Ruland Pakasi

Psychiatric Disorders?

Coverage
Diagnostic Procedure
II. Examination of
Cerebrospinal Fluid (CSF)
III. Lab.Tests in Certain
Neurologic Disorders
I.

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I.Neurologic Diagnostic Procedures

3

Include Studies in:

History

& Physical
Examintaionguide the tests
Laboratory Studies
Blood,

Urine, CSF (cerebrospinal

fluid)
Imaging studies
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II. EXAMINATION OF
CSF
PROCEDURE

OPERATOR

Lumbar

Puncture,
mostly wellknown as
Spinal Tap
To be performed by
Established
Neurologist
Legally licenced
physician
Legally well-trained MT
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II. EXAMINATION OF
CSF
INDICATION

Indication

To evaluate intracranial
pressure & CSF
abnormalities; categories:
1. Menigeal infections
2. Metastatic malignancy, 1mary or
2ndary
Demyelinating diseases

To administer intratrhecal
drugs or radiopaque agent
for myelography.
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II. EXAMINATION OF
CSF
(Relative)
INTRAINDICATION

*brain tissue
protrudes into spinal
canal

Infection

at the
puncture site
Bleeding diathesis
Increased
intracranial pressure
Chiary I type
malfromation*

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II. Examination of CSF

Most

Important indication:
Identification of Meningitis
esp.bacterial
Diseases detected by Lab.Exam.of CSF
sensitivity, specificity
Bacterial, tuberculous, and Fungal specificity
sensitivity, moderate specificity
Viral meningitis
Subarachnoid hemorrhage
Multiple sclerosis
CNS syphilis
Infectious polyneuritis
Paraspinal abscess

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II. Examination of CSF

Most

Important indication: Identification

of Meningitis esp.bacterial

Diseases

detected by
Lab.Exam.of CSF
Moderate sensitivity, specificity
Meningeal malignancy
Moderate sensitivity, moderate specificity
Intracranial hemorrhage
Viral encephalitis
Subdural hematome

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II. EXAMINATION OF
CSF
Recommended CSF Lab.Tests
Routine

Useful under
certain
condition

Opening of CSF Pressure

Total Cell Count (WBC & RBC)
Differential Cell Count (stained smear)
Glucose (CSF/plasma ratio)
Total protein
Cultures (bacteria, fungi, viruses, MTbc)
Gram stain, acid-fast stain
Fungal and bacterial antigens
Enzymes (LD, CK-BB)
Lactate
Polymerase chain reaction, PCR (TB,
viruses)
Cytology
Electrophoresis (protein,
immunofixation)
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II. EXAMINATION OF
CSF
NORMAL

ABNORMAL

1.Gross Examination
Clear, viscocity similar to water.
Cloudy, fankly purulent, pigment
tinged
Turbidity/ cloudness begins to appear:
WBC>200 cells/L or RBC >400 cells/L
Grossly bloody CSF: > 6000/L
Varying degree of cloud:
microorganisms, radiographic contrast
material, aspirated epidural fat,
protein >150 mg/dL

Clot formation:
Traumatic taps
Complete spinal block

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II. EXAMINATION OF
CSF
ABNORMAL

1.Gross Examination
Viscous CSF:
Metastatic mucin-producing
adenocarcinomas
Liquid nucleus pulposus
(needle injury to annulus
fibrosus)

Pink-red:
Indicates presence of blood,
originate from subarachnoid
hemorrhage, intracerebral
hemorrhage, cerebral infarct,
or traumatic tap
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II. EXAMINATION OF
CSF
ABNORMAL

1.Gross Examination
Xanthochromia
Refer to pale pink to yellow
color of in the supernatant
of centrifuged CSF
Owing to RBC lysis and Hgb
breakdown
Pinkorange color
Oxyhemoglobin release
2-4 hrs after subarachnoid
hemorrhage, peak 24-36 hrs,
disappear the next4-8 days

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II. EXAMINATION OF
CSF
ABNORMAL

1.Gross Examination
Xanthochromia

Yellow orange color

Derived from bilirubin

12 hrs after subarachnoid
hemorrhage, peak 2-4 hrs,
may persist 2-4 wks

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II. EXAMINATION OF
CSF
ABNORMAL

1.Gross Examination
Xanthochromia
Also visible in:

Artefactual RBC lysis cause by

detergent or delay > 1 hr without
refrigeration
Bilirubin in jaudiced patients
CSF protein > 150mg/dL
(traumatic tap, complete spinal
block, polyneuritis,meningitis,
carotenoids (dietary
hypercarotenemia), meningeal
metastatic melanoma (melanin),
rifampicin therapy
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II. EXAMINATION OF
CSF

1.Gross Examination
ABNORMAL
Differential Diag
nosis

Traumatic

vs Pathologic hemorrhage
Traumatic
3 tubes: clear CSF in the 2nd
RBC lysis begins as early as 1-2 hrs
after spinal tap
Latex agglutination immunoassay
(test for fibrin degradion (derivative
D-dimer): negative

Pathologic

3 tubes: remains xanthochronic in 2nd

in subarachnoid hemorrhage
Microscopic evidence:
erythrophagocyto sis, hemosiderinladen macrophages
Latex agglutination immunoassay
(test for fibrin degradion (derivative
D-dimer): positive
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II. EXAMINATION OF
CSF
Total Cell Count

2.Microscopic Examination

Fuchs-Rosenthal or Neubauer
counting chamber

WBC

Normal, adult: 0-5 cell/L

Neonates: higher, 0-30 cell/L
RBC should be negative.

WBC
Differential
Count

Normal

DIFF

Lymphocytes: 62 34 %
Monocytes: 36 20 %
Neutrophils: 2 5 %
Eosinophils: rare
Histiocytes: rare
Ependymal cells: rare
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II. EXAMINATION OF
CSF
1.Proteins

3.Chemical Analysis
15-45
:

mg/dL

Traumatic spinal puncture

Increased blood-CSF
permeability

Arachnoiditis (MTX therapy)

Meningitis (bact, viral, fungal, tbc)
Hemorrhage (subarachnoid,
intracerebral)
Endocrine-metabolic disorders

Milk-alakali syndrome w/ hypercalcemia

Ethanol, phenothiazines, phenytoin

CSF circulation defects

Mechanical obstruction (tumor, abscess,

herniated disk)
Loculated CSF effusion

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II. EXAMINATION OF
CSF

3.Chemical Analysis
1.Proteins

Increased IgG synthesis

Neurosyphilis, multiplesclerosis,
subacute sclerosing
panencephalitis

Increased IgG synthesis &

blood-CSF permeability
Guillain-Bare syndrome
Collagen vascular disease
(lupus, periarteritis)
Chronic inflammatory,
demyelinating polyradiculopathy

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II. EXAMINATION OF
CSF
2.Glucose

3.Chemical Analysis
Normal

50-80 mg/dL
Glu CSF/Plasma ratio: 0.3-0.9
Hypoglycorrhachia
Bacterial, tuberculous, & fungal
infections (characteristic)
Meningoencephalitis (some
cases)
Other conditions involving
meniges (tumor, sub arachnoid
hemorrhage, cysticercosis,
sarcoidosis, etc)

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II. EXAMINATION OF
CSF
2.Glucose

3.Chemical Analysis
Hyperglycorrhachia

Has no clinical significance

3.Lactate

9.0

26 mg/dL; higher in
newborns
: Viral meningitis (<25-35
mg/dL) vs
Bacterial,mycoplasma,
fungal and tbc meningitis
(>35 mg/dL)
Persistent : associated
with poor prognosis
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II. EXAMINATION OF
CSF
3.Chemical Analysis
in pleural, peritoneal and meningeal
tuberculosis
Lower level in nontuberculous
> 15 U/L : strong indication of meningeal

3.Enzymes
Adenosine
deaminase
(ADA)

Creatinie

kinase (CK)

tbc.

In hydrocephalus, cerebral
infarction, brain tumors,
subarachnoid hemorrhage
CK-KK & CK-MB not normally
present
CK-BB associated with outcome
of subarachnoid hemorrhage

>40 U/L increased the chance of

unfavorable early or late outcome.
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II. EXAMINATION OF
CSF
3.Enzymes
Lactodehydro
genase (LD)

4.Electrolyes
& Acid Base
Balance

3.Chemical Analysis
Upper

limit: 80 U/L
in bacterial meningitis,
CNS leukemia, lymphoma,
metastatic carcinoma,
sub arachnoid
hemorrhage.
No

clinically indication
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II. EXAMINATION OF
CSF
5.Tumor markers

3.Chemical Analysis

Carcinoemb
Increased CEA in metastatic
yonic
antigen
brain tumors (44%),
(CEA)

metastatic carcinome of the

leptomeninges.

Human
chorionic
gonadotropi
n (HCG), Feto protein

Useful

for diagnosis &

monitoring of response
to therapy in patients
cell tumors.
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II. EXAMINATION OF
CSF
Bacterial

meningitis
Spirochetal

meningitis
Viral

meningitis

4.Microbial
Examination
Go

to Microbial
Department

HIV
Fungal

meningitis
Tuberculous

meningitis

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Condition Pressure

Normal

Wbc/L

Predomin Glucose
ant Cell
Type

Protein

100200
mm H2O

03

50100
mg/dL

2045
mg/dL

Acute
bacterial
meningiti
s

100
10,000

PMN

> 100
mg/dL

Subacute
meningiti
s (TB,
Cryptoco
ccus
infection,
sarcoidos
is,
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N or

100700

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Condition Pressure

Wbc/L

Predomin Glucose
ant Cell
Type

Protein

Acute
syphilitic
meningiti
s

N or

252000

Paretic
neurosyp
hilis

N or

152000

Lyme
disease
of CNS

N or

0500

N or

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Condition Pressure

Wbc/L

Predomin Glucose
ant Cell
Type

Protein

Brain
abscess
or tumor

N or

01000

Viral
infection
s

N or

1002000

N or

Cerebral
hemorrh
age

Bloody

RBCs

Cerebral
thrombos
is

N or

0100

N or

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Condition Pressure

Wbc/L

Predomin Glucose
ant Cell
Type

Protein

Spinal
cord
tumor

050

N or

GuillainBarr
syndrom
e

0100

> 100
mg/dL

Lead
encephal
opathy

0500

Pseudotu
mor
cerebri

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III. Lab.Tests in Several

Neurologic Disorders
Blood
WBC: increased with a shift to the left.
CRP (C-Reactive Protein) increases markedly
Cerebrospinal Fluid
Appearance: opalescent to purulent, slightly yellow, and might have
a coarse clot.
WBC countL <5 to >100 with neutrophilic dominance (>80%); as the
disease progresses there is a gradual increase in lymphoctes and
large monoclear cells. Cell counts above 50.000/l raise the
possibility that a brain abscess has ruptured into the subarachnoid
space.
Gram-stained smear: positive in 60-90% patients.
Culture: positive in 65 to 90% patients. Prior antibiotic treatment
decrease the frequency of positive cultures.
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III. Lab.Tests in Certain

Neurologic Disorders
Blood
WBC: increased with a shift to the left.
CRP (C-Reactive Protein) increases markedly
Cerebrospinal Fluid
Protein > 50 mg/dl..
Glucose < 40 mg/dl (0-40 mg/dl; < 30% of blood level)
LDH (especially LDH4 and LDH5) increase (this derived from
granulocytes).
Bacterial antigens: 50% to 100% sensitivity. This test is of great help
for rapid diagnosis after treatment has been started and the smears
and culture are negative.

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III. Lab.Tests in Certain

Neurologic Disorders
Blood
Serum sodium: decreased
Liquor Cerebrospinal Fluid:
Fluid
Appearance: opalascent, slightly yellow; a delicate clot may
be seen.
Glucose 10 mg/dl 40 mg/dl
Protein 45 mg/dl 500 mg/dl (usually 100-200 mg/dl)
WBC: Lymphycytes 25/l 500 /l; early in the infection,
neutrophils may equal lymphocytes.
Acid-fast (or Auramine-rhodomine) stained smear of the fibrin
clot or pellicle: may positively seen.

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III. Lab.Tests in Certain

Neurologic Disorders

3.Brain Abscess

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III. Lab.Tests in Certain

Neurologic Disorders

3.Brain Abscess

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III. Lab.Tests in Certain

Neurologic Disorders

3.Brain Abscess

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III. Lab.Tests in Certain

Neurologic Disorders

3.Brain Abscess

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III. Lab.Tests in Certain

Neurologic Disorders

3.Brain Abscess

Dept.of Radiology

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Subdural Hematoma
Lab

Studies

The prevalence of coagulation abnormalities

Abnormal findings on prothrombin time
(PT), activated partial thromboplastin time
(aPTT), or platelet count.
Electrolyte abnormalities can exacerbate
brain injury and should be corrected in a
timely manner. For example, hyponatremia
(5-12% estimated incidence in patients with
head injury) can potentiate brain edema
and cause seizures.

Imaging

CT
MRI

Studies

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Epidural Hematoma
Lab

Studies:

Complete blood count (CBC) with platelets - To monitor

for infection and assess hematocrit and platelets for
further hemorrhagic risk
Prothrombin time (PT)/activated partial thromboplastin
time (aPTT) - To identify bleeding diathesis
Serum chemistries, including electrolytes, blood urea
nitrogen (BUN), creatinine, and glucose - To
characterize metabolic derangements that may
complicate clinical course
Toxicology screen and serum alcohol level - To identify
associated causes of head trauma and establish need
for surveillance with regard to withdrawal symptoms
Type and hold an appropriate amount of blood - To
prepare for necessary transfusions needed because of
blood loss or anemia

Imaging

Studies
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Myasthenia Gravis

Thyroid function tests should be done to evaluate for

coexistent thyroid disease.
Anti-MuSK antibody: About half of the patients who are
AChR-ab negative (seronegative MG) may be positive for
antimuscle-specific kinase (MuSK) antibodies. They may
represent a distinct group of autoimmune myasthenia
gravis, as they show some characteristics as a group that
are different from AChR-positive patients.
Antistriational antibodies
Serum from some patients with myasthenia gravis possesses
antibodies that bind in a cross-striational pattern to skeletal and heart
muscle tissue sections. These antibodies react with epitopes on the
muscle protein titin and ryanodine receptors (RyR). Almost all patients
with thymoma and myasthenia gravis and half of the late-onset MG
patients (onset > 50 y) exhibit an antibody profile with a broad
striational antibody response. Striational antibodies are rarely found
in AChR Ab negative patients. These antibodies can be used as
prognostic determinants in MG; as in all subgroups of MG, higher
titers of these antibodies are associated with more severe disease.
As it is often associated with thymoma in young patients with MG, the
presence of titin/RyR antibodies should arouse strong suspicion of
thymoma in a young patient with MG.
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Guillain-Barre
Syndrome
Lab Studies

The diagnosis of Guillain-Barr syndrome (GBS)

istypicallymade by the presence of a progressive
ascending weakness with areflexia. An LP,
electrodiagnostic studies, or occasionally MRI findings
can give support for this diagnosis.
Typically, the LP is suggestive of demyelination (ie,
increased protein >45 mg/dL within 3 wk of onset)
without evidence of active infection (lack of CSF
pleocytosis), as originally noted by Guillain and Barr.
The CSF findings may be normal within the first 48 hours of
symptoms, and occasionally the protein may not rise for a
week. Serial spinal taps are sometimes often warranted if
early studies are normal. Usually by 10 days of symptoms,
elevated CSF protein findings will be most prominent.
Most patients have fewer than 10 leukocytes per milliliter,
but occasionally a mild elevation (ie, 10-50 cells/mL) is
seen. Greater than 50 mononuclear cells/mL of CSF casts
some doubt on the diagnosis of GBS.
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Lab Studies
Complete blood count
Coagulation profile
Electrolytes
Serum glucose
Blood type and screen

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STROKE, HEMORRHAGIC

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CBC serves as a baseline study and may reveal a cause for the
stroke (eg, polycythemia, thrombocytosis, thrombocytopenia,
leukemia) or provide evidence of concurrent illness (eg,
anemia).
Chemistry panel serves as a baseline study and may reveal a
stroke mimic (eg, hypoglycemia, hyponatremia) or provide
evidence of concurrent illness (eg, diabetes, renal
insufficiency).
Coagulation studies may reveal a coagulopathy and are useful
when thrombolytics or anticoagulants are to be used.
Cardiac biomarkers are important because of the association
of cerebral vascular disease and coronary artery disease.
Additionally, several studies have indicated a link between
elevations of cardiac enzyme levels and poor outcome in
ischemic stroke.

Toxicology screening may be useful in selected patients.

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Lab Studies
CBC, basic chemistry panel, coagulation studies, and
cardiac biomarkers should be obtained in most patients.

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STROKE, ISCHEMIC

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Lab Studies

chemistry panel
CBC count
Prothrombin time (PT) and activated partial
thromboplastin time (aPTT) tests
Blood typing/screening tests
CSF findings suggesting subarachnoid hemorrhage
include numerous RBCs, xanthochromia, and
increased pressure.
About 6 h or more after a subarachnoid hemorrhage,
RBCs become crenated and lyse, resulting in a
xanthochromic CSF supernatant and visible crenated
RBCs (noted during microscopic CSF examination)

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Serum

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SUBARACHNOID HEMORRHAGE
(SAH)

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Bell's Palsy
Lab

Studies

In areas where Lyme disease is endemic, Lyme

titers (IgM and IgG) should be obtained.
Blood glucose or hemoglobin A1c may be
obtained to determine if the patient has
undiagnosed diabetes.
Serum titres(IgM and IgA) forMycoplasma
pneumoniae may be obtained.A study in
Germanymeasured titres in patients with Bell
palsy and found that several patients had
elevated titres toM pneumoniae, and only 2 of
those who tested positive had respiratory
symptoms.3
Serum titers for HSV may be obtained, but this
is usually not helpful owing to the ubiquitous
nature of
this caused
virus.by Borrelia burgdorferi.
Lyme disease is a tick-transmitted
infection
Symptoms include an erythema migrans rash, which may be followed weeks to
months later by neurologic, cardiac, or joint abnormalities.
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Lab Studies
WBC count
C-reactive protein (CRP)
Blood and cerebrospinal fluid culture to exclude bacterial

meningitis
CSF :

include mildly or markedly elevated pressure

presence of 10 to > 1000 lymphocytes/L.
Glucose mildly and protein levels
PCR of CSF can detect as few as 10 copies of viral nucleic acid. The
ability to amplify the DNA from HSV-1 and HSV-2, VZV, CMV, HHV6A
and HHV6B, and EBV

Viral culture of throat swabs and stool sample

Serology: Save serum for paired convalescent sample

comparison of serology at 2-3 weeks following acute illness.

CSF protein, and mildly decreased CSF glucose
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