Visualization of the cerebrospinal fluid drainage into the Galen's vein

Chronic cerebral aspects of long COVID, post-stroke syndromes and similar states share their pathogenesis and perispinal etanercept treatment logic

The chronic neurological aspects of traumatic brain injury, post‐stroke syndromes, long COVID‐19, persistent Lyme disease, and influenza encephalopathy having close pathophysiological parallels that warrant being investigated in an integrated manner. A mechanism, common to all, for this persistence of the range of symptoms common to these conditions is described. While TNF maintains cerebral homeostasis, its excessive production through either pathogen‐associated molecular patterns or damage‐associated molecular patterns activity associates with the persistence of the symptoms common across both infectious and non‐infectious conditions. The case is made that this shared chronicity arises from a positive feedback loop causing the persistence of the activation of microglia by the TNF that these cells generate. Lowering this excess TNF is the logical way to reducing this persistent, TNF‐maintained, microglial activation. While too large to negotiate the blood‐brain barrier effectively, the specific anti‐TNF biological, etanercept, shows promise when administered by the perispinal route, which allows it to bypass this obstruction.

A Neurologist's Guide to TNF Biology and to the Principles behind the Therapeutic Removal of Excess TNF in Disease

Tumor necrosis factor (TNF) is an ancient and widespread cytokine required in small amounts for much physiological function. Higher concentrations are central to innate immunity, but if unchecked this cytokine orchestrates much chronic and acute disease, both infectious and noninfectious. While being a major proinflammatory cytokine, it also controls homeostasis and plasticity in physiological circumstances. For the last decade or so these principles have been shown to apply to the central nervous system as well as the rest of the body. Nevertheless, whereas this approach has been a major success in treating noncerebral disease, its investigation and potential widespread adoption in chronic neurological conditions has inexplicably stalled since the first open trial almost a decade ago. While neuroscience is closely involved with this approach, clinical neurology appears to be reticent in engaging with what it offers patients. Unfortunately, the basic biology of TNF and its relevance to disease is largely outside the traditions of neurology. The purpose of this review is to facilitate lowering communication barriers between the traditional anatomically based medical specialties through recognition of shared disease mechanisms and thus advance the prospects of a large group of patients with neurodegenerative conditions for whom at present little can be done.

Clinical outcomes of temporary shunting for infants with cerebral pseudomeningocele

OBJECTIVE

Although in the case of subdural collections temporary shunting has been suggested as a viable alternative for definitive drainage of the accumulated fluid until restoration of the normal CSF dynamics, there is no agreement on the best management strategy for pseudomeningocele.

METHODS

The authors performed a retrospective chart review in order to evaluate the clinical outcomes of infants temporarily shunted for pseudomeningocele without encephalocele at our institution (The University of Illinois at Peoria/Illinois Neurological Institute) in the period from 2004 to 2012. The epidemiological characteristics, clinical management, and final outcomes of such subpopulation were compared with a control group which received temporary shunting for subdural hematomas (SDH) during the same period.

RESULTS

Four patients (100% male) ranging in age from 8.9 to 27.1 months (mean = 13.88) with pseudomeningocele and 17 patients (64.7% male) ranging in age from 1.9 to 11.8 months (mean = 4.15) with SDH were identified. Although the initial management included sequential percutaneous subdural tapping in 82% of the patients, all children ultimately failed such strategy, requiring either subdural-peritoneal (81% of the cases) or subgaleal-peritoneal (19% of the cases) shunting. The mean implant duration was 201 days for the pseudomeningocele group and 384 days for the SDH one. Mean post-shunt hospitalization was 2 days for patients with pseudomeningocele and 4 days for patients with SDH. There was no statistical difference in terms of complications, length of hospitalization post-shunting, or clinical outcomes between the patients with pseudomeningocele and those with SDH.

CONCLUSIONS

Temporary shunting of infants with pseudo-meningocele constitutes a viable therapeutic alternative with favorable clinical outcomes and a low risk of shunt dependency similar to those of children with SDH.

Structural defects in cilia of the choroid plexus, subfornical organ and ventricular ependyma are associated with ventriculomegaly

Background

Hydrocephalus is a heterogeneous disorder with multiple etiologies that are not yet fully understood. Animal models have implicated dysfunctional cilia of the ependyma and choroid plexus in the development of the disorder. In this report, we sought to determine the origin of the ventriculomegaly in four Bardet Biedl syndrome (BBS) mutant mouse strains as models of a ciliopathy.

Methods

Evans Blue dye was injected into the lateral ventricle of wild- type and BBS mutant mice to determine whether obstruction of intra- or extra-ventricular CSF flow contributed to ventriculomegaly. Transmission electron microscopy (TEM) was used to examine the ultrastructure of the choroid plexus, subfornical organ (SFO), subcommisural organ (SCO), and ventricular ependyma to evaluate their ultrastructure and the morphology of their primary and motile cilia.

Results and discussion

No obstruction of intra- or extra-ventricular CSF flow was observed, implying a communicating form of hydrocephalus in BBS mutant mice. TEM analyses of the mutants showed no evidence of choroidal papillomas or breakdown of the blood:CSF barrier. In contrast, structural defects were observed in a subpopulation of cilia lining the choroid plexus, SFO, and ventricular ependyma. These included disruptions of the microtubular structure of the axoneme and the presence of electron-dense vesicular-like material along the ciliary shaft and at the tips of cilia.

Conclusions

Abnormalities in cilia structure and function have the potential to influence ciliary intraflagellar transport (IFT), cilia maintenance, protein trafficking, and regulation of CSF production. Ciliary structural defects are the only consistent pathological features associated with CSF-related structures in BBS mutant mice. These defects are observed from an early age, and may contribute to the underlying pathophysiology of ventriculomegaly.

Human spinal arachnoid villi revisited: immunohistological study and review of the literature

OBJECT

Few have described the relationship between arachnoid protrusions (villi) and adjacent spinal radicular veins, and the descriptions that do exist are conflicting. Some authors have even denied the presence of spinal arachnoid villi, suggesting that they play no role in cerebrospinal fluid (CSF) absorption.

METHODS

To further elucidate these structures, laminectomies from C-2 inferiorly to S-2 were performed in 10 fresh human adult cadavers. Following removal of the laminae, the dural nerve sleeves were identified and the spinal nerves excised 1 cm lateral and medial to the intervertebral foramina. Samples were submitted for histological and immunohistological analysis.

RESULTS

The authors identified arachnoid villi in all specimens. The length of these structures was approximately 50 to 170 microm. Regionally, these villi were more concentrated in the lumbar region, but they were not present at every vertebral level, with observed skip zones. Occasionally, more than one villus was identified per vertebral level. The majority of villi were intimately related to an adjacent radicular vein. There was a direct relationship between the size of the adjacent radicular vein, and the presence and number of arachnoid villi.

CONCLUSIONS

Findings in the present study have demonstrated that arachnoid villi exist and are morphologically associated with radicular veins. These data support the theory that CSF absorption occurs not only intracranially but also along the spinal axis. Further animal studies are necessary to prove that CSF traverses these villi and is absorbed into the spinal venous system.

Nerve fibers innervating the cranial and spinal meninges: morphology of nerve fiber terminals and their structural integration

Pachymeninx and leptomeninx of cranial cavity and spine are considerably different in their collagenous fiber texture, cellular composition, vascularization, and innervation. The majority of meningeal nerve fibers terminate as free nerve endings whereas encapsulated and lamellated nerve terminals additionally occur in higher vertebrates including man. With respect to nerve fiber classification, arborization pattern, topography, and organization of the microenvironment at the termination site afferent and efferent nerve terminals are differentiated. Only the dura mater and the pial subcompartment of the leptomeninx possess the morphological prerequisites for neurogenic inflammation. In the current review, the results of morphological studies regarding the meningeal innervation including the sites of CSF (cerebrospinal fluid) production and absorption are discussed with emphasis on their structure-function relationships.

Scanning electron microscopy of central nervous system cerebrospinal-fluid-contacting surfaces: a bibliography (1963-1995)

This bibliography is compiled to assist in locating papers related to the application of scanning electron microscopy (SEM) to cerebrospinal-fluid-contacting surfaces in vertebrates. The use of SEM by neuroscientists has continued apace since the publication of the first bibliography in 1980. SEM studies now include more than 50 species of vertebrates and range from cyclostomes to humans; they encompass development from embryo to senescence and concern both normal and pathologic morphology. Although remarkable strides have been made toward a greater understanding of many aspects of the structure and function of cerebrospinal-fluid-contacting surfaces, many significant problems await the judicious application of scanning electron microscopy.

Effects of intraventricular implantation of crystalline estradiol benzoate on the sleep-wakefulness circadian rhythm of ovariectomized rats

The effect of estrogen on the sleep-wakefulness circadian rhythm was examined in ovariectomized rats. Implantation of crystalline estradiol benzoate (EB) into the third cerebral ventricle reduced the slow wave sleep (SWS) and paradoxical sleep (PS) appearances within the dark period. This result was similar to that obtained by a systemic administration of 20 micrograms of EB. The inhibition of sleep during the nighttime was more remarkable in PS than in SWS. The reduction of SWS was due to a shorter duration of SWS episodes and the reduction of PS to a fewer number of PS episodes. These results indicate that ovariectomized rats treated with estrogen develop an inability to sustain episodes of SWS and initiate PS episodes.

Vascularization of the telencephalic choroid plexus of a ganoid fish [Acipenser ruthenus (L.)]

The vascularization of the telencephalic choroid plexus of the sterlet Acipenser ruthenus, a ganoid fish, was examined by vascular corrosion casting and by light and transmission electron microscopy. The arterial supply is from the dorsal mesencephalic artery via: 1) the ventral choroidal arteries (left and right); 2) the dorsal choroidal arteries (left and right); 3) the caudal choroidal arteries (left and right); 4) the ventral arteries of the dorsal sac; and, from the olfactory arteries, via 5) the rostral choroidal arteries. The venous drainage is mainly through a single main choroidal vein that can take various courses either directly to the anterior cardinal vein or via the middle cerebral vein to the anterior cardinal vein. To a lesser extent, the plexus is drained via the lateral telencephalic veins and the ventral vein of the dorsal sac to the middle cerebral vein. By angioarchitecture and form, the plexus can be subdivided into five distinct parts: the surface network, the median folds, the large lateral folds, the small lateral folds, and the area common to the bottom of the dorsal sac and the telencephalic plexus. Diameters of terminal vessels as measured from vascular corrosion casts and from paraplast, semithin, and ultrathin sections were never less than 10 micron. It is suggested that the different areas in one plexus may have different functions with respect to secretion and absorption of cerebrospinal fluid.

Tracer in cisternal cerebrospinal fluid is soon detected in choroid plexus capillaries

Horseradish peroxidase was detected in the choroid plexus capillary 5 min after the onset of a 2 1/2-min injection of 7.5 microliter of 40% solution into the cisterna cerebellomedullaris in mice. Venous capillaries in the capillary beds of circumventricular organs including the choroid plexus were indicated as sites of cerebrospinal fluid absorption.