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nutrition
nutrition
5irchow*
5irchow*
Robin
Robin
spaces
spaces
CSF PR489C.:4/* Choroid
CSF PR489C.:4/* Choroid
Plexus
Plexus
CSF is produced by
CSF is produced by
choroid plexus and
choroid plexus and
secreted at ciliated
secreted at ciliated
cuboidal epithelial cell
cuboidal epithelial cell
surfaces of the
surfaces of the
microvilli into the
microvilli into the
ventricles
ventricles
CSF PR489C.:4/* Choroid
CSF PR489C.:4/* Choroid
Plexus
Plexus
;pendymal Cell <embrane
;pendymal Cell <embrane
.ransport
.ransport
CSF Production
CSF Production
CSF secretion
CSF secretion
involves the
involves the
transport of ions
transport of ions
( /a0% Cl= and
( /a0% Cl= and
7C4)=! across
7C4)=! across
the epithelium
the epithelium
from blood to
from blood to
CSF
CSF
#aso%atera% (pica%
)
2
!, Na
*
, )+,
"
-, +%-
Secretion can occur because of the polari>ed distribution of specific
ion transporters in the apical or basolateral membrane of the
epithelial cells(
CSF Production
CSF Production
./)0
./)0
2+ 2+
receptors
receptors
? from &7. subfamily( @e(g A!
? from &7. subfamily( @e(g A!
SSR:Bs bloc+ &*7.
SSR:Bs bloc+ &*7.
A6 A6
receptor presynaptic upta+e
receptor presynaptic upta+e
of &7. '! antimigraine CtriptansD stimulate
of &7. '! antimigraine CtriptansD stimulate
vasoconstriction* agonists mediating &7.
vasoconstriction* agonists mediating &7.
AB AB
A8 A8
receptors )! ondansetrongranisetron are &*7.
receptors )! ondansetrongranisetron are &*7.
) )
receptor antagonists * antinaseau effectsE
receptor antagonists * antinaseau effectsE
./)0
./)0
2+ 2+
receptors found in high concentration in
receptors found in high concentration in
choroid plexus
choroid plexus
CSF Production
CSF Production
6/P receptors found in choroid plexus 6/P receptors found in choroid plexus
Choroid plexus epithelial cells express Choroid plexus epithelial cells express
receptors for atrial natriuretic peptide receptors for atrial natriuretic peptide
that when stimulated increase cF<P that when stimulated increase cF<P
levels and inhibit cerebral spinal fluid levels and inhibit cerebral spinal fluid
production production
J
J
' '
transferrin
transferrin
CSF Constituency*
CSF Constituency*
J
J
' '
transferrin
transferrin
PR4.;:/ PR4.;:/
;K;C.R4P74R;S:S*on ;K;C.R4P74R;S:S*on
celluloseP6F;filter etc celluloseP6F;filter etc
Lund4erg has descri4ed " 5ave patterns 6+7 5aves 8(, #, and +
5aves9. ( 5aves are patho%ogica%. 0here is a rapid rise in 6+7 up to
.!/1!! mm )g fo%%o5ed 4y a varia4%e period during 5hich the 6+7
remains e%evated fo%%o5ed 4y a rapid fa%% to the 4ase%ine and 5hen
they persist for %onger periods, they are ca%%ed :p%ateau: 5aves
5hich are patho%ogica%. :0runcated: or atypica% ones, that do not
e;ceed an e%evation of .! mm )g, are ear%y indicators of
neuro%ogica% deterioration. # < + 5aves are re%ated to respiration
and :0rau4e/)ering/Mayer: 5aves 8rhythmica% variations in 4%ood
pressure9 respective%y and are part of norma% physio%ogy 5ith %itt%e
c%inica% significance.
Kundberg
6* waves
6* wavesPlateau Laves
6* wavesPlateau Laves
Steep rises and abrupt falls in :CP% pea+ing at &#*A## mm Steep rises and abrupt falls in :CP% pea+ing at &#*A## mm
7g% that last &* '# minutes (also +nown as plateau waves!( 7g% that last &* '# minutes (also +nown as plateau waves!(
<ay signify intracranial vasomotor decompensation( <ay or <ay signify intracranial vasomotor decompensation( <ay or
may not be associated with clinical deterioration( may not be associated with clinical deterioration(
Pathogenesis related to dilation of resistance vessels% Pathogenesis related to dilation of resistance vessels%
increased intracranial blood volume% decreased flow% and increased intracranial blood volume% decreased flow% and
increased pressure( increased pressure(
Kymphaticscribiform Kymphaticscribiform
plate plate
8rugs
8rugs
:n cases of subarachnoid hemorrhage or traumatic spinal :n cases of subarachnoid hemorrhage or traumatic spinal
fluid taps% approximately A LBC is added to every "## fluid taps% approximately A LBC is added to every "##
RBCs (literature range% A LBC&##*A%### RBCs!( .his RBCs (literature range% A LBC&##*A%### RBCs!( .his
disagreement in values ma+es formulas (Fisher ratio etc! disagreement in values ma+es formulas (Fisher ratio etc!
unreliable that attempt to differentiate traumatic tap unreliable that attempt to differentiate traumatic tap
artifact from true LBC increase( 6lso% the presence of artifact from true LBC increase( 6lso% the presence of
subarachnoid blood itself may sometimes cause subarachnoid blood itself may sometimes cause
meningeal irritation% producing a mild to moderate meningeal irritation% producing a mild to moderate
increase in P</s after several hours that occasionally increase in P</s after several hours that occasionally
may be greater than &## LBCs mm) ( may be greater than &## LBCs mm) (
Qanthochromia begins in , R hours (literature range% '* Qanthochromia begins in , R hours (literature range% '*
RS hours! due to hemoglobin pigment from lysed RBCs( RS hours! due to hemoglobin pigment from lysed RBCs(
CSF Pathology
CSF Pathology
7atterns of +ere4rospina% $%uid (4norma%ity@ +e%% 0ype and A%ucose Leve%
#rain a4scess
0u4ercu%osis meningitis
=ira% meningitis
=ira% encepha%itis
7ostinfectious encepha%itis
Lead encepha%opathy
CBF N CB5t
CBF N CB5t
pressuremyogenic autoregulation
pressuremyogenic autoregulation
arterioles dilate or constrict in response to changes in BP arterioles dilate or constrict in response to changes in BP
and :CP in order to maintain a constant CBF and :CP in order to maintain a constant CBF
C Cmyogenic theoryD* vascular smooth muscle within myogenic theoryD* vascular smooth muscle within
cerebral arterioles intrinsically contract to stretch thereby cerebral arterioles intrinsically contract to stretch thereby
regulating pressure regulating pressure
/4* limited role overall% but if completely abolish /4 /4* limited role overall% but if completely abolish /4
production then loss of autoregulationM with CBF being production then loss of autoregulationM with CBF being
completely BP*dependent completely BP*dependent
6utoregulation
6utoregulation
<etabolic 6utoregulation
<etabolic 6utoregulation
W
W
A A
%
%
J
J
' '
% and X
% and X
' '
(CdilatorsD!% and X
(CdilatorsD!% and X
A A
(CconstrictorD! receptors
(CconstrictorD! receptors
Carbon dioxide
Carbon dioxide
causes cerebral
causes cerebral
vasodilation( 6s the
vasodilation( 6s the
arterial tension of
arterial tension of
C4' rises% CB5 and
C4' rises% CB5 and
CBF increases and
CBF increases and
when it is reduced
when it is reduced
vasoconstriction is
vasoconstriction is
induced(
induced(
C
C
Cerebrovascular ReserveD
Cerebrovascular ReserveD
Pressure gradients can develop within Pressure gradients can develop within
the brain substance and the compliance the brain substance and the compliance
or CsGuishinessD of pathological brain or CsGuishinessD of pathological brain
(e(g( tumor! can be different from that of (e(g( tumor! can be different from that of
normal brain leading to an altered curve normal brain leading to an altered curve
(shift left!( (shift left!(
.he extent of the change in :CP caused by an alteration in .he extent of the change in :CP caused by an alteration in
the volume of intracranial contents is determined by the the volume of intracranial contents is determined by the
compliance or of the brain( :n other words if compliance is compliance or of the brain( :n other words if compliance is
low% the brain is stiffer or less ZsGuashableZ( .herefore% an low% the brain is stiffer or less ZsGuashableZ( .herefore% an
increase in brain volume will result in a higher rise in increase in brain volume will result in a higher rise in
intracranial pressure than if the compliance were high( intracranial pressure than if the compliance were high(
BloodBrain*BloodCSF Barriers
BloodBrain*BloodCSF Barriers
C
C
.ightD
.ightD
-unctions at
-unctions at
the
the
ependymal
ependymal
level
level
Fenestrated
Fenestrated
-unctions at
-unctions at
the choroidal
the choroidal
capillaries
capillaries
.he choroid plexus is composed of fenestrated
capillaries and an epithelial (ependymal! covering%
which reverts from ZtightZ to moderately ZopenZ at
the base *?not as strenuous of barrier as
bloodbrain
BloodBrain Barrier and
BloodBrain Barrier and
Circumventricular organs
Circumventricular organs
.he circumventricular organs (C54! are midline .he circumventricular organs (C54! are midline
structures bordering the )rd and Rth ventricles( .hese structures bordering the )rd and Rth ventricles( .hese
barrier*deficient areas are recogni>ed as important sites barrier*deficient areas are recogni>ed as important sites
for communicating with the CSF and between the brain for communicating with the CSF and between the brain
and peripheral organs via blood*borne products( C54\s and peripheral organs via blood*borne products( C54\s
include the pineal gland% median eminence% include the pineal gland% median eminence%
neurohypophysis% subfornical organ% area postrema% neurohypophysis% subfornical organ% area postrema%
subcommissural organ% organum vasculosum of the subcommissural organ% organum vasculosum of the
lamina terminalis% and the choroid plexus( .he lamina terminalis% and the choroid plexus( .he
intermediate and neural lobes of the pituitary are intermediate and neural lobes of the pituitary are
sometimes included sometimes included
Causes of an increased :CP
Causes of an increased :CP
cerebral edema
cerebral edema