1
|
Osuna-Ramos JF, Camberos-Barraza J, Torres-Mondragón LE, Rábago-Monzón ÁR, Camacho-Zamora A, Valdez-Flores MA, Angulo-Rojo CE, Guadrón-Llanos AM, Picos-Cárdenas VJ, Calderón-Zamora L, Magaña-Gómez JA, Norzagaray-Valenzuela CD, Cárdenas-Torres FI, De la Herrán-Arita AK. Interplay between the Glymphatic System and the Endocannabinoid System: Implications for Brain Health and Disease. Int J Mol Sci 2023; 24:17458. [PMID: 38139290 PMCID: PMC10743431 DOI: 10.3390/ijms242417458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
The intricate mechanisms governing brain health and function have long been subjects of extensive investigation. Recent research has shed light on two pivotal systems, the glymphatic system and the endocannabinoid system, and their profound role within the central nervous system. The glymphatic system is a recently discovered waste clearance system within the brain that facilitates the efficient removal of toxic waste products and metabolites from the central nervous system. It relies on the unique properties of the brain's extracellular space and is primarily driven by cerebrospinal fluid and glial cells. Conversely, the endocannabinoid system, a multifaceted signaling network, is intricately involved in diverse physiological processes and has been associated with modulating synaptic plasticity, nociception, affective states, appetite regulation, and immune responses. This scientific review delves into the intricate interconnections between these two systems, exploring their combined influence on brain health and disease. By elucidating the synergistic effects of glymphatic function and endocannabinoid signaling, this review aims to deepen our understanding of their implications for neurological disorders, immune responses, and cognitive well-being.
Collapse
Affiliation(s)
- Juan F. Osuna-Ramos
- Faculty of Medicine, Autonomous University of Sinaloa, Culiacán 80019, Mexico
| | - Josué Camberos-Barraza
- Faculty of Medicine, Autonomous University of Sinaloa, Culiacán 80019, Mexico
- Doctorado en Biomedicina Molecular, Autonomous University of Sinaloa, Culiacán 80019, Mexico
| | - Laura E. Torres-Mondragón
- Faculty of Medicine, Autonomous University of Sinaloa, Culiacán 80019, Mexico
- Maestría en Biomedicina Molecular, Autonomous University of Sinaloa, Culiacán 80019, Mexico
| | - Ángel R. Rábago-Monzón
- Faculty of Medicine, Autonomous University of Sinaloa, Culiacán 80019, Mexico
- Doctorado en Biomedicina Molecular, Autonomous University of Sinaloa, Culiacán 80019, Mexico
| | | | | | | | | | | | | | - Javier A. Magaña-Gómez
- Faculty of Nutrition Sciences and Gastronomy, Autonomous University of Sinaloa, Culiacán 80019, Mexico
| | | | | | | |
Collapse
|
2
|
Peng S, Liu J, Liang C, Yang L, Wang G. Aquaporin-4 in glymphatic system, and its implication for central nervous system disorders. Neurobiol Dis 2023; 179:106035. [PMID: 36796590 DOI: 10.1016/j.nbd.2023.106035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
The clearance function is essential for maintaining brain tissue homeostasis, and the glymphatic system is the main pathway for removing brain interstitial solutes. Aquaporin-4 (AQP4) is the most abundantly expressed aquaporin in the central nervous system (CNS) and is an integral component of the glymphatic system. In recent years, many studies have shown that AQP4 affects the morbidity and recovery process of CNS disorders through the glymphatic system, and AQP4 shows notable variability in CNS disorders and is part of the pathogenesis of these diseases. Therefore, there has been considerable interest in AQP4 as a potential and promising target for regulating and improving neurological impairment. This review aims to summarize the pathophysiological role that AQP4 plays in several CNS disorders by affecting the clearance function of the glymphatic system. The findings can contribute to a better understanding of the self-regulatory functions in CNS disorders that AQP4 were involved in and provide new therapeutic alternatives for incurable debilitating neurodegenerative disorders of CNS in the future.
Collapse
Affiliation(s)
- Shasha Peng
- 56 Xinjian southern St, Department of Pharmacology, School of Basical Medical Sciences, Shanxi Medical University, Taiyuan, Shanxi 030001, China
| | - Jiachen Liu
- 172 Tongzipo Rd, Xiangya Medical College of Central South University, Changsha, Hunan 410013, China
| | - Chuntian Liang
- 56 Xinjian southern St, Department of Neurology, Shanxi Medical University, Taiyuan, Shanxi 030001, China
| | - Lijun Yang
- 56 Xinjian southern St, Department of Pharmacology, School of Basical Medical Sciences, Shanxi Medical University, Taiyuan, Shanxi 030001, China
| | - Gaiqing Wang
- 56 Xinjian southern St, Department of Neurology, Shanxi Medical University, Taiyuan, Shanxi 030001, China; 146 JieFang forth Rd, Department of Neurology, SanYa Central Hospital (Hainan Third People's Hospital), Hainan Medical University, SanYa, Hainan 572000, China.
| |
Collapse
|
3
|
Abstract
The lymphatic vasculature forms an organized network that covers the whole body and is involved in fluid homeostasis, metabolite clearance, and immune surveillance. The recent identification of functional lymphatic vessels in the meninges of the brain and the spinal cord has provided novel insights into neurophysiology. They emerge as major pathways for fluid exchange. The abundance of immune cells in lymphatic vessels and meninges also suggests that lymphatic vessels are actively involved in neuroimmunity. The lymphatic system, through its role in the clearance of neurotoxic proteins, autoimmune cell infiltration, and the transmission of pro-inflammatory signals, participates in the pathogenesis of a variety of neurological disorders, including neurodegenerative and neuroinflammatory diseases and traumatic injury. Vascular endothelial growth factor C is the master regulator of lymphangiogenesis, a process that is critical for the maintenance of central nervous system homeostasis. In this review, we summarize current knowledge and recent advances relating to the anatomical features and immunological functions of the lymphatic system of the central nervous system and highlight its potential as a therapeutic target for neurological disorders and central nervous system repair.
Collapse
Affiliation(s)
- Jia-Qi Xu
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, Hunan Province, China,Mobile Health Ministry of Education - China Mobile Joint Laboratory, Changsha, Hunan Province, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Qian-Qi Liu
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, Hunan Province, China,Mobile Health Ministry of Education - China Mobile Joint Laboratory, Changsha, Hunan Province, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Sheng-Yuan Huang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Chun-Yue Duan
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, Hunan Province, China,Mobile Health Ministry of Education - China Mobile Joint Laboratory, Changsha, Hunan Province, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Hong-Bin Lu
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, Hunan Province, China,Mobile Health Ministry of Education - China Mobile Joint Laboratory, Changsha, Hunan Province, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Correspondence to: Yong Cao, or ; Hong-Bin Lu, ; Jian-Zhong Hu, .
| | - Yong Cao
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, Hunan Province, China,Mobile Health Ministry of Education - China Mobile Joint Laboratory, Changsha, Hunan Province, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Correspondence to: Yong Cao, or ; Hong-Bin Lu, ; Jian-Zhong Hu, .
| | - Jian-Zhong Hu
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, Hunan Province, China,Mobile Health Ministry of Education - China Mobile Joint Laboratory, Changsha, Hunan Province, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan Province, China,Correspondence to: Yong Cao, or ; Hong-Bin Lu, ; Jian-Zhong Hu, .
| |
Collapse
|
4
|
Zhao Z, He J, Chen Y, Wang Y, Wang C, Tan C, Liao J, Xiao G. The pathogenesis of idiopathic normal pressure hydrocephalus based on the understanding of AQP1 and AQP4. Front Mol Neurosci 2022; 15:952036. [PMID: 36204139 PMCID: PMC9530743 DOI: 10.3389/fnmol.2022.952036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/12/2022] [Indexed: 11/21/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a neurological disorder without a recognized cause. Aquaporins (AQPs) are transmembrane channels that carry water through cell membranes and are critical for cerebrospinal fluid circulation and cerebral water balance. The function of AQPs in developing and maintaining hydrocephalus should be studied in greater detail as a possible diagnostic and therapeutic tool. Recent research indicates that patients with iNPH exhibited high levels of aquaporin 1 and low levels of aquaporin 4 expression, suggesting that these AQPs are essential in iNPH pathogenesis. To determine the source of iNPH and diagnose and treat it, it is necessary to examine and appreciate their function in the genesis and maintenance of hydrocephalus. The expression, function, and regulation of AQPs in iNPH are reviewed in this article, in order to provide fresh targets and suggestions for future research.
Collapse
Affiliation(s)
- Zitong Zhao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jian He
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Yibing Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yuchang Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Chuansen Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Changwu Tan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Junbo Liao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Gelei Xiao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Gelei Xiao
| |
Collapse
|
5
|
Arighi A, Arcaro M, Fumagalli GG, Carandini T, Pietroboni AM, Sacchi L, Fenoglio C, Serpente M, Sorrentino F, Isgrò G, Turkheimer F, Scarpini E, Galimberti D. Aquaporin-4 cerebrospinal fluid levels are higher in neurodegenerative dementia: looking at glymphatic system dysregulation. Alzheimers Res Ther 2022; 14:135. [PMID: 36115967 PMCID: PMC9482276 DOI: 10.1186/s13195-022-01077-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 09/04/2022] [Indexed: 01/15/2023]
Abstract
Aquaporin-4 (AQP4) is a channel protein that plays a fundamental role in glymphatic system, a newly described pathway for fluid exchange in the central nervous system, as well as a central figure in a fascinating new theory for the pathophysiology of neurodegenerative diseases such as Alzheimer’s disease (AD) and frontotemporal dementia (FTD). In this study, cerebrospinal fluid (CSF) concentration of AQP4, amyloid-β, total tau and P-tau were determined in 103 CSF samples from patients affected by neurodegenerative dementias (AD and FTD) or psychiatric diseases and 21 controls. Significantly higher levels of AQP4 were found in AD and FTD patients compared to subjects not affected by neurodegenerative diseases, and a significant, positive correlation between AQP4 and total tau levels was found. This evidence may pave the way for future studies focused on the role of this channel protein in the clinical assessment of the glymphatic function and degree of neurodegeneration.
Collapse
|
6
|
Buccellato FR, D’anca M, Serpente M, Arighi A, Galimberti D. The Role of Glymphatic System in Alzheimer’s and Parkinson’s Disease Pathogenesis. Biomedicines 2022; 10:2261. [PMID: 36140362 PMCID: PMC9496080 DOI: 10.3390/biomedicines10092261] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 11/30/2022] Open
Abstract
Alzheimer’s disease (AD) is the most common cause of neurodegenerative dementia, whilst Parkinson’s disease (PD) is a neurodegenerative movement disorder. These two neurodegenerative disorders share the accumulation of toxic proteins as a pathological hallmark. The lack of definitive disease-modifying treatments for these neurogenerative diseases has led to the hypothesis of new pathogenic mechanisms to target and design new potential therapeutic approaches. The recent observation that the glymphatic system is supposed to be responsible for the movement of cerebrospinal fluid into the brain and clearance of metabolic waste has led to study its involvement in the pathogenesis of these classic proteinopathies. Aquaporin-4 (AQP4), a water channel located in the endfeet of astrocyte membrane, is considered a primary driver of the glymphatic clearance system, and defective AQP4-mediated glymphatic drainage has been linked to proteinopathies. The objective of the present review is to present the recent body of knowledge that links the glymphatic system to the pathogenesis of AD and PD disease and other lifestyle factors such as sleep deprivation and exercise that may influence glymphatic system function. We will also focus on the potential neuroimaging approaches that could identify a neuroimaging marker to detect glymphatic system changes.
Collapse
|
7
|
Abstract
Aquaporin-4 (AQP4) is the most abundantly expressed aquaporin in the central nervous system (CNS) and is an integral part of the glymphatic system that cannot be ignored. The CNS has the glymphatic system instead of the conventional lymphatic system. The glymphatic system plays an essential role in the pathophysiological processes of many cognitive disorders. AQP4 shows noteworthy changes in various cognitive disorders and is part of the pathogenesis of these diseases. For this reason, AQP4 has attracted attention as a potential and promising target for regulating and even reversing cognitive dysfunction. This review will summarize the role of AQP4 in the pathophysiological processes of several cognitive disorders as reported in recent studies.
Collapse
Affiliation(s)
- Yifan Wang
- 1Department of Gerontology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Chuyi Huang
- 2Health Management Center, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai China
| | - Qihao Guo
- 1Department of Gerontology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Heling Chu
- 1Department of Gerontology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| |
Collapse
|
8
|
Yang S, Kong XY, Hu T, Ge YJ, Li XY, Chen JT, He S, Zhang P, Chen GH. Aquaporin-4, Connexin-30, and Connexin-43 as Biomarkers for Decreased Objective Sleep Quality and/or Cognition Dysfunction in Patients With Chronic Insomnia Disorder. Front Psychiatry 2022; 13:856867. [PMID: 35401278 PMCID: PMC8989729 DOI: 10.3389/fpsyt.2022.856867] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/21/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES To examine serum concentrations of aquaporin-4 (AQP4), connexin-30 (CX30), connexin-43 (CX43), and their correlations with cognitive function in the patients with chronic insomnia disorder (CID). METHODS We enrolled 76 subjects with CID and 32 healthy controls (HCs). Serum levels of AQP4, CX30, and CX43 were measured by enzyme-linked immunosorbent assays. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) and polysomnography, and mood was evaluated with 17-item Hamilton Depression Rating Scale and 14-item Hamilton Anxiety Rating Scale. Cognitive function was evaluated by the Chinese-Beijing Version of Montreal Cognitive Assessment (MoCA-C) and Nine Box Maze Test. RESULTS The serum levels of AQP4, CX43, and CX30 were significantly reduced in the CID group compared to the HCs. Partial correlation analysis showed that the biomarkers showed no significant correlations with PSQI score, AHI, ODI and TS90, but AQP4, CX43, and CX30 were positively associated with the percentage and total time of slow wave sleep in the CID group. Serum concentrations of AQP4 and CX30 were positively associated with MoCA-C score in the CID group, and AQP4 level negatively correlated with spatial working memory errors. CONCLUSIONS Subjects with CID patients have decreased serum levels of AQP4, CX30, and CX43 indicating astrocyte dysfunction, which could be related to poor objective sleep quality and/or cognition dysfunction.
Collapse
Affiliation(s)
- Shuai Yang
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Xiao-Yi Kong
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Ting Hu
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Yi-Jun Ge
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Xue-Yan Li
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Jun-Tao Chen
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Shuo He
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Ping Zhang
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Gui-Hai Chen
- Department of Neurology (Sleep Disorders), The Affiliated Chaohu Hospital of Anhui Medical University, Hefei, China
| |
Collapse
|
9
|
Hiraldo-González L, Trillo-Contreras JL, García-Miranda P, Pineda-Sánchez R, Ramírez-Lorca R, Rodrigo-Herrero S, Blanco MO, Oliver M, Bernal M, Franco-Macías E, Villadiego J, Echevarría M. Evaluation of aquaporins in the cerebrospinal fluid in patients with idiopathic normal pressure hydrocephalus. PLoS One 2021; 16:e0258165. [PMID: 34597351 PMCID: PMC8486078 DOI: 10.1371/journal.pone.0258165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022] Open
Abstract
Brain aquaporin 1 (AQP1) and AQP4 are involved in cerebrospinal fluid (CSF) homeostasis and might participate in the origin of hydrocephalus. Studies have shown alterations of perivascular AQP4 expression in idiopathic normal pressure hydrocephalus (iNPH) and Alzheimer's disease (AD). Due to the overlapping of clinical signs between iNPH and certain neurological conditions, mainly AD, specific biomarkers might improve the diagnostic accuracy for iNPH. The goal of the present study was to analyze and quantify the presence of AQP1 and AQP4 in the CSF of patients with iNPH and AD to determine whether these proteins can be used as biomarkers of iNPH. We examined AQP1 and AQP4 protein levels in the CSF of 179 participants (88 women) classified into 5 groups: possible iNPH (81 participants), hydrocephalus associated with other neurological disorders (13 participants), AD (41 participants), non-AD dementia (32 participants) and healthy controls (12 participants). We recorded each participant's demographic and clinical variables and indicated, when available in the clinical history, the record of cardiovascular and respiratory complications. An ELISA showed virtually no AQP content in the CSF. Information on the vascular risk factors (available for 61 patients) confirmed some type of vascular risk factor in 86% of the patients with possible iNPH and 58% of the patients with AD. In conclusion, the ELISA analysis showed insufficient sensitivity to detect the presence of AQP1 and AQP4 in CSF, ruling out the possible use of these proteins as biomarkers for diagnosing iNPH.
Collapse
Affiliation(s)
- Laura Hiraldo-González
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
| | - José Luis Trillo-Contreras
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
| | - Pablo García-Miranda
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
| | - Rocío Pineda-Sánchez
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
| | - Reposo Ramírez-Lorca
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Department of Physiology and Biophysics, University of Seville, Seville, Spain
| | - Silvia Rodrigo-Herrero
- Clinical Neuroscience Management Unit, Neurology Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Magdalena Olivares Blanco
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Clinical Neuroscience Management Unit, Neurosurgery Service, University Hospital Virgen del Rocío, Seville, Spain
| | - María Oliver
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Clinical Neuroscience Management Unit, Neurosurgery Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Maria Bernal
- Clinical Neuroscience Management Unit, Neurology Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Emilio Franco-Macías
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Clinical Neuroscience Management Unit, Neurology Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Javier Villadiego
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Department of Physiology and Biophysics, University of Seville, Seville, Spain
- Network Center for Biomedical Research in Neurodegenerative Diseases (CIBERNED), Seville, Spain
| | - Miriam Echevarría
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Department of Physiology and Biophysics, University of Seville, Seville, Spain
- * E-mail:
| |
Collapse
|
10
|
Liang PZ, Li L, Zhang YN, Shen Y, Zhang LL, Zhou J, Wang ZJ, Wang S, Yang S. Electroacupuncture Improves Clearance of Amyloid- β through the Glymphatic System in the SAMP8 Mouse Model of Alzheimer's Disease. Neural Plast 2021; 2021:9960304. [PMID: 34484327 DOI: 10.1155/2021/9960304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/12/2021] [Indexed: 12/25/2022] Open
Abstract
Background Memory loss and cognitive impairment characterize the neurodegenerative disorder, Alzheimer's disease (AD). Amyloid-β (Aβ) is the key factor that triggers the course of AD, and reducing the deposition of Aβ in the brain has been considered as a potential target for the treatment of AD. In clinical and animal studies, electroacupuncture (EA) has been shown to be an effective treatment for AD. In recent years, substantial evidence has accumulated suggesting the important role of the glymphatic system in Aβ clearance. Objective The purpose of this study was to explore whether EA modifies the accumulation of Aβ through the glymphatic system and may thus be applied to alleviate cognitive impairments. Methods Seven-month-old SAMP8 mice were randomized into a control group (Pc) and an electroacupuncture group (Pe). Age-matched SAMR1 mice were used as normal controls (Rc). Mice in the Pe group were stimulated on Baihui (GV20) and Yintang (GV29) for 10 min and then pricked at Shuigou (GV26) for ten times. EA treatment lasted for 8 weeks. In each week, EA would be applied once a day for the first five consecutive days and ceased at the remaining two days. After EA treatment, Morris water maze (MWM) test was used to evaluate the cognitive function; HE and Nissl staining was performed to observe the brain histomorphology; ELISA, contrast-enhanced MRI, and immunofluorescence were applied to explore the mechanisms underlying EA effects from Aβ accumulation, glymphatic system function, reactivity of astrocytes, and AQP4 polarization, respectively. Results This EA regime could improve cognition and alleviate neuropathological damage to brain tissue. And EA treatment might reduce Aβ accumulation, enhance paravascular influx in the glymphatic system, inhibit the reactivity of astrocytes, and improve AQP4 polarity. Conclusion EA treatment might reduce Aβ accumulation from the brain via improving clearance performance of the glymphatic system and thereby alleviating cognitive impairment.
Collapse
|
11
|
Wafford KA. Aberrant waste disposal in neurodegeneration: why improved sleep could be the solution. Cereb Circ Cogn Behav 2021; 2:100025. [PMID: 36324713 PMCID: PMC9616228 DOI: 10.1016/j.cccb.2021.100025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 06/16/2023]
Abstract
Sleep takes up a large percentage of our lives and the full functions of this state are still not understood. However, over the last 10 years a new and important function has emerged as a mediator of brain clearance. Removal of toxic metabolites and proteins from the brain parenchyma generated during waking activity and high levels of synaptic processing is critical to normal brain function and only enabled during deep sleep. Understanding of this process is revealing how impaired sleep contributes an important and likely causative role in the accumulation and aggregation of aberrant proteins such as β-amyloid and phosphorylated tau, as well as inflammation and neuronal damage. We are also beginning to understand how brain slow-wave activity interacts with vascular function allowing the flow of CSF and interstitial fluid to drain into the body's lymphatic system. New methodology is enabling visualization of this process in both animals and humans and is revealing how these processes break down during ageing and disease. With this understanding we can begin to envisage novel therapeutic approaches to the treatment of neurodegeneration, and how reversing sleep impairment in the correct manner may provide a way to slow these processes and improve brain function.
Collapse
Key Words
- AQP4, aquaporin-4
- Alzheimer's disease
- Amyloid
- Aquaporin-4
- Astrocyte
- Aβ, beta amyloid
- BOLD, blood-oxygen level dependent imaging
- CAA, cerebral amyloid angiopathy
- CSF, Cerebrospinal fluid
- Clearance
- EEG, electroencephalography
- EMG, electromyography
- Glymphatic
- ISF, interstitial fluid
- MCI, mild cognitive impairment
- MRI, magnetic resonance imaging
- NOS, nitric oxide synthase
- NREM, non-rapid eye movement
- OSA, obstructive sleep apnea
- PET, positron emission tomography
- REM, rapid-eye movement
- SWA, slow wave activity
- SWS, slow-wave sleep
- Slow-wave sleep
- iNPH, idiopathic normal pressure hydrocephalus
Collapse
|
12
|
Ludwig HC, Dreha-Kulaczewski S, Bock HC. Neurofluids-Deep inspiration, cilia and preloading of the astrocytic network. J Neurosci Res 2021; 99:2804-2821. [PMID: 34323313 DOI: 10.1002/jnr.24935] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/15/2021] [Accepted: 07/13/2021] [Indexed: 01/20/2023]
Abstract
With the advent of real-time MRI, the motion and passage of cerebrospinal fluid can be visualized without gating and exclusion of low-frequency waves. This imaging modality gives insights into low-volume, rapidly oscillating cardiac-driven movement as well as sustained, high-volume, slowly oscillating inspiration-driven movement. Inspiration means a spontaneous or artificial increase in the intrathoracic dimensions independent of body position. Alterations in thoracic diameter enable the thoracic and spinal epidural venous compartments to be emptied and filled, producing an upward surge of cerebrospinal fluid inside the spine during inspiration; this surge counterbalances the downward pooling of venous blood toward the heart. Real-time MRI, as a macroscale in vivo observation method, could expand our knowledge of neurofluid dynamics, including how astrocytic fluid preloading is adjusted and how brain buoyancy and turgor are maintained in different postures and zero gravity. Along with these macroscale findings, new microscale insights into aquaporin-mediated fluid transfer, its sensing by cilia, and its tuning by nitric oxide will be reviewed. By incorporating clinical knowledge spanning several disciplines, certain disorders-congenital hydrocephalus with Chiari malformation, idiopathic intracranial hypertension, and adult idiopathic hydrocephalus-are interpreted and reviewed according to current concepts, from the basics of the interrelated systems to their pathology.
Collapse
Affiliation(s)
- Hans C Ludwig
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Steffi Dreha-Kulaczewski
- Division of Pediatric Neurology, Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Hans C Bock
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| |
Collapse
|
13
|
Bergström S, Remnestål J, Yousef J, Olofsson J, Markaki I, Carvalho S, Corvol JC, Kultima K, Kilander L, Löwenmark M, Ingelsson M, Blennow K, Zetterberg H, Nellgård B, Brosseron F, Heneka MT, Bosch B, Sanchez-Valle R, Månberg A, Svenningsson P, Nilsson P. Multi-cohort profiling reveals elevated CSF levels of brain-enriched proteins in Alzheimer's disease. Ann Clin Transl Neurol 2021; 8:1456-1470. [PMID: 34129723 PMCID: PMC8283172 DOI: 10.1002/acn3.51402] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/30/2021] [Accepted: 05/12/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Decreased amyloid beta (Aβ) 42 together with increased tau and phospho-tau in cerebrospinal fluid (CSF) is indicative of Alzheimer's disease (AD). However, the molecular pathophysiology underlying the slowly progressive cognitive decline observed in AD is not fully understood and it is not known what other CSF biomarkers may be altered in early disease stages. METHODS We utilized an antibody-based suspension bead array to analyze levels of 216 proteins in CSF from AD patients, patients with mild cognitive impairment (MCI), and controls from two independent cohorts collected within the AETIONOMY consortium. Two additional cohorts from Sweden were used for biological verification. RESULTS Six proteins, amphiphysin (AMPH), aquaporin 4 (AQP4), cAMP-regulated phosphoprotein 21 (ARPP21), growth-associated protein 43 (GAP43), neurofilament medium polypeptide (NEFM), and synuclein beta (SNCB) were found at increased levels in CSF from AD patients compared with controls. Next, we used CSF levels of Aβ42 and tau for the stratification of the MCI patients and observed increased levels of AMPH, AQP4, ARPP21, GAP43, and SNCB in the MCI subgroups with abnormal tau levels compared with controls. Further characterization revealed strong to moderate correlations between these five proteins and tau concentrations. INTERPRETATION In conclusion, we report six extensively replicated candidate biomarkers with the potential to reflect disease development. Continued evaluation of these proteins will determine to what extent they can aid in the discrimination of MCI patients with and without an underlying AD etiology, and if they have the potential to contribute to a better understanding of the AD continuum.
Collapse
Affiliation(s)
- Sofia Bergström
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Julia Remnestål
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Jamil Yousef
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Jennie Olofsson
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Ioanna Markaki
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Stephanie Carvalho
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Assistance-Publique Hôpitaux de Paris, INSERM, CNRS, Hôpital Pitié-Salpêtrière, Department of Neurology, Centre d'Investigation Clinique Neurosciences, Paris, France
| | - Jean-Christophe Corvol
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Assistance-Publique Hôpitaux de Paris, INSERM, CNRS, Hôpital Pitié-Salpêtrière, Department of Neurology, Centre d'Investigation Clinique Neurosciences, Paris, France
| | - Kim Kultima
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Lena Kilander
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
| | - Malin Löwenmark
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
| | - Martin Ingelsson
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Bengt Nellgård
- Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg
| | - Frederic Brosseron
- Universitätsklinikum Bonn, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | | | - Beatriz Bosch
- Alzheimer's and other cognitive disorders Unit. Service of Neurology, Hospital Clínic de Barcelona, Institut d'Investigació Biomèdica August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Raquel Sanchez-Valle
- Alzheimer's and other cognitive disorders Unit. Service of Neurology, Hospital Clínic de Barcelona, Institut d'Investigació Biomèdica August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Anna Månberg
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Per Svenningsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Peter Nilsson
- Division of Affinity Proteomics, Department of Protein Science, SciLifeLab, KTH Royal Institute of Technology, Stockholm, Sweden
| |
Collapse
|
14
|
Roblot P, Mollier O, Ollivier M, Gallice T, Planchon C, Gimbert E, Danet M, Renault S, Auzou N, Laurens B, Jecko V. Communicating chronic hydrocephalus: A review. Rev Med Interne 2021; 42:781-788. [PMID: 34144842 DOI: 10.1016/j.revmed.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 05/30/2021] [Indexed: 11/25/2022]
Abstract
Formerly called normal pressure hydrocephalus, communicating chronic hydrocephalus (CCH) is a condition affecting 0.1 to 0.5% of patients over 60years of age. The pathophysiology of this disease is poorly understood, but a defect in cerebrospinal fluid (CSF) resorption appears to be commonly defined as the cause of the neurological disorders. The last important discovery is the description of the glymphatic system and its implication in CCH and CSF resorption. Comorbidities (Alzheimer's disease, microangiopathy, parkinsonism) are very frequent, and involve a diagnostic challenge. The clinical presentation is based on the Hakim and Adams triad, comprising gait disorders, mainly impairing walking, cognitive disorders, affecting executive functions, episodic memory, visuospatial cognition, and sphincter disorders as urinary incontinence (detrusor hyperactivity). The diagnosis is suspected through a set of arguments, combining the clinical presentation, the radiological data of the magnetic resonance imaging (MRI) showing a ventriculomegaly associated with signs of transependymomous resorption of the CSF and disappearance of the cortical sulci, and the clinical response to the depletion of CSF. In the presence of all these elements, or a strong clinical suspicion, the standard treatment will be of a permanent CSF shunt, using a ventriculoatrial or ventriculoperitoneal shunt. The effectiveness of this treatment defines the diagnosis. The clinical improvement is better when treatment occurs early after the onset of the disorders, reaching 75 to 90% of motor improvement.
Collapse
Affiliation(s)
- P Roblot
- Neurosurgery department A, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Laboratory of anatomy, university of Bordeaux, Bordeaux, France.
| | - O Mollier
- Neurosurgery department B, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - M Ollivier
- Department of diagnostic and therapeutic neuroimaging, Pellegrin hospital, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - T Gallice
- Neurosurgery department B, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Department of critical care, Bordeaux university hospital, 33076 Bordeaux, France
| | - C Planchon
- Neurosurgery department A, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Neurosurgery department B, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - E Gimbert
- Neurosurgery department A, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - M Danet
- Department of geriatric medicine, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - S Renault
- Department of neurology, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - N Auzou
- Institute for neurodegenerative diseases, CNRS UMR 5293, university Bordeaux, Bordeaux, France
| | - B Laurens
- Department of neurology, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Institute for neurodegenerative diseases, CNRS UMR 5293, university Bordeaux, Bordeaux, France
| | - V Jecko
- Neurosurgery department A, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Université de Bordeaux, CNRS UMR 5287, INCIA, Zone nord, Bat 2, 2e étage, 146, rue Léo-Saignat, 33076 Bordeaux cedex, France
| |
Collapse
|
15
|
Bellaver B, Ferrari-Souza JP, Uglione da Ros L, Carter SF, Rodriguez-Vieitez E, Nordberg A, Pellerin L, Rosa-Neto P, Leffa DT, Zimmer ER. Astrocyte Biomarkers in Alzheimer Disease: A Systematic Review and Meta-analysis. Neurology 2021; 96:e2944-e2955. [PMID: 33952650 DOI: 10.1212/wnl.0000000000012109] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To perform a systematic review and meta-analysis to determine whether fluid and imaging astrocyte biomarkers are altered in Alzheimer disease (AD). METHODS PubMed and Web of Science databases were searched for articles reporting fluid or imaging astrocyte biomarkers in AD. Pooled effect sizes were determined with standardized mean differences (SMDs) using the Hedge G method with random effects to determine biomarker performance. Adapted questions from the Quality Assessment of Diagnostic Accuracy Studies were applied for quality assessment. A protocol for this study has been previously registered in PROSPERO (registration number: CRD42020192304). RESULTS The initial search identified 1,425 articles. After exclusion criteria were applied, 33 articles (a total of 3,204 individuals) measuring levels of glial fibrillary acidic protein (GFAP), S100B, chitinase-3-like protein 1 (YKL-40), and aquaporin 4 in the blood and CSF, as well as monoamine oxidase-B indexed by PET 11C-deuterium-l-deprenyl, were included. GFAP (SMD 0.94, 95% confidence interval [CI] 0.71-1.18) and YKL-40 (SMD 0.76, 95% CI 0.63-0.89) levels in the CSF and S100B levels in the blood (SMD 2.91, 95% CI 1.01-4.8) were found to be significantly increased in patients with AD. CONCLUSIONS Despite significant progress, applications of astrocyte biomarkers in AD remain in their early days. This meta-analysis demonstrated that astrocyte biomarkers are consistently altered in AD and supports further investigation for their inclusion in the AD clinical research framework for observational and interventional studies.
Collapse
Affiliation(s)
- Bruna Bellaver
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - João Pedro Ferrari-Souza
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - Lucas Uglione da Ros
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - Stephen F Carter
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - Elena Rodriguez-Vieitez
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - Agneta Nordberg
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - Luc Pellerin
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - Pedro Rosa-Neto
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - Douglas Teixeira Leffa
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil
| | - Eduardo R Zimmer
- From the Graduate Program in Biological Sciences: Biochemistry (B.B., J.P.F.-S., L.U.d.R., E.R.Z.), Department of Pharmacology (E.R.Z.), and Graduate Program in Biological Sciences: Pharmacology and Therapeutics (E.R.Z.), Universidade Federal do Rio Grande do Sul; Department of Psychiatry (S.F.C.), University of Cambridge; Wolfson Molecular Imaging Centre (S.F.C.), University of Manchester, UK; Department of Neurobiology (E.R.-V, A.N.), Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet (E.R.-V, A.N.); Theme Aging (A.N.), Karolinska University Hospital Stockholm, Stockholm, Sweden; Inserm U1082 (L.P.), Université de Poitiers, France; Translational Neuroimaging Laboratory (P.R.-N.), McGill University Research Centre for Studies in Aging, Alzheimer's Disease Research Unit, Douglas Research Institute, Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Ouest-de-l'Île-de-Montréal; McGill University (P.R.-N.), Montreal, Quebec, Canada; and ADHD Outpatient Program & Development Psychiatry Program (D.T.L.), Hospital de Clínicas de Porto Alegre, Brazil.
| |
Collapse
|
16
|
Tan C, Wang X, Wang Y, Wang C, Tang Z, Zhang Z, Liu J, Xiao G. The Pathogenesis Based on the Glymphatic System, Diagnosis, and Treatment of Idiopathic Normal Pressure Hydrocephalus. Clin Interv Aging 2021; 16:139-153. [PMID: 33488070 PMCID: PMC7815082 DOI: 10.2147/cia.s290709] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/01/2021] [Indexed: 12/16/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a rare neurological disorder with no clear prevalence factors and is a significant danger to the elderly. The intracranial glymphatic system is the internal environment that maintains brain survival and metabolism, and thus fluid exchange changes in the glymphatic system under various pathological conditions can provide important insights into the pathogenesis and differential diagnosis of many neurodegenerative diseases such as iNPH. iNPH can be diagnosed using a combination of clinical symptoms, imaging findings and history, and cerebrospinal fluid biomarkers due to the glymphatic system disorder. However, only few researchers have linked the two. Shunt surgery can improve the glymphatic system disorders in iNPH patients, and the surgical approach is determined using a combination of clinical diagnosis and trials. Therefore, we have composed this review to provide a future opportunity for elucidating the pathogenesis of iNPH based on the glymphatic system, and link the glymphatic system to the diagnosis and treatment of iNPH. The review will provide new insights into the medical research of iNPH.
Collapse
Affiliation(s)
- Changwu Tan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Xiaoqiang Wang
- Pediatric Neurological Disease Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, People's Republic of China
| | - Yuchang Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Chuansen Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Zhi Tang
- Department of Neurosurgery, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, People's Republic of China
| | - Zhiping Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Jingping Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Gelei Xiao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| |
Collapse
|
17
|
de Laurentis C, Cristaldi P, Arighi A, Cavandoli C, Trezza A, Sganzerla EP, Giussani CG, Di Cristofori A. Role of aquaporins in hydrocephalus: what do we know and where do we stand? A systematic review. J Neurol 2020; 268:4078-4094. [PMID: 32747978 DOI: 10.1007/s00415-020-10122-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Glymphatic fluid circulation may be considered the lymphatic system of the brain and the main role of such system seems to be played by aquaporins (AQPs), a family of proteins which regulates water exchange, in particular AQP4 and 1. Alterations of glymphatic fluid circulation through AQPs variations are now emerging as central elements in the pathophysiology of different brain conditions, like hydrocephalus. This systematic review provides an insight about the role of AQPs in hydrocephalus establishment and compensation, investigating their possible role as diagnostic tools or therapeutic targets. METHODS PubMed database was screened searching for the relevant existing literature in English language published until February 29th 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. RESULTS A total of 40 articles met the inclusion criteria for our systematic analysis. AQP4 resulted the most studied water channel, followed by AQP1. The changes in cerebrospinal fluid (CSF), brain parenchyma and choroid plexus (CP) in different hydrocephalus type were analyzed. Moreover, important pharmacological interactions regarding AQP and molecules or conditions were discussed. A very interesting result is the general consensus on increase of AQP4 in hydrocephalic patients, unless in patients suffering from idiopathic normal pressure hydrocephalus, where AQP4 shows a tendency in reduction. CONCLUSION AQP seem to play a central role in the pathophysiology of hydrocephalus and in its compensation mechanisms. Further studies are required to definitively establish their precise roles and their quantitative changes to allow their utilization as diagnostic tools or therapeutic targets.
Collapse
Affiliation(s)
- Camilla de Laurentis
- Unit of Neurosurgery, Ospedale San Gerardo, Azienda Socio Sanitaria Territoriale Monza, Via G. B. Pergolesi 33, 20900, Monza, MB, Italy.,Department of Surgery and Medicine, Università degli Studi Milano-Bicocca, Milan, MI, Italy
| | - Paola Cristaldi
- Unit of Neurosurgery, Ospedale San Gerardo, Azienda Socio Sanitaria Territoriale Monza, Via G. B. Pergolesi 33, 20900, Monza, MB, Italy.,Department of Surgery and Medicine, Università degli Studi Milano-Bicocca, Milan, MI, Italy
| | - Andrea Arighi
- Unit of Neurology - UOSD Malattie Neurodegenerative, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, MI, Italy.,Dino Ferrari Center - Università degli Studi di Milano, Milan, MI, Italy
| | - Clarissa Cavandoli
- Unit of Neurosurgery, Ospedale San Gerardo, Azienda Socio Sanitaria Territoriale Monza, Via G. B. Pergolesi 33, 20900, Monza, MB, Italy.,Università degli Studi di Milano, Milan, MI, Italy
| | - Andrea Trezza
- Unit of Neurosurgery, Ospedale San Gerardo, Azienda Socio Sanitaria Territoriale Monza, Via G. B. Pergolesi 33, 20900, Monza, MB, Italy
| | - Erik P Sganzerla
- Unit of Neurosurgery, Ospedale San Gerardo, Azienda Socio Sanitaria Territoriale Monza, Via G. B. Pergolesi 33, 20900, Monza, MB, Italy.,Department of Surgery and Medicine, Università degli Studi Milano-Bicocca, Milan, MI, Italy
| | - Carlo G Giussani
- Unit of Neurosurgery, Ospedale San Gerardo, Azienda Socio Sanitaria Territoriale Monza, Via G. B. Pergolesi 33, 20900, Monza, MB, Italy.,Department of Surgery and Medicine, Università degli Studi Milano-Bicocca, Milan, MI, Italy
| | - Andrea Di Cristofori
- Unit of Neurosurgery, Ospedale San Gerardo, Azienda Socio Sanitaria Territoriale Monza, Via G. B. Pergolesi 33, 20900, Monza, MB, Italy.
| |
Collapse
|
18
|
Miyan J, Cains S, Larcombe S, Naz N, Jimenez AR, Bueno D, Gato A. Subarachnoid cerebrospinal fluid is essential for normal development of the cerebral cortex. Semin Cell Dev Biol 2020; 102:28-39. [PMID: 31786096 DOI: 10.1016/j.semcdb.2019.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/14/2019] [Accepted: 11/22/2019] [Indexed: 02/07/2023]
Abstract
The central nervous system develops around a fluid filled space which persists in the adult within the ventricles, spinal canal and around the outside of the brain and spinal cord. Ventricular fluid is known to act as a growth medium and stimulator of proliferation and differentiation to neural stem cells but the role of CSF in the subarachnoid space has not been fully investigated except for its role in the recently described "glymphatic" system. Fundamental changes occur in the control and coordination of CNS development upon completion of brain stem and spinal cord development and initiation of cortical development. These include changes in gene expression, changes in fluid and fluid source from neural tube fluid to cerebrospinal fluid (CSF), changes in fluid volume, composition and fluid flow pathway, with exit of high volume CSF into the subarachnoid space and the critical need for fluid drainage. We used a number of experimental approaches to test a predicted critical role for CSF in development of the cerebral cortex in rodents and humans. Data from fetuses affected by spina bifida and/or hydrocephalus are correlated with experimental evidence on proliferation and migration of cortical cells from the germinal epithelium in rodent neural tube defects, as well as embryonic brain slice experiments demonstrating a requirement for CSF to contact both ventricular and pial surfaces of the developing cortex for normal proliferation and migration. We discuss the possibility that complications with the fluid system are likely to underlie developmental disorders affecting the cerebral cortex as well as function and integrity of the cortex throughout life.
Collapse
|
19
|
Skalický P, Mládek A, Vlasák A, De Lacy P, Beneš V, Bradáč O. Normal pressure hydrocephalus—an overview of pathophysiological mechanisms and diagnostic procedures. Neurosurg Rev 2019; 43:1451-1464. [DOI: 10.1007/s10143-019-01201-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/27/2019] [Accepted: 10/25/2019] [Indexed: 01/25/2023]
|
20
|
Lerner AJ, Pieper AA. Neurotherapeutics of the Aging Brain: Complexity Meets Complexity. Neurotherapeutics 2019; 16:539-542. [PMID: 31290090 PMCID: PMC6694363 DOI: 10.1007/s13311-019-00757-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Alan J. Lerner
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH USA
- Department of Neurology, Case Western Reserve University, 3619 Park east Drive, suite 206, Beachwood, OH 44122 USA
| | - Andrew A. Pieper
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH USA
- Harrington Discovery Institute, University Hospitals Cleveland Medical Center, Cleveland, OH USA
- Geriatric Research and Education and Clinical Center, Louis Stokes Cleveland VAMC, Cleveland, OH 44106 USA
| |
Collapse
|