Cerebrospinal Fluid Analysis

 

Am Fam Physician. 2021 Apr 1;103(7):422-428.

Author disclosure: No relevant financial affiliations.

Cerebrospinal fluid (CSF) analysis is a diagnostic tool for many conditions affecting the central nervous system. Urgent indications for lumbar puncture include suspected central nervous system infection or subarachnoid hemorrhage. CSF analysis is not necessarily diagnostic but can be useful in the evaluation of other neurologic conditions, such as spontaneous intracranial hypotension, idiopathic intracranial hypertension, multiple sclerosis, Guillain-Barré syndrome, and malignancy. Bacterial meningitis has a high mortality rate and characteristic effects on CSF white blood cell counts, CSF protein levels, and the CSF:serum glucose ratio. CSF culture can identify causative organisms and antibiotic sensitivities. Viral meningitis can present similarly to bacterial meningitis but usually has a low mortality rate. Adjunctive tests such as CSF lactate measurement, latex agglutination, and polymerase chain reaction testing can help differentiate between bacterial and viral causes of meningitis. Immunocompromised patients may have meningitis caused by tuberculosis, neurosyphilis, or fungal or parasitic infections. Subarachnoid hemorrhage has a high mortality rate, and rapid diagnosis is key to improve outcomes. Computed tomography of the head is nearly 100% sensitive for subarachnoid hemorrhage in the first six hours after symptom onset, but CSF analysis may be required if there is a delay in presentation or if imaging findings are equivocal. Xanthochromia and an elevated red blood cell count are characteristic CSF findings in patients with subarachnoid hemorrhage. Leptomeningeal carcinomatosis can mimic central nervous system infection. It has a poor prognosis, and large-volume CSF cytology is diagnostic.

Cerebrospinal fluid (CSF) analysis is a diagnostic tool for many conditions affecting the central nervous system (CNS). The correct selection and interpretation of CSF tests can assist with diagnosing and treating a variety of conditions. Table 1 lists the normal values of CSF components.14

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

To minimize unnecessary antibiotic use, polymerase chain reaction testing should be used to evaluate for viral infections in all patients with suspected meningitis.911,28

B

Consistent results from cohort studies showing reduced emergency department stays and no change in mortality

Gram stain testing of cerebrospinal fluid should be performed in all patients with suspected meningitis.28,29

C

Expert opinion and consensus guidelines in the absence of clinical trials

Patients with signs and symptoms of subarachnoid hemorrhage who present more than six to 12 hours after symptom onset should undergo cerebrospinal fluid analysis if computed tomography findings are equivocal.48

C

Expert opinion and consensus guideline in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

To minimize unnecessary antibiotic use, polymerase chain reaction testing should be used to evaluate for viral infections in all patients with suspected meningitis.911,28

B

Consistent results from cohort studies showing reduced emergency department stays and no change in mortality

Gram stain testing of cerebrospinal fluid should be performed in all patients with suspected meningitis.28,29

C

Expert opinion and consensus guidelines in the absence of clinical trials

Patients with signs and symptoms of subarachnoid hemorrhage who present more than six to 12 hours after symptom onset should undergo cerebrospinal fluid analysis if computed tomography findings are equivocal.48

C

Expert opinion and consensus guideline in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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TABLE 1.

Normal Values of CSF Components

ComponentAdults and childrenNeonates

Color

Clear

Clear

CSF:serum glucose ratio

0.44 to 0.90

0.42 to 1.10

Differential

70% lymphocytes, 30% monocytes, rare PMNs or eosinophils

PMN count may be normal

Gram stain

Negative for organisms

Negative for organisms

Lactate level*

11.7 to 21.6 mg per dL (1.3 to 2.4 mmol per L)

8.1 to 22.5 mg per dL (0.9 to 2.5 mmol per L)

Opening pressure

Adults and children 8 years and older: 60 to 250 mm H2O Children younger than 8 years: 10 to 100

The Authors

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BRIAN SHAHAN, MD, FAAFP, DFPHM, is the program director of the Family Medicine Hospitalist Fellowship at Womack Army Medical Center, Fort Bragg, N.C., and an assistant professor at the Uniformed Services University of the Health Sciences, Bethesda, Md....

EDWIN Y. CHOI, MD, MS, FAAFP, is the associate program director of the Family Medicine Hospitalist Fellowship at Womack Army Medical Center and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

GILBERTO NIEVES, MD, is a hospitalist at Womack Army Medical Center. At the time this article was written, he was a hospitalist fellow at Womack Army Medical Center.

Address correspondence to Brian Shahan, MD, Womack Army Medical Center, 2817 Reilly Rd., Ft. Bragg, NC 28310 (email: brian.t.shahan.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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