediagnosisofmalignancyinvolvingtheCNS[33].Insuchinstances,atleast10to15mLoffluidshouldbesenttothepathologylaboratoryforpromptexamination. https://www.uptodate.com/contents/cerebrospinal-fluid-physiology-and-utility-of-an-examination-in-disease-states?search=CSF%20PROTEIN&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H13 這篇是給一般民眾看的WhatAbnormalResultsMeanAnabnormalproteinlevelintheCSFsuggestsaprobleminthecentralnervoussystem. Increasedproteinlevelmaybeasignofatumor,bleeding,nerveinflammation,orinjury.Ablockageintheflowofspinalfluidcancausetherapidbuildupofproteininthelowerspinalarea. Adecreaseinproteinlevelcanmeanyourbodyisrapidlyproducingspinalfluid.https://www.mountsinai.org/health-library/tests/csf-total-protein 另外.LUMBARPUNCTURE測量的壓力.通常只有OPENINGPRESSURE有意義.但也有研究將CLOSINGPRESSURE也列出來.    這一篇說.引流出的CSF量.與壓力下降有線性關係.當最大壓力改變在15公分水柱內的情況.每引流0.91CC的CSF.壓力下降1公分水柱高.OBJECTIVETheobjectiveofthisstudywastoidentifyarelationshipbetweencerebrospinalfluid(CSF)volumeremovalandchangeinCSFpressureinchildrenwithsuspectedidiopathicintracranialhypertension(IIH).   METHODSWeperformedacross-sectionalstudyofchildren22yearsandyoungerwhounderwentalumbarpuncture(LP)andhadadocumentedopeningpressure,closingpressure,andvolumeremoved.Relationshipbetweenvolumeremovalandpressurechangewasdeterminedusingafractionalpolynomialregressionprocedure.   RESULTSInthe297patientswhomettheinclusioncriteria,CSFpressuredecreasedby1cmH2Oforevery0.91mLofCSFremovedifthemaximumchangeinpressurewaslessthan15cmH2O(R(2)=0.38).   CONCLUSIONAlinearrelationshipexistsbetweenthevolumeofCSFremovedandtheamountofpressurerelievedwhenthedesiredpressurechangeislessthan15cmH2O.https://www.practiceupdate.com/content/how-much-cerebrospinal-fluid-should-we-remove-prior-to-measuring-a-closing-pressure/50639 下面這篇OpeningPressureinCSFAnalysisanditsRoleinIdiopathicIntracranialHypertension 有提到CLOSINGPRESSURE.前後壓力差達23cmH2O.成人壓力在25公分水柱以下.小兒稍高.在27公分水柱以下.小兒腦壓超過28公分水柱要查原因.  http://www.nuemblog.com/new-page-3/    ymmcc/Xuite日誌/回應(0)/引用(0)沒有上一則|日誌首頁|沒有下一則回應 全部展開|全部收合 ymmcc's新文章2021-06-2419:26COVID相關文章目錄糖尿病患者眼底檢查點數180毒蛇的抗毒血清施打方式門診診察費及調劑費新冠疫苗相關的遲發性過敏反應COVID-19:AllergicreactionstoSARS-CoV-2vaccines因應農曆春節前入境人潮指揮中心說明春節檢疫3方案過期藥物處理勞工一般體格檢查健康檢查項目表Thedarksideofcurcumin潛伏型結核治療民眾對於疫苗,藥物和感冒存在很多誤解 ymmcc's新回應沒有新回應！