Cerebrospinal fluid.

Meningeal
syndrome. Intracranial hypertension.
 Objectives

Describe the anatomy of the meninges and the ventricular system.

Describe the composition of the cerebrospinal fluid.
Describe the functions of cerebrospinal fluid.
Describe the cerebrospinal fluid formation.
Describe the circulation and absorption of the cerebrospinal fluid.
Describe some patholgical changes in CSF composition .
Mention some examples of diseases that cause changes in CSF.
Lumbar Puncture( defintion, indication and contraindication, laboratory
determinations).
Meningeal syndrome
Intracranial hypertansion
 Anatomy of the meninges

The meninges are three

membranes surrounding the
brain and spinal cord:
Dura mater:
Endosteal layer
Meningeal layer
Arachnoid mater
Pia mater.
 The dura mater and venous sinuses
The venous sinuses:
They receive the blood from the
cerebral veins and the CSF from the
subarachnoid space through the
arachnoid villi and then drains into
the internal jugular vein
Superior sagital sinus located at the
upper border of the falx cerebri .
Inferior sagital sinus located at the
lower free border of the falx cerebri .
Straight sinus at the line of junction
of the falx cerebri with the tentorium
cerebelli.
Transverse sinuses occupies the
attached margin of the tentorium
cerbelli .
Sigmoid sinuses are a continuation of
the transverse sinuses and drains into
the internal jugular veins.
 Arachnoid mater

Separated from the dura by a

potential space the subdural
space .
Separated from the pia mater
by the subarachnoid space
which contains the CSF.
The arachnoid projects into the
sinuses to form the arachnoid
villi, and these are numerous in
the superior sagital sinus .
It is covered by flattened
mesothelial cells.
 Pia mater

A vascular membrane that closely

invests the brain.
Covered by mesothelial cells.
Fuses with the ependyma to form
the choroid plexus in the lateral,
third and fourth ventricles of the
brain.
The pia mater of the spinal cord is
thickened on either side between
the nerve roots to form the
ligamentum denticulatum, and this
will suspend the spinal cord in the
middle of the dural sheath.
 Ventricular system
The third ventricle is connected
to the fourth by a narrow
cerebral aqueduct.
The fourth ventricle:
is continuous with the narrow
central canal of the spinal cord
which has a small dilatation at
its end called the terminal
ventricle.
is connected to the
subarachnoid space through
three foraminas in its roof
(median aperture, lateral
openings of the fourth
ventricle).
The ventricles are lined with
ependyma and are filled with
cerebrospinal fluid.
 Formation of CSF
The CSF is formed in the choroid plexus of the lateral, third, fourth ventricles.
The choroid plexuses secrete CSF and at the same time it actively transport
nervous system metabolites from the CSF into the blood.
Formation of the CSF depends mainly on the active transport of sodium ions
through the epithelial cells, and the sodium will pull along the chloride ions. This
increase in sodium and chloride in the CSF will cause osmosis of water.
The production of the CSF is not pressure regulated, it is continuously produced
at a rate of 0.5ml/minute.
 Circulation of CSF

Starting from the choroid plexus of

the ventricles the CSF circulates
from:
The lateral ventricles through the
interventricular foramina into the
third ventricle, then through the
cerebral aqueduct into the fourth
ventricle and then through the
median aperture and lateral
foramina into subarachnoid
space.
The movement of the CSF is assisted
by the pulsations of the choroid
plexus and the cilia lining the
epyndymal cells .
 Circulation of CSF

Then the fluid moves superiorly

over the lateral aspect of each
cerebral hemispheres.
The movement of the CSF is
assisted by the pulsations of the
cerebral arteries.Some of the
fluid moves inferiorly around
the spinal cord and the cauda
aquina, here it reaches a dead
end and its further circulation
lies on the pulsations of the
spinal arteries and the
movement of the vertebral
column.
 Absorbtion
The main sites for absorption are the arachnoid villi that project into the dural venous
sinuses these arachnoid villi are grouped together to form elevations know as arachnoid
granulation:
The absorption of the CSF into the venous sinuses occurs when the CSF pressure
exceeds the venous pressure in the sinus (about 1.5 mm Hg difference) .
Since the production is continuous by the choroid plexus the absorption of the CSF is
the one that controls the CSF pressure.
 Functions of CSF

Cushions and protects the CNS from trauma.

Provides mechanical buoyancy and support for the brain.
Serves as a reservoir and assist in the regulation of the content of the skull.
Nourishes the CNS.
Removes metabolites from the CNS.
Serves as a pathway for the pineal secretion to reach the pituitary gland.
 CSF

Intracranial space 75-100 ml. ventricular (30-50 ml) and nonventricular CSF
spaces (30-50 ml)
Spinal CSF space 50-75ml.
 Lumbar puncture
Lumbar puncture (LP) is the insertion of a needle into the subarachnoid space
(the area under the membrane that surrounds the brain and spinal cord) of the
lumbar (lower back) region for diagnostic or therapeutic purposes. This allows
access to the cerebrospinal fluid (CSF) in which the brain and spinal cord float .
INDICATIONS:
1.Suspected CNS infection .
2.Suspected subarachnoid hemorrhage .
3.Therapeutic reduction of cerebrospinal fluid (CSF) pressure .
4.Sampling of CSF for any other reason .
CONTRAINDICATIONS:
1. Local skin infections over proposed puncture site (absolute contraindication)
2. Raised intracranial pressure (ICP); exception is pseudotumor cerebri
3. Suspected spinal cord mass or intracranial mass lesion (based on lateralizing
neurological findings or papilledema).
4. Uncontrolled bleeding diathesis .
5. Spinal column deformities (may require fluoroscopic assistance).
6. Lack of patient cooperation.
Lumbar puncture
 CSF investigation

Pressure 15 20 mm. g or 150 - 200 mm.

of HO.
Transparency (clear)
Color (colorless)
No of cells ( 1-5 cells in mcl)
Protein ( < 0,33%0 )
Glucose (2,5 4,0 mmol/l)
 Meningeal syndrome

Complaints: headache, nausea, vomiting.

Objective examination: disturbance of consciousness, stiff

neck muscles, Kernigs Brudzinskis signs, phono-and
photophobia.

Causes: inflammatory diseases of the brain and meninges

(meningitis serous, purulent, tuberculosis, etc.),
subarachnoid hemorrhage, carcinomatosis of the
meninges.
 CSF in purulent meningitis

Transparency (muddy)
Color (yellow, green)
Cell count increased significantly (hundreds or
thousands of cells mcl) - polymorphonuclear
leukocytes
Protein content (increased)
Glucose (decreased)
 CSF in hydromeningitis

Transparency (full or opalescence)

Color (colorless)
Increased cell count (tens or hundreds of cells
mcl - lymphocytes)
The protein content (the norm)
Glucose (normal)
CSF in subarachnoid hemorrhage in acute phase

Transparency (opaque)
Color (bloody)
Increased cell count (tens or hundreds of cells
ml - lymphocytes and erythrocytes)
Protein content (increased)
Glucose (normal)
CSF in 4-5 days after subarachnoid hemorrhage

Transparency (part time)

Color (ksantohromny)
Increased cell count (cells per ml dozens -
lymphocytes)
Protein content (increased)
Glucose (normal)
 CSF in carcinomatosis of the meninges

Transparency (full or opalescence)

Color (colorless)
Increased cell count (cells per ml dozens -
lymphocytes, may show abnormal cells)
Protein content (increased)
Glucose (decreased)
Intracranial hypertension syndrome.
The structural components of the intracranial space

The brain - 75 - 80% of the cranial cavity

CSF - 10 - 15%
Blood - 10%
 The causes of increased intracranial pressure

An increase of one or more normal structural

components.

The additional volume of pathological

formation (tumors, hematomas, abscesses,
cysts).
 Cerebral edema

Pathophysiological mechanisms of edema:

Increase in the flow of fluid from the
bloodstream to the intercellular space.
Increase in the flow of fluid from the
intercellular space into cells.
 Hydrocephalus

W. Dandy 1931

Communicating

-due to overproduction of the CSF

-due to decreased resorption

Obstructive

occlusion due to violations of liquor

circulation
Reasons for the decline of CSF resorption

Meningitis Subarachnoid hemorrhage

Adhesive process
subarachnoid
space

Obliteration of granulation
 Hydrocephalus

Hydrocephalus

increase of CSF increase in CSF

in normal brain volume with reduced brain volume

Intracranial Intracranial normotension

hypertension or hypotension
Compensation mechanisms of increased intracranial
pressure in mass lesions

Reducing the amount of CSF

The decrease in venous blood
The decrease in brain volume
 Diagnosis of intracranial hypertension

Indirect (neuroimaging data, clinical)

Direct (pressure measurement)
CT - scan of the brain. Identify tumor with marked perifocal edema
of the brain substance
The clinical picture of the intracranial hypertension
syndrome

Headache

Nausea, vomiting

Congestion of the optic disk

 Congestion of the optic disk

Normal optic disk Congested optic disk

 Methods of measuring intracranial pressure

Lumbar puncture
Pressure test
- epidural
- subdural
- in the brain
- ventricular
 Causes of decompensation in patients with
intracranial hypertension

Disturbance of cerebral hemodynamics with the

development of cerebral ischemia
Dislocation syndrome
 The principles of treatment of intracranial
hypertension syndrome

Struggle with edema of the brain

Elimination of hydrocephalus
Removal of pathological mass lesions
 Treatment of brain edema

Hyperventilation in cases of mechanical ventilation

The elevated position of the head to improve venous
outflow
Osmotic and nonosmotic diuretics
Glucocorticoid hormones (maximum effect in
tumors)
 Treatment of hydrocephalus

Conservative - drugs reduce CSF production

Operative - creating various types of cerebral shunts
It involves the placement of a ventricular catheter (a tube made of silastic),
into the cerebral ventricles to bypass the flow
obstruction/malfunctioning arachnoidal granulations and drain the excess
fluid into other body cavities, from where it can be resorbed. Most shunts
drain the fluid into the peritoneal cavity (ventriculo-peritoneal shunt)
Cerebral shunt
Ventriculo-peritoneal shunt