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[Disturbances of CSF circulation, pathophysiologic, clinical, diagnostic and therapeutic aspects]
Abstract:
Disturbances of CSF circulation arise from the anatomic narrows of the CSF spaces and from the dependence on venous pressure of CSF absorption in the superior sagittal sinus. The author discusses the modern concepts of CSF production and circulation, the causal mechanism for hydrocephalus and the chances of compensating for a rise in CSF pressure by transependymal migration. CSF circulation (CSFc) disturbances can be subdivided into primary processes arising in the internal and external CSF spaces and secondary which are due to distant consequences of intracranial processes via interaction of the blood/CSF volume and parenchyma of the brain within the closed capsule of the skull according to the teaching of Monroe-Kellie. Extra-cranial processes in the neck, the mediastinum and heart are primary CSFc disturbances which-via an increase in intracranial venous pressure-lead to a reduction of CSF absorption. Among the hypotonic CSFc disturbances loss of CSF volume due to fistulae, diagnostic or surgical measures are the most important. 205 cases from the literature are the basis of a description of the clinical picture, the main subjective symptoms and neurologic signs. The problems of diagnosis of CSFc disturvances are demonstrated on 3 cases from the author's department. They were due to a colloid cyst of the foramen of Monroe, a stenosis of the aqueduct and a "normal pressure hydrocephalus". The relative value of additional technical investigations into the diagnosis of CSFc disturbances is assessed critically. The techniques of PEG, ventriculography and radioisotope cisterno- and ventriculography are compared and their special indications determined. Treatment of hypotonic CSFc disturbances is surgical revision and/or an atrio-ventricular shunt. Conservative measures only effect postponement. Treatment of hypotonic CSFc disturbances for which loss of CSF volume cannot be established, has so far had only unsatisfactory results.