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PHYSIOLOGY OF CSF AND PATHOPHYSIOLOGY OF HYDROCEPHALUS.

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Presentation on theme: "PHYSIOLOGY OF CSF AND PATHOPHYSIOLOGY OF HYDROCEPHALUS."— Presentation transcript:

1 PHYSIOLOGY OF CSF AND PATHOPHYSIOLOGY OF HYDROCEPHALUS

2 Introduction Dynamic component of CNS Dynamic component of CNS Invaluable tool to diagnosis Invaluable tool to diagnosis Physiological reservoir of human proteome Physiological reservoir of human proteome Reflects the physiologic state of CNS Reflects the physiologic state of CNS

3 Historical account Hippocrates described fluid in brain Hippocrates described fluid in brain Galen described ventricles Galen described ventricles Vesalius showed the anatomy Vesalius showed the anatomy Megendi performed first cisternal puncture in animals Megendi performed first cisternal puncture in animals Quinke performed first LP Quinke performed first LP Dandy was credited first ventricular puncture Dandy was credited first ventricular puncture Quekensted did first cisternal puncture in humans. Quekensted did first cisternal puncture in humans.

4 Functions of CSF Mechanical cushion to brain Mechanical cushion to brain Source of nutrition to brain Source of nutrition to brain Excretion of metabolic waste products Excretion of metabolic waste products Intracerebral transport medium Intracerebral transport medium Control of chemical environment Control of chemical environment Autoregulation of intracranial pressure Autoregulation of intracranial pressure

5 Production of CSF Choroidal Choroidal Extrachoroidal Extrachoroidal Ependyma Ependyma ? Neighboring brain substance ? Neighboring brain substance

6 Facts of interest Only choroidal CSF production is tightly regulated active process Only choroidal CSF production is tightly regulated active process CSF secretion shows diurnal variation with peak in the morning. CSF secretion shows diurnal variation with peak in the morning.

7 Factors affecting production Vascular bed autoregulation Vascular bed autoregulation Intracranial pressure Intracranial pressure Brain metabolism Brain metabolism Drugs Drugs

8 Absorption of CSF Arachanoid granulations Arachanoid granulations Along the olfactory nerves Along the olfactory nerves Extracellular spaces in brain Extracellular spaces in brain Brain substance ( glial cells). Brain substance ( glial cells).

9 Factors affecting absorption Intracranial pressure Intracranial pressure

10 Quantitative dynamics Daily secretion: Daily secretion: Total CSF volume: Total CSF volume: Ventricular Ventricular Cisternal Cisternal Spinal Spinal

11 Techniques of CSF analysis Lumber puncture Lumber puncture Cisternal puncture Cisternal puncture Ventricular puncture Ventricular puncture

12 Lumber puncture Diagnostic indications: Diagnostic indications: Infective pathology Infective pathology Inflammatory pathology Inflammatory pathology Subarachanoid hemorrhage Subarachanoid hemorrhage Malignancy and spread Malignancy and spread Pressure recordings Pressure recordings Cisternography, myelography, Cisternography, myelography, Therapeutic indications: Therapeutic indications: CSF drainage CSF drainage Drug delivery Drug delivery

13 Contraindications Absolute Absolute Posterior fossa mass Posterior fossa mass Coagulopahty, blood dyscrasias Coagulopahty, blood dyscrasias Known spinal AVM Known spinal AVM Relative Relative Raised ICT (guarded LP) Raised ICT (guarded LP) Local infection Local infection

14 Technique Positioning Positioning Cleaning and draping Cleaning and draping Puncture Puncture CSF CSF

15 Complications Post LP headaches Post LP headaches Hematoma Hematoma Infection Infection Neural injury Neural injury Iatrogenic dermoids Iatrogenic dermoids

16 Other methods Cisternal puncture Cisternal puncture Lateral cervical puncture Lateral cervical puncture Ventricular puncture Ventricular puncture

17 Ventriculostomy Dandy`s point Dandy`s point Keen`s point Keen`s point Frazier`s point Frazier`s point Kocher`s point Kocher`s point

18 Analysis Glucose60-90≥ 0.66 Proteins35mg/dl0.005 globulins10-50 mg/L0.001 RBC0-1 WBC0-1 (L) Lactate1.6

19 Diagnostic characteristics TypeSugarCellsLactate BacterialVery lowNeutrophilsIncreased FungallowL/N- ViralNormal to lowL/N- AsepticNormalNeutrophilsNormal Post operativeNormalNeutrophils (≥1000)

20 Hydrocephalus Definition Definition Imbalance between production and absorption of CSF leading to accumulation of fluid in the ventricular system leading to elevation of intracranial pressure. Imbalance between production and absorption of CSF leading to accumulation of fluid in the ventricular system leading to elevation of intracranial pressure.

21 Epidemiology Infantile HCP: 3-4 per 1000 LB Infantile HCP: 3-4 per 1000 LB As a single congenital disorder: per 1000 live births As a single congenital disorder: per 1000 live births Associated with SD: per 1000 LB Associated with SD: per 1000 LB

22 Classification Communicating Communicating AKA extraventricular, AKA extraventricular, Noncommunicating Noncommunicating AKA obstructive AKA obstructive Triventricular Triventricular Biventricular Biventricular

23

24 Pathogenesis Obstruction of CSF pathways leading to decreased absorption Obstruction of CSF pathways leading to decreased absorption Increased production Increased production Increased venous pressure Increased venous pressure

25 Increased production Choroid plexus papilloma Choroid plexus papilloma

26 Decreased absorption Due to anatomical block in the pathways Due to anatomical block in the pathways Block at arachanoid granulations level Block at arachanoid granulations level

27 Increased venous pressure Evidence with this theory Evidence with this theory VOGM VOGM Experimental studies in animals Experimental studies in animals Evidence against this theory Evidence against this theory Ligation of various sinuses doesn’t cause HCP Ligation of various sinuses doesn’t cause HCP Experimental studies Experimental studies

28 Pathology of hydrocephalus Atrophy of white matter Atrophy of white matter Spongy edema of brain Spongy edema of brain Fibrosis of choroid plexuses Fibrosis of choroid plexuses Stretching and denuding of ependyma Stretching and denuding of ependyma Fenestration of septum pellucidum Fenestration of septum pellucidum Thinning of interhemispheric commisures Thinning of interhemispheric commisures

29 Acute HCP Cerebral, IV or cerebellar hematoma Cerebral, IV or cerebellar hematoma Paraventricular tumors Paraventricular tumors Gunshots Gunshots Subarachanoid hemorrhage Subarachanoid hemorrhage Acute head injuries Acute head injuries Shunt malfunction. Shunt malfunction.

30 Progression Ventricular dilatation Ventricular dilatation Occipital and frontal horns f/b temporals Occipital and frontal horns f/b temporals Anterior and posterior recess of TV Anterior and posterior recess of TV Fourth ventricle Fourth ventricle Third ventricular balloning Third ventricular balloning

31 Hydrocephalic edema Available space in the cavity consumed Available space in the cavity consumed Stretching and denuding of ependyma Stretching and denuding of ependyma Edema of white matter Edema of white matter

32 Mechanism Stasis of brain interstitial fluid Stasis of brain interstitial fluid Reflux of CSF into the periventricular area Reflux of CSF into the periventricular area Increase in cerebral capillary permeability Increase in cerebral capillary permeability

33 Progression Dorsal angles of lateral ventricle Dorsal angles of lateral ventricle 3-6 hrs 3-6 hrs Centrum semiovale Centrum semiovale hrs hrs Diffuse Diffuse afterwards afterwards

34 Chronic HCP Compensatory mechanisms in chronic HCP Compensatory mechanisms in chronic HCP Expansion of skull Expansion of skull Contraction of cerebral vascular volume Contraction of cerebral vascular volume White matter atropy and ventricular enlargement White matter atropy and ventricular enlargement Decreased rate of CSF formation. Decreased rate of CSF formation. Diversion of CSF flow to alternative pathways Diversion of CSF flow to alternative pathways

35 Changes in cerebral circulation Increased venous pressure Increased venous pressure Delayed emptying of cerebral veins Delayed emptying of cerebral veins Narrowing of cerebral arteries Narrowing of cerebral arteries Prolongation of circulation time Prolongation of circulation time Reduced cerebral blood flow Reduced cerebral blood flow Lowering of CMRO2 Lowering of CMRO2 Reduced glucose metabolism Reduced glucose metabolism

36 Clinical features Age Age Expansibility of skull bones Expansibility of skull bones Type of HCP Type of HCP Duration of HCP Duration of HCP

37 Pediatric hydrocephalus Enlargement of head Enlargement of head Thin and glistening scalp Thin and glistening scalp Tense, bulging fontanalles Tense, bulging fontanalles Dilated and tortuous scalp veins Dilated and tortuous scalp veins unilateral or bilateral abducent palsies unilateral or bilateral abducent palsies Cracked pot or macewen`s sign Cracked pot or macewen`s sign Hypopituitarism and growth retardation Hypopituitarism and growth retardation Transillumination of skull Transillumination of skull

38 Adult acute HCP Headache, nausea, vomitting Headache, nausea, vomitting Alteration of sensorium Alteration of sensorium Visual obscurations Visual obscurations Perinaud`s syndrome Perinaud`s syndrome Progression to herniation syndromes Progression to herniation syndromes

39 Adult chronic HCP Bifrontal generalized headache, vomitting Bifrontal generalized headache, vomitting Papilloedema and secondary optic atrophy Papilloedema and secondary optic atrophy Congnitive deficits Congnitive deficits Unilateral or bilateral abducent palsies Unilateral or bilateral abducent palsies Upward gaze palsy Upward gaze palsy Spastic quadriparesis, dysmetria, Spastic quadriparesis, dysmetria, Bitemporal hemianopia Bitemporal hemianopia Endocrine disturbances Endocrine disturbances

40 Normal pressure hydrocephalus “ Hydrocephalus with normal CSF opening pressure on lumber puncture and absence of papilloedema ” “ Hydrocephalus with normal CSF opening pressure on lumber puncture and absence of papilloedema ”

41 Pathophysiology Intermittant rise of CSF pressure causing ventricular dilatation. Intermittant rise of CSF pressure causing ventricular dilatation. Intraventricular pressure head is decreased Intraventricular pressure head is decreased

42 Basis of clinical symptoms Gait problems Gait problems Urinary incontinence Urinary incontinence Memory problems Memory problems

43 Arrested hydrocephalus Definitions Definitions CSF pressure has normalized CSF pressure has normalized Pressure gradient between ventricles and parenchyma has been dessipated Pressure gradient between ventricles and parenchyma has been dessipated Ventricular size remains stable or decrease Ventricular size remains stable or decrease New neurological deficits do not appear New neurological deficits do not appear Advancing psychomotor development with age. Advancing psychomotor development with age.

44 Pediatric NPH Enlarged head usually in or above ninth percentile Enlarged head usually in or above ninth percentile History of delayed psychomotor development History of delayed psychomotor development Mild to moderate mental retardation Mild to moderate mental retardation Glib verbal abilities Glib verbal abilities Mild spastic paraparesis Mild spastic paraparesis

45 Hydrocephalus ex vacuo Cerebral atrophy and dilatation of sulci Cerebral atrophy and dilatation of sulci Intracranial pressure is normal Intracranial pressure is normal Absence of periventricular edema Absence of periventricular edema Absence of retrograde filling Isotope cisternography Absence of retrograde filling Isotope cisternography

46 Thank you Thank you


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