Clinical Applications: Clinical Significance of Proteins in CSF Online Training

Welcome to the Clinical Significance of Proteins in CSF Online Training course.  This course focuses on cerebrospinal fluid analysis as a basic tool for the diagnosis of neurological diseases. Select Next to continue. This course was developed by: Jim Aguanno, PhD Senior Clinical Specialist Disease State Management Upon successful completion of this course, you will be able to: Recall the role of the blood-brain barrier   Identify the clinical significance of selected proteins in CSF   Recall the types of information provided Serum/CSF indices   Select Next to continue. Produced in: Choroid plexus (1, 2, 3) Flows: Apertures (4, 5) Cisternae (6,7,8, 9) Subarachnoid space (10, 11) Arachnoid villi (12, 13, 14) Illustration taken from the book “Klinische Liquordiagnose” by U.K. Zettl et al. (editors), Walter de Gruyter, 2005 (2nd edition)   Adults: 140 – 180 mL Neonates: 10 – 60 mL Mean Flow Rate: 0.3 mL/min Child Rate of Formation: 250 mL/day Adult Rate of Formation: 500 mL/day Turnover: 3 - 4 times per day Blood-brain barrier disturbances Intrathecal immunoglobulin synthesis Inflammatory diseases Infectious pathogens Neurological diseases Therapeutic effectiveness http://www.surgeryencyclopedia.com/Ce-Fi/Cerebrospinal-Fluid-CSF-Analysis.html http://knol.google.com/k/lumbar-puncture# Pictures taken from U.K. Zettl et al., Klinische Liquordiagnostik, Walter de Gruyter Verlag 2005 Lumbar Puncture Cisternal Puncture  Ventricular Puncture Parameter Reference Range Opening Pressure 70-180 mm H2O Appearance Clear, Colorless Specific Gravity 1.006-1.009 Electrolytes     Na     K     Cl     Mg 135-155 mmol/L 2.6-3.0 mmol/L 115-130 mmol/L 1.1-2.4 mmol/L Glucose 50-80 mg/dL WBC 0-5 cells/mm3 RBC None Bacteria, Viruses None Proteins 15-60 mg/dL Am Fam Physician 2003;68:1103-8. Blood CSF Blood-Brain Barrier Slower flow rate = larger serum protein concentration in CSF The larger a molecule, the longer it takes to diffuse into CSF Functions Transports metabolic products Protects brain Maintains constant environment Properties Large molecules do not pass through Low lipid (fat) soluble molecules do not penetrate Lipid soluble molecules rapidly cross Molecules with high electrical charge are slowed Mosby's Medical Dictionary, 8th edition. © 2009.   Development Hypertension Hyperosmolitity Microwaves Radiation Infection Trauma, Ischemia, Inflammation Pressure The Encyclopedia of Science Total Protein / Albumin Prealbumin β-2-Transferrin Myelin Basic Protein Immunoglobulins IgG, IgA, IgM   Oligoclonal Bands CSF/Serum Indices http://meds.queensu.ca Increased Levels Bleeding Meningitis Increased permeability Decreased resorption Mechanical obstruction of CSF flow Trauma Tumor Endocrine or metabolic disorders Inflammation of arachnoid membranes Decreased Levels Over production of spinal fluid Albumin Originates from blood Synthesized in liver, not CSF   Measure for blood-brain barrier function: QAlb = AlbuminCSF / AlbuminSERUM Blood-brain barrier dysfunction corresponds to decreased CSF flow rate and increased CSF/serum  albumin quotient (QAlb)     Age Normal Range of QAlb Ratio Children At birth 8 to 28 x 10-3 1st month 5 to 15 x 10-3 2nd month 3 to 10 x 10-3 3rd month 2 to 5 x 10-3 4th month / 6 years 0.5 to 3.5 x 10-3 Adults up to 15 years < 5 x 10-3 > 15 years (4 + age/15) x 10-3 H. Reiber, Liquordiagnistik. in: Klinische Neurologie. P. Berlit (editor). Springer-Verlag Heidelberg, 2., aktualis. U. erw. Aufl. 2005. Total Protein / Albumin Prealbumin β-2-Transferrin Myelin Basic Protein Immunoglobulins IgG, IgA, IgM   Oligoclonal Bands CSF/Serum Indices http://meds.queensu.ca Normal Levels Normally found in CSF Increased Levels Multiple sclerosis (MS)1 Guillain-Barré syndrome2 Decreased Levels Alzheimer’s disease3 Subarachnoid hemorrhage 1. Clinica Chimica Acta 124,1982,  339-341 2. Acta Neurol Scand 2011 Mar 24. 3. Acta Neurologica Scandinavica 78, 1988, 455-489 Total Protein / Albumin Prealbumin β-2-Transferrin Myelin Basic Protein Immunoglobulins IgG, IgA, IgM   Oligoclonal Bands CSF/Serum Indices http://meds.queensu.ca Normal Levels Identified by electrophoretic migration Clinical Utility Presence suggestive of CSF leak Gold standard in detection of CSF leakage Total Protein / Albumin Prealbumin β-2-Transferrin Myelin Basic Protein Immunoglobulins IgG, IgA, IgM   Oligoclonal Bands CSF/Serum Indices http://meds.queensu.ca Normal Levels Less than 4 ng/mL Increased Levels Demyelinating diseases, in particular, multiple sclerosis Between 4 and 8 ng/mL = chronic breakdown or recovery from an acute episode Greater than 9 ng/mL = active break down Total Protein / Albumin Prealbumin β-2-Transferrin Myelin Basic Protein Immunoglobulins IgG, IgA, IgM   Oligoclonal Bands CSF/Serum Indices http://meds.queensu.ca Test Range (mg/dL) Clinical Utility Additional Information IgA 0.00-0.64 Evaluate the CNS infection, neoplasm, or primary neurological disease (i.e., multiple sclerosis) Local synthesis of IgA within the CNS is most prominent in patients with bacterial infections and has special relevance in the diagnosis of tuberculous meningitis IgM 0.00-0.26 Evaluate the CNS infection, neoplasm, or primary neurological disease (i.e., multiple sclerosis) Local synthesis of IgM within the CNS is most prominent in patients with neuroborreliosis or mumps-meningoencephalitis IgG 0.0-8.6 Elevation of IgG levels in patients with inflammatory diseases of the CNS Elevations are due to local CNS synthesis of IgG   Total Protein / Albumin Prealbumin β-2-Transferrin Myelin Basic Protein Immunoglobulins IgG, IgA, IgM   Oligoclonal Bands CSF/Serum Indices http://meds.queensu.ca Two or more bands = abnormal test Identical bands does not usually indicate MS Found in 83-94% of people with MS Cells from immune system have passed through blood-brain barrier CSF Plasma Oligoclonal Bands present Abnormal Serum CSF Source: http://library.med.utah.edu and http://path.upmc.edu Total Protein / Albumin Prealbumin β-2-Transferrin Myelin Basic Protein Immunoglobulins Oligoclonal Bands CSF/Serum Indices http://meds.queensu.ca CSF/Serum Albumin Quotient CSF/Serum Immunoglobulin Quotient IgG Synthesis Rate Where X = G, A or M Normally CSF albumin originates from blood Albumin is the major CSF protein and represents about 55% of the total protein content IgG, IgA, and IgM also diffuse into CSF from blood Also can be synthesized in central nervous system Journal of the Neurological Sciences 184 (2001) 101–122 Control Group Without symptoms or signs of neurological disease Multiple Sclerosis Group Calculations IgG and Albumin Quotients CLIN. CHEM. 20/5. 571-573 (1974) CLIN. CHEM. 20/5. 571-573 (1974) CSF IgG / CSF Albumin Ratio CSF/Plasma IgG to CSF/Plasma ALB CLIN. CHEM. 20/5. 571-573 (1974) Objective Evaluate CSF/Serum quotients in various neurological diseases Patients With neurological diseases but without intrathecal immunoglobulin synthesis With severe blood-brain barrier dysfunction Albumin CSF/Serum Quotient x 10-3 Normal Patients Blood-Brain Barrier Dysfunction Albumin CSF/Serum Quotient x 10-3 Journal of the Neurological Sciences, 122 (1094) 189 203 Normal Patients   Albumin CSF/Serum Quotient x 10-3 Blood-Brain Barrier Dysfunction   Albumin CSF/Serum Quotient x 10-3 Journal of the Neurological Sciences, 122 (1094) 189 203   Reiber, H. Clinica Chimica Acta 310 (2001) 173–186 (High Normal Range) (Mean Normal Range) (Low Normal Range) Reibergrams or CSF/Serum Quotient Graphs Provide representations of the relationship between QIgG and QAlb Allow for analysis of the function of the blood-brain barrier and intrathecal protein synthesis Aid in the diagnosis of CNS diseases associated with specific patterns of immunoglobulin response Journal of the Neurological Sciences 184 (2001) 101–122 IgG CSF/serum quotient albumin CSF/serum quotient Quotient Diagram Represents reference range for blood-derived immunoglobulins related to QAlb Displays severity of barrier dysfunction and degree of intrathecal immunoglobulin synthesis information H. Reiber, Dynamics of brain-derived proteins in cerebrospinal fluid, Clinica Chimica Acta 310 (2001), 173 - 186 Reibergram QLim QLow 60 and 80% lines Small vertical lines H. Reiber, Dynamics of brain-derived proteins in cerebrospinal fluid, Clinica Chimica Acta 310 (2001), 173 - 186   Normal range Barrier dysfunction Intrathecal synthesis Intrathecal synthesis and barrier dysfunction Analytical error Cell count is elevated; Normal < 0.4 Specific antibody indices are elevated; Normal = 1.4 All proteins are elevated Q CSF/Serum values are all elevated Oligoclonal Bands are present Blood-brain barrier dysfunction in combination with intrathecal IgG synthesis H. Reiber et al., Cerebrospinal   fluid analysis: disease related data patterns and evaluation programs, Journal of Neurological Sciences 184 (2001), 101 - 122 Cell count is normal; Normal < 0.4 Specific antibody indices are elevated; Normal = 1.4 All proteins are elevated Q CSF/Serum values for IgG and IgM are elevated Oligoclonal Bands are absent Intrathecal IgG synthesis without blood-brain barrier dysfunction   H. Reiber et al., Cerebrospinal   fluid analysis: disease related data patterns and evaluation programs, Journal of Neurological Sciences 184 (2001), 101 - 122 Typical results for bacterial meningitis Very high leukocytes cell count of 7,250 per µL Very high QAlb Intrathecal IgA synthesis possible, seldom IgG, IgM H. Reiber et al., Cerebrospinal   fluid analysis: disease related data patterns and evaluation programs, Journal of Neurological Sciences 184 (2001), 101 - 122 1st day Antibiotic therapy starts 3rd day of therapy Leukocyte count 2,730 per µL 6th day of therapy Leukocyte count 213 per µL 13th day of therapy Leukocyte count 2 per µL   Used to evaluate the de novo rate of synthesis of IgG in CNS for the diagnosis of inflammatory and autoimmune diseases involving CNS, in particular, multiple sclerosis About 90% of MS patients will be abnormal Reference Interval Synthesis rate: -9.9 to +3.3 mg/24 hours J Clin Pathol 1996;49:24-28 Patients were divided into two groups: Group 1: without oligoclonal bands Group 2: with oligoclonal bands Group 2a: with MS                       Group 2b: with other neurological diseases        Clinical Chemistry 50, No. 10, 2004 Clinical Chemistry 50, No. 10, 2004 Groups 2a and 2b Group 1 Blood-brain barrier protects the brain   Total Protein, Albumin, Prealbumin, β-2-Transferrin and Myelin Basic Protein can be used to assess patients that might have CNS disorders   IgG, IgA, and IgM  quotients can be used to assist in the diagnosis of patients with intrathecal immunoglobulin synthesis   Reibergrams are useful tools for assessment of patients with CNS disorders   IgG synthesis rate and free kappa light chains may also be used to help diagnosis patients with possible blood-brain barrier dysfunctions