Ventricle wall movements and cerebrospinal fluid flow in hydrocephalus

Clinical article

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The dynamics of fluid flow in normal pressure hydrocephalus (NPH) are poorly understood. Normally, CSF flows out of the brain through the ventricles. However, ventricular enlargement during NPH may be caused by CSF backflow into the brain through the ventricles. A previous study showed this reversal of flow; in the present study, the authors provide additional clinical data obtained in patients with NPH and supplement these data with computer simulations to better understand the CSF flow and ventricular wall displacement and emphasize its clinical implications.


Three NPH patients and 1 patient with aqueductal stenosis underwent cine phase-contrast MR imaging (cine MR imaging) for measurement of CSF flow and ventricle wall movement during the cardiac cycle. These data were compared to data previously obtained in 8 healthy volunteers.

The CSF flow measurements were obtained at the outlet of the aqueduct of Sylvius. Calculation of the ventricular wall movement was determined from the complete set of cine MR images obtained axially at the middle of the lateral ventricle. The data were obtained before and after CSF removal with a ventriculoperitoneal shunt with an adjustable valve. To supplement the clinical data, a computational model was used to predict the transmural pressure and flow.


In healthy volunteers, net CSF aqueductal flow was 1.2 ml/minute in the craniocaudal direction. In patients with NPH, the net CSF flow was in the opposite direction—the caudocranial direction—before shunt placement. After shunting, the magnitude of the abnormal fluid flow decreased or reversed, with the flow resembling the normal flow patterns observed in healthy volunteers.


The authors' MR imaging–based measurements of the CSF flow direction and lateral ventricle volume size change and the results of computer modeling of fluid dynamics lead them to conclude that the directional pattern and magnitude of CSF flow in patients with NPH may be an indication of the disease state. This has practical implications for shunt design and understanding the mechanisms that produce hydrocephalus.

Abbreviations used in this paper: cine MR imaging = cine phase-contrast MR imaging; NPH = normal pressure hydrocephalus; VP = ventriculoperitoneal.

Article Information

Address correspondence to: Richard Penn, M.D., Department of Bioengineering, University of Illinois at Chicago, Science and Engineering Offices (SEO), Room 218 (M/C 063), 851 South Morgan Street, Chicago, Illinois 60607-7052. email:

Please include this information when citing this paper: published online January 28, 2011; DOI: 10.3171/2010.12.JNS10926.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Schematic of the model highlighting areas of interest. Note that the normal pattern of CSF flow is from the third ventricle (3V) to the fourth ventricle (4V) and that this reverses in hydrocephalus. The obstruction to flow out of the subarachnoid space (SAS) to the venous sinus (vSinus) causes a reversal of the pressure gradient from the brain parenchyma to the lateral ventricles (LV), which in turn results in the flow direction change. The model predicts this reversal. The shunt reduces the gradient and brings the flow pattern back to normal. cAr = carotid artery; Ar = artery; AI = arteriole; Cp = capillary; V = vein; VI = venule. Superscript L and R refer to left and right, respectively. The thickness of the arrows indicates volume of flow and the relative size of the boxes indicate degree of wall displacement relative to the normal size.

  • View in gallery

    Computer simulation showing the pressure across the ventricle and brain parenchyma. The normal case (Frame A) shows a higher average brain pressure (solid line), which indicates flow from the brain to the ventricles. Frame B shows higher ventricular pressure (dashed line) due to hydrocephalus, which indicates flow reversal. Frame C shows the effect of fluid removal from the right ventricle and the reversal of pressure to normal.

  • View in gallery

    Computer simulation of CSF net flow in the normal and hydrocephalic brain. Net flow is from the parenchyma to the ventricles in the normal case (left); net flow is from the ventricles to the brain parenchyma in the hydrocephalic case (right).



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