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Meninges and Cerebrospinal Fluid Brad Cole, MD

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Meninges and Cerebrospinal Fluid Brad Cole, MD Meninges and Cerebrospinal Fluid Brad Cole, MD 1. Meninges The CNS is enclosed by three connective tissue membranes that together constitute the meninges: the pia, arachnoid, and dura mater. (a) The innermost layer is the pia mater. It closely adheres to the brain and spinal cord, and into every sulci and depression on the surface of the CNS. The pia is vascular and contains blood vessels that supply the CNS. (b) The next layer, the arachnoid, does not follow the uneven surfaces of the brain but extends across depressions and sulci. The space between the pia and arachnoid is called the subarachnoid space. In places, the subarachnoid space is much larger and is called a cistern Examples of this include the cisterna magna (located posterior to the medulla, below the cerebellum), and the lumbar cistern (a large collection of CSF below L1-2 where the spinal cord terminates). Thin threads of connective tissue extend through the subarachnoid space connecting the pia to the arachnoid (called arachnoid trabeculae). The subarachnoid space is filled with cerebrospinal fluid (CSF) which coats the entire CNS (brain and spinal cord). If blood vessels in the pia mater should bleed (such as occurs when an aneurysm ruptures), they bleed into the subarachnoid space. This is called a subarachnoid hemorrhage. • An infection of the meninges (meningitis) results in inflammatory cells in the subarachnoid space. It is often desirable to examine the CSF for blood or inflammatory cells (normally they are absent in the CSF). A lumbar puncture takes advantage of the large lumbar cistern. During this procedure you withdraw CSF from the subarachnoid space by inserting a long needle between the L4-L5 vertebrae. Since the spinal cord ends at L1-2, you don’t need to worry about hitting the spinal cord. Subarachnoid Space: Normal contents Pathologic contents CSF Blood (aneurysm rupture) Inflammatory Cells (meningitis) CSF can also be collected from the cisterna magna. For obvious reasons of safety, this is rarely performed today. (c) The outermost membrane, the dura mater, consists of dense connective tissue and is very strong. The dura consists of an outer periosteal layer which contains blood vessels and nerves and is attached to the inner surface of the cranium, and an inner meningeal layer which is attached to the arachnoid. The dura covers the entire brain and spinal cord all the way down to the second sacral vertebrae and helps to anchor the spinal cord to the meninges via the denticulate ligaments. At certain areas these two layers separate to form the large venous sinuses, where the venous blood and CSF eventually drain from the intracranial cavity. The potential space between the arachnoid and the dura is called the subdural space. After head trauma, venous blood can collect in the subdural space, due to shearing of the bridging veins. This is called a subdural hematoma. The space between the dura and bone is called the epidural space. Head trauma can also result man epidural hemorrhage. This hemorrhage is more likely to be arterial from a laceration of the middle meningeal artery. Epidural hematomas are more likely to be associated with a skull fracture and, since the dura is attached to the skull, the blood does not cross suture margins resulting a focal wedge into the brain. Notice below the crescent shape of a subdural hematoma (left) in contrast to the wedge shape into the brain of an epidural hematoma (right). The latter also reveals a skull fracture (red arrow): Epidural hematomas more likely occur in younger individuals since the dura becomes more adherent to the skull with age whereas subdural hematomas are more likely in the elderly population. The dura has two important infoldings into the brain. These serve to restrict potentially damaging movements of the brain in the skull. The large falx cerebri extends into the interhemispheric fissure and divides the left and right halves of the brain. Posteriorly, the falx cerebri divides into two parts that extend over the surface of the cerebellum, the cerebellar tentorium. The anterior edge of the cerebellar tentorium has an opening for the brain stem. The cerebellar tentorium and the petrous portions of the temporal bones separate the supratentorial (above) and infratentorial (below) regions. These terms are generally used to refer to the cerebral hemispheres (supratentorial) from the brain stem and cerebellum (infratentorial). • Uncal herniation: Under conditions of increased intracranial pressure (a tumor or a hemorrhage in the brain for example), the temporal lobe may herniate through the opening of the cerebellar tentorium. The most medial portion of the temporal lobe (the uncus) will often push on the ipsilateral oculomotor nerve (Ill) resulting in a 3rd nerve palsy (a dilated pupil with the eye deviated laterally). These patients are also in a coma. 2. Cerebral Ventricles and Cerebrospinal Fluid (CSF) (a) Lateral Ventricles - The paired lateral ventricles are located in the cerebral hemispheres and consist of a central body (posterior to interventricular foramen of Monro), the atrium (or trigone, is the area of convergence of the occipital and temporal horns with the body) and the individual horns that project into three lobes of the brain: anterior (frontal) horn, posterior (occipital) horn, and the inferior (temporal) horn. The frontal horn is the largest and is bordered medially by the septum pellucidum. The caudate nucleus bulges into the lateral aspect of the frontal horn while the tail of the caudate is found in the temporal horn. The hippocampus forms the medial wall of the temporal horn. (b) Third Ventricle - CSF from each lateral ventricle communicates with the third ventricle via the foramen of Monro (there are two foramen of Monro and one third ventricle). The third ventricle is an important landmark, since it is surrounded by the two thalami. (c) Fourth Ventricle - CSF from the third ventricle communicates with the fourth ventricle via the cerebral aqueduct. The cerebral aqueduct divides the tegmentum from the tectum in the midbrain. The fourth ventricle is between the pons and medulla (anterior) and the cerebellum (posterior). (d) Subarachnoid Space - CSF exits the fourth ventricle via two Lateral foramen of Luschka and via a single Middle foramen of Magendie. The outlet of these foramen is initially into the cisterna magna. Once CSF exits the fourth ventricle, it is now in the subarachnoid space and out of the ventricular system. The CSF in the subarachnoid space coats the brain and spinal cord and eventually empties into the superior sagittal sinus (the venous sinus over the interhemispheric fissure), via specialized structures in the wall of the sinus called arachnoid villi. The arachnoid villi are small evaginations of the arachnoid which protrude through the meningeal layer of the dura into the superior sagittal sinus. Several of these villi together are called arachnoid granulations. The CSF is able to pass through the arachnoid villi because the hydrostatic pressure is higher in the subarachnoid space than in the venous sinuses. The superior sagittal sinus eventually drains into the internal jugular vein where both the venous blood and CSF exit the intracranial cavity. The central canal in the spinal cord is a continuation of the ventricular system. It is, however, essentially an embryologic remnant that has no functional significance. 3. Function of the CSF The CSF is produced by the choroid plexus, which is located in the lateral ventricles, third ventricle, and the fourth ventricle. The composition of CSF is similar to that of blood with several important exceptions. Normally there are no red blood cells or white blood cells in the CSF. The CSF glucose is about 2/3 that in the blood, while CSF protein is only 0.5% that of blood. The brain and spinal cord are protected not only by the skull and vertebral canal, but also by the meninges and CSF. The specific weight of nervous tissue is only slightly greater than that of water, which means that the brain and spinal cord almost float in the CSF. This buoyancy reduces the weight of the nervous tissue and results in less traction on vessels and nerves connected to the CNS. The CSF and meninges also minimize the impact of external forces on the brain and spinal cord by serving as a cushion between the CNS and bone. Review of CSF circulation (label the drawing on the previous page): Lateral Ventricles (2) → Interventricular foramen of Monro (2) → Third Ventricle → Cerebral aqueduct → Fourth Ventricle → Foramen of Luschka (2) and Foramen of Magendie→ Cisterna Magna/Subarachnoid Space → Arachnoid Villi → Superior Sagittal Sinus → Cerebral Venous System → Internal Jugular Vein The CSF also filters out potentially toxic substances from the brain (such as potassium ions during periods of intense neuronal activity) and keeping a relatively constant composition for the neurons. Recently the glymphatic system was identified as a perivascular pathway where CSF flows through brain tissue to filter out potential toxins. Most importantly, amyloid beta, which accumulates in Alzheimer’s dementia, is filtered out by this system. 4. Hydrocephalus The total volume of CSF in the ventricular system and the subarachnoid space is about 150 ml in an adult. The choroid plexus produces about 500 ml of CSF every day. Thus, the total amount of CSF is renewed several times every day. If there is a blockage of CSF flow, the ventricles may expand resulting in hydrocephalus. For example, if the cerebral aqueduct becomes occluded, the third ventricle and the lateral ventricles will dilate since the CSF produced in these ventricles cannot drain into the subarachnoid space. The fourth ventricle, however, will not change in size since its flow is not impeded. In infants and children this results in an increased head circumference if the sutures have not yet closed.
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