gms | German Medical Science

68th Annual Meeting of the German Society of Neurosurgery (DGNC)
7th Joint Meeting with the British Neurosurgical Society (SBNS)

German Society of Neurosurgery (DGNC)

14 - 17 May 2017, Magdeburg

CSF dynamics during neuroendoscopy of obstructive hydrocephalus: What can we learn from Real Time MRI?

Meeting Abstract

  • Hans-Christoph Ludwig - Schwerpunkt Kinderneurochirurgie, Neurochirurgische Klinik, Universitätsmedizin Göttingen UMG, Göttingen, Deutschland
  • Hans Christoph Bock - Schwerpunkt Kinderneurochirurgie, Neurochirurgische Klinik, Universitätsmedizin Göttingen UMG, Göttingen, Deutschland
  • Steffi Dreha-Kulaczewski - Universitätsmedizin Göttingen , Klinik für Kinder- und Jugendmedizin, Paediatrische Neurologie, Göttingen, Deutschland

Deutsche Gesellschaft für Neurochirurgie. Society of British Neurological Surgeons. 68. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), 7. Joint Meeting mit der Society of British Neurological Surgeons (SBNS). Magdeburg, 14.-17.05.2017. Düsseldorf: German Medical Science GMS Publishing House; 2017. DocMi.08.07

doi: 10.3205/17dgnc417, urn:nbn:de:0183-17dgnc4170

Published: June 9, 2017

© 2017 Ludwig et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at



Objective: Contemporary hydrocephalus concepts are still mainly derived from the work of Dandy (1913) and Key and Retzius (1875). These historical classifications base on few animal experiments in which the production of CSF was demonstrated at about 80 % originating from choroid plexus and absorption in arachnoid villi. Cardiac gated MRI has further supported the idea of bulk flow and dynamical piston like CSF dynamics out of the ventricles towards arachnoid absorption. Even recent publications conclude mixing and diffusion characteristics but no directed flow in cerebral and spinal CSF. These classifications still do not fit the pathophysiological concepts behind several CSF related diseases as normal pressure hydrocephalus, pseudotumor cerebri and Chiari malformation. Even in obstructive hydrocephalus endoscopically gained visualisation of trapping mechanisms does not support the common concepts of craniocaudal directed CSF movements and their disturbances. Recent flow studies applying Real Time-MRI have opened new insights into CSF dynamics identifying respiration dependent CSF movements (Dreha-Kulaczewski et al, 2015) which are in contrast to our current concepts.

Methods: Video analysis (N=88) of intraoperatively documented trapping mechanisms during microsurgery or neuroendoscopy (N=116) and analyzation of flow void signals by pre- and postoperatively obtained MRI (N=108) in different types of pediatric obstructive HC have been conducted to reveal breathing related CSF movement and dynamics. The mechanisms of trapping were investigated for underlying breathing induced flow characteristics.

Results: Trapping mechanisms could be identified in 85 % of MRI and different types of obstructive HC. Intraoperatively documented CSF flow dynamic was in 64 % related to ventilated breathing and moved in an upward direction from spinal canal towards the head.

Conclusion: 85% of MRI in obstructive HC consist of a trapping component of CSF flow in an opposite movement direction from spinal spaces into the ventricles or into cystic compartments. This observation resembles a movement from bottom to top and not vice versa, which is in agreement with recent Real Time MRI measurements. The implication of an upward directed CSF flow may shift our concepts of the underlying pathophysiology of different subtypes of hydrocephalus.