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Pathogenesis of Obstructive Hydrocephalus
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There are several sites of predilection of obstruction to the ow of CSF One foramen of Monro may be blocked by a tumor or by horizontal displacement of central brain structures by a large unilateral mass This causes expansion of one lateral ventricle or a portion of it Large tumors of the third ventricle (eg, colloid cyst) may block both foramina of Monro, leading to dilation of both lateral ventricles The aqueduct of Sylvius, normally narrow to begin with, may be occluded by a number of developmental or acquired lesions with periaqueductal gliosis (genetically determined atresia or forking, ependymitis, hemorrhage, tumor), and lead to
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dilation of the third and both lateral ventricles In the hereditary cases reported by Bickers and Adams, the transmission was in three generations of males If the obstruction was in the fourth ventricle, the dilation included the aqueduct Other sites of obstruction of the CSF in the ventricular pathways are at the foramina of Luschka and Magendie (eg, congenital failure of opening of the foramina Dandy-Walker syndrome) More common is a blockage to ow of CSF in the subarachnoid space around the brainstem due to in ammatory or hemorrhagic brosing meningitis The latter forms of obstruction result in enlargement of the entire ventricular system, including the fourth ventricle A still useful adage, attributed to Ayer, is that the ventricle closest to the obstruction enlarges the most; meaning, for example, that occlusion of the basal CSF pathways causes a disproportionate enlargement of the fourth ventricle, and a mass within the fourth ventricle leads to a greater dilatation of the third than of the lateral ventricles Another potential obstruction site is in the subarachnoid spaces over the cerebral convexities A matter of considerable practical as well as theoretical interest is whether a meningeal obstruction over the convexities of the cerebral hemispheres, at the site of the arachnoidal villi, or a blockage of the venous sinuses into which the CSF is absorbed, can result in hydrocephalus Russell, in her extensive neuropathologic material and her review of the world s literature, could not nd a single well-documented example of either of these suggested etiologies, and the same is true of the pathologic material collected by our colleague RD Adams Moreover, experiments in animals in which all the draining veins had been occluded, a tension hydrocephalus with enlarging lateral ventricles was produced in only a few cases Yet Gilles and Davidson have stated that tension hydrocephalus in children may be due to a congenital absence or de cient number of arachnoidal villi, and Rosman and Shands have reported an instance that they attributed to increased intracranial venous pressure Our hesitation in accepting such examples stems from the dif culty that the pathologist has in judging the patency of the basilar subarachnoid space This is much more reliably visualized by radiologic than by neuropathologic means Theoretically, as mentioned earlier, if the obstruction is high, near (or in) the superior sagittal sinus, the CSF should accumulate under pressure outside as well as inside the brain, and the ventricles should not enlarge at all or only slightly, and only after a prolonged period The rarely encountered radiologic picture of enlarged subarachnoid spaces over and between the cerebral hemispheres coupled with modest enlargement of the lateral ventricles has been referred to as an external hydrocephalus Although such a condition does exist, many of the cases so designated have proved to be examples of sporadic or familial subdural hygromas or arachnoid cysts Processes such as subarachnoid hemorrhage and cerebral hemorrhage or brain abscess that rupture into the ventricles and rapidly expand the volume of CSF produce the most dramatic forms of acute hydrocephalus The obstruction of the CSF pathways will usually be found within the ventricular system or at the basal meninges The corresponding clinical syndrome of acute hydrocephalus is described below An increase in the rate of formation or decrease in the rate of absorption would be expected to cause an accumulation of CSF and increased ICP The only reported examples of overproduction of CSF are papillomas of the choroid plexus, but even in this circumstance there is usually an associated ventricular obstruction, either of the third or fourth ventricle or of one lateral ventricle
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