THE VENTRICULAR SYSTEM OF THE BRAIN.

CEREBROSPINAL FLUID CIRCULATION

Associate professor, MD, PhD,
Rimma Gamirova
The Ventricular System of the Brain.
Cerebrospinal fluid circulation
• The ventricular system is the
extension of the spinal canal
(canalis centralis) into the brain
and consists of four chambers
which are filled with cerebrospinal
fluid (liquor cerebrospinalis).

• The paired lateral ventricles

(ventriculi laterales I and II) are
two of these four chambers and
are connected to the unpaired
third and fourth ventricle through
the foramen interventriculare.
 The Ventricular System of the Brain.
Cerebrospinal fluid (CSF) circulation
• The third ventricle (ventriculus
tertius) is connected to the
fourth ventricle through the
aquaeductus mesencephali
cerebri so that all ventricles are
connected to each other.

• All ventricles together form the

inner CSF space and are
connected to the outer CSF
space, the subarachnoid space
(spatium subarachnoidem),
through the fourth ventricle via
three apertures.
• A total of 150ml of CSF circulates through the two CSF spaces, of which there are
approximately 30ml of CSF in the inner and approximately 120ml of CSF in the outer CSF
space.
• CSF is produced primarily by the plexus choroideus, which can be found in each of the four
ventricles but it is also partly produced by the specialized epithelium of the ventricles, the
ependyma. The entire inner CSF space is lined with ependyma.
 The Ventricular System of the Brain.
Cerebrospinal fluid (CSF) circulation

Choroid plexus of the brain ventricles → lateral ventricles → interventricular foramen → III ventricle
→ cerebral aqueduct → IV ventricle → median (Magendi) and lateral apertures (Luschkae)→ cisterns
of the brain → subarachnoid space of the brain and spinal cord → outflow through the pachyon
arachnoid granulation to the superior sagittal sinus, which is part of the venous system of the brain.
Cerebrospinal fluid (CSF) - definition
• CSF (cerebrospinal fluid, CSF) is
a clear, colorless, water-like
biological fluid found within the
ventricular system of the brain,
the central canal of the spinal
cord, and the subarachnoid
space.

• CSF, enclosed in an elastic sac

of the dura mater, surrounds
the brain in the form of a water
cushion, and the dorsal one in
the form of a sleeve. Its volume
fluctuates according to changes
in intracranial pressure.
 The functions of cerebrospinal fluid
• 1. mechanical protection of the brain;
• 2.excretory, i.e. removes metabolic products of
nerve cells;
• 3. transport, transports various substances,
including oxygen, hormones, etc. biologically
active substances;
• 4. stabilization of the brain tissue: maintains a
certain concentration of cations, anions and pH,
which ensures the normal excitability of neurons;
• 5. performs the function of a specific protective
immunobiological barrier.
 Lumbar puncture
• CSF can be tested for the diagnosis of a
variety of neurological diseases, usually
obtained by a procedure called lumbar
puncture.
• Lumbar puncture is carried out under
sterile conditions by inserting a needle
into the subarachnoid space, usually
between the third and fourth lumbar
vertebrae.
• CSF is extracted through the needle,
and tested.
• About one third of people experience a
headache after lumbar puncture, and
pain or discomfort at the needle entry
site is common.
• Rarer complications may include
bruising, meningitis or ongoing post
lumbar-puncture leakage of CSF.
Vials containing human CSF
 Lumbar puncture
Indications:
• Suspicion of infectious diseases (especially, meningitis)
• Suspicion of subarachnoid hemorrhage (in the absence of
data on the results of MSCT).
• Autoimmune diseases of the nervous system (multiple
sclerosis, acute inflammatory demyelinating polyneuropathy).
• Measurement of CSF pressure in the following cases:
- increased pressure with a pseudotumor cerebri
- decreased pressure with spontaneous headache
with intracranial hypotension
• Therapeutic goals:
- drug administration
- removal of part of the CSF with an increase in
intracranial pressure
 Lumbar puncture
Contraindications:
• Absolute contraindications for lumbar puncture are the
presence of infected skin over the needle entry site
• Presence of unequal pressures between the
supratentorial and infratentorial compartments.
• Posterior fossa mass
• Coagulopathy
• Suspected brain tumor, with hemi-type neurological
symptoms
• Brain abscess
• Increased intracranial pressure (ICP)
• Subdural hematoma
• Intracranial hemorrhage
• Spinal block
 Indications for performing brain CT scanning
before lumbar puncture in patients with
suspected meningitis :
• Patients who are older than 60 years

• Patients who are immunocompromised

• Patients with known CNS lesions

• Patients with an abnormal level of consciousness

• Patients with focal findings on neurologic examination

• Patients with papilledema seen on physical examination,

with clinical suspicion of an elevated ICP
 Procedure of lumbar puncture (spinal tap)
The puncture is performed strictly along the midline between the spinous
processes L3 and L4 or L4 and L5 at the level of the iliac crest.
 Lumbar puncture in children

In children, a sitting flexed position was as successful as lying on the side with respect to
obtaining non-traumatic CSF, CSF for culture, and cell count. There was a higher success
rate in obtaining CSF in the first attempt in infants younger than 12 months in the sitting
flexed position.

The spine of an infant at the time of birth differs from the adult spine. The conus medullaris
terminates at the level of L1 in adults, but may range in term neonates (newly born babies)
from L1-L3 levels. It is important to insert the spinal needle below the conus medullaris at
the L3/L4 or L4/L5 interspinous levels. With growth of the spine, the conus typically
reaches the adult level (L1) by 2 years of age.
 Lumbar puncture
Cerebrospinal fluid (CSF) analysis
§ 4 test-tubes (vials) :
§ Cell count (leucocytes, erythrocytes and other)
§ Microbiology (bacteria, fungi, and viruses)
§ Chemistry (glucose, protein and other)
§ Control (for specific investigations or re-calculation
of indicators)
 Lumbar puncture
Cerebrospinal fluid (CSF) analysis
Pressure determination

Increased CSF pressure can indicate:

• cerebral edema,
• subarachnoid hemorrhage,
• purulent meningitis, viral or tuberculous meningitis,
• hydrocephalus,
• hypo-osmolality resulting from hemodialysis,
• pseudotumor cerebri
• congestive heart failure
Decreased CSF pressure can indicate:
• complete subarachnoid blockage,
• leakage of spinal fluid,
• severe dehydration, Normal level of pressure is < 200 (100–180
• hyperosmolarity, mmH2O water column) with the patient lying .
• or circulatory collapse. In newborns: 80 to 100 mmH2O

Significant changes in pressure during the procedure can

indicate tumors or spinal blockage resulting in a large pool of
CSF
 Lumbar puncture
Cerebrospinal fluid (CSF) analysis
Color and purity
check by comparing it to light with pure water:
• the increase in protein content in the CSF imparts a slightly yellow color.
• an increase in the level of leukocytes (200-300) gives turbidity.
• dark CSF can be with metastasis of melanoma and with jaundice - hyperbilirubinemia,
• subdural hematoma leads to xanthochromia.

Cell count
CSF always examine for cell count within an hour after lumbar puncture or as soon as
possible.
• The presence of white blood cells in cerebrospinal fluid is called pleocytosis.
• A small number of monocytes (1-5 cells) can be normal;
• Тhe presence of granulocytes is always an abnormal finding.
• A large number of granulocytes often heralds bacterial meningitis.
• White cells can also indicate leukemia or a metastatic tumor.

• Erythrophagocytosis, where phagocytosed erythrocytes are observed, signifies

haemorrhage into the CSF that preceded the lumbar puncture (often intracranial
haemorrhage or, for example, haemorrhagic herpetic encephalitis).
In which case, further investigations are warranted, including imaging and viral culture.
 Lumbar puncture
Cerebrospinal fluid (CSF) analysis
Microbiology
CSF can be sent to the microbiology lab for various types of smears and cultures to
diagnose infections.:
• Gram staining may demonstrate gram positive bacteria in bacterial meningitis.
• Microbiological culture is the gold standard for detecting bacterial meningitis. Bacteria,
fungi, and viruses can all be cultured by using different techniques.
• Polymerase chain reaction (PCR) has been a great advance in the diagnosis of some
types of meningitis, such as meningitis from herpesvirus and enterovirus.
• Antibody-mediated tests : neurosyphilis and Lyme disease, and others

Gram staining Microbiological culture

 Lumbar puncture
Cerebrospinal fluid (CSF) analysis

Chemistry tests of CSF:

Glucose is present in the CSF; the level is usually about 60% (2/3) that in the peripheral
circulation.
• Decreased glucose levels can indicate fungal, tuberculous or pyogenic infections;
lymphomas; leukemia spreading to the meninges; or hypoglycemia.
• A glucose level of less than one third of blood glucose levels in association with low CSF
lactate levels is typical in hereditary CSF glucose transporter deficiency also known as
De Vivo disease.
 Lumbar puncture
Cerebrospinal fluid (CSF) analysis
Chemistry tests of CSF:

Protein
Normal level of protein - 0.2-0.5 g/l.
Changes in protein content of cerebrospinal fluid can result from pathologically increased
permeability of the blood-cerebrospinal fluid barrier, obstructions of CSF circulation:
• meningitis,
• brain and spinal cord tumors
• neurosyphilis,
• brain abscesses,
• multiple sclerosis
• subarachnoid hemorrhage,
• Guillain–Barré syndrome and other
• Very high levels of protein may indicate tuberculous meningitis or spinal block.
 Complications
Post-puncture headache in 10-30%.
§ Increases in a sitting or vertical position of the body,
§ Weakenes in a horizontal position
§ Treatment: bed rest and infusion therapy.
Mechanism
§ With a decrease in the amount of CSF, the amortization of the brain is
impaired.
§ In the vertical position, the meninges and sinuses of the brain is stretched,
which causes pain.
 CSF Syndrome
• 1.Increased cerebrospinal fluid pressure
• 2. Turbid (сloudy) cerebrospinal fluid with purulent
meningitis, opalescent - with serous
• 3.Neutrophilic pleocytosis with purulent meningitis,
lymphocytic - with serous
• 4.Increased level of protein, more pronounced in purulent
meningitis
• 5.Reduction of glucose levels in bacterial, fungal and protozoal
meningitis
 Overview of typical cerebrospinal fluid findings
at CNS infections

Cells Protein Glucose Lactate

Bacterial Often > 1,000 ↑ (100 ‒ 200 ↓ CSF/serum ↑

Meningitis cells/µl, mg/dL) glucose ratio <
dominantly 0.3
granulocytic
Tubercular 50 ‒ 400 ↑↑ (100 ‒ ↓ CSF/serum ↑↑
Meningitis cells/µL, first 500 mg/dL) glucose ratio <
granulocytes, 0.5
later
lymphocytes
and monocytes
Viral < 1,000 ↑ (e.g.: 50 ‒ Normal
Meningitis cells/µL, 150 mg/dL)
dominantly
lymphocytic
CSF/serum glucose ratio
The CSF/serum glucose ratio gives the relation of glucose in the cerebrospinal
fluid compared to glucose in the serum.
Hydrocephalus
Associate professor, MD, PhD,
Rimma Gamirova
 Definition
• Hydrocephalus is a condition in which an
accumulation of cerebrospinal fluid (CSF) occurs
within the brain
 Epidemiology
• About one to two per 1,000 newborns have hydrocephalus.
• Rates in the developing world may be higher.
• Normal pressure hydrocephalus is estimated to affect
about 5 per 100,000 people, with rates increasing with age.
 Hydrocephalus

The different effects of hydrocephalus on the brain and cranium

The choroid plexus, where the process of producing cerebrospinal fluid
takes place
 Classification of hydrocephalus
1. According time of manifestation:
• Congenital
• Acquired
2. According communicating:
• Communicating
• Noncommunicating (occlusal)
3. According to the state of cerebrospinal fluid production and
cerebrospinal fluid resorption (cerebrospinal fluid absorption)
• Resorptive
• Hypersecretory
4. According to the clinical course
• Progressive (acute or chronic)
• Stabilized
 Classification of hydrocephalus
5. According to localization
• Internal with a predominant enlargement of the ventricular
system of the brain
• External - the enlargement of subarachnoid spaces on the outer
surface of the brain and basal cisterns
• Mixed

Internal hydrocephalus External hydrocephalus

Causes of hydrocephalus
 Causes of hydrocephalus
• Congenital hydrocephalus is present in the infant prior to
birth, meaning the fetus developed hydrocephalus in utero
during fetal development.
• The most common cause of congenital hydrocephalus is
aqueductal stenosis, which occurs when the narrow
passage between the third and fourth ventricles is in the
brain. Fluid accumulates in the upper ventricles, causing
hydrocephalus.

• Other causes of congenital hydrocephalus include neural-

tube defects, arachnoid cysts, Arnold–Chiari malformation.
• The causes are usually genetic, but can also be acquired
and usually occur within the first few months of life, which
include intraventricular matrix hemorrhages in premature
infants, infections.
 Causes of hydrocephalus
Acquired hydrocephalus
• This condition is acquired as a consequence of
CNS infections, meningitis, brain tumors, head
trauma, toxoplasmosis, or intracranial
hemorrhage (subarachnoid or
intraparenchymal), and is usually painful.
Multiple brain cysts
 Pathomorphology of hydrocephalus
• Enlargement of the ventricles, thinning
of the brain tissue, atrophy of the
choroid plexus, fibrosis of the arachnoid
membrane, ependymatitis, fusion of
the meninges.
• In severe cases, the hemispheres turn
into thin-walled sacs filled with fluid.
• Brains are flattened, grooves are
smoothed, sometimes atrophy of
subcortical formations.
• The bones of the skull are sharply
thinned, the base of the skull is
flattened.
Severe internal hydrocephalus
 Signs and symptoms of hydrocephalus in
infants
• In infants with hydrocephalus, CSF builds up in the central
nervous system (CNS), causing the fontanelle (soft spot) to
bulge and the head to be larger than expected.
Early symptoms :
• Eyes that appear to gaze downward
• Irritability
• Seizures
• Separated sutures
• Sleepiness
• Vomiting
 Signs and symptoms of hydrocephalus in
infants
• As the hydrocephalus progresses, torpor
sets in, and infants show lack of interest in
their surroundings.
• Later on, their upper eyelids become
retracted and their eyes are turned
downwards ("sunset eyes") (due to
hydrocephalic pressure on the
mesencephalic tegmentum and paralysis of
upward gaze).
• Movements become weak and the arms
may become tremulous.
• Papilledema is absent, but vision may be
reduced.
• The head becomes so enlarged that they
eventually may be bedridden.
 Signs and symptoms of hydrocephalus in
in older children
• Brief, shrill, high-pitched cry
• Vomiting
• Headaches
• Delayed milestones
• Changes in personality, memory, or the ability to reason or think
• Changes in facial appearance and eye spacing (craniofacial
disproportion)
• Crossed eyes or uncontrolled eye movements
• Difficulty feeding
• Excessive sleepiness
• Irritability, poor temper control
• Loss of coordination and trouble walking
• Muscle spasticity (spasm)
• Slow growth (child 0–5 years)
• Slow or restricted movement
 Signs and symptoms of hydrocephalus
• Normal pressure hydrocephalus (NPH) is a particular
form of chronic communicating hydrocephalus,
characterized by enlarged cerebral ventricles, with only
intermittently elevated cerebrospinal fluid pressure.
Characteristic triad of symptoms are:
• dementia,
• apraxic gait and
• urinary incontinence.
The diagnosis of NPH can be established only with the help
of continuous intraventricular pressure recordings (over 24
hours or even longer), since more often than not instant
measurements yield normal pressure values.
 Treatment of hydrocephalus
• Medication - dehydration + impact on the initial
pathological process and concomitant diseases
• Surgical
 Surgical treatment of hydrocephalus
• Hydrocephalus
treatment is surgical,
creating a way for the
excess fluid to drain
away.
• In the short term, an
external ventricular
drain (EVD), also known
as an extraventricular
drain or
ventriculostomy,
provides relief.
 Surgical treatment of hydrocephalus
• Most shunts drain the
fluid into the peritoneal
cavity
(ventriculoperitoneal
shunt), but alternative
sites include the right
atrium (ventriculoatrial
shunt), pleural cavity
(ventriculopleural shunt).
• A shunt system can also be
placed in the lumbar
space of the spine and
have the CSF redirected to
the peritoneal cavity
(lumbar-peritoneal shunt).
CT scan of a patient after ventriculoperitoneal drain
Thank you for your attention!