Lichid cefalorahidian

Lichidul cefalorahidian este un lichid care se gaseste in cavitatile ventriculare ale creierului si in canalul central al maduvei spinarii, precum si intre foitele care invelesc diversele parti ale sistemului nervos central. Secretat de formatiuni speciale din sistemul nervos, lichidul cefalorahidian se compune in cea mai mare parte din apa (98,5%), clorura de sodiu (0,7%), albumine, saruri alcaline si urme de zahar.In total, in toate spatiile amintite ale sistemului nervos se gaseste o cantitate de aproximativ 60 g lichid.

Presiune. La o presiune de circa 10-15 ml apa, unele boli pot modifica cantitatea si presiunea lichidului cefalorahidian, precum si compozitia lui.Astfel, in infectii ale meningelor, albumina poate creste de 3 pana la 10 ori. In infectii meningoencefalice, in lichidul cefalorahidian pot fi gasite globule albe, globule rosii si microbi. Pentru analiza lichidului cefalorahidian este utilizat un manometru care atasat la un ac special poate masura presiunea lichidului cefalorahidian, permitand totodata extragerea unor cantitati de lichid necesare analizei compozitiei lichidului.In interventiile chirurgicale in care se practica anestezia rahidiana, substanta anestezianta (novocaina) este introdusa in lichidul cefalorahidian cu ajutorul unui ac special si dizolvandu-se in acesta ajunge in contact cu substanta nervoasa, realizand anestezia dorita. Tot in lichidul cefalorahidian pot fi injectate antibiotice in caz de inflamatii puternice ale sistemului nervos.

Punctia lombara. In timpul acestei proceduri specialistul va introduce cu grija un ac in zona lombara si va colecta astfel o mostra de lichid cefalorahidian. Mostra va fi supusa unor investigatii medicale care vizeaza culoarea, numarul de celule sangvine, proteine, glucoza, si alte substante prezente in lichidul cefalorahidian. Mostra mai poate fi asezata intr-un mediu favorabil dezvoltarii bacteriilor (procedeu numit cultura de lichid cefalorahidian) pentru a se descoperi daca in lichidul cefalorahidian exista bacterii sau ciuperci. In timpul recoltarii mostrei de lichid cefalorahidian se analizeaza si presiunea acestuia din urma.

De ce se face testul? Punctia lombara se efectueaza in urmatoarele cazuri:- cand pacientul prezinta simptome indicatoare de: meningita, cancer, inflamare, sangerare in zona din jurul creierului sau din jurul coloanei vertebrale.- pentru a se diagnostica conditii medicale ale creierului sau coloanei vertebrale (de ex: scleroza multipla, sindromul Guillain-Barré).-pentru a se masura presiunea lichidului cefalorahidian.- pentru a injecta anestezice sau medicamente in lichidul cefalorahidian. Acest procedeu se executa cand pacientul sufera de leucemie sau de anumite tipuri de cancer.- pacientul trebuie supus unei investigatii cu raze X si in acest scop un colorant este injectat in lichidul cefalorahidian.- in cazuri rare, se executa punctia lombara pentru a se reduce presiunea lichidului cefalorahidian asupra creierului.

1

Pregatire pacient

Informati medicul specialist daca:- urmati tratament medicamentos zilnic.- urmati tratament medicametos pe baza de anticoagulanti (inclusiv antiinflamatori nonsteroidali precum warfarina si ibuprofen) sau aveti probleme legate de coagularea sangelui. Si anumite tratamente naturise pot avea efecte anticoagulante, deci este indicat sa va informati medicul daca urmati un astfel de tratament.- sunteti alergic la anumite medicamente sau sunteti alergic la anestezice.- sunteti sau ati putea fi insarcinata. Inaintea efectuarii testului va trebui sa va goliti vezica urinara.

Punctia lombara nu se va efectua decat cu acordul scris al pacientului. Puteti discuta cu doctorul dumneavoastra daca va nelamuresc sau va ingrijoreaza anumite anumite aspecte ale testului. Doctorul ar trebui de asemenea sa va explice riscurile implicate, cum se va desfasura testul si ce indica rezultatele acestuia.

Cum se face testul? Acest test poate fi efectuat in cabinetul medicului dumneavoastra specialist, la camera de garda, in sala de radiologie, sau chiar in salonul in care sunteti internat. In mod normal durata testului este de 20-30 de minute.

Se vor respecta urmatorii pasi in efectuarea testului:- pacientul trebuie sa stea in pozitie culcata, pe o parte, cu genunchii trasi inspre piept. Este foarte important sa fie coloana vertebrala flectata.- doctorul va marca zona unde se va face punctia lombara.- zona unde se va face punctia lombara este curatata cu un sapun special si sters cu prosoape sterile.- se va folosi un ac lung si subtire pentru punctie; o cantitate mica de lichid cefalorahidian se va scurge prin ac.- pentru a se masura presiunea lichidului cefalorahidian, se va conecta un manomentru la ac. Presiunea va fi masurata in momentul punctiei initiale, cat si dupa ce doctorul va termina de recoltat mostre de lichid cefalorahidian.

Cum se simte? Puteti simti disconfort de la urmatoarele:- unor oameni le este greu sa ridice genunchii spre piep atunci cand stau culcati pe o parte.- sapunul cu care este curatata zona punctiei este rece.- veti simti o usoara intepatura atunci cand va este injectat anestezicul.- veti simti o durere scurta cand acul folosit pentru recoltarea lichidului cefalorahidian este introdus.- daca acul va atinge un nerv, pacientul va simti o furnicatura asemanatoare unui soc electric in unul dintre picioare.- aproximativ 10-25% dintre pacienti resimt o durere de cap dupa prelevarea unei mostre de lichid cefalorahidian. Aceste dureri de cap dureaza in jur de 24-48 de ore. Medicamentele nu au efect asupra acestor dureri; in schimb ele pot fi prevenite daca pacientul sta intins in pat timp de 1-4 ore dupa efectuarea punctiei lombare. Consumul de

2

lichide poate avea efect benefic, reducand intensitatea durerii.- puteti avea dificultati in a adormi timp de 1-2 zile dupa efectuarea unei punctii lombare.

Riscuri General vorbind, punctia lombara efectuata pentru a se recolta o mostra de lichid cefalorahidian este o procedura considerata sigura pentru pacient. Exista unele riscuri totusi implicate in aceasta procedura:- dureri de cap in urmatoarele zile.- senzatie de oboseala si dificultati in a adormi.- leziune minora a nervului (la 1 din 1,000 pacienti) care se va vindeca de la sine in timp.- infectarea pacientului cu meningita.- sangerare in canalul vertebral.- leziuni ale cartilajului dintre vertebre.- pacientii care urmeaza tratament cu anticoagulante au sanse mai mari sa sangereze dupa efectuarea punctiei lombare.- punctia lombara nu este indicata pentru pacientii care prezinta: presiune ridicata la nivelul creierului datorita unei tumori, un abces (infectie) la nivelul creierului, sangerare la nivelul creierului.

Este foarte important ca dupa efectuarea testului sa luati legatura cu medicul specialist in cazul in care prezentati una dintre simptomele:- febra sau frisoane;- gat amortit.- supurarea sau sangerare in locul unde a fost efectuata punctia.- dureri foarte puternice de cap.- amorteala sub locul punctiei.

Rezultate Rezultate normale ale punctiei lombare, in urma analizei lichidului cefalorahidian:

Aspect:- transparent, fara culoare.

Presiune:- pentru adulti – intre 50 si 180 milimetri (mm) apa;- pentru copii – intre 10 si 100 mm apa.

Proteine:- adulti – 15-45 mg/dL (miligrame pe decilitru);- copii si batrani – 15-70mg/dL.

Glucoza:- 40%-80% din nivelul de glucoza din sange. Nivele mai mari se depisteaza daca pacientul a mancat inainte de efectuarea testului.

3

Numarul celule sangvine:- nu se depisteaza celule rosii;- celule albe – 0-10 celule pe milimetru cubic.

Alte rezultate:- nu se depisteaza prezenta bacteriilor, ciupercilor, virusurilor sau altor microorganisme.- Nu se depisteaza prezenta unei tumori.

Rezultate anormale ale punctiei lombare, in urma analizei lichidului cefalorahidian:

Aspect:- prezenta sangelui in lichidul cefalorahidian schimba culoarea acestuia;- prezenta unei infectii (meningita, abces la nivelul creierului) afecteaza transparenta lichidului.

Presiune:- presiune ridicata indica hemoragie la nivelul creierului, infectie (meningita), atac cerebral, probleme circulatorii.- presiune scazuta indica prezenta unui blocaj al canalului spinal.

Proteine:- nivele ridicate de proteina indica: hemoragii in lichidul cefalorahidian, prezenta unei tumori sau a cancerului, diabet, infectie, leziune, sindromul Guillain-Barré, hipotiroidism acut, etc.- prezenta anticorpilor (imunoglobinelor) in lichidul cefalorahidian indica: afectiuni ale sistemului imun, infectii bacteriale sau virale.

Glucoza:- nivele scazute de glucoza indica prezenta unei infectii cu meningita, sau hemoragie la nivelul creierului (hemoragia a inceput cu cateva zile inainte ca nivelul de glucoza sa scada).- nivelele ridicate de glucoza sunt indicatori ai diabetului.

Numarul celule sangvine:- prezenta celulelor rosii in lichidul cefalorahidian este un semn al hemoragiei.- prezenta in numar mare al celulelor albe indica infectia cu meningita.- celule tumorale precum si nivele anormale de celule albe sunt indicatori al cancerului.

Alte rezultate:- pacientul este suspect de infectie cu sifilis daca se depisteaza prezenta anticorpilor, bacteriilor si altor microorganisme in lichidul cefalorahidian.- pacientul este infectat cu meningita daca in lichidul cefalorahidian se indica prezenta antigenilor bacteriali.

4

Ce poate afecta testul? Punctia lombara poate fi afectata de urmatorele:- pacientul nu poate sta nemiscat in momentul recoltarii lichidului cefalorahidian.- obezitate, deshidratare, artrita acuta, leziune recenta a coloanei vertebrale.- hemoragie la nivelul lichidului cefalorahidian.- doctorul nu poate sa recolteze o mostra de lichid cefalorahidian.

Alte informatii

Punctia lombara nu se va efectua daca:- pacientul este suspect de tumoare la nivelul creierului, sau daca pacientul prezinta o umflatura sau presiune ridicata la nivelul creierului.- este prezenta o infectia la nivelul pielii in zona unde trebuie efectuata punctia. In aceste conditii, daca se va efectua o punctie lombara, infectia se poate raspandi in canalul vertebral.- pacientul are probleme de coagulare a sangelui.

Hipertensiunea intracraniana apare ca urmare a unui dezechilibru anatomo-fiziologic dintre continutul cranian si cutia craniana. Sindromul de hipertensiune intracraniana se caracterizeaza prin cefalee frontala sau occipitala, tulburari oculare (diplopie, edem papilar), varsaturi si stare de discomfort general. Hipertensiunea intracraniana este cauzata de o multitudine de cauze: edem cerebral, acumularea de lichid cefalorahidian in cutia craniana, hipertensiunea in vasele cerebrale, procese expansive intracraniene (tumora, hematom, abces), accidente vasculare cerebrale, infectii (meningite, encefalite), hidrocefalie.

Lichidul cefalorahidian este secretat in permanenta la nivelul plexurilor coroide, se reinnoieste continuu fiind resorbit de vasele meningeene si de granulatiile Pacchioni. Acest lichid are rol de protectie fata de socurile mecanice, precum si rol de nutritie prin schimburile metabolice la nivelul tesutului nervos central. Circulatia lichidului cefalorahidian se face in felul urmator: secretat de plexurile coroide, acesta inunda ventriculii laterali, trece apoi in ventricolul III, de unde trece in ventricolul IV prin apeductul lui Silvius. Din ventricolul IV, LCR trece prin gaurile Magendie si Luschka in cisterna bazala, cisterna magna si spatiul subarahnoidian, de unde este resorbit in circulatia generala prin intermediul vaselor meningeene si granulatiilor Pacchioni.

Cresterea presiunii intracraniene peste 200 ml coloana de apa indica o situatie de alarma, iar o crestere a presiunii peste 400 ml coloana de apa poate pune in pericol viata bolnavului prin scaderea perfuziei cerebrale (presiunea intracraniana egalizeaza presiunea sangvina din craniu) si prin comprimarea structurilor nervoase de la nivelul trunchiului cerebral.

Cauzele hipertensiunii intracraniene sunt multiple. Sistematizandu-le, se pot identifica urmatoarele cauze: - malformatiile congenitale: malformatii cranio-faciale cum ar fi craniostenozele sau boala Crouzon; malformatiile craniospinale ca malformatia Arnold-Chiari sau sindromul

5

Dandy-Walker. - tumorile cranio-cerebrale, benigne sau maligne, atat cele primare, cat si cele metastatice. - traumatismele cranio-cerebrale cum ar fi fracturile cu infundare, hematoamele intracraniene subdurale, epidurale sau intraparenchimatoase, plagile cranio-cerebrale. - parazitozele cerebrale, incluzand aici cisticercoza si chistul hidatic. - malformatiile vasculare, ca anevrismele intracraniene, hematoamele intracraniene primare. - afectiunile inflamatorii: abcesele cerebrale, tuberculomul cerebral, goma sifilitica, afectiuni inflamatorii de etiologie virala si cu evolutie pseudotumorala. In cazul pacientilor infectati cu virusul HIV manifest clinic, majoritatea prezinta leziuni vasculare cerebrale. - starile alergice, intoxicatiile, compresiunile medulare care interfera cu drenajul lichidului cefalorahidian.

Valori normale- lichid cefalorahidian

Nr.

Parametru biochimic

Valoarea în unităţi convenţionale

Valoarea în S.I.

1. BILIRUBINĂ 0 mg % ml 0 μmol / l2. CELULE 0-5 -3. CLOR 12-130 mEq / l 120-130 mmol / l 4. GLUCOZĂ 50-75 mg % 2,8- 4,2 mmol / l5. PRESIUNE 70-180 mm Hg -6. PROTEINE TOTALE 15-45 mg % ml 0,15- 0,45 mg / l7. ALBUMINĂ 80 % -8. GAMMA- GLOBULINE 10 % -

Caracteristicile LCR normal si modificarile microbiologice, citologice si biochimice ale LCR in meningite sunt evidentiate mai jos:1. LCR normal:- aspect - clar, incolor;- examen microbiologic - steril;- examen citologic - 0-3 limfocite/mm3;- examen biochimic - proteine=15-40 mg/dl; glucoza=50-70 mg/dl; acid lactic=35 mg/dl; cloruri=680-730 mg/dl.2. Meningita bacteriana acuta:- aspect - opalescent, purulent;- examen microbiologic - depistare rapida microscopica si antigenica; izolare;- examen citologic - PMN> 1000/mm3;- examen biochimic - proteine=>100 mg/dl; glucoza=<40 mg/dl; acid lactic=>35 mg/dl.3. Meningita TBC:- aspect - clar sau usor opalescent, cu val de fibrina;

6

- examen microbiologic - depistare rapida, izolare;- examen citologic - limfocite in jur de 200/mm3;- examen biochimic - proteine=>100 mg/dl; glucoza=<40 mg/dl; acid lactic=>35 mg/dl; cloruri=<600 mg/dl.4. Meningita micotica:- aspect - clar sau opalescent;- examen microbiologic - depistare rapida microscopica si antigenica; izolare;- examen citologic - predomina limfocitele 100-500/mm3;- examen biochimic - proteine=>100 mg/dl; glucoza=<40 mg/dl; alcool etilic prezent.5. Meningita virala:- aspect - clar sau opalescent;- examen microbiologic - steril bacteriologic; se poate izola virusul;- examen citologic - limfocite 500-1000/mm3;- examen biochimic - proteine=15-100 mg/dl; glucoza=50-70 mg/dl; acid lactic=35 mg/dl; cloruri=680-730 mg/dl.

Examenul citologic  - consta in numararea elementelor in suspensie si determinarea tipului de celule din sediment. Numararea elementelor in suspensie se face pe lichidul necentrifugat si se exprima in numar de elemente pe mm3. Numaratoarea se efectueaza cel mai frecvent in camera Fuchs-Rosenthal.In acest scop, o cantitate din LCR-ul bine omogenizat se introduce intr-o alta eprubeta pentru a se evita contaminarea ulterioara.In functie de aspectul macroscopic al lichidului se procedeaza astfel:- LCR clar sau opalin –se preleva aseptic cu pipeta Pasteur o cantitate mica de lichid suficienta pentru a umple camera de numarat Fuchs-Rosenthal;- LCR hemoragic – se adauga acid acetic glacial in proportie de o picatura la zece picaturi de LCR; se asteapta 1-2 minute pentru liza hematiilor, apoi cu pipeta Pasteur se umple camera de numarat;- LCR tulbure, purulent -  se face o dilutie de 1/10 sau eventual 1/100 in ser fiziologic. In acest caz, numarul de celule obtinut va fi inmultit cu 10 sau 100 in functie de dilutia folosita.Camera Fuchs-Rosenthal are o suprafata de 16 mm2, o inaltime de 0.2 mm si un volum de 3.2 mm2.1. Daca densitatea celulelor este mica se face numaratoarea pe toate cele 16 patrate ale camerei si se imparte suma la 3 pentru a afla numarul celulelor pe mm3.2. Daca densitatea celulara este mai mare se numara 5 patrate mari delimitate de linii triple, aceasta valoare reprezentand numarul de celule pe mm3.Concomitent cu numaratoarea de elemente in camera de numarat, cantitatea de LCR ramasa in tubul primar primit la laborator se centrifugheaza 15-20 minute la 3000 rotatii/min, pentru determinarile ulterioare.Dupa centrifugare supernatantul este colectat intr-un tub steril si folosit pentru decelarea de antigene solubile, iar sedimentul este folosit pentru frotiuri si culturi bacteriene.Pentru realizarea frotiurilor se folosesc lame curate, degresate, de preferinta noi, pentru a avea siguranta ca nu au bacterii restante de la examinari anterioare. Sedimentul se intinde cu ansa sau cu pipeta Pasteur pentru a obtine un strat  continuu de celule din centrul lamei spre periferie. Se prepara 4 frotiuri din care 2 vor fi fixate si colorate Gram si respectiv

7

albastru de metilen, 1 frotiu va fi colorat May - Grunwald - Giemsa si unul va ramane de rezerva.In cazul in care exista suspiciune de meningita cu Cryptococcus neoformans se executa un preparat proaspat intre lama si lamela din sediment cu tus India. Prezenta de formatiuni rotund ovalare, capsulate (halou mare, clar si incolor) care pot fi inmugurite este sugestiva pentru Cryptococcus neoformans.Pe frotiul colorat Gram se evidentiaza prezenta germenilor, morfologia, tinctorialitatea, frecventa si localizarea (intra sau extraleucocitari).Lamele colorate May-Grunwald-Giemsa si albastru de metilen se utilizeaza pentru examenul citologic. Se apreciaza procentual tipul elementelor: PMN, limfocite, notandu-se in acelasi timp aspectul lor.Cultivarea este un mijloc de diagnostic specific, dar necesita 24 - 48 de ore si poate fi negativa in cazul prezentei germenilor neviabili sau daca pacientul a inceput tratamentul antibiotic.Insamantarea sedimentului se efectueaza pe placi preincalzite la termostat.Se vor folosi: agar Columbia cu 5% sange de berbec, agar chocolate, geloza lactozata si bulion thioglycolat. In functie de examenul bacterioscopic, pot fi adaugate si alte medii (Sabouraud). Mediile sunt incubate la 37°C, eventual in atmosfera cu 5% CO2 pentru medii ca agar Columbia cu 5% sange de berbec si agar chocolate.Aparitia culturii este urmarita zilnic timp de 3 zile pe mediile solide si 5 zile in tubul cu bulion thioglycolat. In cazul culturilor pozitive se continua identificarea pana la nivel de specie si efectuarea antibiogramei.Daca bacterioscopia atesta prezenta unei mari densitati bacteriene in proba de LCR (zeci de bacterii pe camp microscopic examinat cu marire de 1000x), se poate incerca antibiograma din cultura primara, ale carei rezultate urmeaza a fi confirmate prin antibiograma pe subcultura standardizata.Avand in vedere limitele examenului microscopic si a culturilor, s-au pus la punct metode de detectare a antigenelor solubile in LCR: CIE, Latex-aglutinare, Coaglutinare, ELISA si RIA.In cadrul laboratoarelor Synevo, pentru detectarea antigenelor solubile se foloseste ca test rapid reactia de latex-aglutinare. Tehnica de lucru este conform foii de kit.Un rezultat negativ nu exclude posibilitatea infectiei cu germenul testat deoarece antigenele bacteriene pot fi prezente in concentratie mai mica decat limita de detectie a reactivilor utilizati.Un rezultat pozitiv trebuie, de asemenea, urmat de izolarea germenului, identificarea si testarea sensibilitatii la antibiotice.Examenul citologic, bacterioscopia si latex-aglutinarea permit microbiologului eliberarea unui rezultat partial, necesar clinicianului in orientarea tratamentului de prima intentie.

punctionarea spatiului subarahnoidian la nivel lombar, suboccipital si mai rar ventricular in conditii strict aseptice si de preferat inaintea administrarii de antibiotice.Meningitele bacteriene “decapitate” prin tratament antimicrobian pot evolua cu lichid clar si creeaza adesea mari probleme de diagnostic. Cantitatea de 5–10 mL LCR satisface necesitatile pentru examenele biochimice si microbiologice, iar fragmentarea probei inca de la recoltare in doua tuburi sterile minimalizeaza riscul contaminarii prin splitare ulterioara. Cand cantitatea recoltata este

8

mai mica se va comunica laboratorului ce teste vor fi efectuate prioritar. Procesarea unei cantitati mult prea mici poate indica un rezultat fals negativ, acest lucru fiind mult mai daunator pentru pacient decat efectuarea unei noi punctii lombare. In momentul recoltarii se pot face aprecieri asupra presiunii si aspectului lichidului. Tuburile recoltate sunt etichetate la patul bolnavului si trimise la laborator impreuna cu cerea de analize solicitate care trebuie sa cuprinda: numele si prenumele pacientului, varsta, diagnosticul si daca este sub tratament antibiotic. Proba se transporta imediat la laborator fara a fi refrigerata sau termostatata.

Cerebrospinal fluid Cerebrospinal fluid is a liquid that is found in the ventricular cavities of the brain and central canal of the spinal cord, which wrapped foils and between different parts of the central nervous system. Secreted by specific formations of the nervous system, cerebrospinal fluid consists mostly of water (98.5%), sodium chloride (0.7%), albumin, alkaline salts and traces of sugar. Overall, in all places mentioned nervous system there is a quantity of about 60 g liquid. Pressure. At a pressure of about 10-15 ml of water, some diseases may alter the quantity and cerebrospinal fluid pressure, and its composition. Thus, infections of the meninges, albumin may increase by 3 to 10 times. The infection meningoencephalitis, cerebrospinal fluid can be found white blood cells, red blood cells and microbes.  For cerebrospinal fluid analysis is used to gauge attached to a needle can measure cerebrospinal fluid pressure, while allowing some amount of liquid extraction for the analysis of liquid composition. The surgery in which spinal anesthesia practice, anesthetic substance (novocaine) is introduced into the cerebrospinal fluid with a needle in it and dissolve it comes in contact with nerve substance, making the desired anesthesia. Still in the cerebrospinal fluid can be injected strong antibiotics in case of inflammation of the nervous system. Lumbar puncture. During this procedure the specialist will carefully insert a needle into the lumbar area and thus collect a sample of cerebrospinal fluid. The sample will be subjected to medical investigations aiming color, number of blood cells, protein, glucose, and other substances in the cerebrospinal fluid. Sample can be placed in a development environment bacteria (process called cerebrospinal fluid culture) to discover if there cerebrospinal fluid bacteria or fungi. During harvest sample is analyzed and cerebrospinal fluid pressure to the latter. Why is this test? Lumbar puncture is performed in the following cases: - When the patient shows signs of symptoms: meningitis, cancer, inflammation, bleeding around the brain or the area around the spine. - To diagnose medical conditions of the brain or spine (eg multiple sclerosis, Guillain-Barré syndrome). -To measure cerebrospinal fluid pressure. - To inject anesthetics or drugs in cerebrospinal fluid. This procedure is performed when the patient is suffering from leukemia or certain cancers.

9

- The patient must undergo X-ray investigations and to this end a dye is injected into the cerebrospinal fluid. - In rare cases, lumbar puncture is performed to reduce cerebrospinal fluid pressure on the brain.

Patient preparation Inform your doctor if: - Follow daily medication. - Follow medicametos on anticoagulant therapy (including anti-inflammatory nonsteroidali such as warfarin and ibuprofen) or have blood clotting problems. And some natural therapies can have anticoagulant effects, so it is advisable to inform your doctor if you follow such treatment. - Are allergic to certain medications or are allergic to anesthetics. - You or you may be pregnant. Before the test you have to empty your bladder. Lumbar puncture will not perform without the written consent of the patient. You can discuss with your doctor if your question or concern to certain aspects of the test. The doctor should also explain the risks involved, how it will perform the test and show results. How to test? This test can be performed in your doctor's office specialist, emergency room, the radiology room, or you are boarding lounge. Normally the test is 20-30 minutes. It will meet next steps in the test: - The patient must stay lying down on one side, with knees pulled toward chest. It is very important to be bent spine. - Will mark the area where the doctor will do a lumbar puncture. - The area where the lumbar puncture will be cleaned with a special soap and sterile towels removed. - Will use a long thin needle to puncture, a small amount of cerebrospinal fluid will leak. - To measure cerebrospinal fluid pressure, will connect an AC manomentru. Pressure will be measured when the initial puncture, and after you finish harvesting doctor cerebrospinal fluid samples. How is he? You feel discomfort from the following: - Some people find it difficult to raise your knees to piep when I lie on one side. - Soap with cold puncture area is cleaned. - Will feel a slight sting when the anesthetic will be injected. - Will feel a brief pain when the needle used to collect cerebrospinal fluid is introduced. - If the needle will touch a nerve, the patient will feel a tingling like an electric shock on one foot. - About 10-25% of patients experience a headache after a sample of cerebrospinal fluid. These headaches last about 24-48 hours. These medicines have no effect on pain, instead they can be prevented if the patient lying in bed for 1-4 hours after the lumbar puncture. Liquid consumption may have beneficial effects, reducing pain intensity. - You have trouble falling asleep for 1-2 days after a lumbar punctures. Risks Generally speaking, a lumbar puncture performed to yield a sample of

10

cerebrospinal fluid is considered a safe procedure for the patient. There are still some risks involved in this procedure: - Headaches these days. - Sensation of fatigue and difficulty sleeping. - Minor nerve damage (1 in 1000 patients) that will heal itself over time. - Infected patient with meningitis. - Bleeding in the spinal canal. - Damage to the cartilage between the vertebrae. - Patients receiving anticoagulant were more likely bleed after the lumbar puncture. - Lumbar puncture is not indicated for patients who have: high pressure in the brain due to a tumor, an abscess (infection) in the brain, bleeding in the brain. It is very important that after the test to contact your doctor if you present one of the symptoms: - Fever or chills; - Numb neck. - Suppuration or bleeding where the puncture was performed. - Very strong head pain. - Numbness below the puncture site. Showing results normal lumbar puncture, the cerebrospinal fluid analysis: Appearance: - Transparent, colorless. Pressure: - For adults - between 50 and 180 millimeters (mm) water; - Children - 10 to 100 mm water. Protein: - Adults - 15-45 mg / dL (milligrams per deciliter); - Young and old - 15-70mg/dL. Glucose: - 40% -80% of blood glucose levels. Higher levels are detected if the patient has eaten before the test. Number of blood cells: - Not detected red blood cells; - White blood cells - 0-10 cells per cubic millimeter. Other results: - Not detected the presence of bacteria, fungi, viruses or other microorganisms. - Not a tumor is detected. Results CSF abnormalities in cerebrospinal fluid analysis: Appearance: - Blood in the cerebrospinal fluid changes its color; - The presence of infection (meningitis, brain abscess) affects transparent liquid. Pressure: - High pressure indicates bleeding in the brain, infection (meningitis), stroke, circulatory problems. - Low pressure indicates a blockage of the spinal canal present. Protein: - High levels of protein show: hemorrhage in the cerebrospinal fluid, a tumor or cancer,

11

diabetes, infection, injury, Guillain-Barré syndrome, acute hypothyroidism, etc.. - Presence of antibodies (imunoglobinelor) indicates cerebrospinal fluid: immune system problems, bacterial or viral infections. Glucose: - Low levels of glucose indicate an infection with meningitis or brain hemorrhage (bleeding started several days before to decrease glucose levels). - High glucose levels are indicators of diabetes. Number of blood cells: - The presence of red cells in the cerebrospinal fluid is a sign of bleeding. - Present in large numbers of white blood cells indicate infection with meningitis. - Tumor cells and abnormal levels of white blood cells are indicative of cancer. Other results: - Patient is suspected of being infected with syphilis is detected if this antibody, bacteria and other microorganisms in cerebrospinal fluid. - If the patient is infected with meningitis in cerebrospinal fluid indicate this bacterial antigens.

What can affect the test? Lumbar puncture can be affected by FOLLOWING: - Patient can not sit motionless at harvest cerebrospinal fluid. - Obesity, dehydration, acute arthritis, recent spinal injury. - Bleeding in the cerebrospinal fluid. - Doctor can not collect a sample of cerebrospinal fluid. Miscellaneous Lumbar puncture will not be issued if: - Patient is suspected brain tumor, or if you experience swelling or high pressure in the brain. - Is this an infection in the area where the skin puncture should be performed. In these conditions, you will perform a lumbar puncture, infection can spread into the spinal canal. - Patient has a blood clotting problems. Intracranial hypertension occurs as a result of anatomic and physiologic imbalance between cranial and skull contents. Intracranial hypertension syndrome is characterized by frontal or occipital headache, visual changes (diplopia, papilloedema), vomiting and general feeling of discomfort. Intracranial pressure is caused by a multitude of causes: cerebral edema, the accumulation of cerebrospinal fluid in the skull, high in the cerebral vessels, intracranial expansive processes (tumor, hematoma, abscess), strokes, infections (meningitis, encephalitis), hydrocephalus. Cerebrospinal fluid is continuously secreted at the choroid plexus, it renews itself continuously being reabsorbed by vessels meningeene and granulations Pacchioni. This fluid serves as protection against mechanical shocks, and the role of nutrition in metabolic exchanges in the central nervous tissue. Cerebrospinal fluid circulation is as follows: secreted by the choroid plexus, it floods the lateral ventricles, passing into ventricolul III, where it passes through the aqueduct of Silvius ventricolul IV. From ventricolul IV CSF through holes Magendie and Luschka in the basal cistern, cistern magna and subarachnoidian space, where is reabsorbed into general circulation through vessels and granulations Pacchioni meningeene.

12

Increased intracranial pressure above 200 ml water column indicate an alarm situation and increase pressure over 400 ml column of water can endanger patients' lives by decreasing cerebral perfusion (intracranial pressure equalizes blood pressure in the skull) and by compression of nerve structures brainstem level. There are multiple causes of intracranial hypertension. Sistematizandu them, one can identify the following cases: - Birth defects: cranio-facial malformations such as craniostenozele or Crouzon's disease, malformations craniospinale as Arnold-Chiari malformation or Dandy-Walker syndrome.

- Cranio-cerebral tumors, benign or malignant, both the primary and the metastases. - Cranio-cerebral injuries such as fractures, clogging, intracranial subdural hematoma, epidural or intraparenchimatoase, cranio-cerebral wounds. - Parasitoses brain, including here cysticercosis and hydatid cyst. - Vascular malformations, intracranial aneurysms that, primary intracranial hematoma. - Inflammatory diseases: brain abscess, tuberculomul cerebral gumma, inflammatory disease of viral etiology and pseudo evolution. In patients infected with HIV clinical manifestations, most shows cerebral vascular lesions. - Allergic conditions, intoxication, spinal compressions that interferes with cerebrospinal fluid drainage. Normal cerebrospinal-fluid No. Conventional biochemical parameter value in value in SI units 1. Bilirubin 0 mg% ml 0 μmol / l 2. CELLS 0-5 - 3. Chloride 12-130 mEq / L 120-130 mmol / l 4. Glucose 50-75 mg% 2.8 to 4.2 mmol / l 5. PRESSURE 70-180 mm Hg - 6. 15-45 mg% ml total protein from 0.15 to 0.45 mg / l 7. Albumin 80% - 8. Gamma-globulin 10% - Normal CSF characteristics and microbiological changes, cytological and biochemical CSF in meningitis are outlined below: 1. Normal CSF: - Appearance - clear, colorless; - Microbiological examination - sterile; - Cytologic - limfocite/mm3 0-3; - Biochemical test - protein = 15-40 mg / dl, glucose = 50-70 mg / dl, lactic acid = 35 mg / dL, chloride = 680-730 mg / dL. 2. Acute bacterial meningitis: - Appearance - opalescent, foul; - Microbiological examination - microscopic rapid detection and antigen isolation - Cytologic - neutrophils> 1000/mm3; - Biochemical test - protein => 100 mg / dl, glucose = <40 mg / dL, lactic acid => 35 mg / dL. 3. TB Meningitis: - Appearance - clear or slightly opalescent, with wave of fibrin;

13

- Microbiological examination - rapid detection, isolation - Cytologic - lymphocytes around 200/mm3; - Biochemical test - protein => 100 mg / dl, glucose = <40 mg / dL, lactic acid => 35 mg / dL, chloride = <600 mg / dL. 4. Mycotic meningitis: - Appearance - clear or opalescent; - Microbiological examination - microscopic rapid detection and antigen isolation - Cytologic - 100-500/mm3 lymphocyte predominant; - Biochemical test - protein => 100 mg / dl, glucose = <40 mg / dl, ethyl alcohol present. 5. Meningitis: - Appearance - clear or opalescent; - Microbiological examination - bacteriologically sterile, it can isolate the virus; - Cytologic - 500-1000/mm3 lymphocytes; - Biochemical test - protein = 15-100 mg / dl, glucose = 50-70 mg / dl, lactic acid = 35 mg / dL, chloride = 680-730 mg / dL.

Cytologic - consists of counting the elements in suspension and cell type determination in the sediment. Counting elements in the liquid suspension is necentrifugat and is expressed in number of items on MM3. Count is performed most frequently in Fuchs-Rosenthal chamber. For this purpose, an amount of CSF's is well mixed in another tube inserted to prevent further contamination. Depending on the macroscopic appearance of the fluid proceed as follows: - CSF is clear and opalin Pasteur pipette aseptically remove a small amount of liquid sufficient to fill the Fuchs-Rosenthal counting chamber; - Hemorrhagic CSF - glacial acetic acid is added at a rate of one drop to ten drops of CSF, is expected erythrocyte lysis 1-2 minutes, then Pasteur pipette filled room number; - CRL cloudy, foul - make a dilution of 1 / 10 or possibly 1 / 100 in saline. In this case, the number of cells obtained will be multiplied by 10 or 100 depending on the dilution used. Fuchs-Rosenthal chamber has an area of 16 mm2, a height of 0.2 mm and a volume of 3.2 mm2. 1. If cell density is low is counting on all 16 squares of the chamber and divides the sum of the three to find the number of cells per mm 3. 2. If cell density is higher include five large square bounded by triple lines, this value representing the number of cells per mm 3. While counting the elements in the counting room, the amount of CSF remaining in the primary tube centrifuge laboratory received 15 to 20 minutes at 3000 revolutions per minute for subsequent determinations. After centrifugation supernatant is collected into a sterile tube and used to detect soluble antigens, and the sediment used for smear and bacterial cultures. To achieve smear slides using clean, degreased, preferably in November, to be sure that no bacteria remaining from previous exams. Sediment lies the opportunity or Pasteur pipette to obtain a continuous layer of cells in the blade center to periphery. 4 Prepare smears of which two will be fixed and Gram stained and methylene blue respectively, one stained smear will be May - Grunwald - Giemsa and one will remain the reserve.

14

If there is suspicion of meningitis by Cryptococcus neoformans run a freshly prepared slide of sediment between the blade and India ink. This round formations oval capsule (large halo, clear and colorless) that may be suggestive of Cryptococcus neoformans is ram. Gram-stained smear evidenced by this germ, morphology, tinctorialitatea, frequency and location (intra or extraleucocitari). Slides May-Grunwald-Giemsa stained and methylene blue is used for cytological examination. Type of items is estimated percentage: neutrophils, lymphocytes, while noting their appearance. Cultivation is a specific diagnostic tool, but requires 24-48 hours and can be negative if this germ-viable or if the patient began antibiotic treatment. Sediment seeding is done on plates preheated to thermostat. Will be used: 5% Columbia blood agar ram, chocolate agar, lactose agar and broth thioglycolat. Depending bacterioscopic exam, can be added and other media (Sabouraud). Media are incubated at 37 ° C, possibly with 5% CO2 atmosphere for average as Columbia agar with 5% lamb blood and chocolate agar. The emergence of culture is followed daily for 3 days on solid media and 5 days in broth tube thioglycolat. If positive cultures continue to identify to species level and performing antibiogram. If bacterioscopic testify in the presence of a large sample of CSF bacterial densities (tens of bacteria per microscope field examined with magnification of 1000x), try antibiogram of primary culture, whose results are to be confirmed by subculture on standardized antibiogram. Given the limits of microscopic examination and cultures have devised methods to detect soluble antigens in CSF: CIE, latex agglutination, Coaglutinare, ELISA and RIA. In Synevo laboratories to detect soluble antigens are used as quick test of latex agglutination reaction. Engineering Kit is under the sheet. A negative result does not exclude the possibility infections may be tested as bacterial antigens present in concentrations lower than the limit of detection reagents used. A positive result must also be followed by germ isolation, identification and antibiotic sensitivity testing. Cytologic examination, and latex-agglutination bacterioscopic allow a microbiologist release partial results necessary clinician in targeting treatment of first intention. subarachnoidian space at lumbar puncturing, suboccipital and less subject to strict aseptic ventricle and preferably prior to administration of antibiotics. Bacterial meningitis "decapitated" by antimicrobial therapy may evolve with clear liquid and often creates major problems for diagnosis. Quantity of 5-10 ml CSF satisfy the needs for biochemical and microbiological tests and sample fragmentation since the harvest in two sterile tubes minimizes the risk of contamination by subsequent split. When the amount harvested is less than what laboratory tests will be served will be made a priority. Processing an amount too small may indicate a false negative, this is much more harmful to the patient than making a lumbar punctures. At harvest may appreciate the pressure and fluid appearance. The tubes are labeled at bedside collected and sent to the laboratory with the analysis required to be asked include: patient name and surname, age, diagnosis, and if antibiotic

15

treatment. The sample is immediately transported to the laboratory without being chilled or thermostat.

16