Endothelial surface translocation of mitochondrial PDCE2 involves the non-canonical secretory autophagy pathway: Putative molecular target for radiation-guided drug delivery.

Radiation has been proposed as a priming agent to induce discriminatory luminal biomarkers for vascular targeting and drug delivery in disorders such as brain arteriovenous malformations and cancers. We previously observed ectopic expression of intracellular proteins such as mitochondrial PDCE2 on irradiated endothelium in animal models. In this study we examined the mechanism of PDCE2 trafficking in human endothelial cells to better understand its suitability as a vascular target. Ionizing radiation induced PDCE2 surface localization in association with accumulation of autophagosome markers (L3CB and p62) indicative of late-stage inhibition of autophagic flux. This effect was abolished in the presence of Rapamycin, an autophagy-inducer, but replicated in the presence of Bafilomycin A, an autophagy blocker. PDCE2 co-localized with lysosomal markers of the canonical degradative autophagy pathway in response to radiation but also with recycling endosomes and SNARE proteins responsible for autophagosome-plasma membrane fusion. These findings demonstrate that radiation-induced blockade of autophagic flux stimulates redirection of intracellular molecules such as PDCE2 to the cell surface via a non-canonical secretory autophagy pathway. Intracellular membrane proteins trafficked in this way could provide a unique pool of radiation biomarkers for therapeutic drug delivery.

Stable thrombus formation on irradiated microvascular endothelial cells under pulsatile flow: Pre-testing annexin V-thrombin conjugate for treatment of brain arteriovenous malformations.

BACKGROUND: Our goal is to develop a vascular targeting treatment for brain arteriovenous malformations (AVMs). Externalized phosphatidylserine has been established as a potential biomarker on the endothelium of irradiated AVM blood vessels. We hypothesize that phosphatidylserine could be selectively targeted after AVM radiosurgery with a ligand-directed vascular targeting agent to achieve localized thrombosis and rapid occlusion of pathological AVM vessels. OBJECTIVE: The study aim was to establish an in vitro parallel-plate flow chamber to test the efficacy of a pro-thrombotic conjugate targeting phosphatidylserine. METHODS: Conjugate was prepared by Lys-Lys cross-linking of thrombin with the phosphatidylserine-targeting ligand, annexin V. Cerebral microvascular endothelial cells were irradiated (5, 15, and 25 Gy) and after 1 or 3 days assembled in a parallel-plate flow chamber containing whole human blood and conjugate (1.25 or 2.5 µg/mL). Confocal microscopy was used to assess thrombus formation after flow via binding and aggregation of fluorescently-labelled platelets and fibrinogen. RESULTS AND CONCLUSIONS: The annexin V-thrombin conjugate induced rapid thrombosis (fibrin deposition) on irradiated endothelial cells under shear stress in the parallel-plate flow device. Unconjugated, non-targeting thrombin did not induce fibrin deposition. A synergistic interaction between radiation and conjugate dose was observed. Thrombosis was greatest at the highest combined doses of radiation (25 Gy) and conjugate (2.5 µg/mL). The parallel-plate flow system provides a rapid method to pre-test pro-thrombotic vascular targeting agents. These findings validate the translation of the annexin V-thrombin conjugate to pre-clinical studies.

Inwardly rectifying potassium channel 4.1 expression in post-traumatic syringomyelia.

Post-traumatic syringomyelia (PTS) is a serious neurological disorder characterized by fluid filled cavities that develop in the spinal cord. PTS is thought to be caused by an imbalance between fluid inflow and outflow in the spinal cord, but the underlying mechanisms are unknown. The ion channel Kir4.1 plays an important role in the uptake of K(+) ions from the extracellular space and release of K(+) ions into the microvasculature, generating an osmotic gradient that drives water movement. Changes in Kir4.1 expression may contribute to disturbances in K(+) homeostasis and subsequently fluid imbalance. Here we investigated whether changes in Kir4.1 protein expression occur in PTS. Western blotting and immunohistochemistry were used to evaluate Kir4.1 and glial fibrillary acidic protein (GFAP) expression in a rodent model of PTS at 3 days, 1, 6 or 12 weeks post-surgery. In Western blotting experiments, Kir4.1 expression increased 1 week post-surgery at the level of the cavity. Immunohistochemical analysis examined changes in the spinal parenchyma directly in contact with the syrinx cavity. In these experiments, there was a significant decrease in Kir4.1 expression in PTS animals compared to controls at 3 days and 6 weeks post-surgery, while an up-regulation of GFAP in PTS animals was observed at 1 and 12 weeks. This suggests that while overall Kir4.1 expression is unchanged at these time-points, there are many astrocytes surrounding the syrinx cavity that are not expressing Kir4.1. The results demonstrate a disturbance in the removal of K(+) ions in tissue surrounding a post-traumatic syrinx cavity. It is possible this contributes to water accumulation in the injured spinal cord leading to syrinx formation or exacerbation of the underlying pathology.

Clinical Applications of Cine Balanced Steady-State Free Precession MRI for the Evaluation of the Subarachnoid Spaces.

The purpose of this article is to review the physiology of normal brain and spinal cord motion in the subarachnoid space, principles of cine balanced steady-state free precession (bSSFP) magnetic resonance imaging (MRI), clinical applications, and the pitfalls encountered with this technique. The brain and spinal cord are dynamic structures that move with each heartbeat due to transmitted arterial pulse waves. Conventional MRI sequences do not allow anatomic evaluation of the pulsatile movement of the neural structures in the subarachnoid space due to limitations in temporal resolution. Cine bSSFP MRI uses cardiac gating to evaluate dynamically the brain and spinal cord with high contrast and temporal resolution.Cine bSSFP can be used in the evaluation of idiopathic syringomyelia to assess an underlying treatable cause, including arachnoid bands, which are usually not well visualized with conventional MR sequences due to motion artifact. This MRI technique is also useful in the evaluation of intraspinal and intracranial arachnoid cysts and the degree of mass effect on the cord. Other applications include preoperative and postoperative evaluation of Chiari I malformation and the evaluation of lateral ventricular asymmetry. The major limitation of cine bSSFP is the presence of banding artifacts, which can be reduced by shimming and modifying other scan parameters.

Different responses of cavernous malformations and arteriovenous malformations to radiosurgery.

The vascular structure of cavernous malformations (CMs) and arteriovenous malformations (AVMs) is different and they have differing clinical responses to radiosurgery. The structural differences of irradiated and non-irradiated CMs and AVMs were examined to clarify their differential responses to radiosurgery. CMs showed a greater ratio of intraluminal diameter to vessel wall thickness and a lack of subendothelial fibroblasts, myofibroblasts and smooth muscle cells compared with AVMs. Partial proteinaceous clots (19-22% of lumen) formed in CM sinusoids after radiosurgery but complete vaso-occlusion did not occur for up to 6 years after radiosurgery. In contrast, complete vaso-occlusion (91-98% of lumen) by fibrin thrombi that are permanent clots was observed in AVM vessels. Radiation-induced neuronal loss, neurofibrillary degeneration of neurons and myelin fragmentation were typical in the surrounding brain tissue of the irradiated lesions. The different structure and cellular composition of CMs and AVMs is likely to influence their responses to radiosurgery.

Tensile radial stress in the spinal cord related to arachnoiditis or tethering: a numerical model.

Spinal arachnoiditis comprises fibrous scarring of the subarachnoid space, following spinal trauma or inflammation, and is often associated with syringomyelia. We hypothesised that cord-to-dura attachments could cause transient tensile cord radial stress, as pressure waves propagate. This was tested in a fluid-structure interaction model, simulating three types of cord tethering, with 'arachnoiditis' confined to a short mid-section of the cord. The annular system was excited abdominally with a short transient, and the resulting Young and Lamb waves and reflections were analysed. Radial mid-section tethering was less significant than axial tethering, which gave rise to tensile radial stress locally when the cord was not fixed cranially. Simulated as inextensible string connections to the dura, arachnoiditis caused both localised tensile radial stress and localised low pressure in the cord as the transient passed. The extent of these effects was sensitive to the relative stiffness of the dura and cord. Tensile radial stress may create a syrinx in previously normal cord tissue, and transiently lowered pressure may draw in interstitial fluid, causing the syrinx to enlarge if fluid exit is inhibited. The suggested mechanism could also explain the juxtaposition of syrinxes to regions of arachnoiditis.

Focal spinal arachnoiditis increases subarachnoid space pressure: a computational study.

BACKGROUND: Enlarging fluid filled cystic cavitations form within the spinal cord in up to 28% of spinal cord injured patients. These post-traumatic syrinxes can cause neurological deterioration and current treatment results are unsatisfactory. Localized scar tissue (arachnoiditis) within the subarachnoid space at the level of injury has been suggested to be involved in the pathogenesis of syrinx formation. This study tests the hypothesis that pressure pulses in the subarachnoid space are accentuated adjacent to regions of arachnoiditis, which may drive fluid into the spinal cord and contribute to syrinx formation. METHODS: An axisymmetric, cylindrical computational fluid dynamics model was developed to represent the subarachnoid space under normal physiological conditions and in the presence of arachnoiditis. Cerebrospinal fluid flow into the model was estimated from magnetic resonance imaging flow studies. Arachnoiditis was modelled as a porous obstruction in the subarachnoid space. FINDINGS: Peak fluid pressures were higher above the obstruction than in the absence of obstruction. The peak pressures were strongly dependent on the permeability of the obstruction. INTERPRETATION: Elevations in subarachnoid space pressures due to arachnoiditis may facilitate fluid flow into the spinal cord, enhancing syrinx formation. This suggests that it may be worthwhile to investigate strategies that inhibit arachnoiditis or minimize systolic pressure peaks for treating or preventing syringomyelia.

The origins of syringomyelia: numerical models of fluid/structure interactions in the spinal cord.

A two-dimensional axi-symmetric numerical model is constructed of the spinal cord, consisting of elastic cord tissue surrounded by aqueous cerebrospinal fluid, in turn surrounded by elastic dura. The geometric and elastic parameters are simplified but of realistic order, compared with existing measurements. A distal reflecting site models scar tissue formed by earlier trauma to the cord, which is commonly associated with syrinx formation. Transients equivalent to both arterial pulsation and percussive coughing are used to excite wave propagation. Propagation is investigated in this model and one with a central canal down the middle of the cord tissue, and in further idealized versions of it, including a model with no cord, one with a rigid cord, one with a rigid dura, and a double-length untapered variant of the rigid-dura model. Analytical predictions for axial and radial wave-speeds in these different situations are compared with, and used to explain, the numerical outcomes. We find that the anatomic circumstances of the spinal cerebrospinal fluid cavity probably do not allow for significant wave steepening phenomena. The results indicate that wave propagation in the real cord is set by the elastic properties of both the cord tissue and the confining dura mater, fat, and bone. The central canal does not influence the wave propagation significantly.

Syringomyelia and the arachnoid web.

Three cases of syringomyelia associated with arachnoid webs are reported. Each patient presented with progressive myelopathy and had thoracic syringes detected on magnetic resonance imaging (MRI). In one patient the web was also visible. At operation a thoracic arachnoid web was found, obstructing the subarachnoid compartment in each patient. One patient had intraoperative ultrasound, which demonstrated caudal web movement with each cardiac systole. The webs were divided and shunts inserted into the syringes. All patients improved clinically, and on follow-up MRI. Arachnoid webs are likely to represent a focal band of arachnoiditis and are difficult to visualise on standard preoperative MR imaging. A reduction in the subarachnoid space compliance with resultant increase in pulse pressure and potentiation of an arterial pulsation driven perivascular flow could explain the associated syringes. Treatment should be aimed at restoring compliance, and involve division of the web with or without shunt insertion.

Post-traumatic syringomyelia: a review.

More than a quarter of spinal cord injured patients develop syringes and many of these patients suffer progressive neurological deficits as a result of cyst enlargement. The mechanism of initial cyst formation and progressive enlargement are unknown, although arachnoiditis and persisting cord compression with disturbance of cerebrospinal fluid flow appear to be important aetiological factors. Current treatment options include correction of bony deformity, decompression of the spinal cord, division of adhesions, and shunting. Long-term improvement occurs in fewer than half of patients treated. Imaging evidence of a reduction in syrinx size following treatment does not guarantee symptomatic resolution or even prevention of further neurological loss. A better understanding of the causal mechanisms of syringomyelia is required to develop more effective therapy.

Excitotoxic model of post-traumatic syringomyelia in the rat.

STUDY DESIGN: A rat model was developed to elucidate the role of excitatory amino acids and spinal subarachnoid block in the genesis of post-traumatic syringomyelia. This excitotoxic model produces intramedullary cavities rather than the dilation of the central canal (canalicular syringomyelia) created by previous animal models. OBJECTIVES: To produce extracanalicular cysts in the rat spinal cord with quisqualic acid, a potent agonist of multiple excitatory amino acid receptors, and to compare the effects of excitotoxic injury only with that of excitotoxic injury and subarachnoid block with kaolin. SUMMARY OF BACKGROUND DATA: In post-traumatic syringomyelia, primary injury and excitotoxic cell death secondary to elevated levels of excitatory amino acids may initiate a pathologic process leading to the formation of spinal cavities. Subarachnoid block by arachnoiditis may promote enlargement of the cavities. METHODS: Three control rats received a unilateral injection of normal saline into the spinal cord, and another five rats received an injection of kaolin into the spinal subarachnoid space. Quisqualic acid was injected unilaterally into the spinal cord of 20 rats, and 13 additional rats received a unilateral injection of quisqualic acid into the spinal cord after injection of kaolin into the subarachnoid space. Histologic and immunocytochemical assessments were undertaken. RESULTS: In the control groups, no parenchymal cyst developed in any of the animals. Spinal cord cyst formation was observed in 16 of 19 animals in the quisqualic acid groups, but no cysts exceeding two segments in the length of the spinal cord developed in any of the rats. Much larger cavities were seen in 9 of 11 animals in the group with quisqualic acid and kaolin, and cysts exceeding two segments developed in all 9 of these (9/11; 82%). CONCLUSIONS: In post-traumatic syringomyelia, excitotoxic cell death occurring secondarily to elevated levels of excitatory amino acids may contribute to the pathologic process leading to the formation of spinal cord cysts. Subarachnoid block by arachnoiditis is likely to cause enlargement of the cavity.

Multimedia computer database for neurosurgery.

OBJECTIVE: There is a need for an efficient mechanism of storing and analyzing neurosurgical clinical, imaging, and operative data to facilitate clinical audit, research, education, and preparation of scientific presentations. METHODS: A computer database was developed to meet this need. The recorded data include diagnoses, digitized neuroimaging studies, operative details (with intraoperative video clips), transcranial Doppler studies, outcomes, complications, admissions, and clinic visits. The anatomy, pathology, and clinical presentation are recorded for each diagnosis. RESULTS: The database provides an audit of neurosurgery cases, which includes admission Glasgow Coma Scale score, length of intensive care and hospital stays, Glasgow Outcome Scale score, and complications. Clinical research is facilitated by flexible search strategies based on the anatomy, pathology, or clinical presentation of diseases, or any of the recorded intraoperative or outcome factors. The system can be used to assess the influence on outcome of factors, such as transcranial Doppler velocity, intraoperative blood pressure, and the use of ventricular drainage, intraoperative angiography, or temporary clipping. The database can be used to track patients with untreated or partially treated conditions, such as incidental or incompletely coiled aneurysms. The recorded images and video clips are used for teaching and producing multimedia presentations and reports. The database is designed to enable secure Internet connections among institutions so that outcomes and complications can be compared among surgeons and institutions. CONCLUSION: This multimedia computer database facilitates clinical audit, research, teaching, and presentation activities.

Neurosurgical and neuroendovascular management of Takayasu's arteritis.

OBJECTIVE: The roles of surgical and endovascular treatments for patients with Takayasu's arteritis are not clear. We report our experience in the neurosurgical and/or neuroendovascular treatment of patients with Takayasu's arteritis who exhibited ischemic neurological symptoms. METHODS: Between 1994 and 1998, seven patients with Takayasu's arteritis and neurological symptoms were treated at the Stanford University Medical Center. All patients were angiographically evaluated and received maximal medical therapy. Cerebral blood flow studies were performed for six patients. Three patients underwent surgical revascularization procedures alone, two underwent combinations of surgical and endovascular procedures, and two underwent endovascular treatment alone. RESULTS: The most common neurological symptoms were dysequilibrium, syncope, and visual disturbances. The characteristic angiographic features of Takayasu's arteritis were identified for all patients. The subclavian arteries and proximal carotid and vertebral arteries were involved in all patients. Two patients exhibited improvement of their symptoms after endovascular treatment alone. There were two deaths after surgery, involving patients with severe global cerebral hypoperfusion. All other surgically treated patients exhibited improvement of their symptoms, with patent grafts, up to 4 years after surgery. Cerebral blood flow improved after treatment. CONCLUSION: Improvement of symptoms can be achieved with surgical revascularization and/or endovascular treatment. Staged revascularization might be better than one-stage bilateral high-flow grafting for patients with severe global hypoperfusion.

Cervical and thoracic juxtafacet cysts causing neurologic deficits.

STUDY DESIGN: Case reports and review of the literature. OBJECTIVES: To review the clinical features, treatment, and outcome of juxtafacet cysts. SUMMARY OF BACKGROUND DATA: There have previously been 4 reported cases of thoracic juxtafacet cysts and 19 cases of cervical juxtafacet cysts. Cervical cysts have usually originated from the cruciate ligament and caused myelopathy. Thoracic cysts are usually signaled by myelopathy. METHODS: The records of the Neurosurgery Department of Royal Adelaide Hospital from 1980 through 1995 were reviewed for cases of intraspinal juxtafacet cysts. RESULTS: Eight cases of intraspinal juxtafacet cysts were identified; six were in the lumbar spine. One patient had a cervical cyst related to a facet joint and had unilateral radiculopathy. A second patient with a thoracic cyst had the gradual onset of myelopathy. Both patients had surgical excision of the cyst without resection of the adherent dura. The symptoms and neurologic signs improved in each case. CONCLUSIONS: Cervical and thoracic juxtafacet cysts are rare lesions that are usually signaled by myelopathy. Results of surgery are excellent in most cases, even if the cyst is not completely excised.

Mechanisms underlying the formation and enlargement of noncommunicating syringomyelia: experimental studies.

The pathogenesis of noncommunicating syringomyelia is unknown, and none of the existing theories adequately explains the production of cysts that occur in association with conditions other than Chiari malformation. The authors' hypothesis is that an arterial pulsation-driven perivascular flow of cerebrospinal fluid (CSF) is responsible for syrinx formation and enlargement. They investigated normal CSF flow patterns in 20 rats and five sheep by using the tracer horseradish peroxidase; the effect of reducing arterial pulse pressure was examined in four sheep by partially ligating the brachiocephalic trunk; CSF flow was examined in 78 rats with the intraparenchymal kaolin model of noncommunicating syringomyelia; and extracanalicular cysts were examined using the excitotoxic model in 38 rats. In the normal animals there was a rapid flow of CSF from the spinal subarachnoid space into the spinal cord perivascular spaces and then into the central canal. This flow ceased when arterial pulsations were diminished. In animals with noncommunicating syringomyelia, there was rapid CSF flow into isolated and enlarged segments of central canal, even when these cysts were causing pressure damage to the surrounding spinal cord. Exitotoxic injury of the spinal cord caused the formation of extracanalicular cysts, and larger cysts were produced when this injury was combined with arachnoiditis, which impaired subarachnoid CSF flow. The results of these experiments support the hypothesis that arterial pulsation-driven perivascular fluid flow is responsible for syrinx formation and enlargement.

Familial fatal and near-fatal third ventricle colloid cysts.

BACKGROUND: Despite having a presumed congenital origin, familial cases of colloid cysts have been reported only rarely. The first case of a brother and sister with colloid cysts is reported here, and the relevant literature is reviewed. METHODS: A 25-year-old man presented with a 24-h history of headache and vomiting. He rapidly became unconscious and fulfilled the criteria for brain death on arrival at hospital. No surgical intervention was performed. RESULTS: The patient's sister presented at the age of 41 with headaches and rapidly became unconscious. The sister had urgent bilateral ventriculostomies. followed by transcallosal removal of a colloid cyst. CONCLUSIONS: These cases support the hypothesis that colloid cysts are congenital lesions and provide some evidence of a possible genetic predisposition to their formation. Sudden death remains a real risk for patients harbouring a colloid cyst.

Cerebrospinal fluid flow in an animal model of noncommunicating syringomyelia.

OBJECTIVE: The source of fluid and the mechanism of cyst enlargement in syringomyelia are unknown. It has been demonstrated that cerebrospinal fluid (CSF) normally flows from the subarachnoid space through perivascular spaces and into the spinal cord central canal. The aim of this study was to investigate whether this flow continues during cyst formation in an animal model of syringomyelia and to determine the role of subarachnoid CSF flow in this model. METHODS: The intraparenchymal kaolin model of noncommunicating syringomyelia was established in 78 Sprague-Dawley rats. Horseradish peroxidase was used as a tracer to study CSF flow at 1 day, 3 days, 1 week, and 6 weeks after kaolin injection. CSF flow was studied at 0, 10, and 30 minutes after horseradish peroxidase injection into the cisterna magna or thoracic subarachnoid space. RESULTS: The central canal became occluded at the level of the kaolin injection and at one or more rostral levels. Segments of the central canal isolated between occlusions gradually dilated, and axonal retraction balls were detected in the surrounding white matter. There was a partial blockage of subarachnoid CSF flow at the site of the kaolin injection, both in a rostral-caudal direction and in a caudal-rostral direction. Horseradish peroxidase was detected at all time points, in a distinctive pattern, in perivascular spaces and the central canal. This pattern was seen even where segments of the central canal were isolated and dilated. CONCLUSION: In this animal model, noncommunicating syringes continue to enlarge even when there is evidence that they are under high pressure. There may be an increase in pulse pressure rostral to the block of subarachnoid CSF flow, causing an increase in perivascular flow and contributing to syrinx formation. The source of fluid in noncommunicating syringomyelia may be arterial pulsation-dependent CSF flow from perivascular spaces into the central canal.