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J Neurosurg. 2019 May 17:1-14. doi: 10.3171/2019.2.JNS182675. [Epub ahead of print]

When the air hits your brain: decreased arterial pulsatility after craniectomy leading to impaired glymphatic flow.

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1Center for Translational Neuromedicine, Department of Neurosurgery, and.
2Department of Pathology, University of Rochester Medical Center, Rochester, New York; and.
3Department of Anesthesiology and Perioperative Medicine, and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon.


OBJECTIVECranial neurosurgical procedures can cause changes in brain function. There are many potential explanations, but the effect of simply opening the skull has not been addressed, except for research into syndrome of the trephined. The glymphatic circulation, by which CSF and interstitial fluid circulate through periarterial spaces, brain parenchyma, and perivenous spaces, depends on arterial pulsations to provide the driving force for bulk flow; opening the cranial cavity could dampen this force. The authors hypothesized that a craniectomy, without any other pathological insult, is sufficient to alter brain function due to reduced arterial pulsatility and decreased glymphatic flow. Furthermore, they postulated that glymphatic impairment would produce activation of astrocytes and microglia; with the reestablishment of a closed cranial compartment, the glymphatic impairment, astrocytic/microglial activation, and neurobehavioral decline caused by opening the cranial compartment might be reversed.METHODSUsing two-photon in vivo microscopy, the pulsatility index of cortical vessels was quantified through a thinned murine skull and then again after craniectomy. Glymphatic influx was determined with ex vivo fluorescence microscopy of mice 0, 14, 28, and 56 days following craniectomy or cranioplasty; brain sections were immunohistochemically labeled for GFAP and CD68. Motor and cognitive performance was quantified with rotarod and novel object recognition tests at baseline and 14, 21, and 28 days following craniectomy or cranioplasty.RESULTSPenetrating arterial pulsatility decreased significantly and bilaterally following unilateral craniectomy, producing immediate and chronic impairment of glymphatic CSF influx in the ipsilateral and contralateral brain parenchyma. Craniectomy-related glymphatic dysfunction was associated with an astrocytic and microglial inflammatory response, as well as with the development of motor and cognitive deficits. Recovery of glymphatic flow preceded reduced gliosis and return of normal neurological function, and cranioplasty accelerated this recovery.CONCLUSIONSCraniectomy causes glymphatic dysfunction, gliosis, and changes in neurological function in this murine model of syndrome of the trephined.


AP = anterior-posterior; AU = absolute unit; CSF; ICP = intracranial pressure; ISF = interstitial fluid; IgG = immunoglobulin G; ML = medial-lateral; NDS = normal donkey serum; OA-555 = Alexa Fluor 555–conjugated ovalbumin; PBS = phosphate-buffered saline; ROI = region of interest; TBI = traumatic brain injury; TCD = transcranial Doppler; TRITC = tetramethylrhodamine; aCSF = artificial CSF; arterial pulsatility; craniectomy; cranioplasty; glymphatic; syndrome of the trephined


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