INTRODUCTION: Transependymal movement of cerebrospinal fluid (CSF) is a recognized imaging finding in the setting of hydrocephalus. However it is not well known which ependymal regions display transependymal flow (TEF) and which etiologies of CSF disturbances are associated with TEF. Furthermore, the association of specific TEF patterns with underlying pathology is not known. METHODS: We performed a cross-sectional study of 219 pediatric patients at St. Louis Children’s Hospital between 2008 and 2019 who were found to have TEF on imaging with images available for direct review. TEF pattern, degree, location, underlying pathology and other radiographic and clinical features pertaining to CSF autoregulation and intracranial pressure were noted. RESULTS: Average age of the cohort was 8.2 years and 45.4% were female. TEF was most commonly seen in the setting of an obstructive tumor (70.8%) and rarely in the setting of myelomeningocele (1.8%). TEF was most frequently found in the anterior aspect of the frontal horns and posterior aspect of the occipital horns of the lateral ventricles (typical TEF pattern) and this pattern was seen in 69.4%. TEF less frequently occurred across the ependyma of the third ventricle (37.4%). TEF extension to the splenium of the corpus callosum was more commonly seen in those with medulloblastoma compared to patients with pilocytic astrocytoma (P = .0149). Patients who required temporary, but not ultimately permanent, CSF diversion had a larger degree of TEF, presence of papilledema, a typical TEF pattern, and higher opening pressure. Conversely, patients who ultimately required permanent CSF diversion had a smaller degree of TEF, lack of papilledema, an atypical TEF pattern, and a lower opening pressure. CONCLUSION: TEF is commonly confined to the lateral ventricles (anterior aspect of the frontal horns and posterior aspect of the occipital horns) and is etiology specific. Atypical TEF patterns are associated with need for permanent CSF diversion. Finally, tumor pathology may dictate variations in TEF, suggesting a possible tumor-CSF-ependymal interaction distant from the tumor.