Subarachnoid space

Water-soluble contrast media (CM) are preferred because of effective mixing with CSF, plus the radiopaque is absorbed and effectively excreted in the urine, and does not have to be physically removed from the subarachnoid space after the procedure. Sodium methiodal, the first water-soluble agent used for myelography, produced neurotoxicity problems when exposed to the cells of the spinal cord and brain, thus limiting utility to the lumbar region and requiring the appHcation of spinal or general anesthesia. 

Spinal anesthesia is a type of regional anesthesia that involves the injection of a local anesthetic drug into the subarachnoid space of die spinal cord, usually at the level of the second lumbar vertebra There is a loss of feeling (anesdiesia) and movement in the lower extremities, lower abdomen, and perineum. 

The CSF flows through the ventricles, downward through the central canal of the spinal cord, and then upward toward the brain through the subarachnoid space that completely surrounds the brain and spinal cord. As the CSF flows over the superior surface of the brain, it leaves the subarachnoid space and is absorbed into the venous system. Although CSF is actively secreted at a rate of 500 ml/day, the volume of this fluid in the system is approximately 140 ml. Therefore, the entire volume of CSF is turned over three to four times per day. 

There is also support for a role of PGD2 in sleep control and homeostasis (Hayaishi, 2002). PGD2 is synthesized in the subarachnoid space ventral to the POA. Administration of PGD2 in the subarachnoid space induces normal sleep, and inhibition of synthesis or receptors suppresses sleep. Sleep rebound after deprivation is reduced in mice in which the synthetic enzyme is knocked out. Administration of PGD2 to the subarachnoid space also induces c-Fos in the VLPO as well as dorsal POA neurons (Scammel et a ., 1998). The hypnogenic actions of PGD2 seem to be mediated by an adenosine A2a pathway (Satoh et al, 1966). 

Infusion of prostaglandin D2 (200 pmol/min) or the adenosine A2a receptor agonist CGS21680 (20 pmol/min) for 2 h into the subarachnoid space under the BF, during the dark period, increased NREM sleep and reduced c-Fos protein in the TMN of rats when compared with saline-treated controls (Scammell et al., 1998, 2001). In contrast, infusion of the adenosine Ai receptor agonist N6-cyclopentyl-adenosine (2 pmol/min) in the same area did not have any effect on sleep-wakefulness or c-fos expression in the TMN. 

Intrathecal (IT) Into the subarachnoid space between two of the membranes (meninges) separating the spinal cord from the vertebral column. This route is used for drugs that do not penetrate the blood-brain barrier, but which are required for their central action (e.g., antibiotics). Drugs can also be injected spinally (into the epidural space) for local anaesthesia or analgesia. 

The entire CNS is covered by the meninges, which form a protective covering. The outermost is the dura, which is tough and leathery in consistency. It is highly vascularized and innervated, so it is sensitive to pain. The arachnoid membrane is a weblike, spongy layer beneath the dura. Beneath the arachnoid is the subarachnoid space, which is filled with cerebrospinal fluid. Beneath the subarachnoid space is a thin layer of cells called the pia, which covers the brain and spinal cord. Ventricular System... 

Cerebrospinal fluid is produced in chambers within the brain called ventricles. Two lateral ventricles and a midline third ventricle are contained within the cerebrum, while the fourth ventricle exists within the brain stem. CSF is produced by the choroid plexus in the lateral and third ventricles. It flows out through the ventricles by a series of aqueducts and into subarachnoid space. CSF supports the brain and spinal cord, ab-... 

CSF Alls the intracerebral (intraventricular 20%) and extracerebral (subarachnoidal 80%) space. CSF originates from plasma (ultraflltration) as well as from choroid plexus (active secretion) in the ventricles, flows through cisternae and the subarachnoid space, and finally drains through the arachnoid villi into venous blood. Equilition processes establish a physiological ratio between composition and resorption of CSF. CSF flow starts around the time of birth and reaches its maximum rate at four months after birth, following the complete maturation of the arachnoid villi. 

Fig. 1. Model of subarachnoidal space, CSF flow, and molecular flux (N1). After CSF production in choroid plexus of the ventricles (1,2,3), CSF passes the aperture (4,5), reaches the cistemae (6-9), and divides into a cortical and a lumbar branch of the subarachnoidal space. Finally, CSF drains through the arachnoid villi into venous blood. The illustration represents an idealized cross section through the subarachnoid space. Molecules diffuse from serum with a concentration C(ser) flu ough tissue along the diffusion path x into the subarachnoid space with a concentration C(csF)- Th molecular flux J depends on the local gradient Ac/Ax or dddx and the diffusion constant D. The CSF concentration increases with decreasing volume exchange, i.e., decreasing CSF volume bulk flow (F= 500 ml/day). The flow rate of a molecule in CSF is r= FIA, where A is the varying cross section of the subarachnoid space.

CSF compartment ventricles, basal cisternae, subarachnoid space (CSF flow), and the narrow zone of adjacent extracellular space (diffusion)... 

Blood proteins enter the CSF along its way between the ventricles and lumbar subarachnoid space, inducing a 2.5-fold increase of total protein concentration between ventricular and lumbar CSF. 

A blood-CSF barrier dysfunction (i.e., pathologically reduced CSF flow) can have different causes reduced CSF production rate, restricted flow in the subarachnoid space, or restricted passage through the arachnoid villi (F2, R5). 

The blood-CSF barrier is relatively permeable to hydrophilic macromolecules, (i.e., ai-macroglobulin and IgM). In addition, the passage of smaller molecules, which are larger than 500 Da, is facilitated by lipophilicity (i.e., by antibiotics and cytostatic drugs). The composition of the extracellular fluid of the brain parenchyma is unknown. It resembles CSF only in a narrow margin of a few millimeters adjacent to the free CSF space, a zone where a limited diffusion of water-soluble molecules is possible (F2). The composition of CSF is well known because the subarachnoid space can be tapped at its lowest point. Despite the great distance from the site of production, the choroid plexus, it shows all of the characteristics of a filtrate, even in the lumbar sac. 

The chance of identifying an intraparenchymal metastasis by means of CSF CEA declines with increasing distance from the ventricles. Although intracor-tical metastases communicate with the subarachnoid space of the pallium, the latter is connected only in the basal (temporal) sections with the lumbar sac. The largest portion of the supracortical CSF space (frontoparietal) drains directly to the blood via the Pacchioni granulation. The intact dura is impermeable to proteins (R5). 

J Chn Psychopharmacol 14 358-359, 1994 Rennel ML, Gregory TF, Blaumanis OR, et al Evidence for a paravascular fluid circulation in the mammalian central nervous system, provided by the rapid distribution of tracer protein throughout the brain from subarachnoid space. Brain Res 326 47-63, 1985... 

Local anesthetics have poorly understood effects on inflammation at sites of injury, and these anti-inflammatory effects may contribute to improved pain control in some chronic pain syndromes. At the concentrations used in spinal anesthesia, local anesthetics can inhibit transmission via substance P (neurokinin-1), NMDA, and AMPA receptors in the secondary afferent neurons (Figure 26-1). These effects may contribute to the analgesia achieved by subarachnoid administration. Local anesthetics can also be shown to block a variety of other ion channels, including nicotinic acetylcholine channels in the spinal cord. However, there is no convincing evidence that this mechanism is important in the acute clinical effects of these drugs. High concentrations of local anesthetics in the subarachnoid space can interfere with intra-axonal transport and calcium homeostasis, contributing to potential spinal toxicity. 

AccessMedicine Print Chapter 26. Local Anesthetics Subarachnoid space... 

Schematic diagram of the typical sites of injection of local anesthetics in and around the spinal canal. When local anesthetics are injected extradurally, it is known as epidural (or caudal) blockade. Injections around peripheral nerves are known as perineural blocks (eg, paravertebral block). Finally, injection into the subarachnoid space (ie, cerebrospinal fluid), is known as spinal blockade.

Because of their direct action on the superficial neurons of the spinal cord dorsal horn, opioids can also be used as regional analgesics by administration into the epidural or subarachnoid spaces of the spinal column. A number of studies have demonstrated that long-lasting analgesia with minimal adverse effects can be achieved by epidural administration of... 

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