International Journal of Crashworthiness

ISSN: 1358-8265 (Print) 1754-2111 (Online) Journal homepage: https://www.tandfonline.com/loi/tcrs20

Coup-contrecoup brain injury: fluid–structure

interaction simulations

Milan Toma & Paul D. H. Nguyen

To cite this article: Milan Toma & Paul D. H. Nguyen (2019): Coup-contrecoup brain
injury: fluid–structure interaction simulations, International Journal of Crashworthiness, DOI:
10.1080/13588265.2018.1550910

To link to this article: https://doi.org/10.1080/13588265.2018.1550910

Published online: 01 Mar 2019.

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INTERNATIONAL JOURNAL OF CRASHWORTHINESS
https://doi.org/10.1080/13588265.2018.1550910

Coup-contrecoup brain injury: fluid–structure interaction simulations

Milan Tomaa and Paul D. H. Nguyenb
a
Department of Mechanical Engineering, College of Engineering & Computing Sciences, New York Institute of Technology, New York, NY,
USA; bPenn State College of Medicine, Hershey, PA, USA

ABSTRACT ARTICLE HISTORY

The brain can be severely injured even without the skull being fractured by the impact to the head. Received 24 May 2018
For example, when the head is stationary and struck by a moving object the brain shifts inside the Revised 2 November 2018
skull which results in injuries at point of impact and opposite the side of impact, i.e. coup and contre- Accepted 12 November 2018
coup injuries, respectively. This article presents the results of three-dimensional computational fluid–
KEYWORDS
structure interaction simulations of a frontal impact to the head using a comprehensive finite-element Coup; contrecoup; brain;
model of the head. The cerebrospinal fluid flow inside the head surrounding the brain is modelled injury; cerebrospinal
using smoothed-particle hydrodynamics. For the first time, the cerebrospinal fluid is modelled using a fluid; trauma
fluid domain. The numerical method is validated against known cadaveric experiments by comparing
the coup and contrecoup pressure responses. The results of the fluid–structure interaction analysis are
compared with those from structural only analysis. It is demonstrated that the impact to the frontal
lobe has the potential to cause injuries on both sides of the brain and brain stem. Additional high
stress values are also found on the parietal lobe. The use of fluid-structure interaction analysis provides
additional information and is more realistic.

1. Introduction as the brain rebounds, see Figure 1. Most common causes

In 1981, Goldsmith’s letter to the editor states, ‘The state of
knowledge concerning trauma of the human head is so
scant that the community cannot agree on new and
improved criteria even though it is generally admitted that
present designations are not satisfactory’ [1]. Even decades
later, this assessment can still be considered reasonable to a
degree. In automobile, personal protective gear, and sport
equipment safety, the head injury criterion (HIC) is a meas-
ure of the likelihood of head injury arising from an impact.
The HIC is derived from the measurements of an acceler-
ometer at the centre of gravity of a crash test dummy’s
head, when the dummy is exposed to crash forces.
According to the insurance institute for highway safety, an
HIC value of 700 is the maximum allowed under the provi-
sions of the U.S. advanced airbag regulation [2], it repre-
sents a 5% risk of a severe injury [3]. Generally, experts
agree that HIC values above 1000 are life threatening. This
still commonly used criterion is based only on the measure-
ments from the accelerometer and does not provide any-
thing beyond a percentage to assess the risk of injury. More
advanced models and numerical methods can provide the
insight into the mechanism of closed head injury and allow
us to study the method by which trauma to the brain hap-
pens inside the skull when exposed to loading conditions.
Coup-contrecoup injury is dual impacting of the brain
into the skull; coup injury occurs at the point of impact;
countercoup injury occurs on the opposite side of impact,
of coup-contrecoup brain injury include circumstances
when the head jerks violently during motor vehicle acci-
dents or in sports where baseball players are colliding dur-
ing the chase for a ball, football players tackling, boxers
punching, but any sport that puts the head at risk of suffer-
ing a blow could cause this type of brain injury.
The brain can be structurally divided into the cerebrum,
cerebellum, and brain–stem. The cerebrum is divided into
two roughly equal hemispheres connected by the corpus cal-
losum and a shared ventricular system. The brainstem is
further divided into the midbrain, pons and medulla oblon-
gata. Cerebrospinal fluid (CSF) fills a system of cavities at
the center of the brain, known as ventricles, and the sub-
arachnoid space surrounding the brain and spinal cord
(Figure 2). The CSF cushions the brain within the skull and
serves as a shock absorber for the central nervous
system [4].
The three published constitutive models representing
CSF behaviour are the solid-like, viscoelastic, and fluid-like
CSF. However, they all are solid material models with differ-
ent material properties. The solid-like constitutive model
represents CSF as a linear, nearly incompressible elastic
solid with a bulk modulus much larger than the shear
modulus [5, 6]. The viscoelastic CSF constitutive model is a
linear viscoelastic model with shear relaxation behaviour [7,
8]. The fluid-like CSF is modelled using elastic solid mater-
ial with fluid-like constitutive behaviour using an equation
of state constitutive model [9].

CONTACT Milan Toma tomamil@tomamil.eu

ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 M. TOMA AND P. NGUYEN
Figure 1. Coup-contrecoup injuries, brain shifts inside the skull resulting in injuries at point of impact and away from point of impact, e.g. forehead injury can
result in additional injury to occipital area.
Figure 2. The schematic of the cerebrospinal fluid in which the brain is submerged. The 3D computational model used is designed based on this schematic.
While the significance of including CSF in the numerical
simulations has been shown [10], the current finite element
studies reported in the literature often lack more detailed
anatomical structures [7, 11–14]. The brain has a more
complex structure than what has been described in prior
models. For example, CSF is commonly presented as exist-
ing only outside of the brain, i.e. between the skull and a
single, solid mass representing the brain. Moreover, none of
the existing models simulates the interaction between the
CSF with actual fluid material properties and brain/skull,
even the newest models still use a simple (n ¼ 1) hyperelas-
tic material for the CSF [15]. The model used in this study
is the first fluid–structure interaction (FSI) model that uses
fluid material properties to represent the CSF and includes
all major anatomical features of the brain [16]. A detailed
analysis of the CSF cushioning mechanism is useful for the
treatment and prevention of brain injuries.
2. Methods
2.1. Head model
The five distinct anatomical structures used in this model
are shown in Figure 3. The skull, cerebrum, cerebellum,
pituitary gland and brainstem each have unique material
properties. The patient-specific model is based on the
Digital Imaging and Communications in Medicine
(DICOM) images acquired from an online database.
Anatomical features missing in this model include the skin,
spinal cord, meninges and the arachnoid granulation, Figure
2. When compared to the very short impact impulse time
history used in these simulations, the CSF ow in the head
can be neglected, too. The CSF flow is relatively slow,
0.05–0.08 m s1, i.e. during the impact impulse time history
the CSF flows by 0.2–0.3 mm. These assumptions also make
the presence of the granulations negligible.
The skull part is assigned rigid material properties with
density 1900 kg m3 [17]. Data from studies characterizing
the macroscopic physical characteristics of the brain show
that it is a viscoelastic material [18]. The cerebrum, cerebel-
lum, pituitary gland and brainstem are simulated using a
non-linear elastic constitutive material model with varying
material properties based from the literature [19–23]. The
cerebrum, cerebellum, brainstem, and pituitary gland are
each composed of a different number of tetrahedral ele-
ments; 96385, 40808, 18634, 310, respectively. The CSF was
modelled using the smoothed-particle hydrodynamics (SPH)
method with the bulk modulus of 21.9 GPa [7] and density

Figure 3. The depiction of the entire head model with skull, cerebrum, cerebellum, pituitary gland and brainstem, respectively. The subarachnoid space and other
cavities are filled with fluid particles (blue dots surrounding the brain model, in the lower right corner). The entire model with half the skull is also shown
(lower left).
Figure 4. Impact impulse time history used to simulate the cadaveric experi-
ments in [27] and applied to the skull in the current model.
1000 kg m3 [24]. The number of fluid particles filling the
subarachnoid space between the skull and brain, and other
cavities, is 94,690.
INTERNATIONAL JOURNAL OF CRASHWORTHINESS 3
2.2. Loading conditions
Based on whether the head is stationary and struck by a
moving object, or is moving and strikes a stationary object,
the type of brain injury differs, according to [25]. The sta-
tionary head is usually hit by objects which are of similar
mass to the head. In this study, the scenario in Figure 1 is
used and it is assumed that the impacting object does not
penetrate the skull. Thus, local deformation of the skull in
the frontal area is not resulting in direct contact injury to
the underlying brain tissue. It has been estimated that for a
contact area of approximately 6.5 cm2 the force required to
produce a clinically significant skull fracture in the frontal
area of the cadaver skull is twice that required in the tem-
poroparietal area [26].
Corresponding loading conditions from cadaveric experi-
ments in [27] are used to perform the computational ana-
lysis of a frontal impact. The experiments examined the
blow to the head of a seated human cadaver. The impact
pulse history applied to the skull of the computational
model is shown in Figure 4.
4 M. TOMA AND P. NGUYEN
Figure 5. Coup (a) and contrecoup (b) pressure responses in cerebrospinal fluid compared to the experimental results of Nahum et al. [27].
2.3. Computer simulations
Fluid motion and boundary interaction calculations were
solved with the IMPE-TUS Afea SPH SolverV (IMPETUS
R
Afea AS, Norway), while large deformations in the solid
parts were simultaneously solved with the IMPETUS Afea
SolverV. Both the solvers use a commodity GPU for parallel
R
processing. All solid elements were fully integrated, remov-
ing the possibility of hourglass modes and element inversion
that plagues the classic under-integrated elements. Both
fluid and solid domains and their interaction were solved
with an explicit integration scheme. All simulations were
solved on a standard workstation. Parallel acceleration was
achieved with a Tesla K40 GPU with 12 GB of Graphic
DDR memory and 2880 CUDA Cores. To confirm that con-
vergence was reached, h-refinement of the finite element
mesh was performed, and the solution was found to yield
same results. Similarly, smaller number of fluid particles was
used to obtain results within 5% of the values obtained with
the higher number of particles. The above stated number of
particles, 94,690, is high considering that the volume of the
cavities and subarachnoid space is much smaller than rest of
the model. This confirmed that the results are converged.
Our prior publication describes the SPH equations in
greater detail [28]. The SPH method is chosen for this study
because traditional FSI techniques can be computationally
expensive and challenging regarding their parallelization
[29]. In order to use traditional FSI techniques, geometrical
simplifications would need to occur, and the anatomical
accuracy would have to be sacrificed. Moreover, in recent
years the SPH has been increasingly used in biomedical
applications [30].
3. Results
In the results section, the validation is shown compared
with the experimental results. Also, stress values are shown
as a response to the loading conditions. And, lastly, the FSI
analysis is compared with the structural analysis where, as
in other models from the literature, the CSF is modelled
using solid finite elements.
3.1. Validation
The loading conditions from cadaveric experiments (Figure
4) applied to the frontal lobe yield corresponding coup and
contrecoup pressure responses in CSF, see Figure 5 where
both experimental [27] and computational results are shown
for comparison.
3.2. Principal stress
The stress values on the cerebrum resulting from the frontal
impact are shown in Figure 6. The stress maxima can be
found also on the occipital lobe which supports the experi-
mental observations that forehead injury can result in add-
itional injury to occipital area. Similar conclusion, i.e.
stresses and strains seen in both frontal and occipital lobes,
is also found in other more simplified computational stud-
ies [12].
Similar results, i.e. high stress values on both anterior
and posterior sides, can be seen on the brain stem alone as
well (Figure 7). Additionally, some areas with maximum
stress values are found also on the parietal lobe (Figure 8).
Moreover, here it is possible to make an additional observa-
tion that they only occur on the posterior aspects of
the gyri.
The ventricles are structures that produce CSF, and
transport it around the cranial cavity. Large CSF pressure in
ventricles can lead to a disease called hydrocephalus which
is the buildup of CSF in the ventricles. Inside each ventricle
is a network of small blood vessels that continually produce
CSF by extracting the basic ingredients from the

Figure 6. High values of the second deviatoric principal stress are observed in both the frontal and occipital lobes of the brain, i.e. forehead injury can result in
additional injury to occipital area.
Figure 7. High values of the second deviatoric principal stress are observed on both sides of the brain stem.
Figure 8. High values of the second deviatoric principal stress are observed
also in the parietal lobe. However, in the parietal lobe the areas with high val-
ues are observed only in the posterior aspects of the gyri (schematic and
dashed ellipsoid).
cardiovascular system. The response of lateral ventricle to
head trauma is shown in Figure 9.
3.3. Structural analysis
When the CSF fluid domain is replaced by solid finite ele-
ments, as it is common with the current head models from
the literature, the locations of the principal stress maximum
INTERNATIONAL JOURNAL OF CRASHWORTHINESS 5
and minimum values are more localized, as shown in
Figure 10.
4. Discussion
The different layers of the brain move at different times
because each layer has a different density. Simplified com-
putational models are not able to incorporate this important
aspect. Moreover, interaction between CSF and brain gyri
and sulci cannot be analysed computationally if the methods
used do not model the CSF as fluid. The model used in this
study uses a comprehensive head/brain model with detailed
representation of all the parts and the computational ana-
lysis used is an FSI method with fluid properties for the
CSF. The validation of this model and the computational
method is shown comparing the coup and contrecoup pres-
sure responses in CSF with the experimental results from
cadaveric experiments.
In Figure 5, where coup and contrecoup pressure
responses in CSF compared to the experimental results of
Nahum et al. [27] are shown, it can be observed that the
agreement with the experimental results is better in the
coup response as opposed to that in the contrecoup
6 M. TOMA AND P. NGUYEN
Figure 9. High values of the second deviatoric principal stress observed in the lateral ventricle during the contrecoup response.
Figure 10. The second deviatoric principal stress obtained using (a) FSI analysis and (b) structural analysis.
response. The contrecoup pressure response reaches slightly
higher values compared to the experimental data because
the contrecoup response is secondary and therefore more
dependent on the patient-specific geometry used. However,
both coup and contrecoup computational pressure responses
can be considered of good agreement with the experimental
measurements.
As discussed, if the interaction of CSF with the brain is
to be analysed the CSF has to be modeled with fluid ele-
ments or particles and not just with fluid-like solid ele-
ments. The results then have potential to show more
complex responses to the loading conditions. For example,
Figure 6 shows that the contrecoup stress response is preva-
lent mostly in the inner areas of the two hemispheres close
to the edges where longitudinal fissure separates the two
halves of the brain. The brain model is comprehensive con-
taining multiple parts each with detailed realistic patient-
specific geometry. The complexity of the model enables the
analysis of the brain down to the exact gyrus and sulcus. In
Figure 8, additional areas of high stress values can be found
outside the frontal and occipital lobes. However, interest-
ingly, only the posterior aspect of the gyrus seems to be
affected. This can be explained by following the wave in the
CSF that occurs after the impact to the frontal lobe. During
the acceleration phase when the brain wants to move
backwards relative to the skull the fluid particles move to
concentrate in the space between the skull and occipital lobe
to provide the cushioning effect and prevent the brain from
impacting to the skull. At that point the moving particles
affect mostly the anterior sides of the gyri. When the brain
rebounds and wants to move forward relative to the skull the
fluid particles move to the space between the skull and
frontal lobe to provide the cushioning effect there. At that
point the moving particles affect mostly the posterior side of
the gyri. Other parts of the brain, such as the brain stem, are
equally affected by the coup-contrecoup injury. In Figure 7,
similar results, i.e. high stress values on both anterior and
posterior sides of the brain stem, can be seen. Hence, it can
be concluded that the impact to the frontal lobe has the
potential to cause injuries on both sides of the brain stem.
The vasculature, spinal cord and meninges are omitted to
make the simulations less computationally expensive but
may be considered in future studies. A major uncertainty in
the current study is the omission of cerebral vasculature
[31], and it is to be integrated in the next stage. Similarly,
the displacement of CSF into the spinal subarachnoid space
is to be included. The final goal is to simulate a closed
model of the entire CSF space [32].
As mentioned above, the current head models assume
that the CSF is hyperelastic solid material to simplify the

calculation. In this study, for the first time, the CSF is mod-
elled as an actual fluid, using SPH. For comparison, the
fluid domain has been replaced by solid elements to observe
the difference between these two approaches.
The comparison is shown in Figure 10. Much more local-
ized high values of principal stress can be seen in the struc-
tural analysis. Solid elements, although hyperelastic, cannot
travel back and forth to provide the cushioning effect. They
provide the cushioning effect by sitting there between the
skull and brain. The effect of CSF flow/movement cannot be
analysed using solid material for CSF.
The ventricles, i.e. structures where CSF is produced, are
shown to be affected as well, primarily in the anterior horn
of the lateral ventricle. When an injury (or illness) alters the
circulation of CSF, one or more of the ventricles can
become enlarged yielding excess accumulation of CSF. A
condition in which excess CSF builds up within the ven-
tricles is called Hydrocephalus. Since the skull is rigid and
cannot expand, the pressure in the brain increases. A treat-
ment can be performed by implanting a shunt to divert the
excess CSF away from the brain. The future use of this
model is to be focused on assessing this procedure. This
procedure cannot be studied by structural models that omit
the CSF or model it with solid elements.
Other intended use of this FSI model is in assessing the
efficacy of head protective equipments. Running these simu-
lations with multiple competing designs of helmets and
comparing the interactions between CSF and brain struc-
tures can yield useful insight into which of the designs is
the best to protect the brain and all its structures. While
other existing models can be used for this very purpose,
only FSI model can provide the information on the inter-
action between the brain structures and CSF.
5. Conclusion
This validated model, where an FSI method is used to ana-
lyse the interaction between CSF and brain, is a step closer
to understanding the mechanisms of brain injuries. Closer
collaboration with concussion experts is necessary to find
the relationship between the computational results here pre-
sented and symptoms typical for this kind of head impact.
Concussions are typically diagnosed symptomatically.
Patients may exhibit a range of symptoms, such as head-
ache, photophobia, tinnitus, dizziness, sleepiness, confusion
and behavioural changes. Different area of brain affected
would potentially result in different set of symptoms. The
model and method presented in this study can predict the
areas affected based on the loading conditions. Therefore,
the symptoms can be predicted, too. Since the signs and
symptoms of a concussion can be subtle and may not show
up immediately, a numerical analysis of this kind could
serve as a predictor for the physicians and patients who
then could be warned about what symptoms they are to
expect and be ready for. Hence, if used in practice, it has
the potential to contribute to early diagnosis that is import-
ant in treatment of concussion.
INTERNATIONAL JOURNAL OF CRASHWORTHINESS 7
Funding
This study has been partially supported by New York
Thoroughbred Horsemen’s Association. No benefits in any
form have been or will be received from a commercial party
related directly or indirectly to the subject of this manuscript.
Disclosure statement
The authors declare that they have no conflict of interest.
Ethical approval
This article does not contain any studies with human participants or
animals performed by any of the authors.
Data availability statement
The datasets generated during and/or analyzed during the current study
are available from the corresponding author on reasonable request.
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