Anatomy and Physiology of Hydrocephalus James P. (Pat) McAllister II, PhD 1,2,4 Marion L. Walker
Transcript of Anatomy and Physiology of Hydrocephalus James P. (Pat) McAllister II, PhD 1,2,4 Marion L. Walker
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Anatomy and Physiology of Hydrocephalus James P. (Pat) McAllister II, PhD 1,2,4
Marion L. Walker, MD1; John R.W. Kestle, MD1; Carolyn Harris, PhD1,2; Kelley Deren-Lloyd, MS1; Ramin Eskandari, MD1;
Janet Miller, PhD4; Melissa Packer1; Anders Skjolding, MD, PhD; Hannah Botfield, PhD; Mark Luciano, MD, PhD; Alexa Canady, MD;
Raymond C. Truex, Jr., MD
1 Pediatric Neurosurgery, Primary Children’s Medical Center & University of Utah, Salt Lake City, UT
2 Bioengineering and 3 Physiology, University of Utah, Salt Lake City, UT 4 Biology, Central Michigan University, Mt. Pleasant, MI
Hydrocephalus Association 12th National Conference; 6/27/2012
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Enlarged Ventricles Normal Ventricles
Lateral Ventricles
LV
LV
Hydrocephalus Association 12th National Conference; 6/27/2012
Typical MRI of Hydrocephalus
This is communicating and not obstructive hydrocephalus
The periventricular white matter is thinner than usual
The cause is aqueductal stenosis
This is slit-ventricle syndrome
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Nothing “Magic”
It’s Mostly Just Vocabulary
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Cerebral Ventricular System
FH Netter: The Ciba Collection of Medical Illustrations Vol 1 – Nervous System, 1986, p. 134.
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Anatomical Orientation
*Head & Neck “Horizontal” “Axial”
*
Sagittal Coronal
Axial Hydrocephalus Association 12th National Conference; 6/27/2012
Left Side Left Side
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Hydrocephalus Association 12th National Conference; 6/27/2012
Front
Top
Back
Bottom
“top down”
“front-to-back” “right side”
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Hydrocephalus Association 12th National Conference; 6/27/2012
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Hydrocephalus Association 12th National Conference; 6/27/2012
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Cerebral Ventricular System
FH Netter: The Ciba Collection of Medical Illustrations Vol 1 – Nervous System, 1986, p. 134.
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Netter FH: The Ciba Collection of Medical Illustrations Vol 1 – Nerv. Syst. 1986
Cerebrospinal Fluid (CSF) Production
CSF Formation: • Choroid plexus (80%) • Brain Tissue “Parenchyma” (20%) • Normal rate
12-15 ml/hr; 290-360 ml/day • CSF spaces = 140 ml
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Location of Choroid Plexus in Human Brain
Hydrocephalus Association 12th National Conference; 6/27/2012
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Choroid Plexus Often Blocks the Ventricular Portion of the Shunt
Hydrocephalus Association 12th National Conference; 6/27/2012
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Fishman RA: Cerebrospinal Fluid in Diseases of the Nervous System, 2nd ed, WB Saunders, 1992, Fig. 2-1.
CSF Flow & Absorption Pathways
Greitz D. et al: Acta Pediatrics, 86:125-132, 1997
Directional (bulk) Flow Cranial & Spinal Pathways Bulk Absorption 1. Arachnoid granulations/villi
a. Cranial – superior sagittal sinus to internal jugular vein
b. Spinal 2. Lymphatics – CNI & spinal
roots 3. Tissue capillaries Pulsatile Flow
Hydrocephalus Association 12th National Conference; 6/27/2012
1a
1b
2
3
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CSF Absorption through Arachnoid Granulations into the Venous System
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CSF Absorption through Arachnoid Granulations into the Venous System
Netter FH: The Ciba Collection of Medical Illustrations Vol 1 – Nerv. Syst. 1986
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CSF Flow – Bulk vs. Pulsatile
Cerebral Aqueduct Bulk flow ~ 0.3 cc/min Pulsatile flow ~ 2 cc/min Pulsatile Flow Slower in cerebral aqueduct &
over cortical surface Faster in basal cisterns
Flow Speed
Basal Cisterns
Cerebral Aqueduct
Hydrocephalus Association 12th National Conference; 6/27/2012
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Blood Supply to Choroid Plexus
Netter FH: The Ciba Collection of Medical Illustrations Vol 1 – Nerv. Syst. 1986
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Functions of CSF
Diagnostic – infection, hemorrhage, tumors, brain damage Bouyancy – protection from compressive & shearing forces
Physiological Balance (Homeostasis)
“Clearing” substances from brain Delivery of vitamins and other small molecules Ion balance
Inter-brain Communication (Neurotransmission/Neuromodulation)
Delivery of trophic factors – cell production & maturation
Hydrocephalus Association 12th National Conference; 6/27/2012
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from Richard D. Penn and Andreas Linninger. The Physics of Hydrocephalus. Pediatr Neurosurg 45:161–174, 2009.
CSF Formation • Choroid plexus (70%) & Parenchyma (30%) • Normal rate = 12-15 ml/hr; 290-360 ml/day CSF Absorption Rate • Cranial & Spinal CSF volume = 140 ml
• Absorption must be ~ 2.5x formation per day or the VENTRICLES ENLARGE!
Non-Hydrocephalic
Hydrocephalic
Critical Balance between
CSF Formation & Absorption
CSF is white (T2-weighted MRI)
CSF is white (T2-weighted MRI)
Hydrocephalus Association 12th National Conference; 6/27/2012
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Causes of Hydrocephalus • Intraventricular Hemorrhage
• Meningitis & Encephalitis • Congenital Malformations
• Subarachnoid Hemorrhage • Tumors & Cysts • Normal Pressure Hydrocephalus
Ventricles
White Matter
Gray Matter
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Netter FH: The Ciba Collection of Medical Illustrations Vol 1 – Nerv. Syst. 1986
Types of Hydrocephalus
1 X
X 2 X 4
X 5
X 3 6 X
X 7
1. Intraventricular (obstructive) o Intraventricular hemorrhage o Aqueductal stenosis o Chiari malformations o Infectious Ventriculitis o Tumors
2. Extraventricular (communicating) o Infectious Meningitis o Subarachnoid Hemorrhage
spontaneous traumatic
o Venous hypertension
1
2
3
4
5
6
7
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Vulnerable Brain Structures in Hydrocephalus • Periventricular (“bordering ventricles”) structures • White matter – myelinated (“insulated”) neuron processes
connecting different parts of the brain
Corpus Callosum
Corpus Callosum
Hippocampus
Hippocampus
Corpus Callosum
Periventricular White Matter
Hydrocephalus Association 12th National Conference; 6/27/2012
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MRI CT
Vulnerable Brain Structures in Hydrocephalus
OR – Optic Radiations: transmits impulses to cerebral cortex where vision perceived Visual problems Learning deficits based on visual cues
CC
PVWM OR
F Control Hydrocephalic Hydrocephalic
CC – Corpus Callosum: connects R & L sensory and motor regions PVWM – Periventricular White Matter: connects cerebral cortex to deep brain
structures, cerebellum and spinal cord Muscle control /coordination/seizures Learning deficits
F – Fornix: connections to/from memory and learning center (Hippocampus) Memory deficits and learning problems
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Ventricular Shunting for Hydrocephalus
McComb and Zlokovic 1994 Pre-shunt Post-shunt
LV
v3
LV
shunt
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Third Ventriculostomy
LV
SAS
3rd Vent
P
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Don’t Miss the Shunt Demonstration
You’ll be AMAZED
This is easy! Why do I need a
Neurosurgeon to do this?
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The End – It’s Not Magic!
Hydrocephalus Association 12th National Conference; 6/27/2012
Thank You & Keep Learning!