BRAIN AND MIND SYSTEM. Dept. Patologi Klinik FK USU dr. Tapisari Tambunan SpPK (K) dr. Ozar Sanuddin SpPK (K)

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BRAIN AND MIND SYSTEM

KELAINAN CAIRAN OTAK

Dept. Patologi Klinik FK USU dr. Tapisari Tambunan SpPK (K)

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Physiology

* Cerebrospinal fluid (CSF) :

* merupakan produk aktifitas ventricular choroid plexuses

* bersirkulasi melalui ventricles dan subarachnoid spaces

* diabsorbsi oleh arachnoid villi venous sinuses aliran darah

aliran darah

* fungsi utama : proteksi, memberi bantalan untuk brain dan spinal

* Blood Brain Barrier bekerja dgn proses metabolik aktif menjaga kons sbgn besar substansi dlm CSF dlm kadar yg berbeda dari dlm darah, dgn rentang kadar yang sempit

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Pengambilan spesimen untuk pemeriksaan

• Biasanya dgn Lumbal punksi

• Indikasi LP:

- Suspek Meningitis, Encephalitis, Brain

abscess, subarachnoid hemorrage

- DD cerebral infark dgn cerebral

hemorrhage (80%)

- Pemberian anestesi, media kontras,

obat-obat

- Treatment pada bbrp pasien dgn

hipertensi intracranial benigna

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• Komplikasi LP:

- Herniasi, mortalitas meningkat (pd tek.

Intracranial tinggi)

- Paresis sampai paralisis (pd spinal cord tumor)

- Extradural @ Subdural hematoma (pd

gangguan pembekuan darah)

- Perforasi meninges (pd kasus sepsis)

- Kematian pada bayi jk tindakan berlebihan

(aspiksia, obst trachea)

- Infeksi ( tidak aseptik)

- Postpuncture headache

• Pelaksanaan LP:

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• Pelaksanaan LP utk pengambilan spesimen :

- Sebaiknya pagi hari dan jk dapat setelah puasa 1malam - Dilakukan pada dewasa : L3-L4

anak : L4-L5

- Ditaruh pada 3 tube sentrifus steril yg ditandai dgn no. 1, 2 dan 3. Masing-masing 2-4 ml

Spesimen tube 1, biasanya tdk digunakan karena dapat Spesimen tube 1, biasanya tdk digunakan karena dapat bercampur darah dari trauma punksi

Spesimen tube 2 : utk sel & hitung jenis dan pemeriksaan kimia atau imunologi

Spesimen tube 3 : kultur

• Kadar Protein, Ca, Glukosa bervariasi tergantung tempat spesimen diambil (ventricle, cisterna magna, lumbar

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Composition of Normal Spinal Fluid

• Amount

: 90-150 ml

• Color

: colorless, like water

• Transparency : clear, like water

• Specific Gravity : 1.006-1.008

• Glucose

: 45-100 mg/100ml

(60-70% KGD)

• Urea

: 8-28 mg/100ml

• Sodium

: 117-137 mEq/L

• Pottasium

: 2.33-4,59 mEq/L

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• Acid-base balance :

– pH

: 7.31

– Pco

₂

: 47.9 mmHg

– HCO

₃

: 22.9 mEq/L

• Uric acid

: 0.07- 2.8 mEq/L

• Total protein : 20-40 mg/100ml

– Lumbar

: 20-40 mg/100ml

– Cisternal

: 15-25 mg/100ml

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• Electrophoretic separation of lumbar fluid, mean

values :

– Prealbumin : 4.6 ± 13% – Albumin : 49.5 ± 6.5 % – α₁-globulin : 6.7 ± 2.0 % – α_2- globulin : 8.3 ± 2.1% – Β- and τ- globulin : 18.5 ± 4.8 % – γ-globulin : 11.2 ± 2.7 %

• Calcium (lumbar)

: 2.32 mEq/L

• Magnesium

: 2.20 mEq/L

• Creatinine

: 0.4 – 1.5 mg/100ml

• Lactic dehydrogenase : 8-50 units

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Pemeriksaan Lab

• Makroskopis

• Mikroskopis

• Analisa Kimia

• Imunologi

• Mikrobiologi

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Makroskopis

• Jernih, tidak berwarna

• Darah : - merah

* gross abaikan pem. Kimia

* koreksi perhitungan lekosit :

jlh lekosit = jlh leko terhitung – a

a = jlh eri dlm darah x leko dlm darah jlh eri dlm CSF

- Bloody tap (traumatic tap) :

* Cedera pbl darah pada tindakan LP

* Tube 1, 2, 3 berturut-turut jlh darah makin kurang * Tube 1, 2, 3 berturut-turut jlh darah makin kurang * Jk ragu, bandingkan hitung sel tube 1 dan ke 3

* Supernatan setelah disentrifus : jernih, tak berwarna - Hemorrhage :

* Darah pada tube 1,2 dan 3 sama banyak * Supernatan kekuningan

* Eritrosit crenated

* Jk darah banyak, bisa terlihat clot

* Pada intracerebral hemorrage bisa terlihat jernih

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• Xanthochromia : - Kekuningan

- Bisa warna bilirubin (jk jaundice berat, kronis, @ prematur), derivat Hb, lipidlike substance karena destruksi jar. otak

- Jk mengandung banyak protein dan clot, indikasi adanya obstruksi, mis. tumor

• Transparansi :

- > 200 lekosit : cloudy

200 – 500 lekosit : keruh 200 – 500 lekosit : keruh > 500 : turbid

- acute meningitis : bervariasi berawan s/d spt pus - encephalitis, tuberculous meningitis : jernih

• Sedimen : Normal tdk ada

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Mikroskopis

• Diperiksa pada sedimen

• Total lekosit normal - dewasa : 0 - 6 mononuclear /mm3 - neonati : 0 – 30

• Eritrosit : bedakan dulu trauma atau tidak • Hitung jenis :

- netrofil tinggi : infeksi bakteri, masa dini (1-2 hari) viral, - netrofil tinggi : infeksi bakteri, masa dini (1-2 hari) viral,

TB, jamur

- limfosit meninggi : Viral. TB, jamur, Syphilic - plasma sel meninggi : multiple sclerosis

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Kimia Klinik

• Total Protein

• Glukosa : Normal : 60 – 70 % KGD (seimbang 2-4 jam) Meninggi : hiperglikemia

Menurun : - hipoglikemia

- pemakaian meningkat oleh CNS, lekosit, eritrosit, jar, mo

- gangguan transport dari plasma ke - gangguan transport dari plasma ke

CSF

• LDH : - normal 5 – 10 % kadar plasma - DD bacterial @ viral meningitis

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Lain-lain

• Serologis : sifilis, VDRL, FTA (fluorescent treponemal antibody

• Elektrolit

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Cerebrospinal fluid in disease

Disease Preasure (mm water)

Appearance Clot No & Type of Cell Protein (mg/100ml) Sugar (mg/1 00ml) Chlorides (mEq/L) Remarks Normal 100-200 Clear, colorless 0 0-5 lymphocytes 20-40 45-100 113-127 Meningitis • Pyogenic • Tuberculous • Lymphocytic choroimeningitis 3+ 3+ 2+ Cloudy Clear or slightly turbid Clear or opalescent Large Web 0 3+ PMN 2+ lymphocytes 50-2000 lymphocytes 3+ 2+ + D(0) 20-40 20-40 Slightly D D<100 N Tubercle bacilli

Cord Tumor N Clear & deep

yellow

Mass N to + lymphocytes 3+ N N

Brain Abscess 1+ to 3+ Clear or

turbid

± + PMN + to 2+ N N to slightly

D

turbid D

Brain Tumor 3+ Clear yellow ± N lymphocytes ±to 2+ N N

Poliomyelitis N Clear or opalescent 0 50-2000 PMN early lymphocytes leter + N N to slightly D Filtrable virus Encephalitis N to Clear, colorless

0 N to + lymphocytes ± N N Filtrable virus

Subarachnoid hemorrhage 1+ to 2+ Bloody yellow 0 Blood 3+ N N Neurosyphilis • Meningovascular • Tabes • Paresis + + + Clear, colorless Rare Rare Many, small 20-100 PMN early, lymphocytes leter 25-75 lymphocytes 25-50 lymphocytes + to 2+ + + N N N N N N

Serologic test for syphilis nearly always reactive

80% reactive 100% reactive

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Cerebrospinal fluid in disease

Disease Preasure (mm water)

Appearance Clot No & Type of Cell Protein (mg/100ml) Sugar (mg/1 00ml) Chlorides (mEq/L) Remarks Normal 100-200 Clear, colorless 0 0-5 lymphocytes 20-40 45-100 113-127 Meningitis • Pyogenic • Tuberculous 3+ 3+ Cloudy Clear or Large Web 3+ PMN 2+ lymphocytes 3+ 2+ D(0) 20-40 Slightly D D<100 Tubercle bacilli • Tuberculous • Lymphocytic choroimeningitis 3+ 2+ Clear or slightly turbid Clear or opalescent Web 0 2+ lymphocytes 50-2000 lymphocytes 2+ + 20-40 20-40 D<100 N Tubercle bacilli

Cord Tumor N Clear & deep

yellow

Mass N to + lymphocytes 3+ N N

Brain Abscess 1+ to 3+ Clear or

turbid

± + PMN + to 2+ N N to slightly

D

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Cerebrospinal fluid in disease

Disease Preasure (mm water)

Appearance Clot No & Type of Cell Protein (mg/100ml ) Sugar (mg/100ml) Chlorides (mEq/L) Remarks Poliomyelitis N Clear or opalescent 0 50-2000 PMN early lymphocytes leter + N N to slightly D Filtrable virus

Encephalitis N to Clear, 0 N to + lymphocytes ± N N Filtrable virus

Encephalitis N to Clear,

colorless

0 N to + lymphocytes ± N N Filtrable virus

Subarachnoid hemorrhage 1+ to 2+ Bloody yellow 0 Blood 3+ N N Neurosyphilis • Meningovascular • Tabes • Paresis + + + Clear, colorless Rare Rare Many, small 20-100 PMN early, lymphocytes leter 25-75 lymphocytes 25-50 lymphocytes + to 2+ + + N N N N N N

Serologic test for syphilis nearly always reactive 80% reactive 100% reactive

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