Cerebrospinal Fluid and Intracranial Pressure

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Barnett R. Nathan History

Cerebrospinal Fluid and the Ventricular System

Anatomy Physiology

Normal and Pathological Findings Intracranial Pressure

Basic Principles ICP Monitoring

Treatment of Increased Intracranial Pressure Reviews and Selected Updates References


The cerebrospinal fluid (CSF) has served as an aid to the diagnosis and treatment of a variety of central nervous system (CNS) disorders for more than 100 years. In 1891, Quinke first developed the technique of spinal puncture and introduced it into clinical practice. [i] He was the first to use a needle with a stylet, to measure opening and closing pressures, and to pioneer the measurement of CSF glucose, protein, and cell counts. Much of the CSF literature in the early part of the 20th century dealt with changes related to bacterial meningitis and neurosyphilis. y

The notion that elevated intracranial pressure (ICP) can occur began in 1783 when Alexander Monroe posited that the skull is a closed container and its contents are nearly incomprehensible. These concepts were expanded in 1824 by George Kellie, who proposed that the volume of the blood within the brain was constant. In 1846, Burrows suggested that the volume of blood within the brain could only change in a reciprocal manner with the CSF and brain parenchyma. This concept formed the foundation of the Monroe-Kellie hypothesis, and modern theories of pressure-volume relationships still refer to this hypothesis. Early anatomists hypothesized that the choroid plexus was the source of CSF because of its location within the ventricles. This hypothesis was substantiated by Dandy and Blackfan y and then by Harvey Cushing,[4 who observed oozing of fluid from the choroid plexus during neurosurgery. Later, Ames provided definitive proof that the majority of intraventricular CSF was produced by the choroid plexus. [5] , [6


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