Visualizing CSF Outflow with MRI

Review written by: James Demetrious, DC, DABCO

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In a recent article published in the journal Magnetic Resonance in Medicine, Stanford researchers introduced a novel 3D aMRI post-processing and image visualization approach that enables one to visualize amplified cardiac- and CSF-induced brain motion:


Authors Terem et al. reported, “The physiological and biomechanical response of the human brain in vivo is thought to be altered in various neurological disorders, such as hydrocephalus, Chiari I malformation, idiopathic intracranial hypertension, and age-related diseases in small cerebral vessels. Thus, the ability to observe the manifestation of these disorders in the form of altered brain motion is thought to be of great interest.”


As visualized on the NIH website, Terem’s amplified video offers unique visual cues of intracranial CSF flow and craniocervical outflow (

When one considers the pathophysiology associated with increased intracranial pressure of normal pressure hydrocephalus (NPH), plausible considerations present themselves:


  1. With each cardiac ejection fraction, we generate CSF that circulates through and about the brain providing nutrition, conveyance, and waste elimination.
  2. CSF regulatory waste efflux is contingent upon properly functioning arachnoid granulations, peri-venous, peri-arterial glymphatic pathways and cranio-cervical outflow.
  3. Impaired efflux pathways for brain waste clearance affecting the glymphatic system and obstructed cranio-cervical outflow due to spinal stenosis could plausibly elevate intracranial pressure.
  4. Monroe-Kellie doctrine describes the critical balance between blood, CSF and brain parenchyma.
  5. Kaur et al. report that waste accumulation may lead to various neurological diseases including beta-amyloid and tau protein accumulation in Alzheimer’s disease, alpha-synuclein protein accumulation in Parkinson’s disease, and huntingtin accumulation in Huntington’s disease.
  6. Intracranial hypertension can produce a cascade of neurodegenerative failure via parenchymal apoptosis and progressively increasing intracranial pressures that occurs over decades.

Substantial research is being conducted currently related to each of these considerations. To further our understanding of these phenomena, researchers need to focus on cranio-cervical CSF outflow, systemic reflux pathways and therapeutic applications to alleviate intracranial pressure.

Chiropractic Takeaway…

Obstruction of cranio-cervical outflow may be an important precursor to CNS neurodegneration.  I suspect that empiric mobilization through spinal manipulation, traction, and exercise may improve CSF outflow and reduce intracranial pressure. This may explain the anecdotal relief following chiropractic care of cervicogenic complaints. Improved CSF outflow may benefit those patients with spinal canal intrusions due to stenosis, disc herniations, spondylitic changes, ligamentum flavum infolding, etc.

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