Paul T Akins1, Kern H Guppy2. 1. Department of Neurosurgery, The Permanente Medical Group, Kaiser Sacramento Medical Center, Sacramento, California, USA. Electronic address: paul.t.akins@kp.org. 2. Department of Neurosurgery, The Permanente Medical Group, Kaiser Sacramento Medical Center, Sacramento, California, USA.
Abstract
BACKGROUND: Poorly understood cranial fluid accumulations are frequently observed after decompressive craniectomy and often termed "external hydrocephalus." These findings are difficult to explain using traditional models of hydrocephalus. METHODS: Representative cases, clinical management, and literature overview are presented. RESULTS: We present a hypothesis that abnormal cranial fluid accumulations develop after decompressive craniectomy in a vulnerable subset of patients as a result of 1) the large compliant cranial defect with durotomy causing reduced internal brain expansion, ventricular squeezing, and pulsatile cerebrospinal fluid (CSF) circulation; 2) impaired pulsatile CSF flow along major cerebral arteries and the adjoining perivascular spaces (Virchow-Robin spaces); 3) reduced clearance of interstitial fluid by the glymphatic system; and 4) redistribution of CSF from the subarachnoid space into the subdural and subgaleal compartments and the ventricles. CONCLUSION: Closure of the cranial defect with cranioplasty improves cerebral blood flow and CSF pulsatile circulation and is frequently sufficient to resolve the external hydrocephalus.
BACKGROUND: Poorly understood cranial fluid accumulations are frequently observed after decompressive craniectomy and often termed "external hydrocephalus." These findings are difficult to explain using traditional models of hydrocephalus. METHODS: Representative cases, clinical management, and literature overview are presented. RESULTS: We present a hypothesis that abnormal cranial fluid accumulations develop after decompressive craniectomy in a vulnerable subset of patients as a result of 1) the large compliant cranial defect with durotomy causing reduced internal brain expansion, ventricular squeezing, and pulsatile cerebrospinal fluid (CSF) circulation; 2) impaired pulsatile CSF flow along major cerebral arteries and the adjoining perivascular spaces (Virchow-Robin spaces); 3) reduced clearance of interstitial fluid by the glymphatic system; and 4) redistribution of CSF from the subarachnoid space into the subdural and subgaleal compartments and the ventricles. CONCLUSION: Closure of the cranial defect with cranioplasty improves cerebral blood flow and CSF pulsatile circulation and is frequently sufficient to resolve the external hydrocephalus.
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