Evaluating glymphatic pathway function utilizing clinically relevant intrathecal infusion of CSF tracer
© Yang et al.; licensee BioMed Central Ltd. 2013
Received: 29 December 2012
Accepted: 25 April 2013
Published: 1 May 2013
Neurodegenerative diseases such as Alzheimer’s are associated with the aggregation of endogenous peptides and proteins that contribute to neuronal dysfunction and loss. The glymphatic system, a brain-wide perivascular pathway along which cerebrospinal fluid (CSF) and interstitial fluid (ISF) rapidly exchange, has recently been identified as a key contributor to the clearance of interstitial solutes from the brain, including amyloid β. These findings suggest that measuring changes in glymphatic pathway function may be an important prognostic for evaluating neurodegenerative disease susceptibility or progression. However, no clinically acceptable approach to evaluate glymphatic pathway function in humans has yet been developed.
Time-sequenced ex vivo fluorescence imaging of coronal rat and mouse brain slices was performed at 30–180 min following intrathecal infusion of CSF tracer (Texas Red- dextran-3, MW 3 kD; FITC- dextran-500, MW 500 kD) into the cisterna magna or lumbar spine. Tracer influx into different brain regions (cortex, white matter, subcortical structures, and hippocampus) in rat was quantified to map the movement of CSF tracer following infusion along both routes, and to determine whether glymphatic pathway function could be evaluated after lumbar intrathecal infusion.
Following lumbar intrathecal infusions, small molecular weight TR-d3 entered the brain along perivascular pathways and exchanged broadly with the brain ISF, consistent with the initial characterization of the glymphatic pathway in mice. Large molecular weight FITC-d500 remained confined to the perivascular spaces. Lumbar intrathecal infusions exhibited a reduced and delayed peak parenchymal fluorescence intensity compared to intracisternal infusions.
Lumbar intrathecal contrast delivery is a clinically useful approach that could be used in conjunction with dynamic contrast enhanced MRI nuclear imaging to assess glymphatic pathway function in humans.
Neurodegenerative disorders such as Alzheimer’s disease (AD) are characterized by progressive loss of neurons, sensory and motor impairments, and severe cognitive decline . Extracellular depositions of amyloid β (Aβ) peptides and accumulation of hyperphosphorylated tau in neurofibrillary tangles are believed to contribute to the pathophysiology of AD [2–4], while analogous misfolded proteins aggregate in other neurodegenerative diseases, including Huntington’s disease and amyotrophic lateral sclerosis (ALS) [5–7]. In the case of AD, it is widely believed that amyloid deposition results from an age-related failure of soluble Aβ clearance from the brain . Although neuroimaging approaches are now widely available to detect the deposition of amyloid plaques and the static evolution of plaque burden , no approach yet exists that allows Aβ clearance efficiency to be directly measured in real time. The ability to detect changes in the efficiency of Aβ clearance would be a significant advance in evaluating susceptibility to and progression of AD in addition to potentially opening up a totally novel therapeutic approach to treatment.
The cerebrospinal fluid (CSF) circulation is widely regarded as a major sink for the clearance of interstitial fluid (ISF) and its solutes from the brain. As CSF is reabsorbed across arachnoid granulations, along cranial and spinal nerve sheaths, or along the brain microvasculature, solutes are cleared from the cranial cavity –. In a recent study we reported that a large proportion of subarachnoid cerebrospinal fluid (CSF) recirculates through the brain parenchyma along perivascular spaces, exchanging with brain interstitial fluid (ISF) before being cleared via peri-venous pathways [15, 16]. The continuous circulation of CSF along this pathway facilitates the clearance of extracellular solutes, including soluble Aβ, from the brain. We termed this brain-wide pathway the ‘glymphatic system’, based upon the critical role that astroglial water transport through the astrocytic aquaporin-4 water channel plays in facilitating CSF-ISF exchange and solute clearance . One implication of these findings is that changes in glymphatic pathway function may contribute to the failure of Aβ clearance in the pre-clinical stages of AD, while a method to measure glymphatic pathway function in clinical populations might allow AD disease susceptibility and progression to be evaluated.
Our initial characterization of the glymphatic system utilized in vivo two-photon microscopy and ex vivo fluorescence imaging of intracisternally infused CSF tracers to map the brain-wide pathway and to quantify the efficiency of solute clearance in mice. These approaches are not appropriate for clinical application, given the optical limitations of fluorescence-based imaging and the complications that are associated with intracisternal infusions in humans . In the clinical setting, dynamic nuclear imaging modalities such as magnetic resonance imaging (MRI) are routinely used to monitor CSF flux in the diagnosis of spontaneous intracranial hypotension (SIH) and post-traumatic CSF rhinnorrhea or otorrhea [18, 19]. These approaches permit time-sequenced three-dimensional (3D) representation of the brain with high spatial and temporal resolution of tracer distribution. In a follow-up pre-clinical study we have successfully utilized dynamic contrast-enhanced MRI after intrathecal infusion of gadolinium-based contrast agent into the cisterna magna to measure glymphatic pathway function in rats [20, 21].
In contrast to intracisternal infusions, lumbar intrathecal injections of radio-tracer are presently used along with computer-tomography/mylography and digital subtraction myelography to diagnose dural leaks associated with SIH, pseudomeningocele, and superficial siderosis [22, 23], as well as the integrity of the spinal cord in the setting of injury or tumor [24, 25]. Lumbar intrathecal injections are additionally used in everyday practice for the delivery of local anesthetics , opioids and other analgesics, and would thus provide an ideal delivery route for contrast agents that could then be used in conjunction with dynamic contrast-enhanced MRI to evaluate glymphatic clearance in humans.
In the present pre-clinical study, we extend these recent findings to evaluate whether perivascular CSF-ISF exchange within the brain can be evaluated after lumbar intrathecal CSF tracer infusion. We compare the influx kinetics and parenchymal distribution of these tracers with those corresponding to intracisternal CSF tracer infusion described previously [16, 20]. Our data demonstrate that CSF tracer infused at the lumbar spine enters the brain through perivascular spaces and exchanges with the ISF in a manner consistent with our previous characterization of the glymphatic pathway, suggesting that the lumbar intrathecal infusion is a clinically viable contrast delivery route to asses glymphatic function in humans.
Female Sprague–Dawley rats (200–230 g; Charles River Labs, USA) and mixed sex C57BL/6 mice were used in all experiments. The animals were housed under standard laboratory conditions, with access to food and water, ad libitum. All experiments were approved by the University Committee on Animal Resources of the University of Rochester and carried out according to guidelines from the National Institutes of Health. Animals were initially induced with isofluorane (3%), and then anesthetized with sodium pentobarbital (50 mg/kg i.p.). Supplemental sodium pentobarbital (25 mg/kg) was given as necessary. For intracisternal infusions, anesthetized rats were fixed in a stereotaxic frame, the atlanto-occipital membrane was surgically exposed followed by a durotomy, and a 30GA needle was inserted into the cisterna magna. For lumbar infusions, the lumbar spinal column was exposed, an L2-3 laminectomy was performed, and 30GA needle was inserted into the subarachnoid space.
In the present study, 2 different fluorescent tracers were used: large molecular weight fixable fluorescein isothiocyanate (FITC)-conjugated dextran (500 kD, FITC-d500; Invitrogen) and small molecular weight fixable Texas Red-conjugated dextran (3 k, TR-d3; Invitrogen). FITC-d500 and TR-d3 were selected to roughly correspond with the molecular weights of Gd-DTPA (MW ~ 1 kD) and GadoSpin™ (MW 200 kD), which are commonly used MRI contrast agents . Tracers were constituted in isobaric artificial CSF at a concentration of 0.25%. In a companion study , we evaluated CSF-ISF exchange after intracisternal infusion of MRI contrast agents and found that two key components of the glymphatic system (i.e. para-arterial CSF tracer influx and size-dependent CSF-ISF exchange) could be visualized with dynamic contrast-enhanced MRI. In order to permit comparison with this prior study , in the present study intracisternal and lumbar infusions in rats were conducted in the same manner: an infusion rate of 1.6 μl/min for each of the 30, 60, 120, and 180 min groups. Infusion was stopped at a total volume of 70 μl. At t = 30, 60, or 120 min after the start of infusion, rats were transcardially perfused with ice-cold heparinized PBS, followed by 4% paraformaldehyde (PFA). Brains were removed, post-fixed overnight in 4% PFA at 4°C, and 50 μm coronal slices were cut on a vibratome (Leica) and mounted with PROLONG Anti-Fade Gold with DAPI (Invitrogen). For studies conducted in mice, TR-d3 was infused via the cisterna magna at a rate of 1.6 μl/min for 6.25 min (total volume = 10 μl). This infusion volume was the same as was used previously to define perivascular CSF-ISF exchange by in vivo 2-photon microscopy .
In a separate group of animals, we evaluated the effect of tracer infusion upon intracranial pressure (ICP). A 22GA ICP cannula was inserted stereotactically into the right lateral ventrical and the animal allowed to equilibrate for 30 min. In the first animals, we sequentially increased intracisternal CSF tracer infusion rates from 1.6 to 3.2 to 6.4 μl/min to define the rate that would not evoke an acute elevation of ICP. In 2 additional groups of animals (n = 4 each), we measured ICP during 60 min infusions of CSF tracer via the cisterna magna and the lumbar spine.
Free floating immunofluorescent labeling was conducted on a separate set of 50 μm slices. For intracisternal infusion, 8 slices from each animal (n = 3 to 4 rats per time point) from the 60 min time point were used. For lumbar infusion, 8 slices from each animal from the 120 min time point were used. These time points were chosen based on pilot data, because they corresponded with peak CSF tracer influx via the respective infusion routes. Slices were blocked in 3% normal donkey serum (Jackson Immunoresearch) for 1.5 hrs at room temperature, incubated in mouse anti-glial fibrillary acidic protein (GFAP, an astrocytic marker; 1:1000, Millipore) or Biotinylated Griffonia (Brandeiraea) Simplicifolia Lectin I Isolectin B4 (Ib4, a vascular endothelial marker; 1:100, Vector Laboratories) overnight at 4°C. Secondary detection was conducted for mouse-anti GFAP using Cy5-conjugated donkey anti-mouse secondary antibody (1:500, Jackson Immunoresearch) and for Ib4 using Cy5-conjugated streptavidin (1:250, Jackson Immunoresearch). Slices were incubated for 2 hrs at room temperature in the secondary antibody solution. After washing, all slices were mounted with PROLONG Antifade Gold with DAPI (Invitrogen).
Tracer movement into the brain was measured by conventional fluorescence microscopy. Whole slice 3-channel montages were generated at 4x magnification for 8 slices per animal using the Virtual Slice module of the Microlucida software (Microbrighfield), on an upright fluorescence microscope (Olympus) equipped with a motorized stage. This included separate DAPI, green (for FITC) and red (for Texas Red) emission channels. The gain and exposure settings were determined based on un-infused control slices and held constant throughout all imaging sessions. Slice fluorescence (fluorescent tracer accumulation) was quantified using ImageJ software (NIH), as described previously . Anatomical brain regions of interest (ROIs) were generated based upon the DAPI emission channel for the cortex, white matter (including corpus callosum, internal and external capsule), subcortical structures (striatum, thalamus, hypothalamus) and hippocampus. The background fluorescence for each channel was uniformly subtracted and the mean pixel intensity for each region was measured. Distribution of large and small molecular weight CSF tracers throughout the brain parenchyma was evaluated under high power by laser scanning confocal microscopy (Olympus). Immunofluorescently-labeled slices were imaged at 40X objective power.
All values are expressed as mean ± SEM. Intensities were compared at each time point and across infusion routes by 2-way analysis of variance (ANOVA) with Bonferroni’s post-hoc test to evaluate differences at individual time points (Graphpad Prism software). A ‘P’ value < 0.05 was considered significant.
Results and discussion
In two recent studies, 2-photon in vivo imaging in mice and dynamic contrast-enhanced MRI in rats were used to demonstrate the existence of a brain-wide perivascular route, termed the ‘glymphatic pathway’, that permits CSF to exchange with the brain ISF [16, 20]. CSF-ISF exchange along these perivascular pathways was supported by astroglial aquaporin-4 water channels and the movement of fluid through this pathway facilitated the clearance of interstitial solutes, including soluble Aβ, from the brain. The purpose of the present study was to assess whether a clinically relevant lumbar intrathecal route of CSF tracer delivery could be used to visualize perivascular CSF-ISF exchange in the brain. In contrast to our initial study, which was performed on mice, the current study characterized glymphatic flow in the adult Sprague Dawley rat, which expands our understanding of glymphatic function into a new species, while also moving to a model system that makes it easier to perform lumbar intrathecal infusions. Intracisternal CSF tracer infusions were carried out in a parallel group of animals to provide a direct comparison to the infusion route used previously [16, 20].
Effect of intrathecal lumbar and cisternal tracer infusion upon intracranial pressure
Imaging CSF-ISF exchange in mouse and rat by intracisternal tracer infusion
Analysis of tracer clearance between the four different anatomical regions suggested that tracer clearance from subcortical structures was faster than from the cortex (Figure 2H,J; *P < 0.05 cortex vs. subcortical, 2-way ANOVA). This is consistent with our prior observation that subcortical regions enjoy the largest influxes of subarachnoid CSF along large caliber penetrating arteries from the ventral brain surface . Furthermore, these regions are most proximate to the para-venous clearance pathways that drain medially along the internal cerebral veins. When anterior versus posterior tracer fluxes were compared, both peak values at 30 min and the rate of clearance between 30–120 min post-infusion were lower in the posterior brain compared to the anterior brain (compare Figure 2H,J). These observations are consistent with MRI findings in the rat in which glymphatic fluxes along anterior penetrating arteries were both faster and greater in magnitude than those that followed branches of mediolateral arteries such as the middle cerebral artery . In both the anterior and posterior brain, TR-d3 fluorescence intensity in the white matter was significantly lower than the cortex at all time points (Figure 2H,J; ##P < 0.01 vs. cortex, 2-way ANOVA), while the rate of tracer clearance from the white matter did not appear to consistently differ from other brain regions. The shift in white matter fluorescence intensity likely stems from lower levels of tissue autofluorescence of white matter compared to gray matter. Alternatively, this may reflect the lower levels of CSF tracer penetration into the subcortical white matter observed in our prior study .
Imaging rat CSF-ISF exchange following lumbar intrathecal infusions
Rat lumbar intrathecal tracer influx is independent of molecular weight
CSF moves through the ventricular and subarachnoid compartment through the process of bulk flow [13, 31, 32]. Because under bulk flow, the movement of the solvent is typically more rapid than the movement of the solute by passive diffusion, bulk flow-dependent movement is largely independent of molecular weight . To evaluate whether the rate of intrathecal lumbar tracer influx into the brain parenchyma was dependent upon molecular size, we co-infused large molecular weight fluorescent FITC-d500 (MW 500 kD) and small molecular weight TR-d3 (MW 3 kD). Representative images from this study are shown in Figure 3A-B. When FITC-d500 and TR-d3 movement into the brain parenchyma were quantified within the anterior and posterior cortex, white matter, subcortical structures and hippocampus, no significant differences were observed between either the time course or the magnitude of influx of the small and large molecular weight tracers (Figure 3C-F). This finding is consistent with the movement of fluorescent tracer from the lumbar site of infusion to the brain subarachnoid and perivascular spaces via bulk flow rather than by simple diffusion .
Perivascular pathway of intracthecal CSF tracer influx
In our prior study in mice , we noted that while CSF tracers of all sizes moved rapidly into the brain along perivascular spaces, large molecular weight tracers such as FITC-d2000 (MW 2000 kD) became trapped in the perivascular space and could not move freely into and through the brain interstitium. According to one recent study, astrocytic endfoot processes completely cover the cerebral microcirculation; the only routes between the perivascular spaces and the wider brain interstitium being through ~20 nm clefts between overlapping astroglial endfeet . We surmised that the perivascular astrocytic endfeet acted as a sieve to restrict the movement of large solutes from the perivascular spaces into the brain interstitium . This is consistent of with diameters of hydration measured for both 3 kD dextrans (<20 nm) and 500 kD dextrans (>20 nm) .
In the present pre-clinical study, we report that perivascular CSF-ISF exchange within the rat brain can be evaluated following infusion of CSF tracer via a lumbar, in addition to an inctracisternal, route. In order to translate the initial characterization of the glymphatic pathway to a clinical setting, it is necessary to use a clinically relevant methodology for CSF tracer and contrast infusion as well as imaging modality for evaluation of glymphatic pathway function. A recent analysis showed that the glymphatic system can be evaluated in the rats using contrast-enhanced MRI following intracisternal gadolinium-based contrast infusion . Intracisternal infusions, however, are rarely used in a clinical setting due to their high potential for iatrogenic complications, including traumatic tissue injury . In contrast, the lumbar intrathecal delivery route is routinely employed for administration of contrast for CT-myelography [23, 25], spinal anesthetics and post-operative analgesics [35, 36], as well as chemotherapeutics . By utilizing an intrathecal, rather than a trans-blood brain barrier route for contrast delivery, the difficulties associated with therapeutic agent delivery into the CNS  can be circumvented.
LY carried out experiments, analyzed results, and prepared manuscript. BTK carried out experiments, analyzed results and prepared manuscript. HJW carried out experiments and analyzed results. MT carried out experiments and analyzed results. BW, RD and HB helped develop experimental concept and provided editorial assistance with manuscript. JJI, MN conceived of study concept, supervised research and prepared manuscript. All authors read and approved the final manuscript.
This work was supported by the National Institutes of Health (MN), the United States Department of Defense (MN), the Harold and Leila Y. Mathers Charitable Foundation (MN) and the American Heart Association (JI).
- Jucker M, Walker LC: Pathogenic protein seeding in Alzheimer disease and other neurodegenerative disorders. Ann Neurol. 2011, 70: 532-540. 10.1002/ana.22615.View ArticlePubMedPubMed CentralGoogle Scholar
- Hardy J, Selkoe DJ: The amyloid hypothesis of Alzheimer’s disease: progress and problems on the road to therapeutics. Science. 2002, 297: 353-356. 10.1126/science.1072994.View ArticlePubMedGoogle Scholar
- Small SA, Duff K: Linking Abeta and tau in late-onset Alzheimer’s disease: a dual pathway hypothesis. Neuron. 2008, 60: 534-542. 10.1016/j.neuron.2008.11.007.View ArticlePubMedPubMed CentralGoogle Scholar
- Maccioni RB, Farias G, Morales I, Navarrete L: The revitalized tau hypothesis on Alzheimer’s disease. Arch Med Res. 2010, 41: 226-231. 10.1016/j.arcmed.2010.03.007.View ArticlePubMedGoogle Scholar
- Bruijn LI, Houseweart MK, Kato S, Anderson KL, Anderson SD, Ohama E, Reaume AG, Scott RW, Cleveland DW: Aggregation and motor neuron toxicity of an ALS-linked SOD1 mutant independent from wild-type SOD1. Science. 1998, 281: 1851-1854.View ArticlePubMedGoogle Scholar
- Scherzinger E, Sittler A, Schweiger K, Heiser V, Lurz R, Hasenbank R, Bates GP, Lehrach H, Wanker EE: Self-assembly of polyglutamine-containing huntingtin fragments into amyloid-like fibrils: implications for Huntington’s disease pathology. Proc Natl Acad Sci USA. 1999, 96: 4604-4609. 10.1073/pnas.96.8.4604.View ArticlePubMedPubMed CentralGoogle Scholar
- Ross CA, Poirier MA: Protein aggregation and neurodegenerative disease. Nat Med. 2004, 10 (Suppl): S10-S17.View ArticlePubMedGoogle Scholar
- Deane R, Zlokovic BV: Role of the blood–brain barrier in the pathogenesis of Alzheimer’s disease. Curr Alzheimer Res. 2007, 4: 191-197. 10.2174/156720507780362245.View ArticlePubMedGoogle Scholar
- Nordberg A, Rinne JO, Kadir A, Langstrom B: The use of PET in Alzheimer disease. Nat Rev Neurol. 2010, 6: 78-87. 10.1038/nrneurol.2009.217.View ArticlePubMedGoogle Scholar
- Bradbury MW, Cserr HF, Westrop RJ: Drainage of cerebral interstitial fluid into deep cervical lymph of the rabbit. Am J Physiol. 1981, 240: F329-F336.PubMedGoogle Scholar
- Szentistvanyi I, Patlak CS, Ellis RA, Cserr HF: Drainage of interstitial fluid from different regions of rat brain. Am J Physiol. 1984, 246: F835-F844.PubMedGoogle Scholar
- Johnston M: The importance of lymphatics in cerebrospinal fluid transport. Lymphat Res Biol. 2003, 1: 41-44. 10.1089/15396850360495682. discussion 45View ArticlePubMedGoogle Scholar
- Abbott NJ: Evidence for bulk flow of brain interstitial fluid: significance for physiology and pathology. Neurochem Int. 2004, 45: 545-552. 10.1016/j.neuint.2003.11.006.View ArticlePubMedGoogle Scholar
- Bulat M, Klarica M: Recent insights into a new hydrodynamics of the cerebrospinal fluid. Brain Res Rev. 2011, 65: 99-112. 10.1016/j.brainresrev.2010.08.002.View ArticlePubMedGoogle Scholar
- Begley DJ: Brain superhighways. Sci Transl Med. 2012, 4: 147fs129-View ArticleGoogle Scholar
- Iliff JJ, Wang M, Liao Y, Plogg BA, Peng W, Gundersen GA, Benveniste H, Vates GE, Deane R, Goldman SA, Nagelhus EA, Nedergaard M: A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid beta. Sci Transl Med. 2012, 4: 147ra111-10.1126/scitranslmed.3003748.View ArticlePubMedPubMed CentralGoogle Scholar
- Keane JR: Cisternal puncture complications. Treatment of coccidioidal meningitis with amphotericin B. Calif Med. 1973, 119: 10-15.PubMedPubMed CentralGoogle Scholar
- Burns BJ: Images in emergency medicine. Traumatic cerebrospinal fluid leak. Ann Emerg Med. 2008, 51 (704): 706-Google Scholar
- Daele JJ, Goffart Y, Machiels S: Traumatic, iatrogenic, and spontaneous cerebrospinal fluid (CSF) leak: endoscopic repair. B-ENT. 2011, 7 (Suppl 17): 47-60.PubMedGoogle Scholar
- Iliff JJ, Lee H, Yu M, Feng T, Logan J, Nedergaard M, Benveniste H: Brain-wide pathway for waste clearance captured by contrast-enhanced MRI. J Clin Invest. 2013, 123: 1299-1309. 10.1172/JCI67677.View ArticlePubMedPubMed CentralGoogle Scholar
- Strittmatter WJ: Bathing the brain. J Clin Invest. 2013, 123: 1013-1015. 10.1172/JCI68241.View ArticlePubMedPubMed CentralGoogle Scholar
- Phillips CD, Kaptain GJ, Razack N: Depiction of a postoperative pseudomeningocele with digital subtraction myelography. AJNR Am J Neuroradiol. 2002, 23: 337-338.PubMedGoogle Scholar
- Hoxworth JM, Trentman TL, Kotsenas AL, Thielen KR, Nelson KD, Dodick DW: The role of digital subtraction myelography in the diagnosis and localization of spontaneous spinal CSF leaks. AJR Am J Roentgenol. 2012, 199: 649-653. 10.2214/AJR.11.8238.View ArticlePubMedGoogle Scholar
- Kapila A: Lumbar intraspinal epidermoid tumor. Evaluation with computed tomography and myelography. Spine. 1987, 12: 817-820. 10.1097/00007632-198710000-00020.View ArticlePubMedGoogle Scholar
- Adams C, Babyn PS, Logan WJ: Spinal cord birth injury: value of computed tomographic myelography. Pediatr Neurol. 1988, 4: 105-109. 10.1016/0887-8994(88)90049-5.View ArticlePubMedGoogle Scholar
- Popping DM, Elia N, Marret E, Wenk M, Tramer MR: Opioids added to local anesthetics for single-shot intrathecal anesthesia in patients undergoing minor surgery: a meta-analysis of randomized trials. Pain. 2012, 153: 784-793. 10.1016/j.pain.2011.11.028.View ArticlePubMedGoogle Scholar
- Geraldes CF, Laurent S: Classification and basic properties of contrast agents for magnetic resonance imaging. Contrast Media Mol Imaging. 2009, 4: 1-23. 10.1002/cmmi.265.View ArticlePubMedGoogle Scholar
- Enzmann DR, Pelc NJ: Normal flow patterns of intracranial and spinal cerebrospinal fluid defined with phase-contrast cine MR imaging. Radiology. 1991, 178: 467-474.View ArticlePubMedGoogle Scholar
- Edsbagge M, Tisell M, Jacobsson L, Wikkelso C: Spinal CSF absorption in healthy individuals. Am J Physiol Regul Integr Comp Physiol. 2004, 287: R1450-R1455. 10.1152/ajpregu.00215.2004.View ArticlePubMedGoogle Scholar
- Stoodley MA, Jones NR, Brown CJ: Evidence for rapid fluid flow from the subarachnoid space into the spinal cord central canal in the rat. Brain Res. 1996, 707: 155-164. 10.1016/0006-8993(95)01228-1.View ArticlePubMedGoogle Scholar
- Cserr HF: Physiology of the choroid plexus. Physiol Rev. 1971, 51: 273-311.PubMedGoogle Scholar
- Praetorius J: Water and solute secretion by the choroid plexus. Pflugers Arch. 2007, 454: 1-18. 10.1007/s00424-006-0170-6.View ArticlePubMedGoogle Scholar
- Mathiisen TM, Lehre KP, Danbolt NC, Ottersen OP: The perivascular astroglial sheath provides a complete covering of the brain microvessels: an electron microscopic 3D reconstruction. Glia. 2010, 58: 1094-1103. 10.1002/glia.20990.View ArticlePubMedGoogle Scholar
- Sykova E, Nicholson C: Diffusion in brain extracellular space. Physiol Rev. 2008, 88: 1277-1340. 10.1152/physrev.00027.2007.View ArticlePubMedPubMed CentralGoogle Scholar
- Hong JY, Lee IH: Comparison of the effects of intrathecal morphine and pethidine on shivering after Caesarean delivery under combined-spinal epidural anaesthesia. Anaesthesia. 2005, 60: 1168-1172. 10.1111/j.1365-2044.2005.04158.x.View ArticlePubMedGoogle Scholar
- Gehling M, Tryba M: Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis. Anaesthesia. 2009, 64: 643-651. 10.1111/j.1365-2044.2008.05817.x.View ArticlePubMedGoogle Scholar
- Kerr JZ, Berg S, Blaney SM: Intrathecal chemotherapy. Crit Rev Oncol Hematol. 2001, 37: 227-236. 10.1016/S1040-8428(00)00115-3.View ArticlePubMedGoogle Scholar
- Begley DJ: Delivery of therapeutic agents to the central nervous system: the problems and the possibilities. Pharmacol Ther. 2004, 104: 29-45. 10.1016/j.pharmthera.2004.08.001.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.