Background: During the last decade, our understanding of cerebrospinal fluid (CSF) physiology has dramatically improved, thanks to the discoveries of both the glymphatic system and lymphatic vessels lining the dura mater in human brains. Evidence Acquisition: We detail the recent basic science findings in the field of CSF physiology and connect them with our current understanding of the pathophysiology of idiopathic intracranial hypertension (IIH). Results: Transverse sinus (TS) stenoses seem to play a major causative role in the symptoms of IIH, as a result of a decrease in the pressure gradient between the venous system and the subarachnoid space. However, the intracranial pressure can be highly variable among different patients, depending on the efficiency of the lymphatic system to resorb the CSF and on the severity of TS stenoses. It is likely that there is a subclinical form of IIH and that IIH without papilledema is probably under-diagnosed among patients with chronic migraines or isolated tinnitus. Conclusions: IIH can be summarized in the following pathological triad: restriction of the venous CSF outflow pathway—overflow of the lymphatic CSF outflow pathway—congestion of the glymphatic system. To better encompass all the stages of IIH, it is likely that the Dandy criteria need to be updated and that perhaps renaming IIH should be considered. Address correspondence to Stéphanie Lenck, MD, Department of Neuroradiology, Service de Neuroradiologie, Bâtiment Babinski, Groupe Hospitalier Pitié Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, France; Email: stephanie.lenck@orange.fr The authors report no conflicts of interest. © 2020 by North American Neuro-Ophthalmology Society
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