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05 - CSF + Ventricles - Dr Najeeb Videos

Anatomy (Dow University of Health Sciences)

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o CSF & VENTRICULAR SYSTEM.

 The Ventricular System
 Brain and spinal cord surrounded by meninges for protection.
 For further protection → CNS (brain + spinal cord) is suspended in a clear
color less fluid → CSF.
 CSF is produced inside the brain by specialized cells & then released into a
special compartment called ventricular system.
 CSF surround the brain and spinal cord in subarachnoid space.
 CSF from ventricular system passes into
 Sub arachnoid space & spinal canal
 Within the spinal cord → a central canal → spinal canal

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 There are four compartments inside the brain that house cerebrospinal fluid
(CSF)
Include
 Two Lateral Ventricles
 One third ventricle
 One fourth ventricle

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 Lateral Ventricles
 Lateral ventricles → 2 in number
 Each positioned in one of the cerebral hemispheres,
 Also called ventricles of the Telencephalon
 Reason → Forebrain (Prosencephalon)
Two parts
 Superficially: Cerebral hemispheres (telencephalon)
ⱺ The Cerebral cortex (grey matter present on surface of the brain)
 Deep: diencephalon
Mn → Princess Dian surrounded by Telescopes.

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 Components → Each Lateral ventricle has one body and 3 horns.

 Body → cavity of parietal lobe
 Horns
 Frontal horn → cavity of frontal lobe
 Posterior horn → cavity of occipital lobe
 Temporal horn → cavity of temporal lobe

 The two Lateral ventricles open into the third ventricle via interventricular
foramina aka foramen of Monro.

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 Third Ventricle
 The third ventricle is positioned in the midline between the two thalami.
 It is the ventricle of the diencephalon.
 The third ventricle communicates inferiorly with 4th ventricle via a duct
called Cerebral Aqueduct of Sylvius
 the cerebral aqueduct is only an inferior extension of the third ventricle
 it is not itself a ventricle.
 Lies in cavity of mesencephalon(midbrain) → mcq

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o Fourth Ventricle →
 The cerebral aqueduct of Sylvius opens into the fourth ventricle,
 It is ventricle of the rhombencephalon → primitive term for hindbrain
 Fourth ventricle → rhombus-shaped
 This is reason for etymology for the name of hindbrain as
rhombencephalon.
 Located on the posterior aspect of the pons + medulla oblongata, BUT
anterior to the cerebellum → therefore it is in between these two.
 Upper Anterior half posterior to pons
 Lower Anterior half posterior to medulla
 The fourth ventricle opens into the subarachnoid space via two foramina
 Foramen of Magendie → opens posteriorly → into the subarachnoid space.
 Foramen of Luschka → opens laterally → into the subarachnoid space.
 Deets → 4th ventricle expands laterally as recesses.
 Lateral recesses ends as foramen of Luschka.
 The fourth ventricle is also continuous inferiorly with the spinal canal.
 Spinal canal terminate in a slight dilation known as the terminal
ventricle.

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 Parts of 4th Ventricle ( See pic below)

 Roof → post tent shaped part
 Floor → part anterior to roof

 Production of Cerebrospinal Fluid (CSF)

 Cerebrospinal fluid is produced by specialized structures known as choroid
plexuses
 The choroid plexus is made up of specialized epithelial cells called
Ependymal cells
 Choroid plexus exist in the walls of the
 Lateral ventricle,

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 Main site of production

 The roof of the third ventricle and
 The roof of the fourth ventricle.
 Ependymal cells are also present in spinal canal of spinal cord → mcq.

 Specialized capillary tufts, covered by pia mater extend from the

arterial vessels into the choroid plexus.
 Together capillary tufts + pia matter → called the tela choroidea
 Tela choroidea entering into the choroid plexus come in direct contact
with ependymal cells, which line the ventricular system, to form the
choroid plexuses.

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 The tela choroidea produce a filtrate of the plasma into the extravascular
space.
 This fluid then comes in contact with ependymal cells of Choroid
Plexus.
 Ependymal cells make some modifications to this filtrate & convert this
filtrate into CSF
 CSF is released by ependymal cells into the ventricles.
 Process
 The ependymal cells contains active Na+ transporters.
 As Na+ ions is actively secreted into the ventricular system it also
transports the fluid across the ependymal epithelial layer.
 Cl- ions and water passively follow Na+ ions from capillaries into CSF.
 Glucose is also transported via glucose transporters in ependymal cells
but inefficiently. Thus, CSF has a glucose concentration of about 66%
than that of capillary plasma.
 K+ anions are transported in reverse → (from CSF to capillaries).

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 Circulation of CSF
CSF is secreted as follows
 Choroid plexus in lateral ventricles are the main site of production of CSF.
 CSF from Lateral ventricles flows into third ventricle via foramina of
Monro
 From Third ventricle into to fourth ventricle. via cerebral aqueduct of
Sylvius
 From the fourth ventricle it goes two ways
 Circulates into the spinal canal.
 Enters into the subarachnoid space via Foramina of Magendie &
Foramen of Luschka,
 Arachnoid Cisterns
 Normally Pia matter and Arachnoid matter closely attached together.
 At some points of sub arachnoid spaces – the pia mater and
arachnoid mater are not closely attached.
 Because of this loosening, there is a slight bulge in the sub arachnoid
space in between these meningeal layers & they shows a bulge /
swellings at these points.
 CSF pools in these areas (present in greater amount). These swelled
areas with ↑ CSF in the subarachnoid space are called Arachnoid
cisterns or Cisterns.
 Two important cisterns are located where the CSF enters from Ventricular
system into the sub arachnoid space.
 Foramina of Luschka open laterally at cerebellopontine cistern →
located at junction of cerebellum and pons Not in Img
 The foramen of Magendie opens into the cerebello-medullary
cistern aka Cistern magna→ located at junction of cerebellum and
medulla
 Cistern magna → largest cistern

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 Other major cisterns in the Subarachnoid space include:

 Interpeduncular cistern, which is anterior to the midbrain, between
its two cerebral peduncles.
 The cerebral peduncles are two large bundles of white matter
connecting the brainstem with the cerebrum.
 Superior cistern is posterior to the midbrain
 The interpeduncular and superior cisterns are connected by the
ambient cistern (not in Img) which is a channel passing
anteroposteriorly through the midbrain.

 Recycling of CSF into Circulatory System

 CSF, upon circulating through the subarachnoid space in brain + spinal
cord, drains into Superior sagittal sinus which is a dural venous
sinus in Falx cerebri.
 Recall → At some points the two dural layers (meningeal layer and
periosteal layer) are not attached to each other, here they form a space
between them called Dural venous sinus
 Significance → Dural venous sinus receive deoxygenated blood of Brain
and CSF (for drainage out of the subarachnoid space into the heart)
 CSF drains into all Dural venous sinuses
 Dr Najeeb only talked about Superior sagittal sinus.
 Small finger like projections / processes from Arachnoid matter into dural
venous sinuses are called Arachnoid villi
 Many arachnoid villi combinedly called arachnoid granulations.

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 OLD CSF passes from the subarachnoid space into the dural venous
sinuses via Arachnoid villi.
 Deoxygenated venous blood of cranial cavity also drain into dural
venous sinuses (veins open in to dural venous sinus)

 Superior Sagittal sinus can be said as venosus drainage system of

CNS
 These arachnoid villi are lined by an epithelium with large paracellular
channels through which CSF can flow.
 Additionally, the cells have pinocytotic activity which may allow them to
transport CSF and proteins across the arachnoid layer

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 All the Dural Venous Sinus are interconnected and ultimately drain into
Internal Jugular Vein
 IJV drain into SVC
 SVC drain in RA

 For CSF to drain from the Subarachnoid space into the Superior
sagittal sinus, the pressure in the subarachnoid space must exceed
that of the Superior Sagittal Sinus by 1.5 mm Hg. This pressure

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difference prevents backflow of CSF from the dural venous sinus into the
subarachnoid space.
 Greater pressure differences results in greater rates of out flow.
 If the pressure difference falls below 1.5 mm Hg → the arachnoid
granulations and villi are compressed, and CSF will NOT drain from
subarachnoid space to the superior sagittal sinus.

Up till now all summary in video 2 — 0 mins to 3 minutes.

 Functions of the CSF

 Cushioning effect → The CSF functions as a cushion → dampens forces
that arise between brain and the skull during trauma injuries. Excessive
forces overcome this cushioning effect, and result primarily in two
different types of brain contusion:
 Contre-coup injuries → impact to the brain such that it does not
result in fracture of skull → brain contusions occur on the side opposite
to the site of impact (e.g. blow to the back of the skull results in brain
contusion of the frontal lobes) Rx → CSF cushioning.
 Coup injuries → impact to the brain such that it results in fracture of
skull → skull fractures at the site of injury → result in brain contusions to
the brain to the site of impact
 Buoyancy → Floating in fluid such that the weight becomes lighter – like
boat floating on water becomes easier to drag around.
 Dry brain weight → 1400 gram
 Brain weight immersed in CSF → 50 grams.
 CSF is important in allowing for buoyancy of the brain so that gravity
does not cause traction (pulling downward) of the brain or spinal nerves
against the surfaces of the cranial vault and the vertebral canal.
 If excessive CSF is withdrawn during a lumbar puncture, patient
complain of headache due to the traction forces on intracranial
structures.
 Thus, after a Lumbar puncture patients are required to lie supine for
at least one hour. These “spinal headaches” may be treated by
injecting sterile saline back into the CSF space.
 Buffer Effect → The CSF volume adapts to regulate the total volume of
intracranial contents.
 In mild instances of brain swelling → Initially as the intracranial
pressure rises, body ↑ CSF clearance rate to bring total CSF volume
down to compensate the enlarged brain and dampen the rise in
intracranial pressure.

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 In cases of brain atrophy, e.g., with old age, brain volume decrease, -
CSF volume increase to fill the extra space in order to function
effectively as a cushion.
 Functions as a vehicle for metabolic exchange, and is akin to the
circulatory system of the brain; the pia mater does not pose a significant
barrier between the brain substance and the CSF, and metabolic
substances diffuse freely across it.
 Medium of Exchange → The capacity of the circulatory system to
nourish the brain is less than optimal in brain because of the existence of
the blood-brain barrier, which limits the diffusion of substances across
brain capillaries. This is because the capillaries in brain have continuous
tight junctions which allow very little fluid to enter.
 CSF acts as a vehicle for metabolic exchange, and is akin (just like) to
the circulatory system of the brain → CSF nourishes the brain more than
blood nourishes the brain because
 ECF of brain & CSF have almost same composition
 ECF of brain & CSF are freely exchangeable.
 CSF provides nourishment to Brain as CSF itself get its supply from
capillaries which then undergo modification by ependymal cells.

 The CSF aids in removal of metabolic waste products from the brain
by draining such substances into the blood at site of dural venous
sinuses
 The CSF is produced by the choroid plexus which is not subject to the
blood brain barrier.
 Signaling Medium → The CSF aids in the transport and circulation of
signaling hormones intracranially
 For instance, Melatonin secreted by the pineal gland, circulates
through the CSF to regulate activity of the pituitary gland.

 Thus, the CSF is an important source of nourishment to the brain, which

equilibrates with the interstitial fluid of the brain. That said, the choroid
plexus does not efficiently transport all nutrients either; CSF glucose
concentration is only 66% that of capillary plasma.

 Lumbar Puncture Procedure

o The patient is positioned in the (left or right) lateral position, hugging his
legs, with his knees brought to his chin in order to best expose the lumbar
intervertebral spaces.
o The site for LP is identified by locating the LIV/ LV intervertebral space
(alternatively LIII/LIV in adults may also be used) in the midline.

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o A local anesthetic is applied to the region of LP.

o A needle is inserted at the site, with trajectory pointing towards the patient’s
navel. The structures pierced from superficial to deep are the skin,
subcutaneous fascia, supraspinous ligament, interspinous ligament,
ligamentum flavum, epidural fat layer, dura mater and arachnoid mater.
Multiple resistances will thus be encountered along the way, resulting mainly
from the skin and subcutaneous fascia, ligaments and finally the dura.
o Once the needle has been inserted, a manometer may be attached to measure
the CSF pressure. Subsequently, three bottles of up to 10ml of CSF fluid may be
withdrawn using sterile, clean vials.
o Subsequently, the needle is removed, and the patient is kept in the supine
position to convalesce for one hour. This prevents excessive traction forces
on the brain and spinal nerves on the bony surfaces of the cranium and
vertebral canal, which can cause a headache.

 Contraindications to Lumbar Puncture

 Major contraindication → raised intracranial pressure,
 If LP done in ↑ intra cranial pressure → result in a herniation of the
brainstem through the foramen magnum due to imbalance between
intracranial and intraspinal CSF pressures.
 5 signs of ↑ intracranial pressures are →

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o
o

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Properties of CSF
 CSF → transcellular fluid → mcq
 Density / specific gravity of CSF → 1.0001 to 1.0005 g/ml → mcq
 pH of blood = pH of CSF.
 About 550 ml of CSF is produced daily.
 Mn → bachpan or pachpan
 However, the total capacity of the ventricular system +
subarachnoid space →130 ml.
 Mn → 13 x 4 = almost 55
 Thus, the CSF is replaced three to four times per day.
 If this volume is NOT removed from the ventricular system →
excessive pressure builds up.
 The maximum volume of CSF that can be withdrawn safely in LP is about
30 ml.
 I am 30 years old.
 Normal pressure of CSF → 60 -160 mm of H2O.
 Mn → Shoaib Akhtar 60 se 160 kmh

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 How to measure → Upon inserting a needle for LP, a manometer

attached to measure the CSF pressure
 The normal composition of CSF and its changes in various pathological
conditions are described in the table below

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Pyogenic Tuberculo
meningitis us Subarachn
Viral
(caused by non- meningiti oid Autoimmu
Normal values meningi
tuberculous s– hemorrhag ne Disease
tis
bacteria) Chronic e
Acute bacterial Bacterial
Appearan Xanthochromia
Turbid fluid.
ce of Yellow, turbid fluid (clear, yellow fluid)
Fibrin web Clear, Clear, colorless
fluid Clear, colorless fluid Turbid → not due to bilirubin
may be colorless fluid fluid
crystal clear produced by
observed.
heme degradation
Neutrophils Slightly raised
0 cells / cm3 High* Since neutrophils Slightly raised High Absent
cells of acute Inf
Lymphocyte
< 5 cells / cm3 Slightly raised High* High* High Absent
s
RBCs 0 cells/ cm3 Absent Absent Absent High Absent
Glucose 66% of capillary plasma
glucose concentration. < 50% < 50% > 50%
Equal to
Capillary plasma glucose capillary capillary capillary
capillary Normal
must be taken at the same plasma plasma plasma
plasma glucose
time to glucose ** glucose ** glucose
assess normal values.
Proteins 0.4 g/L in CSF fluid. 1000 mg/dL 1000 Raised, but Equal to Raised due to
(70-80 g/L in due to ↑ mg/dL due < 1000mg/dL capillary immunoglobulin
plasma) microcirculati to *** plasma protein s
on exudate
permeability
→ exudate

*Rule → Neutrophils raised in acute infection — Lymphocytes are raised in Viral infections + Chronic infections
** Bacteria love glucose, so they consume it.
*** Viruses typically do not ↑ microcirculation permeability
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 Hydrocephalus
 Hydrocephalus → excess accumulation of CSF in
 Intracranially in the ventricular system,
 Subarachnoid space
 Both.
 Causes
 ↑ production
 Rare cause
 Due to tumor of choroid plexus
 ↑ production only 1 cause.
 Abnormal circulation of CSF → common cause
 Reduced drainage of CSF → common cause

 Abnormal Circulation & Reduced Drainage

 Divided into communicating and non-communicating Hydrocephalus.

 Non-Communicating Hydrocephalus
 Obstruction that occurs at or above the level of the openings of the
fourth ventricle
 Result → CSF cannot enter into the sub arachnoid space →

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 More CSF → enlargement of one or more of the ventricles →

compression of Brain.

 Obstruction at either of the Foramina of Monro

 Third ventricle → main site of production
 Cause → Choroid plexus cysts in third ventricle results in obstruction
at either of the foramina of Monro
 These choroid plexus cysts are intermittent hydrocephalus because
they form → block foramen of Monro and then dislodge, form again
block foramen of Monro and dislodge.
 Obstruction of any one foramina of Monro produce a unilateral
enlargement of the lateral ventricle.
 Cranial cavity cannot expand → brain substance atrophies to
accommodate the expanded ventricles.
 Result → a thin shell of cerebral cortex surrounding the ventricle on
CT.
 Obstruction of the Cerebral aqueduct
 Cause → Congenital stenosis (narrowing) in children or Tumours in
adults.
 Produce bilateral symmetrical enlargement of the lateral and third
ventricles
 In adults, the cranial cavity cannot expand to accommodate the
increased CSF volume, so bilateral Brain shrinking.
 In infants with congenital stenosis → cranial bones have not yet
formed strong fibrous suture joints, and the cranium can expand
 It however alters normal development.
 Obstruction of the foramina of Luschka or the foramen of Magendie
 Cause → cerebellar tumours compress these openings
 Result → bilateral symmetrical enlargement of the Lateral, third and
fourth ventricles.
 Brain shrinkage on CT Scan.

 Communicating Hydrocephalus
 Obstruction at any level after the CSF has drained out of the fourth
ventricle into the subarachnoid space OR Impaired CSF reabsorption
by arachnoid villi in dural venous Sinus.
 When CSF is not reabsorbed by Arachnoid villi → Normal Pressure
Hydrocephalus ( discussed ahead)
 Communicating Hydrocephalus results in minimal enlargement of
the ventricles.
 Causes →

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 Tuberculous meningitis
 Obstruction of the subarachnoid space near the base of the brain,
in
 After meningitis is cured, healing process involves fibrosis → forms
lateral adhesions within the subarachnoid space walls →
 Result → permanent obstruction of flow of CSF within subarachnoid
space.
 Hemorrhage in the Subarachnoid space
 Recall → Cerebral arteries + cerebral veins are present within the
sub arachnoid space.
 If hemorrhage occurs in any of the cerebral vessel → RBCs leak into
CSF → RBCs obstruct the CSF outflow from arachnoid villi
 CSF reabsorption decreased → ↑ CSF in subarachnoid space →
Normal Pressure Hydrocephalus.
 Inflammation
 WBCs and necrotic tissue due to meningitis and encephalitis, result
in subsequent fibrosis
 Result → permanent obstruction of flow of CSF within subarachnoid
space.
 Normal pressure hydrocephalus
 NPH → def → hydrocephalus that happens because CSF is not
absorbed by arachnoid villi.
 CSF begins to rise slowly & chronically.
 With chronicity the brain atrophies to the extent that a raised CSF
pressure cannot be measured.
 Normal pressure hydrocephalus results in classic Triad of
 Dementia,
 Abnormal gait and
 Loss of control of the external urinary sphincter leading to
incontinence (Wacky, Wobbly and Wet).
 Thrombus
 Thrombus in any Dural venous sinus result in raised dural
venous sinus pressure and compression of the arachnoid villi →
 Results → dec CSF reabsorption → ↑ CSF in subarachnoid space → Normal
pressure Hydrocephalus.

 Tumors
 Recall → All dural venous sinuses ultimately drain into Internal
jugular vein
 IJV obstruction due to tumour results dec CSF outflow + ↑ CSF in
subarachnoid space → Hydrocephalus.

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 Also, If we compress the internal jugular vein during an LP

procedure, a raised CSF pressure would be measured.
 Treatment of Hydrocephalus → silicone tube shunt,
 shunt CSF to the right atrium (ventriculo-atrial shunt)
 Shunt CSF to the peritoneum (ventriculo-peritoneal shunt).
 CSF Rhinorrhea
 CSF rhinorrhea is the leakage of CSF from the nose
 This breach allows potential pathogens to ascend and cause
meningitis.
 Condition called Ascending Meningitis.

UNUSAL TYPES OF HYDROCEPHALUS

 Hydrocephalus ex vacuo is a type of hydrocephalus that is not

due to any abnormality in CSF production, circulation or drainage. It
results from atrophy of the caudate nucleus, which is closely related
to and forms the floor and lateral wall of the frontal horn and body of
the lateral ventricles, and the roof of the temporal horn of the lateral
ventricles, which occurs as part of Huntington’s Disease. This results
in ventricular enlargement secondary to the atrophy associated with
motor deficits.

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 Pseudo tumour cerebri is a syndrome which presents typically in

young, obese women.
 It presents with raised CSF pressure, papilledema, vision problems
and slit-like ventricles observed on CT/ MRI scan.
 These features suggest the presence of a tumour and raised
intracranial pressure. However, upon further investigation no
tumours can be found. The pathogenesis of this disease is unknown.

 Finally, some types of vertebral column tumours external to the CNS

may compress upon the subarachnoid space along the spinal cord,
leading to a communicating hydrocephalus obstruction at that level.

 However, as a result of the compression, the subarachnoid space

above and below the lesion do not communicate with each other,
and thus upon lumbar puncture a raised CSF pressure is not
observed.
 This can be confirmed by asking the patient to cough or by obstructing the
internal jugular vein, which would normally cause an immediate rise in CSF
pressure; however due to the lack of communication this does not occur.
This is known as a positive Quekenstedt’s sign

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Note → Dr Najeeb lecture notes from videos Ventricles + CSF in

neuroanatomy.
I first made notes & added extra points while solving mcqs.
Edit as per your need. Circulate to others if you find them useful.

 For queries or suggestions or mistakes in the document contact me

@ mailto:hiba_jasim@hotmail.com?subject=Dr Najeeb Notes Query

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