Evidence of connections between cerebrospinal fluid and nasal lymphatic vessels in humans, non-human primates and other mammalian species

Noninvasive delivery of gene targeting probes to live brains for transcription MRI

We aimed to test the feasibility of detecting gliosis in living brains when the blood-brain barrier (BBB) is disrupted. We designed a novel magnetic resonance (MR) probe that contains superparamagnetic iron oxide nanoparticles (SPION, a T2 susceptibility contrast agent) linked to a short DNA sequence complementary to the cerebral mRNA of glial fibrillary acidic protein (GFAP) found in glia and astrocytes. As a control, we also used a sequence complementary to the mRNA of beta-actin. Our objectives are to demonstrate that this new probe, SPION-gfap, could be delivered to the brain when administered by eyedrop solution to the conjunctival sac. We induced BBB leakage by puncture wound, global cerebral ischemia, and cortical spreading depression in C57BL6 mice; 1 day after probe delivery we acquired T2* MR images and R2* (R2* = 1/T2*) maps using a transcription MRI technique in live mice. We found that the SPION-gfap probe reported foci with elevated signal in subtraction R2* maps and that these foci matched areas identified as having extensive glial network (gliosis) in postmortem immunohistochemistry. Similarly, animals administered the control probe exhibited foci of R2* elevation that matched beta-actin-expressing endothelia in the vascular wall. We conclude that our modular MR probe, delivered in an eyedrop solution, effectively reports gliosis associated with acute neurological disorders in living animals. As BBB leakage is often observed in acute neurological disorders, this study also served to validate noninvasive delivery of MR probes to the brains of live animals after acute neurological disorders.

Impact of ageing on lymphatic cerebrospinal fluid absorption in the rat

Several parameters associated with the cerebrospinal fluid (CSF) system show a change in the later stages of life, including elevated CSF outflow resistance. The latter implies a CSF absorption deficit. As a significant portion of CSF absorption occurs into extracranial lymphatic vessels located in the olfactory turbinates, the purpose of this study was to determine whether any age-related impediments to CSF absorption existed at this location. In previous studies, we observed rapid movement of the CSF tracer into the olfactory turbinates in young rats (peaking 30 min after injection), with the concentration of the tracer being much higher in the turbinates than in any other tissue measured. In the study reported here, (125)I-human serum albumin was injected into the lateral ventricles of 3-, 6-, 12- and 19-month-old Fisher 344 rats. The animals were sacrificed at various times after injection of the radioactive tracer, and appropriate tissue samples were extracted. At 30 min post injection, the average tracer values expressed as per cent injected/g tissue were 6.68 +/- 0.42 (n = 9, 3 months), 4.78 +/- 0.67 (n = 9, 6 months), 2.49 +/- 0.31 (n = 9, 12 months) and 2.42 +/- 0.72 (n = 9, 19 months). We conclude that lymphatic CSF transport declines significantly with age. In concert with the known drop in CSF formation, the reduction in lymphatic CSF absorption may contribute to a decrease in CSF turnover in the elderly.

Intranasal selective brain cooling in pigs

BACKGROUND

Special clinical situations where general hypothermia cannot be recommended but can be a useful treatment demand a new approach, selective brain cooling. The purpose of this study was to selectively cool the brain with cold saline circulating in balloon catheters introduced into the nasal cavity in pigs.

MATERIAL AND METHODS

Twelve anaesthetised pigs were subjected to selective cerebral cooling for a period of 6 h. Cerebral temperature was lowered by means of bilaterally introduced nasal balloon catheters perfused with saline cooled by a heat exchanger to 8-10 degrees C. Brain temperature was measured in both cerebral hemispheres. Body temperature was measured in rectum, oesophagus and the right atrium. The pigs were normoventilated and haemodynamic variables were measured continuously. Acid-base and electrolyte status was measured hourly.

RESULTS

Cerebral hypothermia was induced rapidly and within the first 20 min of cooling cerebral temperature was lowered from 38.1+/-0.6 degrees C by a mean of 2.8+/-0.6 to 35.3+/-0.6 degrees C. Cooling was maintained for 6 h and the final brain temperature was 34.7+/-0.9 degrees C. Concomitantly, the body temperature, as reflected by oesophageal temperature was decreased from 38.3+/-0.5 to 36.6+/-0.9 degrees C. No circulatory or metabolic disturbances were noted.

CONCLUSIONS

Inducing selective brain hypothermia with cold saline via nasal balloon catheters can effectively be accomplished in pigs, with no major disturbances in systemic circulation or physiological variables. The temperature gradients between brain and body can be maintained for at least 6 h.

Assessment of cerebrospinal fluid outflow resistance

The brain and the spinal cord are contained in a cavity and are surrounded by cerebrospinal fluid (CSF), which provides physical support for the brain and a cushion against external pressure. Hydrocephalus is a disease, associated with disturbances in the CSF dynamics, which can be surgically treated by inserting a shunt or third ventriculostomy. This review describes the physiological background, modeling and mathematics, and the investigational methods for determining the CSF dynamic properties, with specific focus on the CSF outflow resistance, R out. A model of the cerebrospinal fluid dynamic system, with a pressure-independent R out, a pressure-dependent compliance and a constant formation rate of CSF is widely accepted. Using mathematical expressions calculated from the model, along with active infusion of artificial CSF and observation of corresponding change in ICP allows measurements of CSF dynamics. Distinction between normal pressure hydrocephalus and differential diagnoses, prediction of clinical response to shunting and the possibility of assessment of shunt function in vivo are the three most important applications of infusion studies in clinical practice.

Proteomics of human cerebrospinal fluid - the good, the bad, and the ugly

The development of MALDI ESI in the late 1980s has revolutionized the biological sciences and facilitated the emergence of a new discipline called proteomics. Application of proteomics to human cerebrospinal fluid (CSF) has greatly hastened the advancement of characterizing the CSF proteome as well as revealing novel protein biomarkers that are diagnostic of various neurological diseases. While impressive progressions have been made in this field, it has become increasingly clear that proteomics results generated by various laboratories are highly variable. The underlying issues are vast, including limitations and complications with heterogeneity of patients/testing subjects, experimental design, sample processing, as well as current proteomics technology. Accordingly, this review not only summarizes the current status of characterization of the human CSF proteome and biomarker discovery for major neurodegenerative disorders, i.e., Alzheimer's disease and Parkinson's disease, but also addresses a few essential caveats involved in several steps of CSF proteomics that may contribute to the variable/contradicting results reported by different laboratories. The potential future directions of CSF proteomics are also discussed with this analysis.

Properties of the lymphatic cerebrospinal fluid transport system in the rat: impact of elevated intracranial pressure

Previous studies suggested that a major portion of cerebrospinal fluid (CSF) is absorbed by extracranial lymphatics located in the olfactory turbinates. The objective of this study was to determine the impact of elevated intracranial pressure (ICP) on downstream cervical lymphatic pressures in the rat. Pressures were measured in the deep cervical lymph nodes using a servo-null micropressure system. A catheter was placed in a lateral ventricle and fluid was infused from a reservoir at defined ICPs. When Ringer's solution was infused, elevations of ICP from 10 to 50 cm H2O resulted on average in a reduction of diastolic cervical node pressures. In contrast, when a diluted plasma solution (80% plasma in Ringer's) was infused, downstream diastolic lymphatic pressures increased as ICP was elevated to 50 cm H2O. These data are consistent with the view that much of the CSF-derived water that convects into the lymphatics is absorbed into the ethmoidal or nodal blood vessels. This study supports the concept of fluid continuity between the subarachnoid space and extracranial lymphatics and suggests that this loss of CSF-derived water may act as a safety mechanism to reduce the volume load to the downstream lymphatic vessels.

A ferritin tracer study of compensatory spinal CSF outflow pathways in kaolin-induced hydrocephalus

Spinal drainage of cerebrospinal fluid (CSF) into the lymphatic system is important in physiological and pathological conditions in both humans and rodents. However, in hydrocephalus and syringomyelia the exact CSF pathway from the central canal into the lymphatic tissue around the spinal nerves remains obscure. We therefore induced syringomyelia and hydrocephalus in 36 Lewis rats by injection of 0.1 ml kaolin into the cisterna magna. At 2, 4 and 6 weeks later cationized ferritin was stereotactically infused into the cisterna magna of controls and into the lateral ventricles of hydrocephalic animals followed by dissection of brain, spinal cord and spinal nerves. CSF pathway and tracer flow were studied by light and electron microscopy. We found that in rats with kaolin-induced CSF outflow obstruction, CSF passes from central canal syringes through ruptured ependyma and dorsal columns into the spinal subarachnoid space, from where it is absorbed along spinal nerves into extradural lymphatic vessels. Taken into account that spinal hydrostatic pressure in humans differs significantly from pressure in animals due to the upright gait, we conclude that spinal compensatory CSF outflow pathways might be of even greater importance in human hydrocephalus.

Possible role of the cavernous sinus veins in cerebrospinal fluid absorption

The purpose of this investigation was to enhance our understanding of cerebrospinal fluid (CSF) absorption pathways. To achieve this, Microfil (a coloured silastic material) was infused into the subarachnoid space (cisterna magna) of sheep post mortem, and the relevant tissues examined macroscopically and microscopically. The Microfil was taken up by an extensive network of extracranial lymphatic vessels in the olfactory turbinates. In addition however, Microfil also passed consistently through the dura at the base of the brain. Microfil was noted in the spaces surrounding the venous network that comprises the cavernous sinus, in the adventitia of the internal carotid arteries and adjacent to the pituitary gland. Additionally, Microfil was observed within the endoneurial spaces of the trigeminal nerve and in lymphatic vessels emerging from the epineurium of the nerve. These results suggest several unconventional pathways by which CSF may be removed from the subarachnoid space. The movement of CSF to locations external to the cranium via these routes may lead to its absorption into veins and lymphatics outside of the skull. The physiological importance of these pathways requires further investigation.

D2-40 expression demonstrates lymphatic vessel characteristics in the dural portion of the optic nerve sheath

PURPOSE

To investigate the presence or absence of lymphatic vessels in the human optic nerve by means of immunohistochemistry.

METHODS

Use of selective molecular markers to differentiate lymphatics from blood vessels in optic nerve specimens obtained after enucleation or exenteration procedures. Specifically, the lymphatic-specific monoclonal antibody D2-40 was used to identify lymphatic endothelial cells in contrast to CD-34 identification of endothelial cells of blood vessels. Optic nerves obtained from 10 enucleation and 2 exenteration specimens submitted for routine pathology. Paraffin-embedded sections of human optic nerve were immunostained with the lymphatic specific endothelial marker D2-40 and the vascular specific endothelial marker CD-34, using a double-staining method.

RESULTS

Immunostaining with the lymphatic selective marker D2-40 positively demonstrated lymphatic vessels in the dura mater of the optic nerve. CD-34 counter-immunostaining identified blood vessels as separate vascular structures within the optic nerve meninges and adjacent ocular tissues. Positive D2-40 staining of the arachnoid mater in a nonvascular pattern was identified.

CONCLUSIONS

Vessels with features compatible with lymphatic vessels were demonstrated by means of a selective monoclonal immunohistochemical marker for lymphatic endothelium in the dura mater of the human optic nerve.

(Peri)vascular production and action of pro-inflammatory cytokines in brain pathology

In response to tissue injury or infection, the peripheral tissue macrophage induces an inflammatory response through the release of IL-1β (interleukin-1β) and TNFα (tumour necrosis factor α). These cytokines stimulate macrophages and endothelial cells to express chemokines and adhesion molecules that attract leucocytes into the peripheral site of injury or infection. The aims of the present review are to (i) discuss the relevance of brain (peri)vascular cells and compartments to bacterial meningitis, HIV-1-associated dementia, multiple sclerosis, ischaemic and traumatic brain injury, and Alzheimer's disease, and (ii) to provide an overview of the production and action of pro-inflammatory cytokines by (peri)vascular cells in these pathologies of the CNS (central nervous system). The brain (peri)vascular compartments are highly relevant to pathologies affecting the CNS, as infections are almost exclusively blood-borne. Insults disrupt blood and energy flow to neurons, and active brain-to-blood transport mechanisms, which are the bottleneck in the clearance of unwanted molecules from the brain. Perivascular macrophages are the most reactive cell type and produce IL-1β and TNFα after infection or injury to the CNS. The main cellular target for IL-1β and TNFα produced in the brain (peri)vascular compartment is the endothelium, where these cytokines induce the expression of adhesion molecules and promote leucocyte infiltration. Whether this and other effects of IL-1 and TNF in the brain (peri)vascular compartments are detrimental or beneficial in neuropathology remains to be shown and requires a clear understanding of the role of these cytokines in both damaging and repair processes in the CNS.

The inflammatory bases of hepatic encephalopathy

A hypothesis about the inflammatory etiopathogeny mediated by astroglia of hepatic encephalopathy is being proposed. Three evolutive phases are considered in chronic hepatic encephalopathy: an immediate or nervous phase with ischemia-reperfusion, which is associated with reperfusion injury, edema and oxidative stress; an intermediate or immune phase with microglia hyperactivity, which produces cytotoxic cytokines and chemokines and is involved in enzyme hyperproduction and phagocytosis; and a late or endocrine phase, in which neuroglial remodeling, with an alteration of angiogenesis and neurogenesis, stands out. The increasingly complex trophic meaning that the metabolic alterations have in the successive phases making up this chronic inflammation could explain the metabolic regression produced in acute and acute-on-chronic hepatic encephalopathy. In these two types of hepatic encephalopathy, characterized by edema, neuronal nutrition by diffusion would guarantee an appropriate support of substrates, in accordance with the reduced metabolic needs of the cerebral tissue.

Water and solute secretion by the choroid plexus

The cerebrospinal fluid (CSF) provides mechanical and chemical protection of the brain and spinal cord. This review focusses on the contribution of the choroid plexus epithelium to the water and salt homeostasis of the CSF, i.e. the secretory processes involved in CSF formation. The choroid plexus epithelium is situated in the ventricular system and is believed to be the major site of CSF production. Numerous studies have identified transport processes involved in this secretion, and recently, the underlying molecular background for some of the mechanisms have emerged. The nascent CSF consists mainly of NaCl and NaHCO(3), and the production rate is strictly coupled to the rate of Na(+) secretion. In contrast to other secreting epithelia, Na(+) is actively pumped across the luminal surface by the Na(+),K(+)-ATPase with possible contributions by other Na(+) transporters, e.g. the luminal Na(+),K(+),2Cl(-) cotransporter. The Cl(-) and HCO(3) (-) ions are likely transported by a luminal cAMP activated inward rectified anion conductance, although the responsible proteins have not been identified. Whereas Cl(-) most likely enters the cells through anion exchange, the functional as well as the molecular basis for the basolateral Na(+) entry are not yet well-defined. Water molecules follow across the epithelium mainly through the water channel, AQP1, driven by the created ionic gradient. In this article, the implications of the recent findings for the current model of CSF secretion are discussed. Finally, the clinical implications and the prospects of future advances in understanding CSF production are briefly outlined.

The olfactory route for cerebrospinal fluid drainage into the peripheral lymphatic system

Drainage of the cerebrospinal fluid through the olfactory nerves into the nasal lymphatics has been suggested repeatedly. To investigate precisely the morphology of this pathway, India ink was injected into the subarachnoidal space of the rat brain, and samples including the olfactory bulbs, olfactory tracts and the nasal mucosa were observed by light and electron microscopy. Under the dissecting microscope, ink particles were found within the subarachnoid space and along the olfactory nerves. At the nasal mucosa, a lymphatic network stained in black was identified near the olfactory nerves, which finally emptied into the superficial and deep cervical lymph nodes. Light microscopically, ink particles were found in the subarachnoid space, partially distributed around the olfactory nerves and within the lymphatic vessels. By electron microscopy, the subarachnoid space often formed a pocket-like space in the entrance of the fila olfactoria. The olfactory nerves were partially surrounded by ink particles within the space between perineurial cells and epineurial fibroblasts. At the nasal mucosa, the lymphatics were frequently located close to the nerves. These results indicate that the cerebrospinal fluid drains from the subarachnoid space along the olfactory nerves to the nasal lymphatics, which in turn, empties into the cervical lymph nodes. This anatomical communication, thus, allows the central nervous system to connect with the lymphatic system. The presence of this route may play an important role in the movement of antigens from the subarachnoidal space to the extracranial lymphatic vessels, resulting in inducement of an immune response of the central nervous system.

Late rapid deterioration after endoscopic third ventriculostomy: additional cases and review of the literature

OBJECT

Late rapid deterioration after endoscopic third ventriculostomy (ETV) is a rare complication. The authors previously reported three deaths from three centers. Three other deaths and a patient who experienced rapid deterioration have also been reported. Following the death at the University of Toronto of an additional patient who underwent surgery elsewhere, they canvassed pediatric neurosurgeons in North America, Europe, Australia, and Asia for additional cases.

METHODS

An email was sent to the members of the Canadian Congress of Neurological Sciences who are pediatric neurosurgeons, to the pediatric neurosurgery email list of the American Association of Neurological Surgeons, to the email list of the International Society for Pediatric Neurosurgery, and to designated neurosurgeons in the United Kingdom, France, Japan, Korea, Taiwan, and Australia, who in turn contacted pediatric neurosurgeons in their countries. A data form was provided, and data from previously reported cases were extracted. Nine additional cases were identified, and the results were collated with those of the seven cases previously reported. Patient age at surgery ranged from 2 days to 13 years (mean 7.6 years). The most common causes of hydrocephalus were aqueductal stenosis in 50% of patients and tectal glioma in 25% of patients. The time to treatment failure ranged from 5 weeks to 7.8 years (mean 2.5 years). Thirteen patients died, one patient was in a vegetative state, one patient was mildly disabled, and one patient whose condition deteriorated outside the operating room was alive and well. In the 13 patients in whom the ventriculostomy site was visualized at autopsy or repeated endoscopy, the ventriculostomy was shown to be occluded.

CONCLUSIONS

Late rapid deterioration is a rare but lethal complication of ETV. The mechanism is unclear, but deterioration can occur long after the ETV becomes occluded. Patients and caregivers should be counseled regarding this potential complication. An indwelling ventricular access device is an option for patients undergoing ETV.

Quantification of cerebrospinal fluid transport across the cribriform plate into lymphatics in rats

A major pathway by which cerebrospinal fluid (CSF) is removed from the cranium is transport through the cribriform plate in association with the olfactory nerves. CSF is then absorbed into lymphatics located in the submucosa of the olfactory epithelium (olfactory turbinates). In an attempt to provide a quantitative measure of this transport, 125I-human serum albumin (HSA) was injected into the lateral ventricles of adult Fisher 344 rats. The animals were killed at 10, 20, 30, 40, and 60 min after injection, and tissue samples, including blood (from heart puncture), skeletal muscle, spleen, liver, kidney, and tail were excised for radioactive assessment. The remains were frozen. To sample the olfactory turbinates, angled coronal tissue sections anterior to the cribriform plate were prepared from the frozen heads. The average concentration of 125I-HSA was higher in the middle olfactory turbinates than in any other tissue with peak concentrations achieved 30 min after injection. At this point, the recoveries of injected tracer (percent injected dose/g tissue) were 9.4% middle turbinates, 1.6% blood, 0.04% skeletal muscle, 0.2% spleen, 0.3% liver, 0.3% kidney, and 0.09% tail. The current belief that arachnoid projections are responsible for CSF drainage fails to explain some important issues related to the pathogenesis of CSF disorders. The rapid movement of the CSF tracer into the olfactory turbinates further supports a role for lymphatics in CSF absorption and provides the basis of a method to investigate the novel concept that diseases associated with the CSF system may involve impaired lymphatic CSF transport.

Evidence of antibody production in the rat cervical lymph nodes after antigen administration into the cerebrospinal fluid

We previously showed histologically that, in the rat, the cerebrospinal fluid drains from the subarachnoid space along the olfactory nerves to the nasal lymphatics and empties into the superficial and deep cervical lymph nodes. The present study was performed to investigate whether these lymph nodes play a role in the immune response of the central nervous system. For this purpose, keyhole limpet hemocyanin conjugated with fluorescein isothiocyanate (KLH-FITC) was administered into the subarachnoid space of the rat brain, and the time-kinetics and location of FITC and anti-FITC antibody forming cells in the cervical lymph nodes were studied histologically and immunohistochemically. FITC fluorescence was detected in superficial and deep cervical lymph nodes as well as the subarachnoid space and the nasal mucosa 2 h after FITC-KLH injection into the subarachnoid space. The specific antibody-forming cells first appeared in both the superficial and deep cervical lymph nodes on the 4th day after antigen administration although the reaction was more intense in the deep than in the superficial cervical lymph nodes. These cells were located in the medullary cords of the cervical lymph nodes. The number of antibody forming cells increased thereafter, reached a peak around the day 6, and then declined on day 10. These findings indicate that antigens introduced in the cerebrospinal fluid are drained into the cervical lymph nodes through the nasal lymphatics and initiate the antigen-specific immune response there. Thus, the cervical lymph nodes probably act as a monitoring site for cerebrospinal fluid and play a major role in the central nervous system immune response.

Cerebral venous pressure, intra-abdominal pressure, and dural venous sinus stenting in idiopathic intracranial hypertension

Increased pressure in the dural venous sinuses has been proposed as the cause of increased intracranial pressure in the condition known as idiopathic intracranial hypertension (IIH). This hypothesis has received further support from manometry of the dural venous sinuses, showing a substantial proximal-to-distal pressure gradient, and from reports of improvement of IIH following stenting of the dural sinuses. Increased intracranial venous pressure has also been proposed as the cause of IIH in morbid obesity through increased abdominal pressure that is transmitted through the thorax to the cerebral draining veins. Although these hypotheses are intriguing, neither has enough scientific support to be endorsed yet. Moreover, dural venous sinus stenting should not be adopted as a therapeutic procedure in IIH until larger clinical trials attest to its safety and efficacy.

Development of cerebrospinal fluid absorption sites in the pig and rat: connections between the subarachnoid space and lymphatic vessels in the olfactory turbinates

The textbook view that cerebrospinal fluid (CSF) absorption occurs mainly through the arachnoid granulations and villi is being challenged by quantitative and qualitative studies that support a major role for the lymphatic circulation in CSF transport. There are many potential sites at which lymphatics may gain access to CSF but the primary pathway involves the movement of CSF through the cribriform plate foramina in association with the olfactory nerves. Lymphatics encircle the nerve trunks on the extracranial surface of the cribriform plate and absorb CSF. However, the time during development in which the CSF compartment and extracranial lymphatic vessels connect anatomically is unclear. In this report, CSF-lymphatic connections were investigated using the silastic material Microfil and a soluble Evan's blue-protein complex in two species; one in which significant CSF synthesis by the choroid plexus begins before birth (pigs) and one in which CSF secretion is markedly up regulated within the first weeks after birth (rats). We examined a total of 46 pig fetuses at embryonic (E) day E80-81, E92, E101, E110 (birth at 114 days). In rats, we investigated a total of 115 animals at E21 (birth at 21 days), postnatal (P) day P1-P9, P12, P13, P15, P22, and adults. In pigs, CSF-lymphatic connections were observed in the prenatal period as early as E92. Before this time (E80-81 fetuses) CSF-lymphatic connections did not appear to exist. In rats, these associations were not obvious until about a week after birth. These data suggest that the ability of extracranial lymphatic vessels to absorb CSF develops around the time that significant volumes of CSF are being produced by the choroid plexus and further support an important role for lymphatic vessels in CSF transport.

Subarachnoid injection of Microfil reveals connections between cerebrospinal fluid and nasal lymphatics in the non-human primate

Based on quantitative and qualitative studies in a variety of mammalian species, it would appear that a significant portion of cerebrospinal fluid (CSF) drainage is associated with transport along cranial and spinal nerves with absorption taking place into lymphatic vessels external to the central nervous system. CSF appears to convect primarily through the cribriform plate into lymphatics associated with the submucosa of the olfactory and respiratory epithelium. However, the significance of this pathway for CSF absorption in primates has never been established unequivocally. In past studies, we infused Microfil into the subarachnoid compartment of numerous species to visualize CSF transport pathways. The success of this method encouraged us to use a similar approach in the non-human primate. Yellow Microfil was injected post mortem into the cisterna magna of 6 years old Barbados green monkeys (Cercopithecus aethiops sabeus, n = 6). Macroscopic and microscopic examination revealed that Microfil was (1) distributed throughout the subarachnoid compartment, (2) located in the perineurial spaces associated with the fila olfactoria, (3) present within the olfactory submucosa, and (4) situated within an extensive network of lymphatic vessels in the nasal submucosa, nasal septum and turbinate tissues. We conclude that the Microfil distribution patterns in the monkey were very similar to those observed in many other species suggesting that significant nasal lymphatic uptake of CSF occurs in the non-human primate.

A Chronic Fatigue Syndrome - related proteome in human cerebrospinal fluid

BACKGROUND

Chronic Fatigue Syndrome (CFS), Persian Gulf War Illness (PGI), and fibromyalgia are overlapping symptom complexes without objective markers or known pathophysiology. Neurological dysfunction is common. We assessed cerebrospinal fluid to find proteins that were differentially expressed in this CFS-spectrum of illnesses compared to control subjects.

METHODS

Cerebrospinal fluid specimens from 10 CFS, 10 PGI, and 10 control subjects (50 mul/subject) were pooled into one sample per group (cohort 1). Cohort 2 of 12 control and 9 CFS subjects had their fluids (200 mul/subject) assessed individually. After trypsin digestion, peptides were analyzed by capillary chromatography, quadrupole-time-of-flight mass spectrometry, peptide sequencing, bioinformatic protein identification, and statistical analysis.

RESULTS

Pooled CFS and PGI samples shared 20 proteins that were not detectable in the pooled control sample (cohort 1 CFS-related proteome). Multilogistic regression analysis (GLM) of cohort 2 detected 10 proteins that were shared by CFS individuals and the cohort 1 CFS-related proteome, but were not detected in control samples. Detection of >or=1 of a select set of 5 CFS-related proteins predicted CFS status with 80% concordance (logistic model). The proteins were alpha-1-macroglobulin, amyloid precursor-like protein 1, keratin 16, orosomucoid 2 and pigment epithelium-derived factor. Overall, 62 of 115 proteins were newly described.

CONCLUSION

This pilot study detected an identical set of central nervous system, innate immune and amyloidogenic proteins in cerebrospinal fluids from two independent cohorts of subjects with overlapping CFS, PGI and fibromyalgia. Although syndrome names and definitions were different, the proteome and presumed pathological mechanism(s) may be shared.

Integration of the subarachnoid space and lymphatics: is it time to embrace a new concept of cerebrospinal fluid absorption?

In most tissues and organs, the lymphatic circulation is responsible for the removal of interstitial protein and fluid but the parenchyma of the brain and spinal cord is devoid of lymphatic vessels. On the other hand, the literature is filled with qualitative and quantitative evidence supporting a lymphatic function in cerebrospinal fluid (CSF) absorption. The experimental data seems to warrant a re-examination of CSF dynamics and consideration of a new conceptual foundation on which to base our understanding of disorders of the CSF system. The objective of this paper is to review the key studies pertaining to the role of the lymphatic system in CSF absorption.