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Basilio AV, Zeng D, Pichay LA, Ateshian GA, Xu P, Maas SA, Morrison B. Simulating Cerebral Edema and Ischemia After Traumatic Acute Subdural Hematoma Using Triphasic Swelling Biomechanics. Ann Biomed Eng 2024:10.1007/s10439-024-03496-y. [PMID: 38532172 DOI: 10.1007/s10439-024-03496-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
Poor outcome following traumatic acute subdural hematoma (ASDH) is associated with the severity of the primary injury and secondary injury including cerebral edema and ischemia. However, the underlying secondary injury mechanism contributing to elevated intracranial pressure (ICP) and high mortality rate remains unclear. Cerebral edema occurs in response to the exposure of the intracellular fixed charge density (FCD) after cell death, causing ICP to increase. The increased ICP from swollen tissue compresses blood vessels in adjacent tissue, restricting blood flow and leading to ischemic damage. We hypothesize that the mass occupying effect of ASDH exacerbates the ischemic injury, leading to ICP elevation, which is an indicator of high mortality rate in the clinic. Using FEBio (febio.org) and triphasic swelling biomechanics, this study modeled clinically relevant ASDHs and simulated post-traumatic brain swelling and ischemia to predict ICP. Results showed that common convexity ASDH significantly increased ICP by exacerbating ischemic injury, and surgical removal of the convexity ASDH may control ICP by preventing ischemia progression. However, in cases where the primary injury is very severe, surgical intervention alone may not effectively decrease ICP, as the contribution of the hematoma to the elevated ICP is insignificant. In addition, interhemispheric ASDH, located between the cerebral hemispheres, does not significantly exacerbate ischemia, supporting the conservative surgical management generally recommended for interhemispheric ASDH. The joint effect of the mass occupying effect of the blood clot and resulting ischemia contributes to elevated ICP which may increase mortality. Our novel approach may improve the fidelity of predicting patient outcome after motor vehicle crashes and traumatic brain injuries due to other causes.
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Affiliation(s)
- Andrew V Basilio
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Delin Zeng
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Leanne A Pichay
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Gerard A Ateshian
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
- Department of Mechanical Engineering, Columbia University, 220 S. W. Mudd Building, 500 West 120th Street, New York, NY, 10027, USA
| | - Peng Xu
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Steve A Maas
- Department of Bioengineering, University of Utah, 36 S. Wasatch Drive, SMBB 3100, Salt Lake City, UT, 84112, USA
| | - Barclay Morrison
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA.
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Vitullo P, Cicci L, Possenti L, Coclite A, Costantino ML, Zunino P. Sensitivity analysis of a multi-physics model for the vascular microenvironment. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2023; 39:e3752. [PMID: 37455669 DOI: 10.1002/cnm.3752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/17/2023] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
The vascular microenvironment is the scale at which microvascular transport, interstitial tissue properties and cell metabolism interact. The vascular microenvironment has been widely studied by means of quantitative approaches, including multi-physics mathematical models as it is a central system for the pathophysiology of many diseases, such as cancer. The microvascular architecture is a key factor for fluid balance and mass transfer in the vascular microenvironment, together with the physical parameters characterizing the vascular wall and the interstitial tissue. The scientific literature of this field has witnessed a long debate about which factor of this multifaceted system is the most relevant. The purpose of this work is to combine the interpretative power of an advanced multi-physics model of the vascular microenvironment with state of the art and robust sensitivity analysis methods, in order to determine the factors that most significantly impact quantities of interest, related in particular to cancer treatment. We are particularly interested in comparing the factors related to the microvascular architecture with the ones affecting the physics of microvascular transport. Ultimately, this work will provide further insight into how the vascular microenvironment affects cancer therapies, such as chemotherapy, radiotherapy or immunotherapy.
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Affiliation(s)
| | - Ludovica Cicci
- MOX, Department of Mathematics, Politecnico di Milano, Milan, Italy
- School of Biomedical Engineering & Imaging Sciences, King's College, London, UK
| | - Luca Possenti
- Data Science Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
- Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Alessandro Coclite
- Dipartimento di Ingegneria Elettrica e dell'Informazione, Politecnico di Bari, Bari, Italy
| | - Maria Laura Costantino
- Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Paolo Zunino
- MOX, Department of Mathematics, Politecnico di Milano, Milan, Italy
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Tariq K, Toma A, Khawari S, Amarouche M, Elborady MA, Thorne L, Watkins L. Cerebrospinal fluid production rate in various pathological conditions: a preliminary study. Acta Neurochir (Wien) 2023; 165:2309-2319. [PMID: 37354286 PMCID: PMC10409822 DOI: 10.1007/s00701-023-05650-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/22/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION The cerebrospinal fluid (CSF) production rate in humans is not clearly defined but is estimated to be 18-24 ml/h (Trevisi et al Croat Med J 55(4):377-387 (24); Casey and Vries Childs Nerv Syst 5(5):332-334 (8)). A frequent clinical observation is that patients often drain higher volumes of CSF than can be explained by the assumed 'normal' CSF production rate (PRcsf). In the National Hospital for Neurology and Neurosurgery PRcsf was recorded in a variety of common neurosurgical pathologies using LiquoGuard7, an automated peristaltic pump that accurately controls CSF drainage and maintains a pre-set CSF pressure. METHODS A prospective observational study was performed from September 2021 onwards, on all patients in the National Hospital for Neurology and Neurosurgery who required CSF drainage as part of their ongoing treatment. The external drain was connected to a LiquoGuard7 pump (Möller Medical GmbH, Fulda, Germany), and the internal software of LiquoGuard7 was used to measure PRcsf. Statistical analysis used SPSS (version 25.0, IBM) by paired t test, comparing measured rates to hypothetical 'normal' CSF production rates calculated and published by Ekstedt (16-34ml/h) (Ekstedt J Neurol Neurosurg Psychiatry 41(4):345-353 (14)), assuming a similar distribution. RESULTS PRcsf was calculated in 164 patients. Suspected normal pressure hydrocephalus (n=41): PRcsf of 79ml/h±20SD (p<0.0001). Post-surgical CSF leak (n=26): PRcsf of 90ml/h±20SD (p<0.0001). Subarachnoid haemorrhage (n=34): PRcsf of 143ml/h±9SD (p<0.0001). Intracerebral haemorrhage (n=22): PRcsf of 137ml/h±20SD (p<0.0001). Spinal lesions (n=7): PRcsf of 130ml/h±20SD (p<0.0032). Pituitary adenomas (n=10): PRcsf of 29 ml/h±9SD (p<0.049). Idiopathic intracranial hypertension (n=15): PRcsf of 86ml/h±10SD (p<0.0001). Decompensated long-standing overt ventriculomegaly (n=4): PRcsf of 65ml/h±10SD (p<0.0001). Cerebral infection (n=5): PRcsf of 90ml/h±20SD (p<0.0001). CONCLUSION Net CSF production rate may be higher than expected in many conditions, as measured with new device LiquoGuard7 through the study of net flow rate, which may have implications for clinical decisions on CSF diversion. The conventional understanding of CSF production and circulation does not explain the findings of this study. More extensive studies are needed to validate this technique.
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Affiliation(s)
- Kanza Tariq
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Ahmed Toma
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Sogha Khawari
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | | | | | - Lewis Thorne
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Laurence Watkins
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Liu G, Ladrón-de-Guevara A, Izhiman Y, Nedergaard M, Du T. Measurements of cerebrospinal fluid production: a review of the limitations and advantages of current methodologies. Fluids Barriers CNS 2022; 19:101. [PMID: 36522656 PMCID: PMC9753305 DOI: 10.1186/s12987-022-00382-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/13/2022] [Indexed: 12/23/2022] Open
Abstract
Cerebrospinal fluid (CSF) is an essential and critical component of the central nervous system (CNS). According to the concept of the "third circulation" originally proposed by Cushing, CSF is mainly produced by the choroid plexus and subsequently leaves the cerebral ventricles via the foramen of Magendie and Luschka. CSF then fills the subarachnoid space from whence it disperses to all parts of the CNS, including the forebrain and spinal cord. CSF provides buoyancy to the submerged brain, thus protecting it against mechanical injury. CSF is also transported via the glymphatic pathway to reach deep interstitial brain regions along perivascular channels; this CSF clearance pathway promotes transport of energy metabolites and signaling molecules, and the clearance of metabolic waste. In particular, CSF is now intensively studied as a carrier for the removal of proteins implicated in neurodegeneration, such as amyloid-β and tau. Despite this key function of CSF, there is little information about its production rate, the factors controlling CSF production, and the impact of diseases on CSF flux. Therefore, we consider it to be a matter of paramount importance to quantify better the rate of CSF production, thereby obtaining a better understanding of CSF dynamics. To this end, we now review the existing methods developed to measure CSF production, including invasive, noninvasive, direct, and indirect methods, and MRI-based techniques. Depending on the methodology, estimates of CSF production rates in a given species can extend over a ten-fold range. Throughout this review, we interrogate the technical details of CSF measurement methods and discuss the consequences of minor experimental modifications on estimates of production rate. Our aim is to highlight the gaps in our knowledge and inspire the development of more accurate, reproducible, and less invasive techniques for quantitation of CSF production.
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Affiliation(s)
- Guojun Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
- School of Pharmacy, China Medical University, Shenyang, 110122, China
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Antonio Ladrón-de-Guevara
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Yara Izhiman
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Maiken Nedergaard
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark.
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, 14642, USA.
| | - Ting Du
- School of Pharmacy, China Medical University, Shenyang, 110122, China.
- Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen, Denmark.
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, 14642, USA.
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Abstract
We review theoretical and numerical models of the glymphatic system, which circulates cerebrospinal fluid and interstitial fluid around the brain, facilitating solute transport. Models enable hypothesis development and predictions of transport, with clinical applications including drug delivery, stroke, cardiac arrest, and neurodegenerative disorders like Alzheimer’s disease. We sort existing models into broad categories by anatomical function: Perivascular flow, transport in brain parenchyma, interfaces to perivascular spaces, efflux routes, and links to neuronal activity. Needs and opportunities for future work are highlighted wherever possible; new models, expanded models, and novel experiments to inform models could all have tremendous value for advancing the field.
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Rotaru-Zavaleanu AD, Neacșu AI, Neacșu AD, Pirici D, Osiac E, Cătălin B, Gheonea DI. Effects of Acute Sepsis on Cellular Dynamics and Amyloid Formation in a Mouse Model of Alzheimer’s Disease. Curr Issues Mol Biol 2022; 44:3822-3834. [PMID: 36135174 PMCID: PMC9497925 DOI: 10.3390/cimb44090262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/18/2022] Open
Abstract
Our objective was to investigate how sepsis influences cellular dynamics and amyloid formation before and after plaque formation. As such, APP-mice were subjected to a polymicrobial abdominal infection resulting in sepsis at 2 (EarlySepsis) and 4 (LateSepsis) months of age. Behavior was tested before sepsis and at 5 months of age. We could not detect any short-term memory or exploration behavior alterations in APP-mice that were subjected to Early or LateSepsis. Immunohistochemical analysis revealed a lower area of NeuN+ and Iba1+ signal in the cortex of Late compared with EarlySepsis animals (p = 0.016 and p = 0.01), with an increased astrogliosis in LateSepsis animals compared with WT-Sepsis (p = 0.0028), EarlySepsis (p = 0.0032) and the APP-Sham animals (p = 0.048). LateSepsis animals had larger areas of amyloid compared with both EarlySepsis (p = 0.0018) and APP-Sham animals (p = 0.0024). Regardless of the analyzed markers, we were not able to detect any cellular difference at the hippocampal level between groups. We were able to detect an increased inflammatory response around hippocampal plaques in LateSepsis compared with APP-Sham animals (p = 0.0003) and a decrease of AQP4 signal far from Sma+ vessels. We were able to show experimentally that an acute sepsis event before the onset of plaque formation has a minimal effect; however, it could have a major impact after its onset.
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Affiliation(s)
- Alexandra Daniela Rotaru-Zavaleanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Experimental Research Center for Normal and Pathological Aging, Department of Functional Sciences, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Alexandru Ionuț Neacșu
- Experimental Research Center for Normal and Pathological Aging, Department of Functional Sciences, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Department of Biophysics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Adela-Daria Neacșu
- Experimental Research Center for Normal and Pathological Aging, Department of Functional Sciences, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Daniel Pirici
- Department of Histology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Eugen Osiac
- Experimental Research Center for Normal and Pathological Aging, Department of Functional Sciences, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Department of Biophysics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (E.O.); (B.C.)
| | - Bogdan Cătălin
- Experimental Research Center for Normal and Pathological Aging, Department of Functional Sciences, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Department of Physiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (E.O.); (B.C.)
| | - Dan Ionuț Gheonea
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Sheng J, Li Q, Liu T, Wang X. Cerebrospinal fluid dynamics along the optic nerve. Front Neurol 2022; 13:931523. [PMID: 36046631 PMCID: PMC9420993 DOI: 10.3389/fneur.2022.931523] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Abstract
The cerebrospinal fluid (CSF) plays an important role in delivering nutrients and eliminating the metabolic wastes of the central nervous system. An interrupted CSF flow could cause disorders of the brain and eyes such as Alzheimer's disease and glaucoma. This review provides an overview of the anatomy and flow pathways of the CSF system with an emphasis on the optic nerve. Imaging technologies used for visualizing the CSF dynamics and the anatomic structures associated with CSF circulation have been highlighted. Recent advances in the use of computational models to predict CSF flow patterns have been introduced. Open questions and potential mechanisms underlying CSF circulation at the optic nerves have also been discussed.
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Affiliation(s)
- Jinqiao Sheng
- Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
- School of General Engineering, Beihang University, Beijing, China
| | - Qi Li
- Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Tingting Liu
- Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xiaofei Wang
- Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
- *Correspondence: Xiaofei Wang
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Mehta NH, Suss RA, Dyke JP, Theise ND, Chiang GC, Strauss S, Saint-Louis L, Li Y, Pahlajani S, Babaria V, Glodzik L, Carare RO, de Leon MJ. Quantifying cerebrospinal fluid dynamics: A review of human neuroimaging contributions to CSF physiology and neurodegenerative disease. Neurobiol Dis 2022; 170:105776. [PMID: 35643187 PMCID: PMC9987579 DOI: 10.1016/j.nbd.2022.105776] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/21/2022] [Indexed: 01/13/2023] Open
Abstract
Cerebrospinal fluid (CSF), predominantly produced in the ventricles and circulating throughout the brain and spinal cord, is a key protective mechanism of the central nervous system (CNS). Physical cushioning, nutrient delivery, metabolic waste, including protein clearance, are key functions of the CSF in humans. CSF volume and flow dynamics regulate intracranial pressure and are fundamental to diagnosing disorders including normal pressure hydrocephalus, intracranial hypotension, CSF leaks, and possibly Alzheimer's disease (AD). The ability of CSF to clear normal and pathological proteins, such as amyloid-beta (Aβ), tau, alpha synuclein and others, implicates it production, circulation, and composition, in many neuropathologies. Several neuroimaging modalities have been developed to probe CSF fluid dynamics and better relate CSF volume and flow to anatomy and clinical conditions. Approaches include 2-photon microscopic techniques, MRI (tracer-based, gadolinium contrast, endogenous phase-contrast), and dynamic positron emission tomography (PET) using existing approved radiotracers. Here, we discuss CSF flow neuroimaging, from animal models to recent clinical-research advances, summarizing current endeavors to quantify and map CSF flow with implications towards pathophysiology, new biomarkers, and treatments of neurological diseases.
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Affiliation(s)
- Neel H Mehta
- Department of Biology, Cornell University, Ithaca, NY, USA
| | - Richard A Suss
- Division of Neuroradiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan P Dyke
- Citigroup Biomedical Imaging Center, Weill Cornell Medicine, New York, NY, USA
| | - Neil D Theise
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
| | - Gloria C Chiang
- Division of Neuroradiology, Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Sara Strauss
- Division of Neuroradiology, Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | | | - Yi Li
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Silky Pahlajani
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Vivek Babaria
- Orange County Spine and Sports, Interventional Physiatry, Newport Beach, CA, USA
| | - Lidia Glodzik
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Roxana O Carare
- Department of Medicine, University of Southampton, Southampton, UK
| | - Mony J de Leon
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, NY, USA.
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De Andres J, Hayek S, Perruchoud C, Lawrence MM, Reina MA, De Andres-Serrano C, Rubio-Haro R, Hunt M, Yaksh TL. Intrathecal Drug Delivery: Advances and Applications in the Management of Chronic Pain Patient. FRONTIERS IN PAIN RESEARCH 2022; 3:900566. [PMID: 35782225 PMCID: PMC9246706 DOI: 10.3389/fpain.2022.900566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/02/2022] [Indexed: 11/19/2022] Open
Abstract
Advances in our understanding of the biology of spinal systems in organizing and defining the content of exteroceptive information upon which higher centers define the state of the organism and its role in the regulation of somatic and automatic output, defining the motor response of the organism, along with the unique biology and spatial organization of this space, have resulted in an increased focus on therapeutics targeted at this extracranial neuraxial space. Intrathecal (IT) drug delivery systems (IDDS) are well-established as an effective therapeutic approach to patients with chronic non-malignant or malignant pain and as a tool for management of patients with severe spasticity and to deliver therapeutics that address a myriad of spinal pathologies. The risk to benefit ratio of IDD makes it a useful interventional approach. While not without risks, this approach has a significant therapeutic safety margin when employed using drugs with a validated safety profile and by skilled practioners. The present review addresses current advances in our understanding of the biology and dynamics of the intrathecal space, therapeutic platforms, novel therapeutics, delivery technology, issues of safety and rational implementation of its therapy, with a particular emphasis upon the management of pain.
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Affiliation(s)
- Jose De Andres
- Surgical Specialties Department, Valencia University Medical School, Valencia, Spain
- Anesthesia Critical Care and Pain Management Department, Valencia, Spain
- *Correspondence: Jose De Andres
| | - Salim Hayek
- Department of Anesthesiology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Christophe Perruchoud
- Pain Center and Department of Anesthesia, La Tour Hospital, Geneva, Switzerland
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Melinda M. Lawrence
- Department of Anesthesiology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Miguel Angel Reina
- Department of Anesthesiology, Montepríncipe University Hospital, Madrid, Spain
- CEU-San-Pablo University School of Medicine, Madrid, Spain
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
- Facultad de Ciencias de la Salud Universidad Francisco de Vitoria, Madrid, Spain
| | | | - Ruben Rubio-Haro
- Anesthesia and Pain Management Department, Provincial Hospital, Castellon, Spain
- Multidisciplinary Pain Clinic, Vithas Virgen del Consuelo Hospital, Valencia, Spain
| | - Mathew Hunt
- Department of Physiology, Karolinska Institute, Stockholm, Sweden
| | - Tony L. Yaksh
- Departments of Anesthesiology and Pharmacology, University of California, San Diego, San Diego, CA, United States
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10
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Atchley TJ, Vukic B, Vukic M, Walters BC. Review of Cerebrospinal Fluid Physiology and Dynamics: A Call for Medical Education Reform. Neurosurgery 2022; 91:1-7. [PMID: 35522666 DOI: 10.1227/neu.0000000000002000] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The flow of cerebrospinal fluid (CSF) has been described as a unidirectional system with the choroid plexus serving as the primary secretor of CSF and the arachnoid granulations as primary reabsorption site. This theory of neurosurgical forefathers has been universally adopted and taught as dogma. Many neuroscientists have found difficulty reconciling this theory with common pathologies, and recent studies have found that this "classic" hypothesis may not represent the full picture. OBJECTIVE To review modern CSF dynamic theories and to call for medical education reform. METHODS We reviewed the literature from January 1990 to December 2020. We searched the PubMed database using key terms "cerebrospinal fluid circulation," "cerebrospinal fluid dynamics," "cerebrospinal fluid physiology," "glymphatic system," and "glymphatic pathway." We selected articles with a primary aim to discuss either CSF dynamics and/or the glymphatic system. RESULTS The Bulat-Klarica-Orešković hypothesis purports that CSF is secreted and reabsorbed throughout the craniospinal axis. CSF demonstrates similar physiology to that of water elsewhere in the body. CSF "circulates" throughout the subarachnoid space in a pulsatile to-and-fro fashion. Osmolarity plays a critical role in CSF dynamics. Aquaporin-4 and the glymphatic system contribute to CSF volume and flow by establishing osmolarity gradients and facilitating CSF movement. Multiple studies demonstrate that the choroid plexus does not play any significant role in CSF circulation. CONCLUSION We have highlighted major studies to illustrate modern principles of CSF dynamics. Despite these, the medical education system has been slow to reform curricula and update learning resources.
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Affiliation(s)
- Travis J Atchley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Barbara Vukic
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Miroslav Vukic
- Department of Neurosurgery, Sisters of Mercy University Hospital, Zagreb, Croatia
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Valova G, Bogomyakova O, Tulupov A, Cherevko A. Influence of interaction of cerebral fluids on ventricular deformation: A mathematical approach. PLoS One 2022; 17:e0264395. [PMID: 35226657 PMCID: PMC8884699 DOI: 10.1371/journal.pone.0264395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/09/2022] [Indexed: 11/19/2022] Open
Abstract
This paper describes the effects of the interaction of cerebral fluids (arterial, capillary and venous blood, cerebrospinal fluid) on ventricular wall displacement and periventricular pressure using a mathematical multiphase poroelasticity model for the cerebral parenchyma. The interaction of cerebral fluids is given by a set of four numerical coefficients. A multiple linear regression with interaction is constructed that allows us to quantify the effect of these coefficients on the average ventricular wall displacement. The prevailing influence of an arterial-liquor component was observed. The sets of coefficients associated with such pathological conditions were found: normal pressure hydrocephalus, intracranial hypertension, and replacement ventriculomegaly under a prolonged hypoperfusion.
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Affiliation(s)
- Galina Valova
- Lavrentyev Institute of Hydrodynamics of the Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
- * E-mail:
| | - Olga Bogomyakova
- Lavrentyev Institute of Hydrodynamics of the Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
- International Tomography Center of Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - Andrey Tulupov
- Lavrentyev Institute of Hydrodynamics of the Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
- International Tomography Center of Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - Alexander Cherevko
- Lavrentyev Institute of Hydrodynamics of the Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
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12
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Elbert DL, Patterson BW, Lucey BP, Benzinger TLS, Bateman RJ. Importance of CSF-based Aβ clearance with age in humans increases with declining efficacy of blood-brain barrier/proteolytic pathways. Commun Biol 2022; 5:98. [PMID: 35087179 PMCID: PMC8795390 DOI: 10.1038/s42003-022-03037-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 12/27/2021] [Indexed: 12/21/2022] Open
Abstract
The kinetics of amyloid beta turnover within human brain is still poorly understood. We previously found a dramatic decline in the turnover of Aβ peptides in normal aging. It was not known if brain interstitial fluid/cerebrospinal fluid (ISF/CSF) fluid exchange, CSF turnover, blood-brain barrier function or proteolysis were affected by aging or the presence of β amyloid plaques. Here, we describe a non-steady state physiological model developed to decouple CSF fluid transport from other processes. Kinetic parameters were estimated using: (1) MRI-derived brain volumes, (2) stable isotope labeling kinetics (SILK) of amyloid-β peptide (Aβ), and (3) lumbar CSF Aβ concentration during SILK. Here we show that changes in blood-brain barrier transport and/or proteolysis were largely responsible for the age-related decline in Aβ turnover rates. CSF-based clearance declined modestly in normal aging but became increasingly important due to the slowing of other processes. The magnitude of CSF-based clearance was also lower than that due to blood-brain barrier function plus proteolysis. These results suggest important roles for blood-brain barrier transport and proteolytic degradation of Aβ in the development Alzheimer’s Disease in humans. To understand if brain interstitial fluid/cerebrospinal fluid (ISF/CSF) exchange, CSF turnover, blood-brain barrier function or proteolysis were affected by aging or the presence of β amyloid plaques, Elbert et al. develop a non-steady state physiological model using MRI-derived brain volumes, stable isotope labeling kinetics of Aβ, and lumbar CSF Aβ concentration. Their model suggests an important role for blood-brain barrier transport and proteolytic degradation of Aβ in the development Alzheimer’s Disease in humans.
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Affiliation(s)
- Donald L Elbert
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA.
| | - Bruce W Patterson
- Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Brendan P Lucey
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, MO, USA
| | - Tammie L S Benzinger
- Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, MO, USA.,Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Randall J Bateman
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, MO, USA
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13
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Mehta NH, Sherbansky J, Kamer AR, Carare RO, Butler T, Rusinek H, Chiang GC, Li Y, Strauss S, Saint-Louis LA, Theise ND, Suss RA, Blennow K, Kaplitt M, de Leon MJ. The Brain-Nose Interface: A Potential Cerebrospinal Fluid Clearance Site in Humans. Front Physiol 2022; 12:769948. [PMID: 35058794 PMCID: PMC8764168 DOI: 10.3389/fphys.2021.769948] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/26/2021] [Indexed: 12/17/2022] Open
Abstract
The human brain functions at the center of a network of systems aimed at providing a structural and immunological layer of protection. The cerebrospinal fluid (CSF) maintains a physiological homeostasis that is of paramount importance to proper neurological activity. CSF is largely produced in the choroid plexus where it is continuous with the brain extracellular fluid and circulates through the ventricles. CSF movement through the central nervous system has been extensively explored. Across numerous animal species, the involvement of various drainage pathways in CSF, including arachnoid granulations, cranial nerves, perivascular pathways, and meningeal lymphatics, has been studied. Among these, there is a proposed CSF clearance route spanning the olfactory nerve and exiting the brain at the cribriform plate and entering lymphatics. While this pathway has been demonstrated in multiple animal species, evidence of a similar CSF egress mechanism involving the nasal cavity in humans remains poorly consolidated. This review will synthesize contemporary evidence surrounding CSF clearance at the nose-brain interface, examining across species this anatomical pathway, and its possible significance to human neurodegenerative disease. Our discussion of a bidirectional nasal pathway includes examination of the immune surveillance in the olfactory region protecting the brain. Overall, we expect that an expanded discussion of the brain-nose pathway and interactions with the environment will contribute to an improved understanding of neurodegenerative and infectious diseases, and potentially to novel prevention and treatment considerations.
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Affiliation(s)
- Neel H. Mehta
- Undergraduate Department of Biology, Cornell University, Ithaca, NY, United States
| | | | - Angela R. Kamer
- Department of Periodontology and Implant Dentistry, NYU College of Dentistry, New York, NY, United States
| | - Roxana O. Carare
- Department of Medicine, University of Southampton, Southampton, United Kingdom
| | - Tracy Butler
- Department of Radiology, Brain Health Imaging Institute, Weill Cornell Medicine, New York, NY, United States
| | - Henry Rusinek
- Department of Radiology, NYU Langone Health, New York, NY, United States
| | - Gloria C. Chiang
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Yi Li
- Department of Radiology, Brain Health Imaging Institute, Weill Cornell Medicine, New York, NY, United States
| | - Sara Strauss
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - L. A. Saint-Louis
- Department of Radiology, NYU Langone Health, New York, NY, United States
| | - Neil D. Theise
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, United States
| | - Richard A. Suss
- Division of Neuroradiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kaj Blennow
- Clinical Neurochemistry Lab, Inst. of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Michael Kaplitt
- Laboratory of Molecular Neurosurgery, Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, United States
| | - Mony J. de Leon
- Department of Radiology, Brain Health Imaging Institute, Weill Cornell Medicine, New York, NY, United States
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14
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Toro EF, Celant M, Zhang Q, Contarino C, Agarwal N, Linninger A, Müller LO. Cerebrospinal fluid dynamics coupled to the global circulation in holistic setting: Mathematical models, numerical methods and applications. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3532. [PMID: 34569188 PMCID: PMC9285081 DOI: 10.1002/cnm.3532] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/13/2021] [Indexed: 06/13/2023]
Abstract
This paper presents a mathematical model of the global, arterio-venous circulation in the entire human body, coupled to a refined description of the cerebrospinal fluid (CSF) dynamics in the craniospinal cavity. The present model represents a substantially revised version of the original Müller-Toro mathematical model. It includes one-dimensional (1D), non-linear systems of partial differential equations for 323 major blood vessels and 85 zero-dimensional, differential-algebraic systems for the remaining components. Highlights include the myogenic mechanism of cerebral blood regulation; refined vasculature for the inner ear, the brainstem and the cerebellum; and viscoelastic, rather than purely elastic, models for all blood vessels, arterial and venous. The derived 1D parabolic systems of partial differential equations for all major vessels are approximated by hyperbolic systems with stiff source terms following a relaxation approach. A major novelty of this paper is the coupling of the circulation, as described, to a refined description of the CSF dynamics in the craniospinal cavity, following Linninger et al. The numerical solution methodology employed to approximate the hyperbolic non-linear systems of partial differential equations with stiff source terms is based on the Arbitrary DERivative Riemann problem finite volume framework, supplemented with a well-balanced formulation, and a local time stepping procedure. The full model is validated through comparison of computational results against published data and bespoke MRI measurements. Then we present two medical applications: (i) transverse sinus stenoses and their relation to Idiopathic Intracranial Hypertension; and (ii) extra-cranial venous strictures and their impact in the inner ear circulation, and its implications for Ménière's disease.
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Affiliation(s)
| | - Morena Celant
- Department of MathematicsUniversity of TrentoTrentoItaly
| | - Qinghui Zhang
- Laboratory of Applied Mathematics, DICAMUniversity of TrentoTrentoItaly
| | | | | | - Andreas Linninger
- Department of BioengineeringUniversity of Illinois at ChicagoChicagoIllinoisUSA
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15
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Ludwig HC, Bock HC, Gärtner J, Schiller S, Frahm J, Dreha-Kulaczewski S. Hydrocephalus Revisited: New Insights into Dynamics of Neurofluids on Macro- and Microscales. Neuropediatrics 2021; 52:233-241. [PMID: 34192788 DOI: 10.1055/s-0041-1731981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
New experimental and clinical findings question the historic view of hydrocephalus and its 100-year-old classification. In particular, real-time magnetic resonance imaging (MRI) evaluation of cerebrospinal fluid (CSF) flow and detailed insights into brain water regulation on the molecular scale indicate the existence of at least three main mechanisms that determine the dynamics of neurofluids: (1) inspiration is a major driving force; (2) adequate filling of brain ventricles by balanced CSF upsurge is sensed by cilia; and (3) the perivascular glial network connects the ependymal surface to the pericapillary Virchow-Robin spaces. Hitherto, these aspects have not been considered a common physiologic framework, improving knowledge and therapy for severe disorders of normal-pressure and posthemorrhagic hydrocephalus, spontaneous intracranial hypotension, and spaceflight disease.
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Affiliation(s)
- Hans C Ludwig
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Hans C Bock
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Jutta Gärtner
- Division of Pediatric Neurology, Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Stina Schiller
- Division of Pediatric Neurology, Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Frahm
- Biomedical NMR, Max Planck Institute for Biophysical Chemistry, Göttingen, Germany
| | - Steffi Dreha-Kulaczewski
- Division of Pediatric Neurology, Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, Göttingen, Germany
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16
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Naseri Kouzehgarani G, Feldsien T, Engelhard HH, Mirakhur KK, Phipps C, Nimmrich V, Clausznitzer D, Lefebvre DR. Harnessing cerebrospinal fluid circulation for drug delivery to brain tissues. Adv Drug Deliv Rev 2021; 173:20-59. [PMID: 33705875 DOI: 10.1016/j.addr.2021.03.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/10/2021] [Accepted: 03/01/2021] [Indexed: 12/31/2022]
Abstract
Initially thought to be useful only to reach tissues in the immediate vicinity of the CSF circulatory system, CSF circulation is now increasingly viewed as a viable pathway to deliver certain therapeutics deeper into brain tissues. There is emerging evidence that this goal is achievable in the case of large therapeutic proteins, provided conditions are met that are described herein. We show how fluid dynamic modeling helps predict infusion rate and duration to overcome high CSF turnover. We posit that despite model limitations and controversies, fluid dynamic models, pharmacokinetic models, preclinical testing, and a qualitative understanding of the glymphatic system circulation can be used to estimate drug penetration in brain tissues. Lastly, in addition to highlighting landmark scientific and medical literature, we provide practical advice on formulation development, device selection, and pharmacokinetic modeling. Our review of clinical studies suggests a growing interest for intra-CSF delivery, particularly for targeted proteins.
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17
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González J, Pinzón A, Angarita-Rodríguez A, Aristizabal AF, Barreto GE, Martín-Jiménez C. Advances in Astrocyte Computational Models: From Metabolic Reconstructions to Multi-omic Approaches. Front Neuroinform 2020; 14:35. [PMID: 32848690 PMCID: PMC7426703 DOI: 10.3389/fninf.2020.00035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/14/2020] [Indexed: 12/12/2022] Open
Abstract
The growing importance of astrocytes in the field of neuroscience has led to a greater number of computational models devoted to the study of astrocytic functions and their metabolic interactions with neurons. The modeling of these interactions demands a combined understanding of brain physiology and the development of computational frameworks based on genomic-scale reconstructions, system biology, and dynamic models. These computational approaches have helped to highlight the neuroprotective mechanisms triggered by astrocytes and other glial cells, both under normal conditions and during neurodegenerative processes. In the present review, we evaluate some of the most relevant models of astrocyte metabolism, including genome-scale reconstructions and astrocyte-neuron interactions developed in the last few years. Additionally, we discuss novel strategies from the multi-omics perspective and computational models of other glial cell types that will increase our knowledge in brain metabolism and its association with neurodegenerative diseases.
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Affiliation(s)
- Janneth González
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Andrés Pinzón
- Laboratorio de Bioinformática y Biología de Sistemas, Universidad Nacional de Colombia Bogotá, Bogotá, Colombia
| | - Andrea Angarita-Rodríguez
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia.,Laboratorio de Bioinformática y Biología de Sistemas, Universidad Nacional de Colombia Bogotá, Bogotá, Colombia
| | - Andrés Felipe Aristizabal
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - George E Barreto
- Department of Biological Sciences, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Cynthia Martín-Jiménez
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
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18
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Donatelli D, Romagnoli L. Nonreflecting Boundary Conditions for a CSF Model of Fourth Ventricle: Spinal SAS Dynamics. Bull Math Biol 2020; 82:77. [PMID: 32535866 DOI: 10.1007/s11538-020-00749-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 05/15/2020] [Indexed: 11/24/2022]
Abstract
In this paper, we introduce a one-dimensional model for analyzing the cerebrospinal fluid dynamics within the fourth ventricle and the spinal subarachnoid space (SSAS). The model has been derived starting from an original model of Linninger et al. and from the detailed mathematical analysis of two different reformulations. We show the steps of the modelization and the rigorous analysis of the first-order nonlinear hyperbolic system of equations which rules the new CSF model, whose conservative-law form and characteristic form are required for the boundary conditions treatment. By assuming sub-critical flows, for the particular dynamics we are dealing with, the most desirable option is to employ the nonreflecting boundary conditions, that allow the simple wave associated with the outgoing characteristic to exit the computational domain with no reflections. Finally, we carry out some numerical simulations related to different cerebral physiological conditions.
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Affiliation(s)
- Donatella Donatelli
- Department of Information Engineering, Computer Science and Mathematics, University of L'Aquila, 67100, L'Aquila, Italy.
| | - Licia Romagnoli
- Department of Information Engineering, Computer Science and Mathematics, University of L'Aquila, 67100, L'Aquila, Italy
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19
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Vinje V, Eklund A, Mardal KA, Rognes ME, Støverud KH. Intracranial pressure elevation alters CSF clearance pathways. Fluids Barriers CNS 2020; 17:29. [PMID: 32299464 PMCID: PMC7161287 DOI: 10.1186/s12987-020-00189-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/28/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Infusion testing is a common procedure to determine whether shunting will be beneficial in patients with normal pressure hydrocephalus. The method has a well-developed theoretical foundation and corresponding mathematical models that describe the CSF circulation from the choroid plexus to the arachnoid granulations. Here, we investigate to what extent the proposed glymphatic or paravascular pathway (or similar pathways) modifies the results of the traditional mathematical models. METHODS We used a compartment model to estimate pressure in the subarachnoid space and the paravascular spaces. For the arachnoid granulations, the cribriform plate and the glymphatic circulation, resistances were calculated and used to estimate pressure and flow before and during an infusion test. Finally, different variations to the model were tested to evaluate the sensitivity of selected parameters. RESULTS At baseline intracranial pressure (ICP), we found a very small paravascular flow directed into the subarachnoid space, while 60% of the fluid left through the arachnoid granulations and 40% left through the cribriform plate. However, during the infusion, 80% of the fluid left through the arachnoid granulations, 20% through the cribriform plate and flow in the PVS was stagnant. Resistance through the glymphatic system was computed to be 2.73 mmHg/(mL/min), considerably lower than other fluid pathways, giving non-realistic ICP during infusion if combined with a lymphatic drainage route. CONCLUSIONS The relative distribution of CSF flow to different clearance pathways depends on ICP, with the arachnoid granulations as the main contributor to outflow. As such, ICP increase is an important factor that should be addressed when determining the pathways of injected substances in the subarachnoid space. Our results suggest that the glymphatic resistance is too high to allow for pressure driven flow by arterial pulsations and at the same time too small to allow for a direct drainage route from PVS to cervical lymphatics.
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Affiliation(s)
- Vegard Vinje
- Department of Scientific Computing and Numerical Analysis, Simula Research Laboratory, Lysaker, Norway.
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Kent-Andre Mardal
- Department of Scientific Computing and Numerical Analysis, Simula Research Laboratory, Lysaker, Norway.,Department of Mathematics, University of Oslo, Oslo, Norway
| | - Marie E Rognes
- Department of Scientific Computing and Numerical Analysis, Simula Research Laboratory, Lysaker, Norway
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20
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De Andrés J, Rubio-Haro R, De Andres-Serrano C, Asensio-Samper JM, Fabregat-Cid G. Intrathecal Drug Delivery. Methods Mol Biol 2020; 2059:75-108. [PMID: 31435916 DOI: 10.1007/978-1-4939-9798-5_3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Targeted intrathecal (IT) drug delivery systems (IDDS) are well established as an effective treatment of patients with chronic nonmalignant or malignant pain, and as a tool for management of patients with severe spasticity. The risk to benefit ratio of IDD makes it a relatively safe therapy for both cancer- and noncancer-related pain, but it is not free of risks, so it should be managed at specific centers. Recent technological advances, new therapeutic applications, reported complications, and the costs as well as maintenance required for this therapy require the need to stay up to date about new recommendations that may improve outcomes. This chapter reviews all technological issues regarding IDDS implantation with follow-up and pharmacological recommendations published during recent years that provide evidence-based decision-making process in the management of chronic pain and spasticity in patients.
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Affiliation(s)
- José De Andrés
- Unit of Anesthesia, Department of Surgical Specialties, Valencia University Medical School, Valencia, Spain. .,Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain.
| | - Rubén Rubio-Haro
- Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | | | - Juan Marcos Asensio-Samper
- Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | - Gustavo Fabregat-Cid
- Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
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21
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Salerni F, Repetto R, Harris A, Pinsky P, Prud’homme C, Szopos M, Guidoboni G. Biofluid modeling of the coupled eye-brain system and insights into simulated microgravity conditions. PLoS One 2019; 14:e0216012. [PMID: 31412033 PMCID: PMC6693745 DOI: 10.1371/journal.pone.0216012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/08/2019] [Indexed: 12/23/2022] Open
Abstract
This work aims at investigating the interactions between the flow of fluids in the eyes and the brain and their potential implications in structural and functional changes in the eyes of astronauts, a condition also known as spaceflight associated neuro-ocular syndrome (SANS). To this end, we propose a reduced (0-dimensional) mathematical model of fluid flow in the eyes and brain, which is embedded into a simplified whole-body circulation model. In particular, the model accounts for: (i) the flows of blood and aqueous humor in the eyes; (ii) the flows of blood, cerebrospinal fluid and interstitial fluid in the brain; and (iii) their interactions. The model is used to simulate variations in intraocular pressure, intracranial pressure and blood flow due to microgravity conditions, which are thought to be critical factors in SANS. Specifically, the model predicts that both intracranial and intraocular pressures increase in microgravity, even though their respective trends may be different. In such conditions, ocular blood flow is predicted to decrease in the choroid and ciliary body circulations, whereas retinal circulation is found to be less susceptible to microgravity-induced alterations, owing to a purely mechanical component in perfusion control associated with the venous segments. These findings indicate that the particular anatomical architecture of venous drainage in the retina may be one of the reasons why most of the SANS alterations are not observed in the retina but, rather, in other vascular beds, particularly the choroid. Thus, clinical assessment of ocular venous function may be considered as a determinant SANS factor, for which astronauts could be screened on earth and in-flight.
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Affiliation(s)
- Fabrizia Salerni
- Department of Mathematical, Physical and Computer Sciences, University of Parma, Parma, Italy
| | - Rodolfo Repetto
- Department of Civil, Chemical and Environmental Engineering, University of Genoa, Genoa, Italy
| | - Alon Harris
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Peter Pinsky
- Department of Mechanical Engineering, Stanford University, Stanford, CA, United States of America
| | - Christophe Prud’homme
- Institute of Advanced Mathematical Research UMR 7501, University of Strasbourg CNRS, Strasbourg, France
| | - Marcela Szopos
- Laboratoire MAP5 (UMR CNRS 8145), Université Paris Descartes, Sorbonne Paris Cité, France
| | - Giovanna Guidoboni
- Department of Electrical Engineering and Computer Science, Department of Mathematics, University of Missouri, Columbia, MO, United States of America
- * E-mail:
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22
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Bothwell SW, Janigro D, Patabendige A. Cerebrospinal fluid dynamics and intracranial pressure elevation in neurological diseases. Fluids Barriers CNS 2019; 16:9. [PMID: 30967147 PMCID: PMC6456952 DOI: 10.1186/s12987-019-0129-6] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/19/2019] [Indexed: 01/09/2023] Open
Abstract
The fine balance between the secretion, composition, volume and turnover of cerebrospinal fluid (CSF) is strictly regulated. However, during certain neurological diseases, this balance can be disrupted. A significant disruption to the normal CSF circulation can be life threatening, leading to increased intracranial pressure (ICP), and is implicated in hydrocephalus, idiopathic intracranial hypertension, brain trauma, brain tumours and stroke. Yet, the exact cellular, molecular and physiological mechanisms that contribute to altered hydrodynamic pathways in these diseases are poorly defined or hotly debated. The traditional views and concepts of CSF secretion, flow and drainage have been challenged, also due to recent findings suggesting more complex mechanisms of brain fluid dynamics than previously proposed. This review evaluates and summarises current hypotheses of CSF dynamics and presents evidence for the role of impaired CSF dynamics in elevated ICP, alongside discussion of the proteins that are potentially involved in altered CSF physiology during neurological disease. Undoubtedly CSF secretion, absorption and drainage are important aspects of brain fluid homeostasis in maintaining a stable ICP. Traditionally, pharmacological interventions or CSF drainage have been used to reduce ICP elevation due to over production of CSF. However, these drugs are used only as a temporary solution due to their undesirable side effects. Emerging evidence suggests that pharmacological targeting of aquaporins, transient receptor potential vanilloid type 4 (TRPV4), and the Na+-K+-2Cl- cotransporter (NKCC1) merit further investigation as potential targets in neurological diseases involving impaired brain fluid dynamics and elevated ICP.
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Affiliation(s)
- Steven William Bothwell
- Brain Barriers Group, School of Biomedical Sciences and Pharmacy, The University of Newcastle, Medical Sciences Building, University Drive, Callaghan, NSW 2308 Australia
| | - Damir Janigro
- FloTBI Inc., Cleveland, OH USA
- Department of Physiology, Case Western Reserve University, Cleveland, OH USA
| | - Adjanie Patabendige
- Brain Barriers Group, School of Biomedical Sciences and Pharmacy, The University of Newcastle, Medical Sciences Building, University Drive, Callaghan, NSW 2308 Australia
- Hunter Medical Research Institute, Newcastle, NSW Australia
- The Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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23
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Oh MI, Gupta M, Oh CI, Weaver DF. Understanding the effect of nanoconfinement on the structure of water hydrogen bond networks. Phys Chem Chem Phys 2019; 21:26237-26250. [DOI: 10.1039/c9cp05014k] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Dynamic hydrogen bond trails in water confined between two phospholipid membranes traced by the information flow model.
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Affiliation(s)
- Myong In Oh
- Krembil Research Institute
- University Health Network
- Toronto
- Canada
| | - Mayuri Gupta
- Krembil Research Institute
- University Health Network
- Toronto
- Canada
| | - Chang In Oh
- Department of Mathematics
- University of Western Ontario
- London
- Canada
| | - Donald F. Weaver
- Departments of Medicine, Chemistry, and Pharmaceutical Sciences
- University of Toronto
- Toronto
- Canada
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24
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Cerebrospinal Fluid Dynamics and Intrathecal Delivery. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00067-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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25
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Krishnamurthy S, Li J, Shen Y, Duncan TM, Jenrow KA, Haacke EM. Normal macromolecular clearance out of the ventricles is delayed in hydrocephalus. Brain Res 2017; 1678:337-355. [PMID: 29066366 DOI: 10.1016/j.brainres.2017.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 10/04/2017] [Accepted: 10/12/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Satish Krishnamurthy
- Department of Neurosurgery, Upstate Medical University, Syracuse, NY 13210, USA.
| | - Jie Li
- Department of Neurosurgery, Upstate Medical University, Syracuse, NY 13210, USA
| | - Yimin Shen
- Department of Radiology, Wayne State University, Detroit, MI 48201, USA
| | - Thomas M Duncan
- Department of Biochemistry and Molecular Biology, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | - Kenneth A Jenrow
- Department of Psychology, Central Michigan University, Mount Pleasant, MI 48859, USA
| | - E Mark Haacke
- Department of Radiology, Wayne State University, Detroit, MI 48201, USA
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26
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Stoner R, Camilleri V, Calleja-Agius J, Schembri-Wismayer P. The cytokine-hormone axis - the link between premenstrual syndrome and postpartum depression. Gynecol Endocrinol 2017; 33:588-592. [PMID: 28443697 DOI: 10.1080/09513590.2017.1318367] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Premenstrual syndrome (PMS) and related disorders, and postpartum depression (PPD) can affect women to the extent that their quality of life and that of their near ones can be severely impaired. This review focuses on the different theories regarding the etiologies of PMS and PPD, and attempts to draw a link between the two. Theories focus mainly on hormonal and cytokine factors throughout different phases in the female reproductive cycle. Changes in this symptomatology during pregnancy are also reviewed, as are changes in hormones and cytokine levels. Hypotheses are thus developed as to why the symptoms experienced in PMS often subside during pregnancy yet may recur and be exacerbated after birth, giving rise to the symptoms experienced in PPD.
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Affiliation(s)
- Rebecca Stoner
- a Department of Anatomy , Faculty of Medicine and Surgery, University of Malta , Msida , Malta
| | - Victoria Camilleri
- a Department of Anatomy , Faculty of Medicine and Surgery, University of Malta , Msida , Malta
| | - Jean Calleja-Agius
- a Department of Anatomy , Faculty of Medicine and Surgery, University of Malta , Msida , Malta
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27
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Intracranial volumetric changes govern cerebrospinal fluid flow in the Aqueduct of Sylvius in healthy adults. Biomed Signal Process Control 2017. [DOI: 10.1016/j.bspc.2017.03.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Role of choroid plexus in cerebrospinal fluid hydrodynamics. Neuroscience 2017; 354:69-87. [DOI: 10.1016/j.neuroscience.2017.04.025] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 04/19/2017] [Accepted: 04/19/2017] [Indexed: 12/24/2022]
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Goffin C, Leonhardt S, Radermacher K. The Role of a Dynamic Craniospinal Compliance in NPH—A Review and Future Challenges. IEEE Rev Biomed Eng 2017; 10:310-322. [DOI: 10.1109/rbme.2016.2620493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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30
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Hladky SB, Barrand MA. Fluid and ion transfer across the blood-brain and blood-cerebrospinal fluid barriers; a comparative account of mechanisms and roles. Fluids Barriers CNS 2016; 13:19. [PMID: 27799072 PMCID: PMC5508927 DOI: 10.1186/s12987-016-0040-3] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 09/01/2016] [Indexed: 12/24/2022] Open
Abstract
The two major interfaces separating brain and blood have different primary roles. The choroid plexuses secrete cerebrospinal fluid into the ventricles, accounting for most net fluid entry to the brain. Aquaporin, AQP1, allows water transfer across the apical surface of the choroid epithelium; another protein, perhaps GLUT1, is important on the basolateral surface. Fluid secretion is driven by apical Na+-pumps. K+ secretion occurs via net paracellular influx through relatively leaky tight junctions partially offset by transcellular efflux. The blood-brain barrier lining brain microvasculature, allows passage of O2, CO2, and glucose as required for brain cell metabolism. Because of high resistance tight junctions between microvascular endothelial cells transport of most polar solutes is greatly restricted. Because solute permeability is low, hydrostatic pressure differences cannot account for net fluid movement; however, water permeability is sufficient for fluid secretion with water following net solute transport. The endothelial cells have ion transporters that, if appropriately arranged, could support fluid secretion. Evidence favours a rate smaller than, but not much smaller than, that of the choroid plexuses. At the blood-brain barrier Na+ tracer influx into the brain substantially exceeds any possible net flux. The tracer flux may occur primarily by a paracellular route. The blood-brain barrier is the most important interface for maintaining interstitial fluid (ISF) K+ concentration within tight limits. This is most likely because Na+-pumps vary the rate at which K+ is transported out of ISF in response to small changes in K+ concentration. There is also evidence for functional regulation of K+ transporters with chronic changes in plasma concentration. The blood-brain barrier is also important in regulating HCO3- and pH in ISF: the principles of this regulation are reviewed. Whether the rate of blood-brain barrier HCO3- transport is slow or fast is discussed critically: a slow transport rate comparable to those of other ions is favoured. In metabolic acidosis and alkalosis variations in HCO3- concentration and pH are much smaller in ISF than in plasma whereas in respiratory acidosis variations in pHISF and pHplasma are similar. The key similarities and differences of the two interfaces are summarized.
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Affiliation(s)
- Stephen B. Hladky
- Department of Pharmacology, University of Cambridge, Tennis Court Road, Cambridge, CB2 1PD UK
| | - Margery A. Barrand
- Department of Pharmacology, University of Cambridge, Tennis Court Road, Cambridge, CB2 1PD UK
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31
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Desai B, Hsu Y, Schneller B, Hobbs JG, Mehta AI, Linninger A. Hydrocephalus: the role of cerebral aquaporin-4 channels and computational modeling considerations of cerebrospinal fluid. Neurosurg Focus 2016; 41:E8. [DOI: 10.3171/2016.7.focus16191] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Aquaporin-4 (AQP4) channels play an important role in brain water homeostasis. Water transport across plasma membranes has a critical role in brain water exchange of the normal and the diseased brain. AQP4 channels are implicated in the pathophysiology of hydrocephalus, a disease of water imbalance that leads to CSF accumulation in the ventricular system. Many molecular aspects of fluid exchange during hydrocephalus have yet to be firmly elucidated, but review of the literature suggests that modulation of AQP4 channel activity is a potentially attractive future pharmaceutical therapy. Drug therapy targeting AQP channels may enable control over water exchange to remove excess CSF through a molecular intervention instead of by mechanical shunting. This article is a review of a vast body of literature on the current understanding of AQP4 channels in relation to hydrocephalus, details regarding molecular aspects of AQP4 channels, possible drug development strategies, and limitations. Advances in medical imaging and computational modeling of CSF dynamics in the setting of hydrocephalus are summarized. Algorithmic developments in computational modeling continue to deepen the understanding of the hydrocephalus disease process and display promising potential benefit as a tool for physicians to evaluate patients with hydrocephalus.
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Affiliation(s)
| | - Ying Hsu
- 2Bioengineering, University of Illinois at Chicago; and
| | | | | | | | - Andreas Linninger
- Departments of 1Neurosurgery and
- 2Bioengineering, University of Illinois at Chicago; and
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32
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The Role of the Craniocervical Junction in Craniospinal Hydrodynamics and Neurodegenerative Conditions. Neurol Res Int 2015; 2015:794829. [PMID: 26770824 PMCID: PMC4681798 DOI: 10.1155/2015/794829] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 09/07/2015] [Accepted: 09/17/2015] [Indexed: 02/07/2023] Open
Abstract
The craniocervical junction (CCJ) is a potential choke point for craniospinal hydrodynamics and may play a causative or contributory role in the pathogenesis and progression of neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, MS, and ALS, as well as many other neurological conditions including hydrocephalus, idiopathic intracranial hypertension, migraines, seizures, silent-strokes, affective disorders, schizophrenia, and psychosis. The purpose of this paper is to provide an overview of the critical role of the CCJ in craniospinal hydrodynamics and to stimulate further research that may lead to new approaches for the prevention and treatment of the above neurodegenerative and neurological conditions.
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Jessen NA, Munk ASF, Lundgaard I, Nedergaard M. The Glymphatic System: A Beginner's Guide. Neurochem Res 2015; 40:2583-99. [PMID: 25947369 DOI: 10.1007/s11064-015-1581-6] [Citation(s) in RCA: 1025] [Impact Index Per Article: 113.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/06/2015] [Accepted: 04/10/2015] [Indexed: 12/16/2022]
Abstract
The glymphatic system is a recently discovered macroscopic waste clearance system that utilizes a unique system of perivascular tunnels, formed by astroglial cells, to promote efficient elimination of soluble proteins and metabolites from the central nervous system. Besides waste elimination, the glymphatic system also facilitates brain-wide distribution of several compounds, including glucose, lipids, amino acids, growth factors, and neuromodulators. Intriguingly, the glymphatic system function mainly during sleep and is largely disengaged during wakefulness. The biological need for sleep across all species may therefore reflect that the brain must enter a state of activity that enables elimination of potentially neurotoxic waste products, including β-amyloid. Since the concept of the glymphatic system is relatively new, we will here review its basic structural elements, organization, regulation, and functions. We will also discuss recent studies indicating that glymphatic function is suppressed in various diseases and that failure of glymphatic function in turn might contribute to pathology in neurodegenerative disorders, traumatic brain injury and stroke.
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Affiliation(s)
- Nadia Aalling Jessen
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 645, Rochester, NY, 14642, USA.
| | - Anne Sofie Finmann Munk
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 645, Rochester, NY, 14642, USA
| | - Iben Lundgaard
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 645, Rochester, NY, 14642, USA
| | - Maiken Nedergaard
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 645, Rochester, NY, 14642, USA
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34
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Nanoparticle-mediated growth factor delivery systems: A new way to treat Alzheimer's disease. J Control Release 2015; 206:187-205. [DOI: 10.1016/j.jconrel.2015.03.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/19/2015] [Accepted: 03/20/2015] [Indexed: 01/03/2023]
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35
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Gates PC. Resolution of idiopathic intracranial hypertension after sustained lowering of cerebrospinal fluid pressure. World J Neurol 2015; 5:47-51. [DOI: 10.5316/wjn.v5.i1.47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 01/28/2015] [Accepted: 03/09/2015] [Indexed: 02/06/2023] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a syndrome of headache due to raised intracranial pressure (ICP) where the cerebrospinal fluid (CSF) is normal and there is no alternative pathology on imaging. The aetiology is unknown. This review questions many of the prevailing views regarding aetiology and treatment of IIH. It explores the concept that there is a vicious cycle of fluctuating raised ICP leading to secondary compression of the transverse sinuses and further elevation of ICP. It also raises the question as to whether this vicious cycle could be relieved by prolonged drainage of CSF as seen in Lumbar puncture induced low-pressure headache or alternatively a lumbar drain.
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36
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Spector R, Keep RF, Robert Snodgrass S, Smith QR, Johanson CE. A balanced view of choroid plexus structure and function: Focus on adult humans. Exp Neurol 2015; 267:78-86. [PMID: 25747036 DOI: 10.1016/j.expneurol.2015.02.032] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/22/2015] [Accepted: 02/25/2015] [Indexed: 12/21/2022]
Abstract
Recently tremendous progress has been made in studying choroid plexus (CP) physiology and pathophysiology; and correcting several misconceptions about the CP. Specifically, the details of how CP, a locus of the blood-CSF barrier (BCSFB), secretes and purifies CSF, generates intracranial pressure (ICP), maintains CSF ion homeostasis, and provides micronutrients, proteins and hormones for neuronal and glial development, maintenance and function, are being understood on a molecular level. Unequivocal evidence that the CP secretory epithelium is the predominant supplier of CSF for the ventricles comes from multiple lines: uptake kinetics of tracer (22)Na and (36)Cl penetration from blood to CSF, autoradiographic mapping of rapid (22)Na and (36)Cl permeation (high permeability coefficients) into the cerebroventricles, CSF sampling from several different in vivo and in vitro CP preparations, CP hyperplasia that increases CSF formation and ICP; and in vitro analysis of CP ability to transport molecules (with expected directionality) and actively secrete fluid against an hydrostatic fluid column. Furthermore, clinical support for this CP-CSF model comes from neurosurgical procedures to remove lateral ventricle CPs in hydrocephalic children to reduce CSF formation, thereby relieving elevated ICP. In terms of micronutrient transport, ascorbic acid, folate and other essential factors are transported by specific (cloned) carriers across CP into ventricular CSF, from which they penetrate across the ependyma and pia mater deeply into the brain to support its viability and function. Without these choroidal functions, severe neurological disease and even death can occur. In terms of efflux or clearance transport, the active carriers (many of which have been cloned and expressed) in the CP basolateral and apical membranes perform regulatory removal of some metabolites (e.g. choline) and certain drugs (e.g. antibiotics like penicillin) from CSF, thus reducing agents such as penicillin to sub-therapeutic levels. Altogether, these multiple transport and secretory functions in CP support CSF homeostasis and fluid dynamics essential for brain function.
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Affiliation(s)
- Reynold Spector
- Department of Medicine, Robert Wood Johnson Medical School, Piscataway, NJ 08554, USA.
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI 48105, USA.
| | - S Robert Snodgrass
- Departments of Neurology and Pediatrics, Harbor-UCLA Medical Center, David Geffen UCLA School of Medicine, Torrance, CA 90502, USA.
| | - Quentin R Smith
- Department of Pharmaceutical Sciences, School of Pharmacy, Amarillo, TX 79106, USA.
| | - Conrad E Johanson
- Department of Neurosurgery, Alpert Medical School at Brown University, Providence, RI 02903, USA.
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