Fluids and Barriers of the CNS

Background: Cerebrospinal fluid (CSF) circulation is important for maintaining homeostasis of the central nervous system. Previous studies have largely focused on the ventricular system, the craniocervical junction, or local spinal segments, leaving the overall and spatially heterogeneous characteristics of CSF flow across the craniospinal axis insufficiently characterized. The spinal subarachnoid space (SAS) is often treated as a homogeneous annular compartment surrounding the spinal cord, an approach that may obscure directional differences among its internal regions. Methods: This single-center, exploratory, prospective imaging study enrolled 15 healthy volunteers. All participants underwent 3.0-T electrocardiography-gated two-dimensional cine phase-contrast magnetic resonance imaging (Cine PC-MRI) and high-resolution T2-weighted imaging. CSF was evaluated at the level of the cerebral aqueduct outlet/fourth-ventricle inlet, C1-C2, C5-C6, T5-T6, L1-L2, and the lumbar cistern. Region-of-interest (ROI)-based quantitative analysis using Q-Flow software recorded mean velocity, absolute peak velocity, and directional peak velocity. Results: Multiplanar Cine PC-MRI showed that CSF phase signals within the spinal SAS were not uniformly distributed but formed two principal flow regions, ventral and dorsal. Mean velocity and absolute peak velocity were similar between the ventral and dorsal regions, whereas directional peak velocity differed (1.50 +/- 2.98 cm/s vs. -0.38 +/- 3.23 cm/s, P = 0.036). High-resolution T2-weighted imaging showed denticulate ligaments, nerve roots, and associated fibrous connective tissue in the lateral transition zones between the two regions. Conclusions: In healthy adults, CSF flow in the spinal SAS was not synchronous motion within a single homogeneous compartment; rather, it showed longitudinal oscillatory flow in ventral and dorsal regions coupled to the cardiac cycle. These findings provide preliminary in vivo evidence for studies of CSF hydrodynamics across the craniospinal axis and an imaging basis for investigating CSF circulation disturbances in conditions such as hydrocephalus, Chiari malformation, syringomyelia, and arachnoid adhesions.

Hydrocephalus arises from pathological disturbances in cerebrospinal fluid (CSF) homeostasis, yet current treatment relies almost exclusively on neurosurgical diversion procedures that frequently require surgical revision. No specific and efficient pharmacological alternative is available as a complement to the invasive neurosurgery due to our lack of understanding of the molecular regulators of CSF secretion. By in vivo determination of CSF dynamics in rats and in vitro quantification of choroid plexus transporter activity, we demonstrate that the STE20-proline-alanine-rich kinase (SPAK) is a critical modulator of CSF secretion via its regulation of the Na+/K+/2Cl- cotransporter 1 (NKCC1) and the Na/K-ATPase. Systemic administration of a SPAK inhibitor after a mimicked hemorrhagic event attenuated posthemorrhagic hydrocephalus formation 24h post-hemorrhage. Activation of the choroid plexus transient receptor potential vanilloid 4 (TRPV4) ion channel induced hydrocephalus through CSF hypersecretion. This TRPV4-mediated hypersecretion occurred via activation of NKCC1, not the Na+/K+-ATPase, and required SPAK activity as a molecular link. Together, these findings identify SPAK as a central integrator of TRPV4-dependent signaling and choroid plexus transporter activity, positioning the TRPV4-SPAK axis as a potential pharmacological target for modulating CSF dynamics in hydrocephalus and other pressure-related pathologies.

BACKGROUND: Cerebral ischemia following subarachnoid hemorrhage (SAH) has traditionally been considered transient because functional alterations of the cerebral microcirculation are thought to be self-limiting. However, we identified a previously unrecognized vasculopathy, perivascular fibrosis of the cerebral microcirculation (PFCM), characterized by excessive type I collagen deposition after SAH. This study investigated the mechanisms underlying PFCM and its subsequent effects on cerebral hemodynamics. METHODS: In vivo SAH was modeled in mice by autologous blood injection, whereas oxygenated hemoglobin (OxyHb) exposure was used to mimic SAH in vitro. Pericyte-deficient mice (Pdgfr{beta}+/-) and pericyte-specific vestigial-like family member 3 (VGLL3) conditional knockout mice (Vgll3{Delta}PC) were generated. Pericyte contractility was measured by nanoindentation and traction force microscopy. Molecular mechanisms were examined using Western blotting, immunofluorescence, CUT&Tag, RNA-seq, transmission electron microscopy, and molecular docking. PFCM, impaired dilation of the cerebral microcirculation, and cerebral autoregulation were assessed by two-photon imaging, transcranial Doppler with continuous blood pressure monitoring, super-resolution ultrasound imaging, and photoacoustic imaging. RESULTS: After SAH, mice developed long-term cerebral autoregulation dysfunction marked by impaired dilation of the cerebral microcirculation, with the abnormality being most evident within the relatively lower blood pressure range. The marked reduction in PFCM in Pdgfr{beta}+/- mice indicated that pericytes were the principal cellular contributors. Mechanistically, OxyHb-induced cytoskeletal remodeling in vitro increased pericyte contractility and promoted nuclear translocation of SAH-upregulated VGLL3. This was followed by increased genomic occupancy, Col1a1 transcriptional activation, and type I collagen deposition. Pericyte-specific VGLL3 knockout abolished PFCM and, consequently, significantly alleviated long-term cerebral autoregulation dysfunction. CONCLUSIONS: Our findings identify PFCM mediated by pericytic VGLL3 as a novel vasculopathy leading to long-term cerebral autoregulation dysfunction after SAH.

Spinal cord injury (SCI) is an incurable neurological condition in which post-traumatic edema contributes to secondary ischemic damage because the spinal cord is confined within the rigid vertebral canal. However, glymphatic transport in the healthy and injured spinal cord remains poorly characterized. We hypothesized that spinal cerebrospinal (CSF) and glymphatic transport is shaped by anatomy, administration route, and molecular size of the tracer; is disrupted after SCI; and is further impaired by loss of aquaporin-4 (AQP4). CSF tracers were administered by cisterna magna or lumbar intrathecal injection to anesthetized adult C57BL/6 mice. Dynamic contrast-enhanced MRI, ex vivo fluorescence imaging, and histology were used to characterize tracer distribution, influx, and clearance. Constrictions of the spinal subarachnoid space at C3-C7, T6-T12 and L5-S1 spinal segments accelerated contrast-agent dispersion, demonstrating that local anatomy regulates spinal CSF transport. Tracer influx into the cord itself occurred primarily along periarterial pathways.Tracer distribution depended on the administration route: cisterna magna injection preferentially labeled white matter in the upper spinal cord, whereas lumbar injection preferentially labeled grey matter in the lower spinal cord. Gadobutrol and ovalbumin penetrated and dispersed throughout the parenchyma, whereas fibrinogen remained confined to the meninges. Under physiological conditions, intraparenchymal tracers cleared within 24 h. SCI was modeled using a minimally invasive NMDA-induced lesion at T11 that produced focal necrosis while preserving the dura and vertebral structures. Glymphatic transport, lesion volume, and motor recovery were compared between wild-type and AQP4-knockout mice using imaging, the Basso Mouse Scale, and voluntary wheel running. After SCI, intrathecal contrast propagated more rapidly, especially at T7-T8 segments and at the S1 segment, but tissue clearance was profoundly impaired, with tracer retention persisting for up to seven days. AQP4-knockout mice showed greater clearance impairment, larger lesions, and poorer motor recovery than wild-type controls compared at 24 h. These findings define major determinants of spinal glymphatic transport and show that accelerated tracer propagation after SCI does not indicate effective clearance. Instead, SCI produces glymphatic dysfunction that is exacerbated by loss of AQP4 and associated with greater tissue damage and functional impairment. The results extend the glymphatic framework to the spinal cord and identify fluid-clearance pathways as potential therapeutic targets for limiting edema and secondary injury. Future studies should determine whether restoring glymphatic function improves neurological recovery after SCI.

Chiari I malformation (CM-I) is conventionally defined by cerebellar tonsil position, yet tonsil position is an indirect surrogate for the anatomic obstruction that impairs cerebrospinal fluid (CSF) flow across the craniocervical junction (CCJ). We hypothesized that CCJ crowding, quantified as subarachnoid space narrowing at the foramen magnum and C1, would explain CSF flow impairment more directly than tonsil position. Using non-invasive low b-value diffusion-weighted MRI (low-b dMRI), we quantified effective CSF motility, indexed by mean pseudo diffusivity (M{psi}), across the upper cervical spine, CCJ, and posterior fossa. Voxel-wise CCJ CSF pseudo-diffusion spatial statistics were integrated with CSF Waterways atlas-based regional analyses. We applied this approach in 81 pediatric and adult participants with CM I to determine how CCJ structural features shape regional CSF dynamics and clinical outcomes. Voxel wise analyses revealed that crowding at the foramen magnum was the dominant structural determinant of reduced intracranial CSF effective motility across the CCJ, basilar cisterns, and fourth ventricular outflow pathways (family-wise error corrected p < 0.05). While lower tonsil position and C1 level crowding were also associated with reduced CSF effective motility across the CCJ and fourth ventricular outflow pathways, but their associations within the basilar cisterns were spatially restricted to regions adjacent to the Liliequist membrane. Atlas-based region-of-interest analyses confirmed that greater foramen magnum crowding was associated with lower M{psi} across multiple basilar cisterns, but with higher M{psi} in the ventral spinal CSF compartment. Mediation analyses indicated that CCJ crowding at the foramen magnum and C1 accounted for the majority of the relationship between tonsil position and reduced CSF motility in the basilar cisterns. Multivariate M{psi} profiles across the CSF regions identified data-driven foramen magnum crowding thresholds of 69.5% and 77.5%, stratifying patients into mild, moderate, and severe physiological crowding groups. Exploratory analyses linked lower pre-operative CSF M{psi} to greater pain-related functional impairment, reduced cognitive function, and a higher likelihood of subsequent decompression surgery. Together, these findings demonstrate that CCJ crowding, particularly at the foramen magnum, exerts a quantifiable, region specific impact on CSF effective motility in CM I, and that low b dMRI provides a sensitive, complementary marker of CSF flow impairment. This integrative CCJ structural and CSF flow imaging framework establishes a mechanistic link between CCJ anatomy, CSF dynamics, and symptom burden, offering a scalable tool for phenotyping CM I and informing clinical decision making.

Cerebrospinal fluid (CSF) flows through perivascular spaces (PVSs) surrounding brain vasculature, and impaired flow has been linked to neurodegenerative diseases such as Alzheimer's. However, the mechanisms driving CSF flow and its oscillatory dynamics remain poorly understood. Using high frame rate two-photon imaging (up to 113 Hz), we show that CSF flow is spatially heterogeneous and highly pulsatile, quantified using a regional CSF pulsatility index (PI). Reduced-order simulations with realistic domain length and Windkessel boundary conditions show that arterial pulsations generate peak CSF velocities but contribute negligibly to net transport. PI varies non-monotonically in space and substantially with downstream hydraulic resistance and compliance, indicating that CSF pulsatility is an emergent property of the hydraulic network rather than simply a consequence of local arterial wall motion. Measurements and simulations of the phase between arterial wall motion and CSF velocity further constrain proposed CSF driving mechanisms. Finally, we perform mouse-specific simulations to estimate average and peak wall shear stresses which support the potential role of pulsatile CSF flow in perivascular mechanotransduction. Together, these results establish CSF pulsatility as a measurable signature of network-scale CSF dynamics.

Cerebrospinal fluid (CSF) provides a specialized extracellular environment for the central nervous system, which is predominantly produced by the choroid plexus, a highly vascularized epithelial structure whose ion transport processes are fundamental to CSF secretion, composition, and homeostasis. The mechanisms of Na+ entry into choroid plexus epithelial cells (CPECs) from the interstitial side remain disputed. The slc4a10 gene product encoding the Na+-dependent Cl-/HCO3- exchanger, Ncbe, was suggested as a key transport mechanism based on its impact on the cell's Na+-dependent regulation of intracellular pH and its basolateral membrane expression. The current study was undertaken to directly assess the contribution of Ncbe to the Na+ uptake into CPECs. Intracellular Na+ was recorded by fluorometry using the Na+ probe Sodium Binding Fluorescent Indicator in clusters of CPECs with access to both the luminal and basolateral membranes. Removal of extracellular Na+ reduced the apparent ex vivo intracellular [Na+] to ~5 mM from a baseline of ~43 mM in the absence of CO2/HCO3- and ~54 mM in the presence of CO2/HCO3-. Flame photometry estimated the intracellular [Na+] ex vivo to ~28 mM. The CO2/HCO3--dependent rate of [Na+] recovery amounted to ~53% of the total recovery rate upon re-addition of Na+. Experiments with access to only the luminal membrane show a [Na+] recovery of a similar rate as observed in the absence of CO2/HCO3- in the clusters. The CO2/HCO3--independent [Na+] recovery was inhibited to ~50% by the NKCC1 inhibitor bumetanide and to ~30% by the TRPv4 inhibitor RN1734. NHE contributed to a minor extent to the CO2/HCO3--independent transport. The HCO3- transport inhibitor DIDS, however, inhibited the total [Na+] recovery rate to ~50%, indicating a role for Ncbe rather than NBCn1 in the cellular [Na+] recovery. Indeed, docking of DIDS into Ncbe and NBCn1 indicated that both proteins can accommodate the binding of DIDS. However, the orientation of the DIDS poses in Ncbe suggests a binding mode more similar to that found in the Anion Exchangers (SLC4A1-3), which seems to accommodate the covalent-type docking more than NBCn1. The Ncbe inhibition by DIDS was supported by the rate of [Na+] recovery that was significantly higher in CPECs from Ncbe-wt than Ncbe-ko mice in the presence of CO2/HCO3-. As both NKCC1 and TRPv4 are localized to the luminal membrane, the findings collectively suggest that Ncbe is the most prominent mechanism for Na+ entry into CPECs expressed at the basolateral side. We suggest Ncbe as the rate-limiting mechanism in the vectorial Na+ transport driving CSF secretion.

Introduction: Anesthesia is known to modulate glymphatic clearance and cerebrospinal fluid (CSF) transport in rodents, but how these effects translate to a larger, gyrencephalic brain is unknown. With its anatomical similarity to the human brain, the pig offers a valuable translational model for examining anesthesia-dependent CSF-to-brain transport. Methods: We used dynamic in vivo SPECT/CT imaging for six hours following cisterna magna injection of [99mTc]-DTPA to quantify CSF-to-brain tracer transport in pigs under two anesthesia regimens: ketamine/dexmedetomidine (K/D, n=5) which previously has been shown in rodents to enhance glymphatic influx relative to GABAergic anesthesia, and propofol (PRO, n=5). Brain and CSF spaces were delineated using a data-driven non-negative matrix factorization approach, and tracer kinetics were quantified using a one-tissue compartment model. Results: Brain influx could be stably estimated from 2 hours post-injection. Hierarchical sub-division of the brain parenchyma identified two kinetically distinct components with different anatomical distributions: a surface component, located ventrally and within the interhemispheric fissure, showed faster kinetics than the anatomically deeper and lateral-dorsal component. Consistent with rodent findings, K/D-anesthetized pigs showed 62% (p=0.002) greater brain tracer accumulation than PRO-anesthetized pigs. However, while the brain influx rates did not differ substantially (p=0.047), a 52% higher cumulative CSF tracer concentration (p=0.047) could account for most of the difference by providing greater tracer availability for brain entry. Conclusions: In the larger gyrencephalic pig brain, we found higher brain tracer accumulation under K/D anesthesia compared to PRO anesthesia. A significant portion of this difference is readily explained by higher CSF retention, likely driven by a slower CSF turnover. This underscores the necessity of dynamic CSF tracer concentration measurements when assessing CSF-brain influx, a factor we suggest that future glymphatic studies should take into account.

In the brain, the water channel Aquaporin 4 (AQP4) is largely restricted to astrocytes, enriched at perivascular astrocytic processes, and involved in fluid balance and neurological disease. The perivascular pool is functionally unique as it is depolarized in diseases, targeted by neuromyelitis optica autoantibodies, and implicated in the clearance of brain metabolites such as amyloid beta. The perivascular AQP4 was recently shown to be AQP4X, an extended isoform arising from readthrough, where approximately 20% of translating ribosomes continue through the Aqp4 stop codon. Because Aqp4 terminates with a UGA, here we tested whether Aqp4 readthrough can be enhanced by 2,6-diaminopurine, a purine analog known to promote UGA decoding. Using dual luciferase and immunoblotting for AQP4X in cultured cells, we show that the drug promotes Aqp4 readthrough and increases AQP4X levels. For in vivo validation, we use the wild-type mouse as well as a genetically engineered mouse with a stop-to-sense mutation allowing Aqp4 readthrough at 100%. 2,6-diaminopurine elevates perivascular AQP4X levels by approximately 10% after 20 hours of single intracranial injection. It fails to enhance AQP4X levels in animals with stop-to-sense mutation, suggesting its action involves Aqp4 readthrough. Aqp4 readthrough can be a pharmacological target for modulating perivascular AQP4X in neurological disease models.

Neonatal intraventricular haemorrhage (IVH) is a form of haemorrhagic stroke which is most common in premature infants and can cause mortality and lifelong disability. The reaction of brain tissue to extraneous blood is known to trigger several complications including post-haemorrhagic hydrocephalus (PHH), furthering the likelihood of neurological disability and death. The molecular response of the neuron-rich cortex to blood within the first 24 hours of injury, and how this may precipitate secondary brain injury or neurodegeneration, remains poorly defined. This lack of understanding may reduce the development of novel therapeutics aiming to limit the injury caused by neonatal IVH. Here, we utilised a proteome and transcriptome cross-omics approach to characterise cortical responses to blood in a neonatal mouse model of IVH to improve understanding of the effects and drivers of IVH-induced brain injury. The pleiotropic proteoglycan decorin, a well-characterised modulator of the inflammatory cytokine transforming growth factor beta 1, was also studied to identify if it can have any beneficial effects in the cortex. Cross-omics analysis between the transcriptome and proteome highlighted ferroptosis-associated signatures as a key post-IVH cortical injury mechanism. IVH caused a marked depletion of cortical neurons, neurofilaments, and synaptic vesicle proteins, observed through transcriptomics, immunostaining, and proteomics, which were attenuated by decorin treatment. Decorin also produced an enhanced phagocytic response potentially through activation of microglia. These findings highlight the vulnerability of cortical neurons to early injury following IVH in neonates and support decorin as a potential neuroprotective agent. They also suggest that ferroptosis-associated pathways may contribute to early cortical injury and represent a potential therapeutic target in this context.

BACKGROUND. After aneurysmal subarachnoid hemorrhage (aSAH), erythrocyte lysis within cerebrospinal fluid (CSF) releases cell-free hemoglobin, a potential driver of secondary brain injury (SBI). Whether hemolysis precedes SBI and how its temporal associations compare with those of inflammation and neuroglial injury remain unclear. METHODS. In this biomarker profiling study of the prospective multicenter HeMoVal cohort, 259 patients with aSAH requiring external ventricular drainage contributed 2,411 serial CSF samples over days 1-4 after hemorrhage. We quantified 22 analytes using spectrophotometry, immunoassay, and mass spectrometry; 19 were assigned to five prespecified disease pathway composites. Day- and site-adjusted generalized estimating equations estimated associations with same-day SBI and future first SBI (angiographic vasospasm, delayed cerebral ischemia, or delayed ischemic neurological deficit); a day-wise landmark analysis assessed robustness. RESULTS. On the day of sampling, SBI was associated with four pathways, with the largest estimates for inflammation and neuroglial injury. Within the prespecified +72-hour horizon, only hemolysis (OR 1.40 per SD; 95% CI, 1.17-1.68) and the erythrophagocyte response (OR 1.28; 1.07-1.54) had FDR-significant forward associations with first SBI. Hemolysis had the largest forward estimate at every horizon; landmark analysis was concordant (pooled OR 1.86; 95% bootstrap CI, 1.37-2.65). The protective scavenger proteins haptoglobin and hemopexin declined to fitted plateaus of 2.4% and 12.5% of day-1 concentrations, versus ~36% for plasma-protein references. CONCLUSION. In a scavenger-depleted CSF compartment, hemolysis and the erythrophagocyte response were associated with subsequent SBI. These findings identify hemolysis as a candidate upstream process and support testing sustained CSF hemoglobin scavenging to prevent SBI. TRIAL REGISTRATION. ClinicalTrials.gov NCT04998370. FUNDING. CSL Behring; Swiss National Science Foundation; University of Zurich

Human iPSC-derived brain organoids are revolutionizing tools to study layers biology, synergize disease modeling, and accelerate therapeutic discoveries that overcome obstacles in monolayer cell culture or animal models. The neurovascular unit including vasculature and microglia is critical for brain development, maintenance of synaptic plasticity and neural activity, and the high metabolic demands of long-term culture. We present a methodology to incorporate these important components during organoid generation and discuss potential approach, aiming consistent production of vascularized organoids for longitudinal study. We also demonstrate that this vascularized organoid is a versatile platform to model brain cancer and traumatic brain injury.

Background: Cervical spinal cord (CSC) compression and myelopathy are frequent, severe complications in mucopolysaccharidosis (MPS) types I and VI. Early detection is critical to prevent irreversible neurological deficits and preserve quality of life. This prospective study aimed to identify quantitative neuroimaging biomarkers of structural CSC damage and myelopathy in MPS I and VI. Methods: Structural and diffusion magnetic resonance imaging (MRI) of the CSC was analyzed in 17 MPS I patients, 3 MPS VI patients (19{+/-}7 years), and 19 case-matched healthy controls (20{+/-}7 years). CSC macrostructure (cross-sectional area, diameters) and microstructure (fractional anisotropy [FA], radial [RD], mean, axial diffusivities) were evaluated within and beyond the maximal compression areas. Results: MPS patients demonstrated reduced CSC cross-sectional area and anterior-posterior diameter at upper cervical levels, alongside widespread microstructural alterations (lower FA, higher RD) throughout the CSC versus controls (pFDR<0.05). Restricted foramen magnum space was associated with microstructural damage at lower cervical levels without overt macrostructural compression. Morphological and microstructural metrics were sensitive to CSC compression and myelopathy severity (pFDR<0.05). Lower CSC integrity correlated with more advanced growth retardation (p<0.001). Among patients receiving hematopoietic stem cell transplantation, earlier treatment correlated with preserved upper CSC morphology (p<0.05). Distinct neuroimaging phenotypes were observed across MPS genotypes (pFDR<0.05). Conclusions: CSC MRI provides candidate neuroimaging biomarkers for early detection and characterization of myelopathy in MPS I and VI. Structural damage extends beyond primary maximal compression areas, highlighting these markers for clinical monitoring and future therapeutic trials.

BackgroundFlow diversion stent treatment of cerebral aneurysms has demonstrated high rates of aneurysm occlusion and long-term durability. However, complete endothelization of the flow diverting stent is required for parent vessel healing which closes the aneurysm and metal stent from the circulation. Therefore, stent coatings which enhance endothelial migration and attachment may increase the rate of aneurysm occlusion and reduce complications associated with flow diversion treatment. Here we investigate the use of gelatin as a stent surface coating to enhance the rate of stent endothelialization and coverage and increase aneurysm healing. MethodsNitinol- Neuroform stents (Stryker, Kalamazoo, MI) and cobalt-chromium-Pipeline Flex flow diverting stents (Medtronic, Minneapolis, MN) were used for this study. The stents were coated with gelatin and endothelial cell attachment, proliferation and stent coverage were determined in vitro and compared to uncoated stent controls. A rabbit elastase-aneurysm model was used to determine the effects of endothelial cell seeded-gelatin coated flow diverting stents on aneurysm obliteration and parent vessel healing. ResultsIn vitro, gelatin coating of nitinol stents did not significantly alter endothelial cell attachment, proliferation, or stent coverage. However, gelatin coating of cobalt-chromium stents significantly increased endothelial cell attachment, proliferation and migration. In fact, gelatin coating significantly (p< 0.001) increased the rate of complete stent endothelization by 33% compared to unmodified controls. In vivo, treating aneurysm with endothelial cell seeded-gelatin coated stents resulted in aneurysm occlusion in 8 of 8 (100%) rabbit aneurysms at 90 days compared to only 4 of 7 (57%) in unmodified controls (p< 0.001). Histologically, there were trends in increased neoarterial wall thickness across the aneurysm neck and neointimal formation in the parent artery. Angiographic assessment demonstrated strong parent and side branch patency. ConclusionsGelatin coating enhances EC attachment and stent coverage which is dependent upon the type of stent. Endothelial cell seeded-gelatin coated-flow diverting stents allowed 100% aneurysm obliteration and neoarterial formation without affecting side branch patency or parent artery perfusion. Gelatin coating therefore represents a valuable strategy to enhance stent cellularization and aneurysm occlusion rates.

Maternal thermal strain is associated with adverse pregnancy outcomes, yet fetal temperatures cannot currently be directly measured, limiting quantification of fetal thermal strain. Here, we develop two steady-state models for estimating internal temperatures in a near-term fetus. First, we improve the only previously published human fetal thermoregulation model, deriving a closed-form solution within its simplified uniform-cylinder representation. Second, we introduce a multilayer, anatomically segmented model that resolves tissue-specific temperatures. Both couple the fetal body to central blood pool and amniotic fluid compartments and incorporate a new placenta-umbilical cord heat-exchanger representation. Predictions agree with available intrauterine scalp measurements, with fetal core and head-center temperatures approximately 0.5{degrees}C and 0.8{degrees}C above maternal core, respectively. Physiologically plausible changes in umbilical cord heat-exchanger effectiveness or blood flow increased fetal temperatures by approximately 0.3{degrees}C. These models enable estimation of otherwise inaccessible temperatures, while the multilayer formulation lays a foundation for transient, coupled maternal-fetal thermoregulation modeling.

Objectives: Aneurysmal subarachnoid haemorrhage is a life-threatening emergency that commonly presents with a sudden, severe headache. The diagnosis is usually confirmed on CT imaging, however a small subset of patients demonstrate normal imaging, particularly if presentation is delayed - in which case spectrophotometric analysis of cerebrospinal fluid (CSF) is undertaken. Nevertheless, thunderclap headache is a common presentation and the vast majority of investigated patients do not have aneurysmal subarachnoid haemorrhage. This ten-year service evaluation at a tertiary neurosurgery centre aims to estimate the utility of lumbar puncture in the diagnostic work-up of these patients. Methods: All instances of CSF spectrophotometry between 01/01/2011 and 31/12/2020 were evaluated. Clinical records of patients with positive spectrophotometry were analysed. A second method identified all coded diagnoses of non-traumatic subarachnoid haemorrhage over the same time period, with review of clinical records in cases of negative imaging. Results: Of 2158 instances of CSF spectrophotometry performed at the tertiary neurosurgery centre, four aneurysms were identified and treated by coiling or clipping, resulting in a number needed to treat of 540 patients to diagnose one case of aneurysmal subarachnoid haemorrhage. Of 648 patients with a coded diagnosis of non-traumatic subarachnoid haemorrhage (including local patients and transfers from satellite hospitals), 27 patients displayed initial negative imaging, of which 9 were found to have aneurysms and underwent neuro-intervention. Lumbar puncture was instrumental in the diagnosis and led to intervention in three patients identified by this method. Conclusion: CSF analysis resulted in diagnosis and intervention for missed (CT-negative) aneurysmal subarachnoid haemorrhage in approximately 1/540 tested patients. The estimated yield in a real-world setting may be useful for clinicians or provide a basis for discussion when counselling patients on benefit and risk.

Introduction and objectives Hydrocephalus is a common complication of aneurysmal subarachnoid haemorrhage. This is one of several standard indications for the insertion of an external ventricular drain, but there are no standard guidelines for timing of extraventricular drain discontinuation in this population. Therefore, the study aims were to examine the 1) factors associated with extraventricular drain duration in aneurysmal subarachnoid haemorrhage and 2) association between extraventricular drain duration and clinical and resource-based outcomes. Methods In this single centre retrospective cohort study, data for adult patients treated in the ICU between 2015-2023 with aneurysmal subarachnoid haemorrhage and requiring an extraventricular drain were analysed. Data were extracted from both a prospective patient registry and the electronic medical record. Linear regression modelling was used to identify the factors associated with extraventricular drain duration. Measures used to examine the association between extraventricular drain duration, and the outcomes of interest included hazard ratio, relative risk, and mean differences as appropriate for a specific outcome. Results Of the participants (n=205), 68% (n = 140) were female, mean age was 60.7 (SD 13.3) years and 71% (n = 145) had a modified Fisher score of 4. Mean extraventricular drain duration was 15.3 (SD 8.6) days. The number of days mechanically ventilated and extraventricular drain challenge by clamp trial were associated with an increased duration of extraventricular drain treatment. Increased extraventricular drain duration was associated with an increased incidence of ventriculoperitoneal shunt insertion, and an increase in ICU and hospital length of stay when extraventricular drain duration exceeded 20 days. Conclusion The factors associated with an increased duration of extraventricular drain treatment were a longer duration of mechanical ventilation. The outcomes associated with an increased duration of extraventricular drain treatment were an increased incidence of ventriculoperitoneal shunt insertion, an increased incidence of ventriculitis when extraventricular drain duration exceeded 20 days, and an increase in ICU length of stay. These study findings may inform the conduct of a larger multi-centre study to examine the factors associated with duration of treatment with extraventricular drain, and outcomes associated with extraventricular drain duration.

The Notch signaling pathway plays a central role in development and cell fate determination. Its function depends on tightly regulated intracellular trafficking of the Notch receptor and the Notch intracellular domain (NICD) after cleavage by {gamma}-secretase. Notch signaling is essential for principal cell differentiation within the renal collecting duct and for proximal-distal patterning during kidney development. Notch activity has also been shown to influence the trafficking of several membrane proteins, including nephrin in kidney cells and monocarboxylate transporter 1 in brain endothelial cells. Aquaporin-2 (AQP2) is the key vasopressin-regulated water channel in the collecting duct, and proper AQP2 trafficking and recycling are required for physiologically appropriate urine concentration. To determine whether and, if so, how Notch signaling modulates AQP2 trafficking, we performed studies using LLCPK1 renal epithelial cells stably expressing AQP2 (LLCPK1-AQP2). Exposing cells to 35 M DAPT (which inhibits y-secretase, preventing cleavage and activation of Notch receptor signaling) for 30 min significantly increased AQP2 membrane accumulation in LLCPK1-AQP2 cells as revealed by immunofluorescence staining. Using a rhodamine-transferrin internalization assay, we found that DAPT reduced clathrin-mediated endocytosis by 60%. This blockade increases AQP2 membrane accumulation by preventing the reinternalization of AQP2 that is delivered to the plasma membrane by exocytosis during its constitutive recycling pathway. Using an F-actin polymerization assay, we then found that Notch inhibition decreases F-actin polymerization by de-activating the small GTPase RhoA, using GSTRBD, a substrate that binds to active RhoA, as seen by western blotting using phospho-specific antibodies. Because actin polymerization is required for AQP2 endocytosis, RhoA inhibition by DAPT would result in the decreased internalization of AQP2 that we observed by immunofluorescence. While the mechanism by which DAPT inhibits RhoA activity remains to be determined, our study shows that AQP2 trafficking is regulated by the Notch signaling pathway in vitro and suggests that modulation of Notch signaling may represent a novel strategy to address water balance disorders that involve defects in the AQP2 trafficking process.

Ependymal (E1) cells, with their tufts of [~]50 motile cilia, line the walls of the brain ventricles and help propel the cerebrospinal fluid (CSF). The CSF is rich in signaling molecules, but the cellular targets that detect these signals and their function remain unknown. Here, we describe a distinct population of ependymal cells (E2) in the forebrain of mice and humans, the majority having only 1 or 2 cilia. These cilia were motile, but unlike E1 cells cilia, their pattern of motility and high expression of Arl13b and Inpp5e suggest a sensory function. E2 cells were characterized by an enormous, donut-like basal body that contained an increased number and size of subdistal appendages. In mice, E2 cells were mostly born in the embryo, but completed their differentiation in juveniles and young adults; they were found at higher densities in regions of high CSF flow and neurogenesis. E2 cilia contained the G protein-coupled receptor Smoothened, which accumulated in their cilia upon exposure to Sonic Hedgehog (Shh). Together, these findings identify E2 cells as a novel CSF-sensing ependymal cell type and provide a cellular target for the CSF signaling.

Objectives To validate two computational fluid dynamics (CFD) models derived from computed tomography angiography (CTA) for estimating trans-stenotic pressure gradients, using invasive intra-arterial pressure measurements as the reference standard in patients with renal artery stenosis (RAS). Background We assessed whether non-invasive assessment of the pressure gradient using CFD could be a reliable alternative to intra-arterial measurements for identifying hemodynamically significant RAS. Methods We performed intra-arterial measurements at rest and during dopamine-induced hyperemia to assess the trans-stenotic pressure gradient in 28 patients with RAS. A pre-intervention CTA scan was used to simulate the pressure gradient with a CFD model using a strategy based on Murray's law (CFD-Mu) and cortical volume (CFD-C). The agreement between the simulated and measured pressure gradients was assessed using intraclass correlation coefficients (ICC), Bland-Altman analysis and diagnostic agreement on the presence of a hemodynamically significant stenosis. Results In 20 patients, successful measurements and simulations were obtained. The ICC between measured pressure gradient and the CFD pressure gradient was 0.78 and 0.94 during baseline and 0.86 and 0.72 during hyperemia, for CFD-Mu and CFD-C, respectively. The sensitivity of CFD-Mu and CFD-C was 70% for both models at rest and 100% compared to the hyperemic measurements, whereas the specificity was 90% and 70% at rest and 79% and 72% during hyperemia, respectively. Conclusions The results support the use of individualized CFD simulations for hemodynamic assessment of RAS using CTA as input. The CFD models demonstrated high accuracy for the identification of a hemodynamically significant stenosis.