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Fluids and Barriers of the CNS
Published in: Fluids and Barriers of the CNS 1/2021

Open Access 01-12-2021 | Magnetic Resonance Imaging | Research

Direction and magnitude of cerebrospinal fluid flow vary substantially across central nervous system diseases

Authors: Per Kristian Eide, Lars Magnus Valnes, Erika Kristina Lindstrøm, Kent-Andre Mardal, Geir Ringstad

Published in: Fluids and Barriers of the CNS | Issue 1/2021

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Abstract

Background

Several central nervous system diseases are associated with disturbed cerebrospinal fluid (CSF) flow patterns and have typically been characterized in vivo by phase-contrast magnetic resonance imaging (MRI). This technique is, however, limited by its applicability in space and time. Phase-contrast MRI has yet to be compared directly with CSF tracer enhanced imaging, which can be considered gold standard for assessing long-term CSF flow dynamics within the intracranial compartment.

Methods

Here, we studied patients with various CSF disorders and compared MRI biomarkers of CSF space anatomy and phase-contrast MRI at level of the aqueduct and cranio-cervical junction with dynamic intrathecal contrast-enhanced MRI using the contrast agent gadobutrol as CSF tracer. Tracer enrichment of cerebral ventricles was graded 0–4 by visual assessment. An intracranial pressure (ICP) score was used as surrogate marker of intracranial compliance.

Results

The study included 94 patients and disclosed marked variation of CSF flow measures across disease categories. The grade of supra-aqueductal reflux of tracer varied, with strong reflux (grades 3–4) in half of patients. Ventricular tracer reflux correlated with stroke volume and aqueductal CSF pressure gradient. CSF flow in the cerebral aqueduct was retrograde (from 4th to 3rd ventricle) in one third of patients, with estimated CSF net flow volume about 1.0 L/24 h. In the cranio-cervical junction, net flow was cranially directed in 78% patients, with estimated CSF net flow volume about 4.7 L/24 h.

Conclusions

The present observations provide in vivo quantitative evidence for substantial variation in direction and magnitude of CSF flow, with re-direction of aqueductal flow in communicating hydrocephalus, and significant extra-cranial CSF production. The grading of ventricular reflux of tracer shows promise as a clinical useful method to assess CSF flow pattern disturbances in patients.

Graphic abstract

Appendix
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Metadata
Title
Direction and magnitude of cerebrospinal fluid flow vary substantially across central nervous system diseases
Authors
Per Kristian Eide
Lars Magnus Valnes
Erika Kristina Lindstrøm
Kent-Andre Mardal
Geir Ringstad
Publication date
01-12-2021

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