Cerebrospinal Fluid

Dynamics and Pathology

Deependra Mahato, Kevin Ray, john D. Cantando, Dan E. Miulli, and
Javed Siddiqi
Introduction
Cerebrospinal fluid (CSF) is found within the four ventricles of the brain,
the subarachnoid space, and the central canal of the spinal cord. It is
also called liquor cerebrospinalis. CSF circulates a variety of chemicals
and nutrients nec­essary for normal brain function and metabolism; it
also acts as a shock absorber, cushioning the brain from both day-to-
day activity and traumatic events.
Cerebrospinal Fluid Identification
Grossly, CSF should be a colorless, odorless, serous fluid. There is an
estimated 70 to 1 60 mL of fluid in the central nervous system at any
given time (- 50% intracranial, 50% spinal).
Certain pathological conditions will change both the chemical and the
gross appearance of CSF. In the majority of cases, it is simple to
ascertain whether fluid is CSF or not
The following tests can determine if a fluid is CSF:
• Glucose analysis: Analysis should be done immediately after collection to
pre­vent fermentation. Nasal/lacrimal fluid or mucosal secretion will have
< 5 mg/dL of glucose. A negative test is more reliable because, even with
menin­gitis, the glucose level is usually 5 to 20 mg/dL and associated with
other changes. However, there is a 45 to 75% chance of a false-positive
• Beta2-transferrin: This test can be performed only by electrophoresis of
at least 0.5 mL of sample. Beta2-transferrin is found only in CSF and
vitreous humor. (Note: This test is not reliable in patients with liver
disease or in new­borns)
• Ring sign: Also known as the halo,
this sign is particularly useful for
blood­tinged samples. A drop of
suspected fluid is placed on linen;
as the fluid feathers out into the
surrounding area, blood and
mucus will stay centrally placed,
and the CSF (which is less
viscous) will continue spreading,
creating a clear ring around the
central colored area.
Chemical Regulators of Cerebrospinal Fluid
Constituents of CSF are affected by secretion and absorption rates of
CSF, hor­mones, and chemicals. The secretion rates and effects of
hormones and chem­icals on CSF vary from the vascular to the
ventricular side of the choroid plexus
Vascular side of choroid plexus
Ventricular side of choroid plexus
Flow Pattern of Cerebrospinal Fluid
CSF from blood plasma is actively transported by the choroid plexus
(80%), or invaginations of the pia mater, into the ventricles, with the
remaining 10 to 20% produced by ventricular ependymal cells, brain
parenchyma, and indirect cellular fluid shifts

The approximate CSF secretion is 450 mL per day, which corresponds to

a rate of 0.3 (0.35-0.37) mL/min.
The CSF is in constant flow in a continuous
pattern. Starting from the choroid plexus in
the lateral ventricles, CSF continues through
the foramen of Monro into the third
ventricle and passes into the cerebral
aqueduct prior to the fourth ventricle. From
the fourth ventricle, fluid escapes into the
cisterns and subarachnoid space via the fora­
men of Luschka and the foramen of
Magendie. Some enters the central canal of
the spinal cord, although most spinal fluid
then circulates through the subar­ achnoid
space and is reabsorbed in the venous
system via the arachnoid villi.
Pathology Involving Cerebrospinal Fluid
Disorders of Volume and Pressure
NPH
Normal pressure hydrocephalus (NPH) is associated
with a classic triad of symptoms: dementia, gait
disturbance, and urinary incontinence. The etiology is
usually idiopathic but can be secondary to other
intracranial pathology, such as Alzheimer's disease,
carcinomatosis, infectious meningitis, and subarach­
noid hemorrhage.

Diagnosis is primarily clinical, with documented

normal pressure via lumbar puncture and a full
workup of other causes of dementia.

Treatment of NPH is shunt­ing, either ventricular or,

at rare times, lumboperitoneal.
Hydrocephalus
Communicating and • Obstructive (noncommunicative)
noncommunicating hydrocephalus hydrocephalus is blockage of the normal
symptoms include nausea, vomiting, flow ofCSF, causing dilatation of the
ventricles proximal to the obstruction.
gait disturbance, frontal headache
• Communicating (nonobstructive)
(frequently worse in the morning),
hydrocephalus is a disruption of the equi­
paresis of upward gaze, disorders of librium of secretion and absorption of
sodium, and papilledema. Tem­ CSF, yielding an increased volume of CSF.
porizing measures for relief may It is most commonly caused by
include a ventricular catheter and/or malabsorption of the CSF by the
diuretics (acetazolamide or arachnoid granulations. Common
furosemide). etiologies include infection, hemorrhage,
trauma, and noninfectious meningitis.
Leptomeningeal or Arachnoid Cysts
Leptomeningeal cysts are congenital fluid collections between two layers
of the arachnoid.

There are two types of arachnoid cysts classified by h i s t o l o g i c a l fi n

dings:
(1)simple,inwhich the lining of the cyst consistso
f c e l l s capable of secreting CSF (this is the most common type of
middle fossa arach­noid cyst), and
(2) complex, in which the lining of the cyst is multicellular, often
containing neuroglia and ependyma.
Infectious and Noninfectious Irritants Causing
Meningitis
• Posttraumatic meningitis is usually limited to head trauma with an
associated skull fracture. Organisms are most commonly gram-positive
cocci and gram­negative bacilli.
Trauma-Related Cerebrospinal Fluid
Abnormalities
• Cerebrospinal Leaks
CSF leaks are associated with basal skull fractures and anterior fossa fractures resulting
in otorrhea and/or rhinorrhea.
Diagnosis is made by clinical exam; however, MRl, contrasted CT scans, and
radionuclide cisternograms can help identify the source of the leak.
Treatment consists of general measures to lower ICP, raising the head of the bed,
administering acetazolamide to decrease CSF pro­duction, inserting a lumbar drain,
and/or surgical repair. Surgical repair is indi­cated in refractory and recurrent CSF leaks.
Pneumocephalus is evidence of air intracranially. Air can be intraparenchymal,
intraventricular, subdural, or epidural. It is associated with a skull defect or injury to the
tegmen tympani (congenital/traumatic/ related to pressure changes, e.g., deep-sea
diving).
• Traumatic Lumbar Puncture
Traumatic lumbar puncture can occur during a procedure to obtain CSF;
local trauma or disruption of nearby vascular structures can produce a
traumatic tap.