Summary
On the basis of the laws of Pascal and Laplace, it is shown that the ventricular dilatation in acquired hydrocephalus is due to a primary increase in the intraventricular pressure (IVP), and that a new steady state can be reached, whether the IVP is increased or normal. The pressure increase is due to a disproportion between the production and reabsorption of cerebrospinal fluid (CSF). As water and salts pass freely across the ependyma and the choroid plexus in hydrocephalus, the pressure increase is caused by an increased protein concentration in the ventricular CSF, leading to increased fluid contents according to the Gibbs-Donnan equilibrium. During the ventricular dilatation, the ependyma is destroyed, and the protein molecules penetrate into the subependymal part of the white matter. This results in a reduction in the colloid osmotic pressure of the ventricular CSF, and a new steady state can be reached, with a normal protein concentration in an increased volume.
The attendant microscopic changes in the ventricular wall were demonstrated in a patient with acquired hydrocephalus, and the observations made were in conformity with the results of a number of animal experiments.
The symptomatology of acquired hydrocephalus is in agreement with a primary affection of the axons running in the juxtaventricular part of the white matter.
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References
Adams, R. D., Fisher, C. M., Hakim, S., Ojeman, R. G., Sweet, W. H., Symptomatic occult hydrocephalus with “normal” cerebrospinal fluid pressure. New Engl. J. Med.273 (1965), 117–126.
Breig, A., Ekbom, K., Greitz, T., Kugelberg, E., Hydrocephalus due to elongated basilar artery. Lanceti (1967), 874–875.
Coblentz, J. M., Mattis, S., Zingesser, L. H., Kasoff, S. S., Wisniewski, H. M., Katzman, R., Presenile dementia. Arch. Neurol.29 (1973), 299–308.
Dandy, W. E., Blackfan, K. D., Internal hydrocephalus: an experimental, clinical, and pathological study. Amer. J. Dis. Child.8 (1914), 406–482.
Davson, H., Dynamic aspects of cerebrospinal fluid. Dev. med. Child. Neurol.14, suppl.12 (1972), 1–16.
De Land, F. H., James Jr., A. E., Ladd, D. J., Konigsmark, B. W., Normal pressure hydrocephalus. Amer. J. Clin. Path.58 (1972), 58–63.
Di Chiro, G., Hammock, M. K., Bleyer, A., Spinal descent of cerebrospinal fluid in man. Neurology26 (1976), 1–8.
Early, C. B., Fink, L. H., Some fundamental applications of the law of La Place in neurosurgery. Surg. Neurol.6 (1976), 185–189.
Eisenberg, H. M., McLennan, J. E., Welch, K., Treves, S., Radioisotope ventriculography in cats with kaolin-induced hydrocephalus. Radiology110 (1974), 399–402.
Geschwind, N., The mechanism of normal pressure hydrocephalus. J. neurol. Sci.7 (1968), 481–493.
Granholm, L., Svendgaard, N., Hydrocephalus following traumatic head injuries. Scand. J. Rehab. Med.4 (1972), 31–34.
Gutierrez, Y., Friede, R. L., Kaliney, W. J., Agenesis of arachnoid granulations and its relationship to communicating hydrocephalus. J. Neurosurg.43 (1975), 553–558.
Hakim, S., Adams, R. D., The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. J. neurol. Sci.2 (1965), 307–327.
Hakim, S., Venegas, J. G., Burton, J. D., The physics of the cranial cavity, hydrocephalus and normal pressure hydrocephalus. Surg. Neurol.5 (1976), 187–210.
Hammock, M. K., Milhorat, T. H., Davis, D. A., Isotope cisternography and ventriculography in the diagnosis of hydrocephalus. Dev. med. Child. Neurol.16, suppl.32 (1974), 58–71.
Heinz, E., Davis, D. O., Karp, H. R., Abnormal isotope cisternography in symptomatic occult hydrocephalus. Radiology95 (1970), 109–120.
Hussey, F., Schanzer, B., Katzman, R., A simple constant-infusion manometric test for measurement of CSF absorption II. Clinical studies. Neurology20 (1970), 665–680.
Jensen, F., Malmros, R., Hvid Hansen, H., Cold, G., Intraventricular isotope encephalography. A methodological study. Dan. med. Bull.24 (1977), 7–14.
Jensen, F., Jensen, F. T., Acquired hydrocephalus I. A clinical analysis of 160 patient studied for hydrocephalus. Acta Neurochir. (Wien)46 (1979), 119–133.
Jensen, F., Olsen, K. J., Acquired hydrocephalus IV. Determination of the absorption rate of albumin from the cerebrospinal fluid. Acta Neurochir. (Wien) (in press).
Jensen, F., Jensen, F. T., Acquired hydrocephalus V. Determination of the formation rate of albumin in the ventricular system. Acta Neurochir. (Wien) (in press).
Jensen, F., Reske-Nielsen, E., Ratjen, E., Obstructive hydrocephalus following Pantopaque myelography. Neurorad. (in press).
Koto, A., Rosenberg, G., Zingesser, L. H., Horoupian, D., Katzman, R., Syndrome of normal pressure hydrocephalus: possible relation to hypertensive and arteriosclerotic vasculopathy. J. neurol. neurosurg. psych.40 (1977), 73–79.
Little, J. R., Houser, O. W., Mac Carty, C. S., Clinical manifestations of aqueductal stenosis in adults. J. Neurosurg.43 (1975), 546–552.
Maemarou, A., Shulman, K., La Morgese, J., Compartmental analysis of compliance and outflow resistance of the cerebrospinal fluid system. J. Neurosurg.43 (1975), 523–534.
Messert, B., Henke, T. K., Langheim, W., Syndrome of akinetic mutism associated with obstructive hydrocephalus. Neurology16 (1966), 635–649.
Milhorat, T. H., Clack, R. G., Hammock, M. K., McGrath, P. P., Structural, ultrastructural and permeability changes in the ependyma and surrounding brain favoring equilibration in progressive hydrocephalus. Arch. Neurol.22 (1970), 397–407.
Milhorat, T. H., Hammock, M. K., Isotope ventriculography. Arch. Neurol.25 (1971), 1–8.
Moore, M. T., Progressive akinetic mutism in cerebellar hemangioblastoma with “normal-pressure hydrocephalus”. Neurology19 (1969), 32–36.
Page, L. K., Bresman, M. J., Lorenzo, A. V., Cerebrospinal fluid perfusion studies in childhood hydrocephalus. Surg. Neurol.1 (1973), 317–320.
Pollay, M., CSF formation and mechanism of drainage. In: Cisternography and hydrocephalus, pp. 13–24. Springfield, Ill.: Ch. C Thomas. 1972.
Rinaldi, I., Harris, W. O., Di Chiro, G., Radionuclide cisternography in subdural hematomas. Radiology105 (1972), 597–602.
Rubin, R. C., Hochwald, G. M., Tiell, M., Mizutani, H., Ghatak, N., Hydrocephalus I. Histological and ultrastructural changes in the preshunted cortical mantle. Surg. Neurol.5 (1976), 109–114.
Rubin, R. C., Hochwald, G. M., Tiell, M., Lienicz, B. H., Hydrocephalus II. Cell number and size and myelin content of the preshunted cortical mantle. Surg. Neurol.5 (1976), 115–118.
Rubin, R. C., Hochwald, G. M., Tiell, M., Epstein, F., Ghatak, N., Wisniewski, H., Hydrocephalus III. Reconstitution of the cerebral cortical mantle following ventricular shunting. Surg. Neurol.5 (1976), 179–183.
Rudd, T. G., O'Neal, J. T., Nelp, W. B., Cerebrospinal fluid circulation following subarachnoid hemorrhage. J. Nucl. Med.12 (1971), 61–63.
Schønheyder, F., Nørby, J., Biokemi. Universitetsforlaget i Aarhus (1959), 8–10.
Singounas, E. G., Krasanakis, C., Karvounis, P. C., Observations on the pathogenesis of low pressure hydrocephalus. Analysis of 25 cases. Neurochir.19 (1976), 22–25.
Smith, D. E., Streicher, E., Milković, K., Klatzo, I., Observations on the transport of proteins by the isolated choroid plexus. Acta Neuropath.3 (1964), 372–386.
Stein, B. M., Fraser, R. A. R., Tenner, M. S., Normal pressure hydrocephalus: complication of posterior fossa surgery in children. Pediatrics49 (1972), 50–58.
Strecker, E. P., James Jr., E. J., The evaluation of cerebrospinal fluid flow and absorption: clinical and experimental studies. Neurorad.6 (1973), 200–205.
Sweet, W. H., Silverstone, B., Soloway, S., Stetten, D., Studies of formation, flow and absorption of cerebrospinal fluid. Surg. Forum1 (1950), 376–381.
Sweet, W. H., Locksley, H. B., Formation, flow and reabsorption of cerebrospinal fluid in man. Proc. Soc. exp. biol. Med.84 (1963), 397–402.
Sweet, W. H., Histological development of tracer uses in CSF dynamics. In: Central nervous system investigation with radionuclides, pp. 39–51. Springfield, Ill.: Ch. C Thomas. 1971.
Sweet, W. H., Early uses of radioisotopic tracers in the study of CSF dynamics. In: Cisternography and hydrocephalus, pp. 545–553. Springfield, Ill.: Ch. C Thomas. 1972.
Sweet, W. H., Brownell, G. L., Scholl, J. A., Bowsher, D. R., Benda, P., Stickley, E. E., The formation, flow and absorption of cerebrospinal fluid; newer concepts based on studies with isotopes. In: Neurology and psychiatry in childhood, pp. 101–159. Baltimore: The Williams and Wilkins Co. 1974.
Timmons, G. D., Johnson, K. P., Aqueductal stenosis and hydrocephalus after mumps encephalitis. New Engl. J. Med.283 (1970), 1505–1507.
Tonali, P., Laudisio, A., Belloni, G., Moschini, M., Functional obstructive hydrocephalus. Neurorad.5 (1973), 220–222.
Ucar, S., Florez, G., Garcia, J., Increased intracranial pressure associated with spinal cord tumours. Neurochir.19 (1976), 265–268.
Welch, K., Friedman, V., The cerebrospinal fluid valves. Brain83 (1960), 454–469.
Welch, K., The principles of physiology of the cerebrospinal fluid in relation to hydrocephalus including normal pressure hydrocephalus. In: Advances in neurology, pp. 247–332. New York: Raven Press. 1975.
Williams, J. P., Pribram, H. F. W., Lynde, R. H., Sharpe, A. R., Isotope cisternography in the evaluation of patients with subarachnoid hemorrhage. J. Nucl. Med.11 (1970), 592–596.
Wozniak, M., McLone, D. G., Raimondi, A. J., Micro- and macrovascular changes as the direct cause of parenchymal destruction in congenital murine hydrocephalus. J. Neurosurg.43 (1975), 535–545.
Yakovlev, P. I., Paraplegias of hydrocephalus. Amer. J. ment. Defic.51 (1947), 561–576.
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Jensen, F. Acquired hydrocephalus III. Acta neurochir 47, 91–104 (1979). https://doi.org/10.1007/BF01404666
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DOI: https://doi.org/10.1007/BF01404666