CNS Pathology

CSF
1. to cushion brain and spinal cord
2. clear composition
A. RBCs may be present after traumatic brain injury
B. Tumor cells may be present in CNS tumor
C. 0 - 4 lymphocytes or mononuclear cells per mm3
D. presence of PMN leukocytes ALWAYS abnormal (bacterial
meningitis)
3. compared with serum, CSF has
A. protein
B. increased protein in CNS tumors
C. increased in Guillain-Barre syndrome
i. albuminocytologic dissociation
D. pH
E. equal [Na+]
F. [Cl-] and [Mg2+]
G. [K+], [Ca2+], [HCO3-], and [glucose]
4. produced by the choroid plexus epithelial cells
A. found in lateral, third, and fourth ventricles
5. reabsorbed into circulation by arachnoid granulations
A. enters dural venous sinuses
B. entire volume of CSF is recycled 2-3 times per 24 hours
6. transported via the ventricular system
7. Ventricular system communications
A. Lateral ventricle 3rd ventricle
i. interventricular foramen of Monro
B. 3rd ventricle 4th ventricle
i. cerebral aqueduct
C. 4th ventricle subarachnoid space via
i. foramina of Luschka (lateral)
ii. foramina of Magendie (medial)
Diseases

Hydrocephalus = dilated ventricles via several types

Communicating
a. reabsorption of CSF
a. scarring of arachnoid granulations following meningitis
b. production of CSF
a. e.g. choroid plexus tumor
Noncommunicating/obstructive
a. obstructed flow of CSF
a. stenosis at narrow point along ventricular system
i. most common at foramen of Monro and cerebral
aqueduct (MC in newborn)

Normal pressure
 a. reabsorption of CSF with chronic dilation of ventricles and normal
CSF pressure
a. distortion of corona radiata produces triad of
i. urinary incontinence
ii. dementia
iii. apraxic gain
iv. "wet, wacky, and wobbly"
b. Imaging
i. enlarged ventricles on CT/MRI

ex vacuo
a. in CSF due to in brain size
b. caused by stroke, Alzheimer's, advanced HIV, and trauma
c. ventricles appear large but CSF pressure is normal

Herniation

A result of increased intracranial pressure

o coma or death when brainstem herniates

Types

o cingulate (subfalcine)

pressure by falx cerebri

presentation

ischemia due to occlusion of anterior cerebral artery

o cerebellar tonsillar

pressure by foramen magnum

coning of cerebellar tonsils

Produce cardiorespiratory arrest

o downward transtentorial (central)

pressure by tentorium cerebelli

presentation
 compression of CN VI results in diplopia and inability to
abduct eye

ischemia due to arterial compromise

o uncal (medial temporal lobe)

pressure by tentorium cerebelli

presentation triad

blown pupil (fixed and dilated) + ptosis

compression of CN III

can also result in "down-and-out" eye

ipsilateral hemiplegia

compression of contralateral cerebral peduncle

coma

can also result in

contralateral homonymous hemianopia

result of compression of ipsilateral posterior

cerebral artery

Duret hemorrhages (brainstem)

result of paramedian artery rupture

Pseudotumor cerebri

Idiopathic intracranial hypertension

o characterized by headache, increased ICP, and papilledema

usually not explained by any other identifiable cause

Epidemiology

o incidence

1 per 100,000

o demographics

more common in younger women

median age is approximately 30 years old

o risk factors

child-bearing aged women

 obesity

medications

excessive vitamin A or D intake

growth hormone

OCPs

discontinuation of steroids

Associated conditions

o cushings

o steroid use

o pregnancy

Prognosis

o does not seem to alter life expectancy

Symptoms

o pulsatile tinnitus

o 6th nerve (abducens) palsies

o severe headaches

o visual disturbances

Physical exam

o inspection

papilledema on fundoscopic exam

Diagnosis

o spinal tap

elevated CSF pressure (usually > 50 cm)

normal CSF profile

o imaging

slit-like ventricles

otherwise normal brain MRI