Masahiro Kameda
Yoshinaga Kajimoto
Masahiko WanibuchiCurrent standard therapy for hydrocephalus
Cerebrospinal fluid (CSF) shunting, as exemplified by the ventriculoperitoneal (VP) shunt, is the gold standard for the treatment of hydrocephalus in both adults and children. In fact, the SINPHONI and SINPHONI-2 studies demonstrated that shunting for idiopathic normal pressure hydrocephalus (iNPH) is medically and economically beneficial due to its therapeutic effect (1, 2). However, the short- and long-term complications of shunt surgery for hydrocephalus remain unresolved. For example, shunt failure is reported to occur in up to 40% of cases within the 1st year after surgery (3–6). Shunt infections have not been completely eliminated, although they are less common than in the past (7–9).
Furthermore, especially pediatric cases, it is indisputable that the long-term psychosocial burden associated with the shunt system affects the quality of life, as the shunt system is required for the rest of the patient's life.
Current status of hydrocephalus treatment research
The VP shunt, the standard treatment for hydrocephalus, is a countermeasure to bring a progressive and worsening state of hydrocephalus into a state of arrested hydrocephalus. Shunt surgery is already an established treatment for hydrocephalus, and many outcomes have been reported for the shunt itself (10–12).
In contrast, because shunt surgery requires permanent implantation of the shunt system, surgical techniques that do not require permanent implantation, such as endoscopic third ventriculography (ETV) and choroid plexus coagulation (CPC), have been developed. Some reports have compared the therapeutic efficacy of these techniques with that of shunting (13–16). Simply stated, ETV is more effective for obstructive hydrocephalus than non-obstructive hydrocephalus, and has a therapeutic effect for obstructive hydrocephalus comparable to shunting. In addition, the combination of ETV and CPC has been tried in non-obstructive hydrocephalus, but the results have not been satisfactory, while shunting is effective in both non-obstructive and obstructive hydrocephalus. Therefore, the combination of ETV and CPC is not a common treatment option at this time.
Failure to control progressive neurologic deterioration and ventricular enlargement on imaging requires shunt placement. However, there is insufficient research to develop histopathology-based treatments that prevent progressive deterioration and avoid shunt surgery.
In routine practice, a number of patients have enlarged ventricles on imaging but no obvious symptoms of hydrocephalus. Furthermore, before closure of the anterior fontanel in infants, intracranial hypertension may, for some time, be compensated for by an increase in head circumference, even with ventricular enlargement (17).
Although basic and translational histopathology-based research for central nervous system (CNS) diseases such as stroke and Parkinson's disease has been well-established for future clinical application (18–21), histopathology-based treatments for hydrocephalus have not been adequately explored.
If restoring the microenvironment in the brain could prevent the progression of hydrocephalus to a condition requiring surgery, it would mark the beginning of a new era in the treatment of infantile extrinsic hydrocephalus, such as post-hemorrhagic hydrocephalus from shunt surgery to shunt avoidance.
Importance of proper discharge and removal of hazardous materials
To maintain neurological activity, waste products and other toxic substances must be properly eliminated from the brain. Lymphatic vessels play this role in other organs, but a similar system in the CNS had not been identified. In 2012, the glymphatic system was proposed as a pathway to transport and drain substances into the subarachnoid space of the brain via astrocytes. This pathway was found to be dependent on aquaporin-4 (AQP4), a water channel protein in astrocytes (22).
It has now been established that the glymphatic system in the brain plays a role analogous to that of the lymphatic system in the body, efficiently removing waste products to the outside of the brain by generating extracellular flow.
In recent years, we have gained new information about the physiology of the cerebrospinal fluid, including the glymphatic system, the paravascular space, and the interstitial fluid (22–26), and we believe that this is a good time to develop new treatment and management methods for hydrocephalus based on this new knowledge.
Development of a new treatment incorporating the glymphatic system theory: Alzheimer's disease
Recently, it was reported in a mouse model that when the removal of extracellular tau protein by the glymphatic system is inhibited, the amount of tau in the brain increases, affecting neurodegeneration. AQP4 is involved in this clearance process, and mice lacking AQP4 showed increased tau accumulation and neuronal cell death (27).
In addition, the greater the dysfunction of the glymphatic system, the less amyloid-β is found in the CSF; similarly, the more that amyloid-β is unable to be cleared from the CSF, the greater the deposition of amyloid-β in the brain (28).
Thus, delayed clearance of Alzheimer-related proteins due to dysfunction of the glymphatic system has been reported to contribute, at least in part, to the development of Alzheimer's disease.
In addition to hydrocephalus, at least some cases of chronic fatigue syndrome have been reported to benefit from CSF drainage, leading to speculation that accumulation of toxic substances in the CNS due to glymphatic dysfunction may be involved (29).
Improvement of hydrocephalus is expected by improving inflammatory findings in the ventricular and paraventricular microenvironment
Intraventricular hemorrhage in preterm babies is caused by perforation of the ventricle in neonates with germinal matrix layer hemorrhage, and neuroinflammation in the paraventricular tissue is reportedly involved in the pathogenesis of this condition. This inflammatory milieu generates free radicals and pro-inflammatory cytokines such as interleukin (IL)-6, IL-4, tumor necrosis factor-α (TNFα), and transforming growth factor-β1 (TGFβ1), which contribute to the development and progression of hydrocephalus (30).
According to the osmotic gradient theory, brain diseases with excess macromolecules in the intracerebroventricular spinal fluid alter the osmotic gradient and cause hydrocephalus. In other words, hydrocephalus can be considered a macromolecular clearance disorder rather than a circulatory disorder (23).
AQPs, known water transport proteins, are transmembrane water channel, and the direction of water transport by AQP follows only an osmotic gradient; that is, AQPs are passive water transport proteins (25).
Although the relationship between the CSF in the ventricles and the glymphatic system is not well-understood, effective removal of the toxic macromolecular proteins underlying the pathogenesis of hydrocephalus may prevent glymphatic dysfunction, prevent neurological deterioration, ventricular enlargement, and ultimately shunting. Furthermore, based on the osmotic gradient theory, effective removal of the toxic macromolecular proteins underlying the pathogenesis of hydrocephalus may prevent progressive neurological deterioration and ventricular enlargement on imaging thus avoiding shunt surgery. Regardless of whether it follows the osmotic gradient theory or the glymphatic system theory, AQP is considered to play a key role.
Development of new treatment and management methods for hydrocephalus
To develop a new treatment and management of hydrocephalus that prevents the transition to hydrocephalus requiring a shunt, it is necessary to improve the inflammatory environment through efficient removal of toxic macromolecular proteins and to improve the ventricular and paraventricular microenvironment.
The question is how to effectively remove toxic macromolecular proteins. There is a history of developing new treatments for CNS diseases in terms of scavenging free radicals and improving the microenvironment. For example, edaravone was initially approved for cerebral infarction but the indication was later expanded to include amyotrophic lateral sclerosis (ALS) (31).
In the human brain, neurogenesis has been observed in the subventricular zone and the hippocampus. Given the background pathology of hydrocephalus, improving the ventricular and paraventricular microenvironment is expected to be effective in preserving the function of neurogenesis, which is thought to be innate in the human brain (32). If microenvironmental repair can prevent hydrocephalus from progressing to the state where it requires surgery, it will usher in a new era in infantile extrinsic hydrocephalus management, from surgery to prevention.
The glucagon-like peptide-1 (GLP-1) receptor drug liraglutide (33, 34) and erythropoietin (EPO) (35, 36) have been shown to promote neurogenesis and to have anti-inflammatory properties. GLP-1 receptor agonists are drugs used to treat patients with diabetes without the risk of hypoglycemic events, and their ability to enhance neurogenesis and anti-inflammatory effects is attractive for application in the treatment of hydrocephalus (37). In addition, although EPO has a side effect of polycythemia, carbamoylated erythropoietin (CEPO), a neuroprotective agent without the risk of polycythemia, has been developed, and its ability to enhance neurogenesis and anti-inflammatory effects is attractive when considering its application in the treatment of hydrocephalus (38–41).
In terms of the osmotic gradient and glymphatic system theories, AQP4 has been shown to play an important role in the efficient removal of toxic macromolecular proteins; moreover, EPO upregulates AQP4 expression and improves the clearance of excess water via AQP4 (42). Moreover, exenatide, a GLP-1 passive agonist similar to liraglutide, has been reported to restore reduced AQP4 levels in the hippocampus of diabetic rats (43).
In this context, cocktail therapy with edaravone, liraglutide and EPO is expected to prevent progressive neurological deterioration and ventricular enlargement, thus avoiding shunt surgery. In addition, if enhanced neurogenesis leads to recovery of neurological function, it is expected to lead to a new treatment that improves the functional prognosis of even surgically treated cases of hydrocephalus.
Author contributions
MK contributed to conception and design of the study and wrote the manuscript under supervision of YK and MW. All authors contributed to manuscript revision, read, and approved the submitted version.
Funding
This work was supported by Grant-in-Aid for Scientific Research (C) JP 20K09390.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Kameda M, Yamada S, Atsuchi M, Kimura T, Kazui H, Miyajima M, et al. Cost-effectiveness analysis of shunt surgery for idiopathic normal pressure hydrocephalus based on the SINPHONI and SINPHONI-2 trials. Acta Neurochir. (2017) 159:995–1003. doi: 10.1007/s00701-017-3115-2
2. Nakajima M, Yamada S, Miyajima M, Ishii K, Kuriyama N, Kazui H, et al. Guidelines for management of idiopathic normal pressure hydrocephalus (third edition): endorsed by the Japanese Society of Normal Pressure Hydrocephalus. Neurol Med Chir. (2021) 61:63–97. doi: 10.2176/nmc.st.2020-0292
3. Al-Tamimi YZ, Sinha P, Chumas PD, Crimmins D, Drake J, Kestle J, et al. Ventriculoperitoneal shunt 30-day failure rate: a retrospective international cohort study. Neurosurgery. (2014) 74:29–34. doi: 10.1227/NEU.0000000000000196
4. Anderson IA, Saukila LF, Robins JMW, Akhunbay-Fudge CY, Goodden JR, Tyagi AK, et al. Factors associated with 30-day ventriculoperitoneal shunt failure in pediatric and adult patients. J Neurosurg. (2018) 2018:1–9. doi: 10.3171/2017.8.JNS17399
5. Drake JM, Kestle JR, Milner R, Cinalli G, Boop F, Piatt J Jr, et al. Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery. (1998) 43:294–303. doi: 10.1097/00006123-199808000-00068
6. Kestle J, Drake J, Milner R, Sainte-Rose C, Cinalli G, Boop F, et al. Long-term follow-up data from the Shunt Design Trial. Pediatr Neurosurg. (2000) 33:230–6. doi: 10.1159/000055960
7. Ramasy Razafindratovo RM, Migliavaca CB, Chevret S, Champeaux-Depond C. Internal ventricular cerebrospinal fluid shunt for adult hydrocephalus: a systematic review and meta-analysis of the infection rate. Neurosurgery. (2022) 2022:2301. doi: 10.1227/neu.0000000000002301
8. Kestle JR, Holubkov R, Douglas Cochrane D, Kulkarni AV, Limbrick DD Jr, Luerssen TG, et al. A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr. (2016) 17:391–6. doi: 10.3171/2015.8.PEDS15253
9. Reddy GK, Bollam P, Caldito G. Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. World Neurosurg. (2012) 78:155–63. doi: 10.1016/j.wneu.2011.10.034
10. Paulsen AH, Lundar T, Lindegaard KF. Pediatric hydrocephalus: 40-year outcomes in 128 hydrocephalic patients treated with shunts during childhood. Assessment of surgical outcome, work participation, and health-related quality of life. J Neurosurg Pediatr. (2015) 16:633–41. doi: 10.3171/2015.5.PEDS14532
11. Gmeiner M, Wagner H, Schlogl C, van Ouwerkerk WJR, Senker W, Sardi G, et al. Adult outcome in shunted pediatric hydrocephalus: long-term functional, social, and neurocognitive results. World Neurosurg. (2019) 132:e314–e23. doi: 10.1016/j.wneu.2019.08.167
12. Lumenta CB, Skotarczak U. Long-term follow-up in 233 patients with congenital hydrocephalus. Child's Nervous System. (1995) 11:173–5. doi: 10.1007/BF00570260
13. Kulkarni AV, Riva-Cambrin J, Rozzelle CJ, Naftel RP, Alvey JS, Reeder RW, et al. Endoscopic third ventriculostomy and choroid plexus cauterization in infant hydrocephalus: a prospective study by the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr. (2018) 21:214–23. doi: 10.3171/2017.8.PEDS17217
14. Coulter IC, Dewan MC, Tailor J, Ibrahim GM, Kulkarni AV. Endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) for hydrocephalus of infancy: a technical review. Child's Nervous System. (2021) 21:5. doi: 10.1007/s00381-021-05209-5
15. Kulkarni AV, Sgouros S, Leitner Y, Constantini S, International Infant Hydrocephalus Study I. International Infant Hydrocephalus Study (IIHS): 5-year health outcome results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus. Child's Nervous System. (2018) 34:2391–7. doi: 10.1007/s00381-018-3896-5
16. Arynchyna-Smith A, Rozzelle CJ, Jensen H, Reeder RW, Kulkarni AV, Pollack IF, et al. Endoscopic third ventriculostomy revision after failure of initial endoscopic third ventriculostomy and choroid plexus cauterization. J Neurosurg Pediatr. (2022) 2022:1–10. doi: 10.3171/2022.3.PEDS224
17. Di Rocco C, Frassanito P. Hydrocephalus: generalities and clinical presentations. In:C Di Rocco, D Pang, JT Rutka, , editors, Textbook of Pediatric Neurosurgery. Cham: Springer International Publishing (2019). p. 1–46.
18. Kawauchi S, Yasuhara T, Kin K, Yabuno S, Sugahara C, Nagase T, et al. Transplantation of modified human bone marrow-derived stromal cells affords therapeutic effects on cerebral ischemia in rats. CNS Neurosci Ther. (2022) 28:1974–85. doi: 10.1111/cns.13947
19. Kin I, Sasaki T, Yasuhara T, Kameda M, Agari T, Okazaki M, et al. Vagus nerve stimulation with mild stimulation intensity exerts anti-inflammatory and neuroprotective effects in Parkinson's disease model rats. Biomedicines. (2021) 9:70789. doi: 10.3390/biomedicines9070789
20. Kin K, Yasuhara T, Date I. Encapsulation of mesenchymal stem cells: dissecting the underlying mechanism of mesenchymal stem cell transplantation therapy. Neurosci Insights. (2020) 15:2633105520959064. doi: 10.1177/2633105520959064
21. Kuwahara K, Sasaki T, Yasuhara T, Kameda M, Okazaki Y, Hosomoto K, et al. Long-term continuous cervical spinal cord stimulation exerts neuroprotective effects in experimental Parkinson's disease. Front Aging Neurosci. (2020) 12:164. doi: 10.3389/fnagi.2020.00164
22. Iliff JJ, Wang M, Liao Y, Plogg BA, Peng W, Gundersen GA, et al. A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid beta. Sci Transl Med. (2012) 4:147ra11. doi: 10.1126/scitranslmed.3003748
23. Krishnamurthy S, Li J. New concepts in the pathogenesis of hydrocephalus. Transl Pediatr. (2014) 3:185–94. doi: 10.3978/j.issn.2224-4336.2014.07.02
24. Jessen NA, Munk AS, Lundgaard I, Nedergaard M. The glymphatic system: a beginner's guide. Neurochem Res. (2015) 40:2583–99. doi: 10.1007/s11064-015-1581-6
25. MacAulay N. Molecular mechanisms of brain water transport. Nat Rev Neurosci. (2021) 22:326–44. doi: 10.1038/s41583-021-00454-8
26. Bohr T, Hjorth PG, Holst SC, Hrabetova S, Kiviniemi V, Lilius T, et al. The glymphatic system: current understanding and modeling. iScience. (2022) 25:104987. doi: 10.1016/j.isci.2022.104987
27. Ishida K, Yamada K, Nishiyama R, Hashimoto T, Nishida I, Abe Y, et al. Glymphatic system clears extracellular tau and protects from tau aggregation and neurodegeneration. J Exp Med. (2022) 219:1275. doi: 10.1084/jem.20211275
28. Kamagata K, Andica C, Takabayashi K, Saito Y, Taoka T, Nozaki H, et al. Association of MRI indices of glymphatic system with amyloid deposition and cognition in mild cognitive impairment and Alzheimer disease. Neurology. (2022) 99:e2648–60. doi: 10.1212/WNL.0000000000201300
29. Wostyn P, De Deyn PP. The putative glymphatic signature of chronic fatigue syndrome: a new view on the disease pathogenesis and therapy. Med Hypotheses. (2018) 118:142–5. doi: 10.1016/j.mehy.2018.07.007
30. Karimy JK, Reeves BC, Damisah E, Duy PQ, Antwi P, David W, et al. Inflammation in acquired hydrocephalus: pathogenic mechanisms and therapeutic targets. Nat Rev Neurol. (2020) 16:285–96. doi: 10.1038/s41582-020-0321-y
31. Ohta Y, Nomura E, Shang J, Feng T, Huang Y, Liu X, et al. Enhanced oxidative stress and the treatment by edaravone in mice model of amyotrophic lateral sclerosis. J Neurosci Res. (2019) 97:607–19. doi: 10.1002/jnr.24368
32. Campos-Ordonez T, Herranz-Perez V, Chaichana KL, Rincon-Torroella J, Rigamonti D, Garcia-Verdugo JM, et al. Long-term hydrocephalus alters the cytoarchitecture of the adult subventricular zone. Exp Neurol. (2014) 261:236–44. doi: 10.1016/j.expneurol.2014.05.011
33. Sato K, Kameda M, Yasuhara T, Agari T, Baba T, Wang F, et al. Neuroprotective effects of liraglutide for stroke model of rats. Int J Mol Sci. (2013) 14:21513–24. doi: 10.3390/ijms141121513
34. Hunter K, Holscher C. Drugs developed to treat diabetes, liraglutide and lixisenatide, cross the blood brain barrier and enhance neurogenesis. BMC Neurosci. (2012) 13:33. doi: 10.1186/1471-2202-13-33
35. Hierro-Bujalance C, Infante-Garcia C, Sanchez-Sotano D, Del Marco A, Casado-Revuelta A, Mengual-Gonzalez CM, et al. Erythropoietin improves atrophy, bleeding and cognition in the newborn intraventricular hemorrhage. Front Cell Dev Biol. (2020) 8:571258. doi: 10.3389/fcell.2020.571258
36. Iwai M, Cao G, Yin W, Stetler RA, Liu J, Chen J. Erythropoietin promotes neuronal replacement through revascularization and neurogenesis after neonatal hypoxia/ischemia in rats. Stroke. (2007) 38:2795–803. doi: 10.1161/STROKEAHA.107.483008
37. Nauck MA, Quast DR, Wefers J, Meier JJ. GLP-1 receptor agonists in the treatment of type 2 diabetes - state-of-the-art. Mol Metab. (2021) 46:101102. doi: 10.1016/j.molmet.2020.101102
38. Coleman TR, Westenfelder C, Togel FE, Yang Y, Hu Z, Swenson L, et al. Cytoprotective doses of erythropoietin or carbamylated erythropoietin have markedly different procoagulant and vasoactive activities. Proc Natl Acad Sci USA. (2006) 103:5965–70. doi: 10.1073/pnas.0601377103
39. Thomas Tayra J, Kameda M, Yasuhara T, Agari T, Kadota T, Wang F, et al. The neuroprotective and neurorescue effects of carbamylated erythropoietin Fc fusion protein (CEPO-Fc) in a rat model of Parkinson's disease. Brain Res. (2013) 1502:55–70. doi: 10.1016/j.brainres.2013.01.042
40. Tiwari NK, Sathyanesan M, Schweinle W, Newton SS. Carbamoylated erythropoietin induces a neurotrophic gene profile in neuronal cells. Prog Neuropsychopharmacol Biol Psychiatry. (2019) 88:132–41. doi: 10.1016/j.pnpbp.2018.07.011
41. Ma Y, Zhou Z, Yang GY, Ding J, Wang X. The effect of erythropoietin and its derivatives on ischemic stroke therapy: a comprehensive review. Front Pharmacol. (2022) 13:743926. doi: 10.3389/fphar.2022.743926
42. Rizwan Siddiqui M, Attar F, Mohanty V, Kim KS, Shekhar Mayanil C, Tomita T. Erythropoietin-mediated activation of aquaporin-4 channel for the treatment of experimental hydrocephalus. Child's Nervous System. (2018) 34:2195–202. doi: 10.1007/s00381-018-3865-z
Keywords: pediatric hydrocephalus, glucagon-like peptide-1 (GLP-1), erythropoietin (EPO), free radical scavenger, post-hemorrhagic hydrocephalus
Citation: Kameda M, Kajimoto Y and Wanibuchi M (2023) New therapeutic hypothesis for infantile extrinsic hydrocephalus. Front. Neurol. 14:1215560. doi: 10.3389/fneur.2023.1215560
Received: 02 May 2023; Accepted: 23 August 2023;
Published: 19 September 2023.
Edited by:
Hao Xu, USTC Life Sciences and Medicine, ChinaReviewed by:
Joseph Piatt, Alfred I. duPont Hospital for Children, United StatesCopyright © 2023 Kameda, Kajimoto and Wanibuchi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Masahiro Kameda, bXJrYW1lZGEmI3gwMDA0MDtnbWFpbC5jb20=