CEREBRAL CIRCULATION AND

CEREBROSPINAL FLUID [CSF]

CEREBRAL CIRCULATION
The brain receives its blood supply from four main arteries: the two internal carotid arteries and the two vertebral arteries. The clinical consequences of vascular disease in the cerebral circulation is dependent upon which vessels or combinations of vessels are involved.

CEREBRAL CIRCULATION

CEREBROSPINAL FLUID
The cerebrospinal Fluid [CSF] is a clear, colorless, transparent, tissue fluid present in the cerebral ventricles, spinal canal, and subarachnoid spaces.

CEREBROSPINAL FLUID

CEREBROSPINAL FLUID [FORMATION]

CSF is largely formed by the choroid plexus of the lateral ventricle and remainder in the third and fourth ventricles.

About 30% of the CSF is also formed from the ependymal cells lining the ventricles and other brain capillaries.
The choroid plexus of the ventricles actively secrete cerebrospinal fluid. The choroid plexuses are highly vascular tufts covered by ependyma.

FORMATION & CIRCULATION OF CSF

MECHANISM OF FORMATION OF CSF

CSF is formed primarily by secretion and also by filtration from the net works of capillaries and ependymal cells in the ventricles called choroid plexus. Various components of the choroid plexus form a bloodcerebrospinal fluid barrier that permits certain substances

to enter the fluid, but prohibits others.

Such a barrier protects the brain and spinal cord from

harmful substances.

MECHANISM OF FORMATION OF CSF

The entire cerebral cavity enclosing the brain and spinal cord has a capacity of about 1600 to 1700 milliliters About 150 milliliters of this capacity is occupied by cerebrospinal fluid and the remainder by the brain and cord.

MECHANISM OF FORMATION OF CSF

Rate of formation: About 20-25 ml/hour 550 ml/day in adults. Turns over 3.7 times a day Total quantity: 150 ml: 30-40 ml within the ventricles About 110-120 ml in the subarachnoid space [of which 75-80 ml in spinal part and 25-30 ml in the cranial part].

MECHANISM OF FORMATION
CSF is formed at a rate of about 550 milliliters each day,. About two thirds or more of this fluid originates as secretion from the choroid plexuses in the four ventricles, mainly in the two lateral ventricles.
Additional small amount of fluid is secreted by the ependymal surfaces of all the ventricles and by the arachnoidal membranes Small quantity comes from the brain itself through the perivascular spaces that surround the blood vessels passing through the brain.

MECHANISM OF FORMATION
Secretion by the Choroid Plexus. The choroid plexus, is a cauliflower-like growth of blood vessels covered by a thin layer of epithelial cells. Secretion of fluid by the choroid plexus depends mainly on active transport of sodium ions through the epithelial cells lining the outside of the plexus. The sodium ions in turn pull along large amounts of chloride ions because the positive charge of the sodium ion attracts the chloride ion's negative charge. The two of these together increase the quantity of osmotically active sodium chloride in the cerebrospinal fluid, which then causes almost immediate osmosis of water through the membrane, thus providing the fluid secretion.

MECHANISM OF FORMATION
Less important transport processes move small amount of glucose into the cerebrospinal fluid and both potassium and bicarbonate ions out of the cerebrospinal fluid into the capillaries. The resulting characteristics of the CSF are: Osmotic pressure approximately equal to that of plasma sodium ion concentration approximately equal to that of plasma chloride ion about 15 per cent greater than in plasma potassium ion approximately 40 per cent less glucose, about 30% less

ABSORPTION OF CSF THROUGH ARACHNOID VILLI

The arachnoidal villi are fingerlike inward projections of the arachnoidal membrane through the walls into venous sinuses. villi form arachnoidal granulations can protrude into the sinuses. The endothelial cells covering the villi have vesicular passages directly through the bodies of the cells large enough to allow relatively free flow of (1) cerebrospinal fluid, (2) dissolved protein molecules, and (3) even particles as large as red and white blood cells into the venous blood.

COMPOSITION OF CSF
Proteins Glucose Cholesterol Na+ Ca+ Urea Creatinine Lactic acid = = = = = = = = 20-40 mg/100 ml 50-65 mg/100 ml 0.2 mg/100 ml 147 meq/Kg H2O 2.3 meq/kg H2O 12.0 mg/100 ml 1.5 mg/100 ml 18.0 mg/100 ml

CHARACTERISTICS OF CSF
Nature: Colour = Specific gravity = Reaction = Cells Pressure = = Clear, transparent fluid 1.004-1.007 Alkaline and does not coagulate 0-3/ cmm 60-150 mm of H2O, 10mmHg

The pressure of CSF is increased in standing, coughing, sneezing, crying, compression of internal Jugular vein (Queckenstedts sign

CIRCULATION OF CSF
Circulation: CSF is mainly formed in choroid plexus of the lateral ventricle. CSF passes from the lateral ventricle to the third ventricle through the interventricular foramen (foramen of Monro). From third ventricle it passes to the fourth ventricle through the cerebral aqueduct. The circulation is aided by the arterial pulsations of the choroid plexuses. From the fourth ventricle (CSF) passes to the sub arachnoid space, around the brain and spinal cord through the foramen of magendie and foramina of luschka.

CIRCULATION OF CSF
Lateral ventricle
Foramen of Monro [Interventricular foramen]

Third ventricle:
Cerebral aqueduct Fourth ventricle: Foramen of magendie and foramen of luschka

Subarachnoid space of Brain and Spinal cord

Cushioning effect: for CNS, it keeps CNS lubricated and protected from traumatic shock Homeostasis: CSF maintains FUNCTIONS OF CSF by floating physical environment the brain and absorbing the shock, CSF maintains chemical environment by preventing toxins in blood from entering CNS. Nutritive function: It brings nutrients to brain and removes waste products from brain tissue. Diagnosis of illness: Laboratory examination of CSF reveals any illness or pathological condition e.g. hemorrhages, inflammation.

CSF AND INFLAMMATION

Increased inflammatory cells may be caused by infectious and noninfectious processes. Polymorphonuclear cells indicate acute suppurative meningitis. Mononuclear cells are seen in viral infections, syphilis, tuberculous meningitis, multiple sclerosis, brain abscess and brain tumors.

CSF AND PROTEINS

Increased protein: CSF proteins may rise to 500 mg/dl in bacterial meningitis, intracranial tumors, hemorrhage & infarction.

CSF & LOW GLUCOSE

Low glucose in CSF: This condition is seen in tuberculosis
Fungal infections Meningeal dissemination of tumors Glucose is consumed by leukocytes and tumor cells

BLOOD IN CSF

Blood: Blood may be spilled into the CSF by accidental puncture of a vein during entry of the LP needle. Such blood stains the fluid that is drawn initially and clears gradually. If it does not clear, blood indicates subarachnoid hemorrhage.

CSF AND TUMOUR CELLS

Tumor cells indicate dissemination of metastatic or primary brain tumors in the subarachnoid space. The most common among the latter is medulloblastoma.

They can be best detected by cytological examination.

A mononuclear inflammatory reaction is often seen in addition to the tumor cells.

INDICATIONS OF CSF EXAMINATION

Infections: meningitis, encephalitis Tumors: Administration of drugs in CSF (Therapeutic aim) Antibiotics: (In case of meningitis) Antimitotics Diagnostic aim: Myelography, Cisternography Anesthetics are also given through the lumbar Puncture.

LUMBAR PUNCTURE
A lumbar puncture also called a spinal tap is a procedure where a sample of cerebrospinal fluid is taken for examination. CSF is mainly used to diagnose meningitis [an infection of the meninges]. It is also used to diagnose some other conditions of the brain and spinal cord.

LUMBAR PUNCTURE
Patient usually lie on a bed on side with knees pulled up against the chest. It may also done with sitting up and leaning forward on some pillows. Sterilize the area. push a needle through the skin and tissues between two vertebra, into the space around the spinal cord which is filled with CSF. CSF leaks back through the needle and is collected in a sterile container. As soon as the required amount of fluid is collected the needle is taken out and a plaster is put over the site of needle entry.

LUMBAR PUNCTURE

CEREBROSPINAL FLUID

CEREBROSPINAL FLUID

CEREBROSPINAL FLUID

HYDROCEPHALUSL
Hydrocephalus" means excess water in the cranial vault. This condition is frequently divided into communicating hydrocephalus and noncommunicating hydrocephalus. In communicating hydrocephalus fluid flows readily from the ventricular system into the subarachnoid space, in noncommunicating hydrocephalus fluid flow out of one or more of the ventricles is blocked.

Hydrocephalus