Fluid Dynamics of the Cranium and...

Fluid Dynamics of the Cranium and OMT

hellipwhere the cerebrospinal fluid is the ldquogreat river of liferdquo which ldquomust be tapped and the withering fields irrigatedrdquo

Rebecca Giusti DO Associate Professor- COMP Western University Pomona CA

Convocation- Broadmoor Colorado Springs

March 2017

DISCLOSURES

bull Dr Rebecca Giusti has no financial interests or relationships to disclose

bull The opinions offered in this presentation are of the presenter and do not represent the opinions of the American Academy of Osteopathy

bull All materials and content are the intellectual property of the presenter or are cited and do not infringe on the intellectual property of any other person or entity

bull The speaker does not endorse any product service or device with this presentation

With kind acknowledgement to

bull Kelli Hines- Scholarly Communications Librarian-WesternU Library

bull Dr Natalie Nevins for this opportunity

bull My mentors

bull Dr Viola Frymann Dr Ray Hruby Dr Mickey Seffinger Dr Mitchell Hiserote

httpwwwnationalgeographiccommagazine201703dark-star-deepest-cave-climbing-uzbekistan


Learning Objectives

bull Review literature that supports Dr Sutherlandrsquos statements on cerebrospinal fluid from almost 70 years agobull CSF is vital to CNS metabolism

bull CSF provides the body with protective and restorative powers

bull The CSF does not circulate it fluctuates

bull Respiratory cooperation will bring about a generalized increase in fluid fluctuation

bull Conductivity

bull Lymphatics

bull Identify current theories on CSF motion properties and fluid dynamics

CSFbull Dr AT Still

bull ldquothe highest known element in the human body and unless the brain furnishes this in abundance a disabled condition of the body will remainrdquo

bull Dr Sutherlandbull ldquoHe feels that the CSF receives and is

endowed with ldquothe breath of liferdquohellipHe finds it to be an intelligent physiologic functioning that transcends all others in the body Dr Sutherland takes advantage of this intelligence this lsquounerring potencyrsquo in the diagnosis and correction of cranial membranous articular lesions Because of this dynamic relationship between the CSF and the physiological function of every cell in the body and particularly those of the CNS the CSF is the initiating and controlling factor in the PRMrdquo

CSF- according to Dr Sutherland- has 2 main attributesbull 1) ldquohighest known elementrdquo

bull Described as a ldquofluid within a fluidrdquo ldquoliquid-lightrdquo the juice in the electric battery ldquothe sheet lightning in the cloudrdquo

bull 2) Fluctuates within a closed container

bull May be directed to assist in the release of ligamentous and membranous articular strains by virtue of its intelligence and potency

bull When so directedhellipthe CSF wave or ldquotiderdquo continues to a functional conclusion unless interrupted

How does it start

In the beginninghellipbull There are chemicals in the cerebrospinal fluid and there are

chemicals in the arterial stream You find that in your texts They tell you what you will find in the cerebrospinal fluid yet the same text tells you there is something there they cannot find something invisible in the cerebrospinal fluid We call your attention to the Breath of Life Intelligence Authorities have various ideas as to how the cerebrospinal fluid originates They know about as much as I do and that is zero I am satisfied to know that it does originate and that it has to be replenished from time to time It has to be like the water in the battery of your carbull Contributions of Thought the Collected Writings of William Garner Sutherland DO 2nd ed

The Sutherland Cranial Teaching Foundation Inc 1998 191

In the beginninghellip

bull The fluid possesses an innate intelligence which molds the head of the newborn and often reduces the traumatic lesions encountered in childhood and laterhellipbull Contributions of Thought the Collected Writings of William Garner Sutherland DO 2nd ed


Stages of CSF

eCSF

fCSF

Adult CSF

bull Embryonic CSF

bull The ends of the neural tube close as the anterior portion of the tube develops into the brain and the posterior part into the spinal cord after the medullar collapse of the cervical part of the neural tube forming a closed cavity

bull Current thought is that initial CSF is amniotic fluid trapped by the closing tube

bull The anterior cavity where the CSF is sealed is surrounded by neuroepithelialprecursors There is no communication between the brain cavity and the space outside The eCSF and neuroepitheliumfunction interdependently within this cavity

bull Therefore it would seem that the origin of CSF would be mediated by neuroepithelialprecursors and the neuroepithelialprecursors must be the target cells

Figure 1 Development of the mouse embryo after 105 days (A) Transversal histological hematoxilin-eosin stained section(B) Macroscopic view showing the neural tube by transiluminationGato A et al Embryonic cerebrospinal fluid in brain development neural progenitor control Croat Med J 201455299-305

In the beginninghellipbull Role of embryonic CSF

bull Create an expansive force within the brain cavity involved in the generation and regulation of brain anlagen growth and morphogenesis

bull Regulation of basic cellular behavior of brain neuroepithelialprecursors cell survival replication and neuronal differentiation

bull Many studies in different species found proteins to be the most important componentsbull Gato A et al Embryonic cerebrospinal fluid in brain development neural

progenitor control Croat Med J 201455299-305

bull Damkier H Brown P Praetorius J Cerebrospinal fluid secretion by the choroid plexus Physiol Rev October 2013 93 1847-92

eCSFbull Twenty-six proteins contained within eCSF were recognized identified and

classified into eight groups according to their functional characteristicsbull 1) gene products related to extracellular matrix proteinsbull 2) proteins associated with regulation of osmotic pressure and ion transport bull 3) proteins related to cell quiescence and death bull 4) lipid transport or metabolism proteins bull 5) retinol and vitamin D carriers bull 6) antioxidant and antimicrobial proteins bull 7) intra-cellular proteins bull 8) unknown proteins

bull Data strongly suggests the existence of a blood-eCSF barrier activity before the formation of the functional fetal choroid plexus acting in both directions to control eCSF formation and homeostasis In addition it has also been demonstrated that this precise regulation of protein transport and eCSFhomeostasis ensures maximum efficiency of eCSF activity during neural developmentbull Bueno D Parvas M Garcia- Fernandez J The embryonic blood-cerebrospinal fluid barrier

function before the formation of the fetal choroid plexus role in cerebrospinal fluid formation and homeostasis Croat Med J 2014 August 55(4) 306ndash316

Factors known to be active in CSF during embryonic brain development

bull Fibroblast factors (FGFs)bull Stimulate proliferation of progenitor cells in the brain

bull Insulin-like growth factors (IGF1 and 2)bull IGF1- regulates neuronal differentiation glial development cell sizebull IGF2- endows CSF with robust growth and survival-promoting effects during neurogenesis

Expressed by choroid plexus

bull Sonic hedgehog (Shh)bull Expressed by hindbrain choroid plexus epithelial cells into CSF Well established in ventral brain

and cerebellar development (May act in a paracrine manner to instruct cerebellar development)bull Also signals directly to choroid plexus pericytes to direct vascular growth- an essential component

of normal choroid plexus development and expansion

bull Retinoic acid (RA)bull Expressed from both the meninges and the choroid plexus Provides key long range signaling

activity for the developing brain ChP RA secreted directly into ventricular CSF Meningeal secreted RA may reach the neuroepithelial cells via the lateral ventricular CSF

bull Bone morphogenic proteins (BMPs)bull Regulates specification of the choroid plexus epithelium (Liddelow)

bull Wnt signalingbull fundamental role in regulating early development of CNSZappaterra M Lehtinen MK The cerebrospinal fluid regulator of neurogenesis behavior and beyond Cell Mol Life Sci (2012) 692863-78

Fetal CSF

bull The end of the embryonic CSF period is marked by 2 processesbull The appearance of the choroid plexus anlagen which is a new CSF production

centerbull The opening of the rombencephalic roof an area involved in communication

with the mesenchyme where the subarachnoid space will be developed

bull CP in roof of 4th ventricle first appears at 9th week gestation shortly after neural tube closure

bull Lateral ventricle CP develop from neuroepithelium and mesenchyme from the roof of the 3rd ventricle and medial wall of the cerebral hemisphere

bull Fully developed lateral ventricle CP extends from foramen of Monroand posterior to the choroidal fissure

bull 3rd ventricle CP is last to form (a continuation of the lateral ventricle Cp through the foramen of Monro

bull Fig 1 Coronal section of the human embryonic brain at gestational week 9 Left panel At gestational week 9 in the human embryo the telencephalicchoroid plexus occupies a large portion of the lateral ventricle The choroid-plexus-secreted CSF in the lateral ventricles bathes the cortical neuroepithelium thereby regulating neurogenesis and the formation of the cortical plate Right panel a more posterior view of the developing human embryo at gestational week 9 shows that the lateral ventricle continues to be filled by the choroid plexus The fourth ventricle choroid plexus is observed to extend along the length of the fourth ventricle Asterisks denote third ventricle choroid plexus ChP choroid plexus LV lateral ventricle NEP neuroepithelium Tel telencephalon Rhomb rhombencephalon V ventriclebull Zappaterra M Lehtinen MK The

cerebrospinal fluidregulator of neurogenesis behavior and beyond Cell Mol Life Sci (2012) 692863-78

Cortical Plate

Cortical NEP

Tel ChP

LV

Anterior Coronal Section Posterior Coronal Section

3rd V

4th VRhomb ChP

eCSF to Adulthood

bull The neural precursors from the eCSF persist into adulthood preserving their precursor characteristics self-renewing to expand the population and causing differentiation into glia and neurons

bull Main difference is intensity rates- at a maximum during embryonic phase and decreasing as we age

bull Cellular niche the neural precursor cells including mature cells (neurons and glia) immature cells generated by the precursors ECM and all forms of intercellular signals from microvessels and the fluid content of the ventricular system

bull CSF is likely part of these niches and is likely a key source of instructive signaling to niche activity that continues into adulthoodbull Gato A et al Embryonic cerebrospinal fluid in brain development neural progenitor control Croat

Med J 201455299-305

CSF provides body with protective and restorative powers

Immunity

Choroid Plexus and Immunitybull Cell adhesion moelcules (CAMs) mediate the binding of lymphocytes via

ligandsbull The CAMs- ICAM-1 VCAM-1 and MAdCAM-1 are expressed and synthesized

by the epithelial cells of the choroid plexusbull During inflammatory processes there is increased synthesis of ICAM-1 and

VCAM-1 and de novo expression of MAdCAM-1 by inflamed choroid plexus epithelium

bull The expression of CAMs suggests that the choroid plexus may play a role in the communication of the immune system with the CNS by either regulating leukocyte traffic across the blood-CSF barrier or mediating the interaction of immune cells

bull This suggests that the epithelial blood-CSF barriers plays an important role in the immunosurveillance of the CNS

bull Steffen BJ ICAM-1 VCAM-1 and MAdCAM-1 are expressed on choroid plexus epithelium but not endothelium and mediate binding of lymphocytes in vitro Am J Pathol 1996148(6)1819-1838

Choroid Plexus and Immunitybull The resolving M2 macrophages (Ly6cloCX3CR1hi) derived from monocytes are trafficked through a

remote blood-cerebrospinal-fluid (CSF) barrier the brainventricular choroid plexus (CP) via VCAM-1-VLA-4 adhesion molecules and epithelial CD73 enzyme for extravasation and epithelial transmigration Blockage of these determinants or mechanical CSF flow obstruction inhibited M2 macrophage recruitment and impaired motor-function recovery

bull The CP along with the CSF and the central canal provided an anti-inflammatory supporting milieu potentially priming the trafficking monocytes

bull The mouse choroid plexus is constitutively populated with CD4+ effector memory T cells with a T cell receptor (TCR) repertoire specific for CNS antigens

bull The similarity in T cell composition of ventricular and lumbar CSF supports the notion that leukocytes enter the CSF through the ventricular choroid plexus bull Shechter R et al Recruitment of beneficial M2 macrophages to injured spinal cord is orchestrated by remote

brain choroid plexus Immunity March 21 201338555ndash569

bull The CSF of healthy individuals contains approximately 150thinsp000 cells gt80 of which are CD4+CD45RO+ CD27+ CXCR3+ central-memory T lymphocytes These cells maintain expression of the lymph node homing markers CCR7 and high expression of L-selectin and about half express CD69 an activation marker

bull The cells re-enter the bloodstream and are replaced by newly immigrating lymphocytes approximately every 12thinsph

bull It has been proposed that CSF central-memory CD4+ T lymphocytes carry out routine immunosurveillance of the CNS by searching within the CSF-filled SASs for antigen presented by meningeal macrophages many with dendritic cell properties or by macrophages of the choroid plexus or those in the VirchowndashRobin perivascular spacesSchwartz M and Schechter R Protective autoimmunity functions by

Intracranial immunosurveillance to support the mind the missing linkBetween health and disease Mol Psychiatry 201015342-354

Choroid Plexus and Immunity

bull The choroid plexus is suggested to function as an active immunomodulatory gate rather than an inert barrier

bull It is enriched with anti-inflammatory CX3C-chemokine receptor 1 (for monocytes)and expresses the CX3CR1 ligand which is crucial to the recruitment and survival of these monocytes

bull Its epithelium constitutively expresses ecto-5ʹ-nucleotidase (also known as CD73) which converts the pro-inflammatory ATP-metabolite AMP into the anti-inflammatory molecule adenosine and the adenosine receptor A2AAR

bull The healthy choroid plexus epithelium also expresses IL-10 IL-13 and macrophage colony-stimulating factor (M-CSF) and the choroidal endothelium constitutively expresses TGFβ bull Shechter R London A Schwartz M Orchestrated leukocyte recruitment to immune-

privileged sites absolute barriers versus educational gates Nature March 201313206-218

Choroid Plexus- Immunitybull It regulates and supports the

development and migration of cells in the adult brain and is required for neural stem cell maintenance

bull Neuroinflammation is a process that depends on a network of immune cells operating in a tightly regulated sequence involving the brainrsquos choroid plexus (CP) a unique neuro-immunological interface positioned to integrate signals it receives from the CNS parenchyma with signals coming from circulating immune cells and to function as an on-alert gate for selective recruitment of inflammation-resolving leukocytes to the inflamed CNS parenchyma

bull Was recently identified as a site through which circulating monocytes which locally become resolving macrophages (Ly6clowCX3CR1high) are preferentially recruited to the CNS after SCI (spinal cord injury)bull Ziegler et alwwwcellcom

Choroid Plexus- Role in Inflammation and Immunity

bull Cells in the choroid plexus have critical roles in brain inflammation

bull They express receptors for and respond to cytokines present in the blood including IL1B TNF alpha and IL-6

bull They express receptors for TLR4 TLR7 and TLR9 indicating that they respond to both bacterial and viral infections of the body

bull They express and release cytokines (IL1B TNF alpha etc) and chemokines (IP-10 MCP-1- which regulate the migration of leukocytes into tissues) during systemic inflammation in response to cytokine stimulation bacterial and viral mimics and injuries and ischemia

bull Regulate the recruitment of T-cells and other leukocytes into the CSF

bull They are key regulators of the entry of inflammatory lymphocyte cells (T-cells macrophages neutrophils) into the CNS under normal basal and pathological conditions Entry of lymphocytes into the brain is a key target for the development of drugs to reduce brain inflammationbull Dragunow M Meningeal and choroid plexus cells-novel drug targets for CNS disorders Brain

Research 2013150132-55

Growth Factors upregulated in CSF in brain injury(Zappaterra M Lehtinen MK The cerebrospinal fluid regulator of neurogenesis behavior and beyond Cell Mol Life Sci (2012)692863-78)

Growth factor Proposed function in brain injury Species injury condition

BDNF Neuroprotection Human Ischemia

Erythropoietin Neuroprotection Human Ischemia

IGF-2 Assists with wound healing via stimulation of neurogenesis and tissue homeostasis

Rat Penetrating injury

NGF Supports survival and growth of neurons Human TBI

sAPP Neuroprotection stimulates proliferation of neural stem cells

Human TBI

TGF-B Supports neuronal survival suppresses inflammation regulates glial scar formation fibrosis and microglial activation

Human TBI

TNF-alpha Dual role exhibiting both neurotoxic properties in striatum and neuroprotection in hippocampus

Human TBI

VEGF Neuroprotection Human TBI

The CSF is in command of metabolism

bull All the physiological centers are located in the floor of the fourth ventricle The endocrine system is regulated to the immediate needs of the body and to interchange between the ldquoleader of the flockrdquo and the endocrine system The cerebrospinal fluid is in command of metabolism and much of the involuntary operation and the autoprotective mechanism of the systembull Contributions of Thought the Collected Writings of William Garner

Sutherland DO 2nd ed The Sutherland Cranial Teaching Foundation Inc 1998 196

SleepWakeCardiotropin-like cytokineMelatoninOleamideOrexin HypocretinTGF-alpha

AppetiteInsulinLeptin

Brain Injury and RepairAugurinBDNFEGFEythropoietinFGFGDNFIGF1 and 2NGFTGF- betaVEGF

Schematic illustratingbrain states and associatedfactors distributed in the CSFDifferent brainbody statesincluding sleepwake appetiteand brain injury and repair havebeen linked with the presence ofdistinct factors in the CSF Inthe case of brain injury andrepair most of the factors listedhave been introducedintraventricularly into injurymodels where they werereported to have beneficialeffects on recovery from injuryThe primary source and mode ofaction for many CSF factorsremain to be elucidated

(Zappaterra M Lehtinen MK The cerebrospinal fluid regulator of neurogenesis behavior and beyond Cell Mol Life Sci (2012)692863-78)

CSF- Endocrine-like Effectsbull Substances synthesized by the choroid plexus and released into the CSF may exert

distal endocrine-like effects on target cells in the brain due to flow of CSF

bull Interleukin-1B- induces widespread vascular-mediated leukocyte (neutrophils and monocytes) infiltration and activation of astrocytes and microglia (Proescholdt et al 2002) IL-1B in the CSF reaches its target receptors on the endothelia via perivascular volume transmission

bull Transthyretin (TTR)- main thyroid hormones carrier protein in the CSF- may have implications in the sequestration of thyroid hormones in the brain

bull Lipocalin- type prostaglandin D synthase (L-PGDS)- synthesized by leptomeningesand choroid plexus and produces prostaglandin D2- a potent sleep inducer

bull Gonadotropin-releasing hormone (GnRH) is present in CSF

bull The choroid-plexus-CSF system has been regarded as an important pathway for conveying prolactin (PRL) to the hypothalamus as a signal input that ultimately controls pituitary release

bull Leptin an important regulator of energy balance is transported through the blood-CSF-barrier and then carried via the CSF to its target in hypothalamusbull Skipor J Thiery JC The choroid plexus- cerebrospinal fluid system undervalauted pathway of

neuroendocrine signaling into the brain Acta Neurobiol Exp 200868414-428

CSF and Metabolism

bull Many CSF-distributed factors have been speculated to influence a wide range of behaviors including sleep and appetite

bull Oleamide- levels are elevated in CSF of sleep-deprived rats When injected into lab rats they exhibit decreased sleep latency and physiologic sleep

bull Orexin-A (also known as hypocretin-1)- an arousal-promoting factor It is a key regulator of wakefulness and is found in lower levels in the CSF of narcoleptic patients

bull Melatonin- released by the pineal body into the CSF- regulates circadian rhythms and is a neuroprotective agent that decreases oxidative stress and removes reactive oxygen species from the CNSbull Zappaterra M Lehtinen MK The cerebrospinal fluid regulator of

neurogenesis behavior and beyond Cell Mol Life Sci (2012)692863-78

CSF and Metabolism

bull The meninges meningeal cells and the choroid plexus may also link peripheral inflammation (eg occurring in the metabolic syndrome-obesity diabetes and after infections) to CNS inflammation which may contribute to the development and progression of a range of CNS neurological and psychiatric disorders

bull Systemic inflammation and infections can worsen several neurodegenerative disorders and metabolic disorders such as obesity and diabetes which are highlighted by systemic inflammation increase psychiatric and neurologic brain disease risk

bull How obesity causes systemic inflammation and insulin resistance is beginning to be understood and the NLR family pyrin domain-containing 3 (NLRP3) inflammasome seems to be an important pathway (this pathway also seems to be involved in the inflammatory and neurotoxic actions of B-amyloid in Alzheimerrsquos disease providing a mechanistic link between systemic and central inflammation)bull Dragunow M Meningeal and choroid plexus cells- novel drug targets for CNS

disorders Brain Research 1501(2013)32-55

It (the CSF) is the vehicle for secretions of the posterior lobe of the pituitary

bull Magoun HI Osteopathy in the Cranial Field Original Edition Sutherland Cranial Teaching Foundation Inc 1997 17

Yamada et albull Placed endoscope into the 3rd ventricle by advancing it from the lateral ventricle

through the foramen of Monro after opening a small hole in the brain- could visualize capillaries running from the pituitary gland in the anterior direction exposed red-colored blood vessels can be seen in the 3rd ventricle

bull A new theory of volume transmission involving hormonal transmitters (orexin prostaglandin D) has been proposed in contrast to the so-called neurotransmission in the form of synaptic transmission

bull Volume transmission is thought to transmit signals to surrounding tissues by means of hormonal transmitters (ie paracrine system in the CNS) This mechanism by which the CSF transports hormonal transmitters and allows their interaction via the CSF is referred to as CSF signaling

bull This mechanism transmits signals over a considerable distance for example from the pineal body to the pituitary gland The turbulence and swirling CSF flow in the 3rd ventricle should have some functional significance in terms of CSF signaling which can be referred to as the CSF paracrine systembull Yamada S Cerebrospinal fluid physiology visualization of cerebrospinal fluid dynamics using

the magnetic resonance imaging time-spatial inversion pulse method Croat Med J 201455337-46

Regulation of CSF Water and Monovalent Electrolyte Balancebull Many key hormones and their receptors which regulate systemic

water and electrolyte homeostasis are found in the choroid plexus ventricular system

bull Aldosterone (produced in hypothalamus and high affinity binding and receptor expression in the choroid plexus)

bull Renin angiotensinogen and angiotensin converting enzyme (ACE) are produced in the CPE cells Angiotension II receptor AT1 expressed on choroid plexus

bull Arginine vasopressin detected in CSFbull Damkier HH et al Cerebrospinal fluid secretion by the choroid plexus Physiol

Rev 2013931847-92

CNS Metabolism

bull Lipid insoluble substances proteins are transferred across 40 of choroid plexus epithelial cells in development and in adulthood

bull Requirement for proteins is 2-foldbull initially in development to set up osmotic pressure gradient causing the influx

of water (improves ventricular expansion and normal brain growth and development)

bull plasma proteins attached to large number of growth factors and other required molecules for normal CNS maintenance

bull 65 of the known 400 solute carrier transporters (SLC) are expressed by epithelial cells of the choroid plexusbull Glucosebull Amino acids (acidic basic neutral)bull Monocarboxylic acids and ions including iron copper and magnesium

bull Liddelow SA Development of the choroid plexus and blood-CSF barrier Front Neurosci March 3 20151-39

Choroid Plexus Role Overview

bull Secretion of CSF

bull Regulation of access for chemical substances from blood to the CSF

bull Synthesis and secretion of biologically active substances important for the functions of the CNS such as plasma proteins polypeptides and cytokines

bull Target of centrally released transmittersbull Skipor J Thiery JC The choroid plexus- cerebrospinal fluid system undervalauted pathway of


The cerebrospinal fluid not only fluctuates but also nourishes the nerve cells

Sutherland WG The Cranial Bowl 2009 4

Provides body with protective and restorative powers

Thus we have been thinking between the lines with Dr Still in an endeavor to tap ldquothis great river of liferdquo the cerebrospinal fluidhellip

hellipthe studious consideration of that highest known element the cerebrospinal fluid the element that is thought by the cranial concept to provide nourishment to the brain cells with consequent transmutation of the element throughout nerve fiber to terminalContributions of Thought the Collected Writings of William Garner Sutherland DO 2nd ed The Sutherland Cranial Teaching Foundation Inc 1998 214-15

bull Zappaterra- due to its immediate contact with neural stem cells in the developing and adult brain the CSFrsquos ability to swiftly distribute signals across a vast distance in the CNS is opening avenues to novel and exciting therapeutic approaches

bull Media conditioned with choroid plexus supports neural stem cell proliferation compared to media conditioned with cortical tissuebull Lehtinen MK et al The cerebrospinal fluid provides a proliferative niche for

neural progenitor cells Neuron 201169(5)893-905

Choroid plexusbull Unique and incomparable tissue with different niches of cells as

pluripotent hematopoietic neuronal progenitors and telocyte cells which provide its complexity differentiated functionality and responsibility on brain balance and neural stem cell regulationbull Roballo KC Regulation of neural stem cells by choroid plexus cells population

Neurosci Lett 2016 Jul 2862635-41

bull Stem cells reside in unique micro-environments so-called niches which provide key signals that regulate stem cell self-renewal and differentiation

bull Choroid plexus secretes a wide variety of important signaling factors in the CSF which are important for stem cell regulation throughout life

bull During aging the levels of stem cell division and formation of new neurons decrease- still present in the aged brain and have capacity to divide but do so less

bull Shen et al found that neural stem cells reside in the adult subventricular zone (SVZ)

bull SVZ stem cells are a subpopulation of type B cells which express the astrocyte marker GFAP (apical type B cells)

bull Some of these apical type B cells contact both the ventricle and the blood vessel beneath

bull There is a rich vascular plexus running within the striatal SVZ parallel to the ventricular surface

bull These cells are in a unique microenvironment with access to CSFependymal factors at one end and bloodvascular endothelial factors at the other

bull SVZ blood vessels promote the development of the adult NSC lineage and are functionally important elements of the normal adult SVZ stem cell nichebull Shen Q et al Adult SVZ stem cells lie in a

vascular niche a quantitative analysis of niche cell-cell interactions Cell Stem Cell Sept 20083289-300

(A) SVZ whole mounts were dissected from the striatal wall of the lateral ventricle (red outline) OB olfactory bulb RMS rostral migratory stream LV lateral ventricle(B) Laminin staining shows the dense network of blood vessels in the SVZ whole mount (viewed from the ventricular surface anterior shown on left of image and dorsal at top) (Arrows) Vessels running along the dorsal border of the SVZ (Arrowhead) A large vessel in the ventral aspect Scale bar 300 mm

bull The ventricular zone involutes as the animal develops while the SVZ rapidly increases in size The size of the SVZ peaks during the first week of postnatal development in rodents and at ~35 weeks gestation in humans Once gliogenesis begins to slow down the SVZ begins to involute however a portion of the SVZ persists into adulthood Therefore although the adult human SVZ has the potential to make new neurons its primary function is to serve as a source of new glial cellsbull Ziegler AN Levison SW Wood T Insulin and IGF receptor signaling in neural-

stem-cell homeostasis Nat Rev Endocrinol 201511161-170

Choroid Plexus and Insulin-Like Growth Factors

bull A unique feature of neural stem cells (NSCs) that reside in the supraventricular zone (SVZ) is that they extend a process through the wall of the ventricle to contact the CSF

bull Whereas the CSF was once thought to be a simple ultrafiltrate of plasma it is now known that this fluid is rich in polypeptides growth factors and hormones that promote maintenance of NSCs Many of these factors are produced by the choroid plexus and include ciliary neurotrophic factor (CNTF) leukaemiainhibitory factor (LIF) members of the Slit family and transforming growth factor β (TGF-β) CNTF and LIF are predominantly expressed in the embryonic choroid plexus which suggests that they are developmentally regulated Of late the insulin-like growth factors (IGFs) have received considerable attention owing to their presence in the CSF and their actions on NSCs and neural progenitor cells bull Ziegler AN Levison SW Wood T Insulin and IGF receptor signaling in neural-stem-cell

homeostasis Nat Rev Endocrinol 201511161-170


bull In 1997 ultrastructural and immunohistochemicalexamination was used to classify the cells of the adult SVZ into six cell types (excluding resident microglia) NSCs (type B1) immature astrocytes (type B2) transit-amplifying cells (type C) neuroblasts (type A) tanycytes (type D) and ependymal cells (type E) NSCs are descendants of radial glial cells and retain some of their properties NSCs are located in the most medial aspect of the SVZ and are fairly quiescent polarized cells that contact the ventricle via an apical process that contains a single primary cilium

bull A major source of the factors that regulate NSCs in the SVZ is the choroid plexus which has been neglected in many current models of the NSC niche bull Ziegler AN Levison SW Wood T Insulin and IGF

receptor signaling in neural-stem-cell homeostasis Nat Rev Endocrinol 201511161-170


bull Insulin and insulin-like growth factors function in stem-cell homeostasis across species

bull The choroid plexus produces IGF-II that functions in the neural stem cell (NSC) niche within the SVZ

bull Choroid plexus major source of IGF-II- levels and biological activity are modulated by IGFBP2- which is expressed by CP

bull IGF-II in the CSF binds to the primary cilium of NSC that protrudes into the lateral ventricles

bull Replacing the high levels of insulin in cell culture media with IGF-II significantly increases the production of neurospheres from the postnatal SVZ and enhances NSC self-renewal

bull This and other studies show that IGF-II promotes neurogenesis in both the SZV and subgranular zone (SGV) NSC

bull IGF-II has autocrine andor paracrine function in sustaining the CP epithelial cells so as levels decline with age the CP also degenerates

bull IGF-I- major mediator of the effects of growth hormone on postnatal growthbull Ziegler AN Levison SW Wood T Insulin and IGF receptor signaling in neural-stem-cell homeostasis

Nat Rev Endocrinol 201511161-170

Choroid Plexusbull Produces CSF and is an important regulator of adult neural stem cellsbull The lateral ventricle choroid plexus is a novel component of the adult V-SVZbull LVCP secretome supports the recruitment and proliferation of NSCs and their

progenybull Specialized niches support the lifelong maintenance and function of tissue-

specific stem cellsbull Adult neural stem cells in the ventricular subventricular zone (V-SVZ) contact

the CSF which flows through the lateral ventriclesbull A largely ignored component of the V-SVZ stem cell niche in the LVCP a

primary producer of CSFbull The LVCP in addition to performing important homeostatic support functions

secretes factors that promote colony formation and proliferation of purified quiescent and activated V-SVZ stem cells and transit-amplifying cellsbull Silva-Vargas V et al Age dependent niche signals from the choroid plexus regulate adult

neural stem cells Cell Stem Cell Published online 21 July 2016 DOI101016jstem201606013

bull ldquoWe can imagine the choroid plexus as a watering can that provides signals to the stem cells Our investigations also open a new route for understanding how different physiological states of the body influence stem cells in the brain during health and disease and opens new ways of thinking about therapyrdquo ndashFiona Doetschbull Silva-Vargas V et al Age dependent niche

signals from the choroid plexus regulate adult neural stem cells Cell Stem Cell Published online 21 July 2016 DOI101016jstem201606013

Conductivity

wwwflickrcom

Electrical Charge and the CSF

bull Dr Sutherland describes the potency of the CSF as an electrical potential which is constantly charging and discharging throughout its substance and sphere of influence

bull ldquoModelers of electrical sources of the human brain have underestimated human CSF conductivity by as much as 44 for nearly 2 decades and this should be corrected to increase the accuracy of source localization modelsrdquobull Baumann SB et al The electrical conductivity of human cerebrospinal fluid at

body temperature IEEE Trans Biomed Eng 1997 Mar44(3)220-3

Electrical Propertiesbull Modified multiscale entropy (mMSE) computed on the basis of resting

state EEG data may be used as a biomarker of normal brain development

bull Appears that mMSE may go through a different development trajectory in infants at higher risk for ASDbull Bosl W et al EEG complexity as a biomarker for ASD BMC Medicine 20119(18)1-16

bull EEG demonstrates lower spectral power in all frequency bands at 6 months in those children who developed ASDbull Tierney AL Developmental trajectories of resting EEG power an endophenotype of

autism spectrum disorder PLoS One June 20127(6)1-10

bull EEG studies are different between high risk and typical children The difference of the EEG may be due to CSF which is known to alter the conductivity of the EEG signal

bull Figure 1 (A) Low-risk infant with normal MRI at 9 months confirmed as having typical development at 36 months

bull (B) High-risk infant with excessive extra-axial fluid at 9 months

bull (C) The same high-risk infant with excessive extra-axial fluid still present at 15 months and

bull (D) at 21 months infant was diagnosed with ASD at 36 months

bull Shen MD et al Early brain enlargement and elevated extra-axial fluid in infants who develop autism spectrum disorder Brain 2013 Sep136(Pt 9)2825-35

Glymphatic System Finally Recognized

bull The presence of lymphatics in human dura mater had been described by an Italian anatomist Mascagni in 1787 in ldquoVasorumlymphaticorum corporis humani historia et ichnographiardquo The studies could not replicated at that time and this observation faded from view

bull Anatomical research has not disclosed just how far this influence (of the potency of the CSF) extends but therapeutic evidence from Dr Still on down would seem to indicate that perineural and perivascular channels are far-reaching and that the connection with the lymphatic system is rather definitebull Magoun HI Osteopathy in the Cranial Field Original Edition Sutherland

Cranial Teaching Foundation Inc 1997 72

Glymphatic System Finally Recognizedbull He (Dr AT Still) refers to the waters of the brain- the highest known

element-then he tells you that the lymphatics drink more of the waters of the brain than all the internal viscera combinedbull Contributions of Thought the Collected Writings of William Garner


bull Such alternating membranous tension and relaxation probably aid in the regulation of venous blood lymph and cerebrospinal fluids along the longitudinal sinus channels (superior sagittal sinus)bull Contributions of Thought the Collected Writings of William Garner

Sutherland DO 2nd ed The Sutherland Cranial Teaching Foundation Inc 199895

Glymphatic System Finally Recognizedbull Louveau et al found the following

bull Functional lymphatic vessels line the dural sinuses and drain CSF

bull Express all of the molecular hallmarks of lymphatic endothelial cells are able to carry both fluid and immune cells from the CSF and are connected to deep lymphatic cervical nodes

bull Are similar to diaphragm lymphatic vessels

bull Many do not possess lymphatic valves

bull Are unique in that the network seems to start from both eyes and tracks above the olfactory bulb before aligning adjacent to the sinuses

bull Vessels are larger and more complex in the transverse sinuses than in the superior sagittal sinus

bull Meningeal lymphatic vessels not nasal mucosa lymphatic vessels are the primary route of drainage of CSF-derived soluble and cellular constituents into the deep cervical lymph nodes

bull Abluminal distribution of meningeal T cells and identification of Lyve-1 (LEC marker- lymphatic endothelial cell) expressing vessels adjacent to the duralsinuses

bull Representative image of Lyve-1 labelling on whole-mount meningesbull Louveau A et al Structural

and functional features of central nervous system lymphatic vessels Nature July 16 2015

bull Abluminal distribution of meningeal T cells and identification of Lyve-1 expressing vessels adjacent to the dural sinuses

bull Higher magnification of Lyve-1-expressing vesselsbull Louveau A et al Structural and functional

features of central nervous system lymphatic vessels Nature July 16 2015

Aspelund et albull Aspelund et al discovered a similar structure in mice They found that dural

lymphatic vessels are found extensively at the base of the skull and penetrate the base of the skull along with cranial nerves Tracers administered into the brain parenchyma exit into the dural lymphatics vessels

bull The lymphatic vessels form an extensive network in the meninges underlying cranial bones

bull The lymphatic vessels are visualized along the transverse sinus sigmoid sinus retroglenoid v rostral rhinal v and middle and anterior meningeal and pterygopalatine a

bull Were also present at many exit sites along arteries veins and in distal portions and exit points of CN II V IX X XI

bull Relatively scarce at superior portion of skull ndash more extensive at base of cranium and only these contained valves

Aspelund et albull Dural lymphatic vessels absorb CSF from the adjacent subarachnoid space

and brain interstitial fluid (ISF) via the glymphatic system

bull Dural lymphatic vessels transport fluid into deep cervical lymph nodes (dcLNs) via foramina at the base of the skull

bull When efferent lymphatic vessel of the dcLN was ligated there was enhanced filling of the dural lymphatic vessels- suggesting that the dura mater lymphatic vessels absorb brain ISFCSF from subarachnoid space for transport into downstream dcLNs

bull Dura mater lymphatic vessels contribute to the clearance of macromolecules from the brain

bull Interestingly- surgical removal of the deep cervical lymph nodes result in cognitive impairment in mice (Rajadvi et al) and ligation is reported to aggravate cerebral ischemia after stroke in rats (Si et al)

bull Terminally differentiated lymphatic vessels in the dura mater of the brain-visualization of CNS lymphatic vasculature using Prox1-GFP reporter mice with Dil counterstaining for blood vasculature Vegfr3LacZreporter mice and immunofluorescence for PECAM1 and the lymphatic markers PROX1 LYVE1 PDPN CCL21 and VEGFR3 as indicated

bull White arrowheads denote lymphatic vessels yellow arrowheads denote skull exit sitesbull Aspelund A et al A dural lymphatic

vascular system that drains brain interstitial fluid and macromolecules J Exp Med 2015 212(7)991-99

A- schematic image of the various areas analyzedB-lymphatic vessels running down along the sigmoid sinus and exiting the skullC-lymphatic vessels running down along the proximal middle meningeal (MMA) artery branchesD-lymphatic vessels around the retroglenoid vein with some vessels exiting the skull

A- schematic image of the various areas analyzed E-lymphatic vessels along the superior sagittal sinus (SSS) and the distal parts of the anterior MMA branch extending toward the bregmaF-lymphatic vessels along the SSS bifurcating into the transverse veins (TV)at the confluence of sinusesG-lymphatic vessels exiting the skull along the optic (II) and trigeminal (V) nervesand through the cribiformplate (CP)H-lymphatic vessels associated with CNIX X XI XII

Aspelund A et al A dural lymphatic vascular system that drains brain interstitial fluid and macromolecules J Exp Med 2015 212(7)991-99

bull Dura mater lymphatic vessels drain brain ISF into dcLNs (deep cervical lymph nodes) Analysis of lymphatic outflow routes of cerebral ISF by fluorescent stereomicroscopy in Prox1-GFP (green) mice 1 h after PEG-IRDye (red) injection into brain without (A-F) and with (G-J) ligation of the efferent lymphatic vessel of the dcLN

bull Lymphatic vessels around the posterior branch of the MMA showing increased filling of lymphatic vessels after ligation extending above the retroglenoid vein

bull Aspelund A et al A dural lymphatic vascular system that drains brain interstitial fluid and macromolecules J Exp Med 2015 212(7)991-99

bull Response (to a CV4) there will be a lsquosofteningrsquo of the area between the hands with added warmth to the areahellipbull Magoun H Osteopathy in the Cranial Field Original Edition Sutherland


Aquaporinbull AQP-1 is present in the choroid plexus and AQP-4 is distributed widely in

the brain in areas such as astrocyte foot processes glia limitans and ependymal and subependymal astrocytes

bull AQP-4 represents the isoform of the membrane integral water channel aquaporin family within the brain

bull AQP-4 facilitates a water exchange between the interstitial fluid and the CSF cavity

bull AQP-4 is responsible for removing metabolites produced by neural activity through water permeability thereby greatly contributing to the functional maintenance of the brain

bull Evidence continues to suggest that AQP-4 may play a role in the pathophysiology of various brain diseases from Alzheimerrsquos to epilepsy

bull Fig 1 Upper Representative 11C-TGN-020 PET images of normal human brain images are constructed based on the frames acquired 15ndash60 minutes post-injection

bull All five subjects studied exhibited virtually identical findings Images are color coded according to standardized uptake value (SUV) of each pixel in the range of 0ndash12

bull Over ranged (12 gt SUV) pixels are expressed as red Strongest uptake was seen in the skull and within large veins and dural sinuses Radioactivities within large veins and duralsinuses are believed to reflect AQP-1 of red cells The cause for strong uptake within the skull remains to be elucidated Lower Time-activity curves of uptake in SUV of three representative regions

bull Red circle cortex green triangle choroid plexus blue diamond skull Data are shown as mean SUV plusmn standard error of means (SEM)

Suzuki Y Aquaporin-4 positron emission topography imaging of thebrain first report J Neuroimaging 201323219-223

bull Fig 2 Images constructed with filling pixels which showed the SUV over 12 in black Axial images based on identical data [Fig 1 (A)] and representative images of sagittal and coronal views (B) All images were constructed based on the frames acquired 15ndash60 minutes post injection

bull Distribution of radioactivitieswithin the brain are highly consistent with known distribution of AQP-4 namely subpial and perivascular endfeet of astrocytes

bull Choroid plexus where both AQP-4 and AQP-1 are known to be significantly expressed also showed significant uptake

Suzuki Y Aquaporin-4 positron emission topography imaging of the brain first report J Neuroimaging 201323219-223

The CSF does not ldquocirculaterdquo- it has fluctuation

bull The rhythmical fluctuation of the cerebrospinal fluid is now readily and intelligently observed through palpation of skillful non-incisive surgeons who include the cranial field in their practice of the science of osteopathy

Contributions of Thought the Collected Writings of William Garner Sutherland DO 2nd ed The Sutherland Cranial Teaching Foundation Inc 1998 300

wwwjustanothersciencenerdwordpresscom

Motionbull According to the classic hypothesis of CSF physiology CSF is mainly produced

by the choroid plexus then circulates unidirectionally through the ventricles and further along the subarachnoid spaces to be passively absorbed into the venous blood by the arachnoid villi (Oreskovic and Klarica)

bull Progression of technologybull CSF flow was thought to be primarily due to the cardiac pulsation and CSF

movement was synchronized with the cardiac beat (Yamada 2013)bull This was shown using phase-contrast MRI- useful with cardiac cycle and can

only be used if CSF is moving (Yamada 2013)bull Echo planar imaging (EPI)bull Now Time-SLIP (Time-spatial labeling inversion pulse)- 2D and now 4D

(Yamada 2015)bull Continue to be issues- research conducted on anesthetized prone animals

supine still humans

CSF Fluctuation or Motionbull CSF motion is not fully knownbull Respiration seemed to have the most influence- high CSF flow elicited with

forced inspiration breath holding suppressed itbull Found a cardiac-related CSF flow component but appears to be minor as

compared to respirationbull Presence of slow frequency waves (Friese) Lundberg first described slow

oscillations as so called B-waves during ICP-monitoringbull Strik et al (with MR-EPI technique) that slow rhythmic oscillations in the

cerebral blood- and CSF-flow can be analyzed non-invasively and independently from the cardiac cycle The comparable distribution of slow waves in the pulse arteries and CSF may reflect an origin in autoregulation whereas divergent patterns like in the incompressible venous sinus may be of a passive origin

bull Ciliary motion of the ependymal cells lining the ventriclesbull The CSF flow is variable amongst all subjectsbull (Strik et al Friese et al Yamada et al Dreha-Kulaczewski et al Zappaterra)

So letrsquos examine respiration for a momenthellip

Respiratory cooperation will bring about a generalized increase in the fluid fluctuation

-Magoun H Osteopathy in the Cranial Field Original ed Sutherland Cranial Teaching Foundation Inc 199760

CSF Motion with Respiration

bull During involuntary activity one can feel the CSF being drawn from beneath the arachnoid membrane into the fourth ventricle and fluctuated up into the third and lateral ventricles during the period of inhalation Likewise one can feel the cerebrospinal fluid being drawn from the lateral and third ventricles into the fourth and then fluctuated out into the area beneath the arachnoid membrane during the period of exhalationbull Contributions of Thought the Collected Writings of William Garner


bull Patient supine

bull Time-SLIP bSSFP cine images during inhalation and exhalation- Time-SLIP pulse applied perpendicular to sagittal plane to encompass red dotted rectangle a)ndashinhalation-caudo-cranial movement of CSF observed at aqueduct of Sylvius (blue arrow) and the prepontinesubarachnoid space toward the suprasellar cistern and the 3rd

ventricle (red arrows)b)during exhalation- a cranio-caudadmovement of CSF to the prepontinesubarachnoid space was observed (red arrow)

bull (Time-SLIP time-spatial labeling inversion pulse)

bull (bssFP balanced steady-state free precession)

bull CSF in prepontine subarachnoid space moved cephalad 165 +-77mm with inhalation and caudad116 +- 30mm with exhalation

Yamada S et al Influence of respiration on cerebrospinal fluid movement using magnetic resonance spin labeling Fluids Barriers CNS- 2013 Dec 2710(1)36 doi1011862045-8118-10-36

bull Time-SLIP bssFP cine images during breath holding- in the prepontine region only a small amount of cephalad and caudad CSF movements were observed in the mid-sagittal view

bull For breath holding small but rapid cephalad and caudad CSF volume movements were observed Average cephalad movement 30 +- 04mm and average caudad movement was 30 +-05mm with a net distance of 60mm

bull Conclusion significant caudad CSF movement with deep exhalation

bull Corresponding cephalad CSF movement during deep inhalation observed in both the ventricular system and cranial and spinal subarachnoid spaces

bull Turbulent flow and mixing of CSF in 3rd

and 4th ventricles in response to respiration


Yamada et al

Figure 3- Inhalation and exhalation- the points represent the average maximum distance cephalad and caudad with standard deviation in the pre-pontine SAS

Figure 5- Inhalation and exhalation- the points represent the average maximum cephalad and caudad distance in prepontine SAS with breath holding


CSF Motion and Respiration

bull Chen et al with their work using simultaneous multi-slice (SMS) EPI showed similar results to Yamada et al

bull While they found that the CSF velocity matched up with both respiratory and cardiac pulsation it seems that respiration has a strong effect on CSF direction and speed

bull Superior directed CSF motion into cranial cavity and lateral ventricles occurred during the inspiration phase and ldquodownwardrdquo directed velocity occurred in the expiration phase

bull Also reported additional low-frequency modulations bull Bi-directional respiratory motion occurs primarily along central axis

through the basal cisterns and intraventricular passageways and to a lesser extent in the peripheral Sylvian fissure with little CSF motion present in subarachnoid spaces

bull While researchers seem to be able to identify in part what influences CSF motion the cause seems to remain elusive

bull Bering et al stated that the choroid plexus arterial pulsation drives the CSF

bull Du Boulay et al in 1966 stated it is the bilateral thalamic movement that pumps the CSF

bull Enzmann et al (1992) stated it is the entire brain in response to the arterial pulsation that propels CSF


bull The CSF doesnrsquot necessarily ldquoflowrdquo inferiorly along the dorsal aspect and return superiorly along the ventral aspect This idea is based on observations by Di Chiro in 1966 where the vertebral arches of an animal in the prone positon were cut and dye was injected into the ventricles The dye was seen to move inferiorly so it was concluded that CSF flows downward in the spinal subarachnoid space

bull In 1964 radioisotope injected into the lumbar subarachnoid space entered the cranium- it was assumed CSF must flow superiorly on the ventral side (same researcher by the way)

wwwapsubiologyorg

bull Oreskovic and Klarica in numerous studies state that their results do not support unidirectional CSF circulation but strongly suggest that there are cardiac cycle-dependent systolic-diastolic to-and ndashfro cranio-spinal CSF movements These are based on a) physiological oscillations of arterial and venous blood during cranio-spinal blood circulation b) respiratory activity and c) body activity and posture

bull State that when discussing CSF dynamics a more appropriate term would be CSF movement rather than CSF circulationbull Oreskovic and Klarica A new look at cerebrospinal fluid movement Fluids and

Barriers of the CNS 2014 1116

CSF Motion bull Turbulent reflux flow between the aqueduct of Sylvius and the 3rd ventricle

bull Flow moves from the 3rd

ventricle to the lateral ventricles through the foramen of Monro in normal healthy volunteers

bull There is linear and turbulent flowbull Yamada S et al Current and

emerging MR imaging techniques for the diagnosis and management of CSF flow disorders a review of phase-contrast and time-spatial labeling inversion pulse AJNR Apr 201536623-30

wwwapsubiologyorg

Yamada et albull CSF in the lateral ventricles and the CSF in the 3rd ventricle

are actively exchanged through the foramen of Monro in a normal brain (reflux)

bull There is either no flow or very slow flow of CSF in the body of the lateral ventricles except in the area adjacent to the foramen of Monro

bull CSF motion in the 3rd and 4th ventricles is swirling vortex-type flow even when the head is stationary The area around the 3rd ventricle contains a dense arrangement of vital structures that are related to the circadian rhythm

CSF Fluctuation- Spinal Cord

bull Fig 5 Diagram showing the commonly accepted bulk flow model (A) and the two types of cerebrospinal fluid circulation related to the proposed concept of the circulation (B and C) The dominant pulsatile flow shown in B is responsible for the rapid spread of tracers within the extraventricular cerebrospinal fluid spaces and the comparatively small almost minute bulk flow (C) explains the appearance of the cisternogram in normal cases causing washout of tracer in the ventricular system and the basal cisterns

bull B There is a dominant pulsatile flow with a fast-velocity compartment in the brain stemndashcord area and slow velocities at the upper and lower ends of the subarachnoid spaces The amplitude and velocity are indicated by the length of the segments of the dashed line The systolic and diastolic flows in the spinal canal follow one main channel which is located toward the convexities showing a meandering S-shaped route caused by centrifugal forces and lower resistance in wider subarachnoid spaces

bull C The minute bulk flows are exaggerated for clearer illustration The thickness of the arrows is related to the magnitude of the bulk flow which decreases in both directions from the foramen magnum The cerebrospinal fluid is resorbed everywhere in the central nervous system by the circulating blood The spinal nerves including the cauda equina are represented solely by one caudal root in this schematic drawing

Greitz D Hannerz J A proposed model of cerebrospinal fluid circulation observation with radionuclide cisternographyAJNR March 199617431-38


bull Haughton et al concludedbull Spinal CSF has complex oscillatory flow patterns resulting from the

displacement of cranial CSF Flow patterns differ from one spinal level to another

bull CSF moves caudally when the systolic pulse wave reaches the brain ad cephalad during diastole Caudal CSF flow has greater velocities and shorter duration than cephalad flow

bull MR flow imaging shows cyclic changes in spinal fluid flow related to the cardiac cycle spinal fluid flow jets related to the complex spinal anatomy and flow vortices

bull Engineering calculations suggest that the inertial and viscous forces in CSF have similar proportions to blood flowing in the aortabull Haughton V Mardal K-A Spinal fluid biomechanics and imaging an update for

neuroradiologists AJNR Oct 2014351864-69

bull Midsagittal view of the entire brain and spine showing labeled CSF motion at different locations in the subarachnoid space as well as in the ventricles The labeled CSF tended to spread over time but no unidirectional bulk CSF flow (from site of production to site of absorption) was observedbull Yamada S Cerebrospinal fluid

physiology visualization of cerebrospinal fluid dynamics using the magnetic resonance imaging Time-Spatial Inversion Pulse method Croat Med J201455337-46

Spinal CSF

bull Spinal absorption through arachnoid granulations located along the nerve roots (morphologically similar to cranial villi) suggested by Kido et al

bull Eddsbagge et al found a spinal CSF absorption of 011-023 mLmin near lumbar spinal level of tracer injection This was more pronounced in active individuals than in resting individuals Spinal absorption has been suggested to be 25-50 in animal models Only followed radionuclide trace for 1 hour so a minor slow bulk cranial-directed flow cannot be excludedbull Eddsbagge M et al Spinal CSF absorption in healthy individuals American J

Physiol- Regulatory Integrative ad Comparative Physiology Dec 1 2004287(6)1450-55

CSF Fluctuationbull Inspiratory pressure reduction empties the venous plexus of the epidural venous

system of the spinal canal leading to a compensatory CSF flow downward into the spinal canal

bull Elevated thoracic pressure concurrent with expiration fills the venous plexus and facilitates reverse CSF flow to the head

bull Indicates that inspiratory thoracic pressure reduction elicits pronounced CSF flow as it is transmitted to the brain SAS via the interconnected venous plexus around the thoracic spinal column and within the spinal canalbull Dreha- Kulaczewski S et al Inspiration is the major regulator of human CSF flow J

Neurosci Feb 11 201535(6)2485-91

bull Concomitant analyses of CSF dynamics and cerebral venous blood flow that is in epidural veins at cervical level 3 uniquely demonstrated CSF and venous flow to be closely communicating cerebral fluid systems in which inspiration-induced downward flow of venous blood due to reduced intrathoracic pressure is counterbalanced by an upward movement of CSFbull Dreha- Kulaczewski S et al Identification of the upward movement of human CSF in vivo

and it relation to the brain venous system J of Neurosci March 1 201737(9)2395-2402

Motility

bull The third unit in the mechanism is known as motility of the brain and spinal cord affording dilation and contraction of the ventricles that occur during alternate respiratory periodic changes

bull Authoritative writers on the subject of cerebrospinal fluid call attention to an interchange with the arterial blood at the choroid plexus We are inclined to reason that the interchange could not occur without some degree of motility within the plexuses Motility common to the walls necessarily occurs throughout the structural form of the plexuses

bull Contributions of Thought the Collected Writings of William Garner Sutherland DO 2nd ed The Sutherland Cranial Teaching Foundation Inc 1998 220

Motilitybull Faubel et al found that the ventricular surfaces are lined with ependymal cells whose

apical surfaces contain bundles of motile cilia

bull The motile cilia are eyelash-shaped cellular protrusions containing a microtubule-based axoneme that confers motility by bending

bull CSF flow is driven by continuous CSF secretion into the ventricles and by this orchestrated beating of the cilia

bull They discovered a cilia-based switch that reliably and periodically alters the flow of the pattern which may control substance distribution in the third ventricle

bull There are major physiologic differences in the pattern of beating in an awake animal and an animal at rest

bull This may indicate that the distribution of CSF varies with time of day

bull The flow may play a role in delivery or uptake of substances from the entrance of the 3rd

ventricle to the arcuate nucleus which is characterized by numerous chemosensory tanocytes

bull Tanocyte cell bodies are in contact with CSF and their processes extend deep into the brain parenchyma Therefore they serve as a bridge between the ventricle and the neuronsbull Faubel R et al Cilia-based flow network in the brain ventricles Science July 8

2016353(6295)176-178

bull In conclusion

bull Complex fluid movements are present in the brain in the form of a transport network driven by coordinated cilia beating patterns

bull Flows and whirls may establish and modulate intraventricular boundaries capable that assist with targeted substance delivery

bull Transient local changes in the beating pattern evoked a major change in ventricular subdivision

bull Underlying factor of beating direction is unknown may be planar cell polarity or cell-cell interactionsbull Faubel R et al Cilia-based flow

network in the brain ventricles Science July 8 2016353(6295)176-178

Anatomy of the 3rd ventricle in the mouse and its flow mapC- flow map of the ventral 3rd ventricle showing the near wall flow into multiple domains- 8 major flow directions indicated with arrows

Motilitybull The structure and function of the central nervous system depends on precisely controlled

movements of young neurons

bull In the adult brain neuroblasts born in the subventricular zone migrate from the walls of the lateral ventricles to the olfactory bulb

bull It was found that there is a remarkable similarity between the direction of CSF flow and the organization of the network of chains of migrating neuroblasts in the SVZ Essentially neuroblast migration parallels CSF flow The orientation of neuroblast migration correlates with the flow of CSF rather than with the relative position of the olfactory bulb

bull The pattern of ink flow generated by the beating ependymal cilia paralleled that of CSF flow observed in vivo Furthermore the orientation of cilia beating observed live under the light microscope or after fixation by scanning electron microscopy was similar to the patterned flow observed in vivo and in vitro indicating that ciliary beating and planar polarity of ependymal cells generate directed currents of fluid adjacent to the ventricular wall

bull It seems that beating of ependymal cilia is required for normal CSF flow concentration gradient formation of CSF guidance molecules and directional migration of neuroblasts Results suggest that polarized epithelial cells contribute important vectorial information for guidance of young migrating neurons

bull The present work suggests that polarized epithelia and motile cilia in the brain serve as important conveyors of directional information for neuronal migration

bull Sawamoto K New neurons follow the flow of cerebrospinal fluid in the adult brain Science Feb 3 2006 311629-32

Motilitybull Scanning electron micrographs

showing orientation of ependymal cilia at various locations on the lateral wall of the lateral ventricle as indicated in (L) Cilia beat ventrally in the anterior part of the anterior horn (I) beat anteriorly in the dorsal anterior horn (J) and beat anterodorsally in the intermediate region dorsal to the choroid plexus (K)bull Sawamoto K New neurons

follow the flow of cerebrospinal fluid in the adult brain Science Feb 3 2006 311629-32

Food for thoughthellip

bull With manually initiated movement the fluctuation is the continuance of initiated movement which carries the mechanism as directed unless prevented by locking We start the mechanism and let the fluid carry it

bull Specific direction of the potency of the tide from one point on the cranium to another for lesion diagnosis (or correction) has been described above Here we take advantage of the potency of the fluctuating tide to normalize the parts of the mechanism which are not in physiologic harmonybull Magoun HI Osteopathy in the Cranial Field Original Edition Sutherland

Cranial Teaching Foundation Inc 1997 60-61

In Summarybull Research is now demonstrating what Dr Sutherland so eloquently

stated about 70 years ago based on his clinical observations and palpatory skills

bull The CSF and the choroid plexus seem to bebull vital to CNS metabolism

bull provide the body with protective and restorative powers



bull The CSF has conductivity

bull The CSF is intimately involved in the lymphatic system

bull All that I have done is to pull aside a curtain for further vision

bull William Sutherland DO

bull With Thinking Fingers p98


Referencesbull Aspelund A et al A dural lymphatic vascular system that drains brain interstitial fluid and macromolecules

J Exp Med 2015 212(7)991-99

bull Baumann SB et al The electrical conductivity of human cerebrospinal fluid at body temperature IEEE Trans BiomedEng 1997 Mar44(3)220-3

bull Bueno D Parvas M Garcia- Fernandez J The embryonic blood-cerebrospinal fluid barrier function before the formation of the fetal choroid plexus role in cerebrospinal fluid formation and homeostasis Croat Med J 2014 August 55(4) 306ndash316


bull Dragunow M Meningeal and choroid plexus cells-novel drug targets for CNS disorders Brain Research 2013150132-55

bull Dreha- Kulaczewski S et al Inspiration is the major regulator of human CSF flow J Neurosci Feb 11 201535(6)2485-91

bull Dreha- Kulaczewski S et al Identification of the upward movement of human CSF in vivo and it relation to the brain venous system J of Neurosci March 1 201737(9)2395-2402

bull Du Boulay GH Pulsatile movements in the CSF pathways Br J Radiol 196639255-262

bull Eddsbagge M et al Spinal CSF absorption in healthy individuals American J Physiol- Regulatory Integrative ad Comparative Physiology Dec 1 2004287(6)1450-55

Referencesbull Enzmann DR Pelc NJ Brain motion measurement with phase-contrast MR imaging Radiology

1992185653-660

bull Faubel R et al Cilia-based flow network in the brain ventricles Science July 8 2016353(6295)176-178

bull Gato A et al Ebryonic cerebrospinal fluid in brain development neural progenitor control Croat Med J 201455299-305

bull Greitz D et al On the pulsatile nature of intracranial and spinal CSF-circulation demonstrated by MR imaging Acta Radiol 199334(4)321-8

bull Greitz D Hannerz J A proposed model of cerebrospinal fluid circulation observation with radionuclide cisternography AJNR March 199617431-38

bull Haughton V Mardal K-A Spinal fluid biomechanics and imaging an update for neuroradiologists AJNR Oct 2014351864-69

bull Iliff et al ldquoBrain-wide pathway for waste clearance captured by contrast-enhanced MRIrdquo The Journal of Clinical Investigation March 2013 Vol 123(3) 1299-1309

bull Iliff and Nedergaard ldquoIs there a Cerebral Lymphatic Systemrdquo Stroke 2013 44 [suppl 1]S93-S95

bull Iliff et al ldquoCerebral Arterial Pulsation Drives Paravascular CSF-Interstitial Fluid Exchange in the Murine Brainrdquo The Journal of Neuroscience Nov 13 2013 33(46)18190-18199

Referencesbull Lehtinen MK et al The cerebrospinal fluid provides a proliferative niche for neural progenitor cells

Neuron 201169(5)893-905


bull Louveau A et al Structural and functional features of central nervous system lymphatic vessels Nature July 16 2015 523337-41

bull Magoun HI Osteopathy in the Cranial Field Original Edition Sutherland Cranial Teaching Foundation Inc 1997

bull Oreskovic and Klarica A new look at cerebrospinal fluid movement Fluids and Barriers of the CNS 2014 1116

bull Proescholdt MG et al Intracerebroventricular but not intravenous interleukin-1beta induces widespread vascular-mediated leukocyte infiltration and immune signal mRNA expression followed by brain-wide glial activation Neuroscience 2202112731-749

bull Radjavi A etal Dynamics of the meningeal CD4+ T-cell repertoire are defined by the cervical lymph nodes and facilitate cognitive task performance in mice Mol Psychiatry 201419531-532

Referencesbull Sawamoto K New neurons follow the flow of cerebrospinal fluid in the adult brain Science Feb 3

2006 311629-32

bull Schwartz M and Schechter R Protective autoimmunity functions by intracranial immunosurveillance to support the mind the missing link between health and disease MolPsychiatry 201015342-354

bull Shechter R London A Schwartz M Orchestrated leukocyte recruitment to immune-privileged sites absolute barriers versus educational gates Nature March 201313206-218

bull Shechter R et al Recruitment of beneficial M2 macrophages to injured spinal cord is orchestrated by remote brain choroid plexus Immunity March 21 201338555ndash569

bull Shen MD et al Early brain enlargement and elevated extra-axial fluid in infants who develop autism spectrum disorder Brain 2013 Sep136(Pt 9)2825-35 Si J Chen L Xia Z Effects of cervical-lymphatic blockade on brain edema and infarction volume in cerebral ischemic rats ClinJ Physiolo 200649258-265

bull Skipor J Thiery JC The choroid plexus- cerebrospinal fluid system undervalauted pathway of neuroendocrine signaling into the brain Acta Neurobiol Exp 200868414-428

bull Steffen BJ ICAM-1 VCAM-1 and MAdCAM-1 are expressed on choroid plexus epithelium but not endothelium and mediate binding of lymphocytes in viro Am j Pathol 1996148(6)1819-1838

Referencesbull Strik C Klose U Kiefer C Grodd W Slow rhythmic oscillations in intracranial CSF and blood flow

registered by MRI 200281139-42

bull Sutherland WG Contributions of Thought the Collected Writings of William Garner Sutherland DO 2nd ed The Sutherland Cranial Teaching Foundation Inc 1998 191

bull Suzuki Y Aquaporin-4 positron emission topography imaging of the brain first report J Neuroimaging 201323219-223

bull Tierney AL Developmental trajectories of resting EEG power an endophenotype of autism spectrum disorder PLoS One June 20127(6)1-10

bull Yamada S Cerebrospinal fluid physiology visualization of cerebrospinal fluid dynamics using the magnetic resonance imaging time-spatial inversion pulse method Croat Med J 201455337-46

bull Yamada S et al Influence of respiration on cerebrospinal fluid movement using magnetic resonance spin labeling Fluids Barriers CNS- 2013 Dec 2710(1)36 doi1011862045-8118-10-36

bull Zappaterra M Lehtinen MK The cerebrospinal fluid regulator of neurogenesis behavior and beyond Cell Mol Life Sci (2012)692863-78

DISCLOSURES

bull Dr Rebecca Giusti has no financial interests or relationships to disclose

bull The opinions offered in this presentation are of the presenter and do not represent the opinions of the American Academy of Osteopathy

bull All materials and content are the intellectual property of the presenter or are cited and do not infringe on the intellectual property of any other person or entity

bull The speaker does not endorse any product service or device with this presentation




bull My mentors




Learning Objectives





bull Conductivity

bull Lymphatics


CSFbull Dr AT Still









How does it start







Stages of CSF

eCSF

fCSF

Adult CSF

bull Embryonic CSF



























Fetal CSF










Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32


















bull My mentors




Learning Objectives





bull Conductivity

bull Lymphatics


CSFbull Dr AT Still









How does it start







Stages of CSF

eCSF

fCSF

Adult CSF

bull Embryonic CSF



























Fetal CSF










Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32

















Learning Objectives





bull Conductivity

bull Lymphatics


CSFbull Dr AT Still









How does it start







Stages of CSF

eCSF

fCSF

Adult CSF

bull Embryonic CSF



























Fetal CSF










Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32















CSFbull Dr AT Still









How does it start







Stages of CSF

eCSF

fCSF

Adult CSF

bull Embryonic CSF



























Fetal CSF










Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32




















How does it start







Stages of CSF

eCSF

fCSF

Adult CSF

bull Embryonic CSF



























Fetal CSF










Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32





















Stages of CSF

eCSF

fCSF

Adult CSF

bull Embryonic CSF



























Fetal CSF










Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32















bull Embryonic CSF



























Fetal CSF










Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32




































Fetal CSF










Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32

















Cortical Plate

Cortical NEP

Tel ChP

LV


3rd V

4th VRhomb ChP

eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32















eCSF to Adulthood





Med J 201455299-305


Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32
















Immunity



































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32

















































Research 2013150132-55









Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32























Human TBI


Human TBI


Human TBI



















CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32
































CSF and Metabolism






CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32















CSF and Metabolism


















Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32




























Rev 2013931847-92

CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32















CNS Metabolism
































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32








































































Conductivity

wwwflickrcom























































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32





































































































supine still humans













bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32



























bull Patient supine














Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32






















Yamada et al

















wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32




























wwwapsubiologyorg









wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32























wwwapsubiologyorg



















Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32

































Spinal CSF








Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32



















Neurosci Feb 11 201535(6)2485-91



Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32















Motility














2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32

























2016353(6295)176-178

bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32















bull In conclusion



































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32











































J Exp Med 2015 212(7)991-99










1992185653-660










Neuron 201169(5)893-905








2006 311629-32
















1992185653-660










Neuron 201169(5)893-905








2006 311629-32
















Neuron 201169(5)893-905








2006 311629-32
















2006 311629-32















Fluid Dynamics of the Cranium and...

Documents

Transcript of Fluid Dynamics of the Cranium and...