Theories of cerebrospinal fluid dynamics and hydrocephalus: historical trend

A review

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According to the CSF bulk flow theory, hydrocephalus is caused by an imbalance between CSF formation and absorption, or a block at various locations in the major CSF pathway. New theories, however, have been proposed in which minor CSF pathways may play a significant role in the development of congenital hydrocephalus. The authors review major contributions to the literature and analyze the evolution of theories of CSF dynamics in relation to hydrocephalus, dividing their development into 4 stages on the basis of historical trends.

In Stage I (prior to 1950), 2 systems of classifying hydrocephalus were proposed, namely Dandy's classifications of communicating and noncommunicating hydrocephalus and Russell's nonobstructive and obstructive hydrocephalus. In Stage II (1950–1974), based on these theories of major CSF pathway dynamics, treatment focused on ventriculostomy as an alternative to reduction of CSF production by choroid plexus coagulation. In Stage III (1975–1999), some of the specific forms of hydrocephalus, especially in premature infants, were found to be unsuitable for ventriculostomy. In Stage IV (2000–2008), selection of treatment modalities evolved further, with a focus on analysis of the chronological changes in CSF dynamics and the differences in absorption pathways in the developing and mature brains. The authors focus on “minor pathway hydrocephalus” in the immature brain, differentiating it from the conventional classification of obstructive and nonobstructive “major pathway hydrocephalus.”

Abbreviations used in this paper:HCA = hydrocephalus chronology in adults; ICP = intracranial pressure; NPH = normal pressure hydrocephalus.

Article Information

Address correspondence to: Shizuo Oi, M.D., Ph.D. Division of Pediatric Neurosurgery, Jikei Women's and Children's Medical Center, Jikei University School of Medicine, 3-25-8 Nishi Shinbashi, Minato-ku, Tokyo, Japan 105-8461. email:

Please include this information when citing this paper: published online December 7, 2012; DOI: 10.3171/2012.3.PEDS0934.

© AANS, except where prohibited by US copyright law.



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    Schematic of Dandy and Blackfan's 1914 classification of hydrocephalus. The classification is based on the major CSF pathway, with noncommunicating hydrocephalus being characterized by a block between the ventricles and the lumbar subarachnoid space. Drawing by S. Oi. With kind permission from Springer Science + Business Media: Childs Nerv Syst, Proposal of “evolution theory in cerebrospinal fluid dynamics” and minor pathway hydrocephalus in developing immature brain, vol. 22, 2006, pp 662–669, S Oi and C Di Rocco, Fig. 2. © Springer-Verlag, 2006.

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    Schematic of Russell's 1949 classification of hydrocephalus. This classification is based on the major CSF pathway, with obstructive hydrocephalus involving a block anywhere in that pathway and nonobstructive hydrocephalus being caused by oversecretion due to a choroid plexus papilloma. Drawing by S. Oi. With kind permission from Springer Science + Business Media: Childs Nerv Syst, Proposal of “evolution theory in cerebrospinal fluid dynamics” and minor pathway hydrocephalus in developing immature brain, vol. 22, 2006, pp 662–669, S Oi and C Di Rocco, Fig. 3. © Springer-Verlag, 2006.

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    Schematic of Oi and Di Rocco's 2006 description of the minor CSF pathway in immature brain and classification for hydrocephalus. Drawing by S. Oi. With kind permission from Springer Science + Business Media: Childs Nerv Syst, Proposal of “evolution theory in cerebrospinal fluid dynamics” and minor pathway hydrocephalus in developing immature brain, vol. 22, 2006, pp 662–669, S Oi and C Di Rocco, Fig. 9. © Springer-Verlag, 2006. SSS = superior sagittal sinus.

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    Schematic of HCA staging. LOVA = long-standing overt ventriculomegaly in adults. With kind permission from Springer Science + Business Media: Crit Rev Neurosurg, Hydrocephalus chronology in adults: confused state of the terminology. How should “normal-pressure hydrocephalus” be defined?, vol. 8, 1998, pp 346–356, S Oi, Fig. 2. © Springer-Verlag, 1998.



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