Hydrocephalus: is impaired cerebrospinal fluid circulation only one problem involved?

Hydrocephalus is a complex disease of the brain as a whole, and imbalance between cerebrospinal fluid (CSF) formation and absorption is not the sole mechanism involved in its pathophysiology. In the absence of a lymphatic system in the central nervous system, open communication between CSF and interstitial fluid (ISF) of the brain may contribute to maintaining homeostasis of the brain, keeping the microchemical environment in good balance. Membranes or cell layers separating CSF from ISF of the brain do not provide impermeability, so the CSF communicates with ISF across the ependymal layer and the pial surface of the brain. In contradiction of the classical theory, the CSF one may obtain at the cisterna magna, for instance, is different from the newly formed CSF out of the choroid plexus, because it has been modified by the free communication between CSF and ISF spaces as the CSF descends along the neural axis. Free flow of water and some smaller molecules provides a bidirectional movement of water and other materials, and this must play an important role in brain volume control. The significance of this role should not be overlooked in regard to the pathophysiology of hydrocephalus.