. Human and nonhuman primate meninges harbor lymphatic vessels that can be visualized noninvasively by MRI. Elife. 2017 Oct 3;6 PubMed.


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  1. This manuscript strengthens the data observed in rodents and described in Louveau et al. (2015). Using T2-FLAIR and T1-weighted black-blood imaging in humans and marmoset monkeys, the dural lymphatic vessels were observed in the present work bilaterally along the superior sagittal sinus, and immunocytochemistry for lymphatic markers demonstrated their presence in dura mater.

    The German neuroanatomist Karl-Hermann Andres (1929-2005, Ruhr-Universität Bochum) published in 1987 that:

    Lymphatic vessels occur within the dura mater. They leave the cranial cavity through the openings of the cribriform plate, rostral to the bulla tympani together with the transverse sinus, and the middle meningeal artery.

    There is firm evidence that lymphatic drainage of the cerebrospinal fluid is along different anatomical compartments compared to that of the cerebral parenchyma, resulting in distinct implications in neuroimmunology (Engelhardt et al., 2016). Some parenchymal interstitial fluid escapes into the CSF and will most likely reach the dural lymphatic vessels (McIntee et al., 2016; Szentistvanyi et al., 1984). 

    The work reported in this paper is a major step forward in the study of dural lymphatics. Although much can be discovered by histology and tracer studies in experimental animals, visualizing dural lymphatics by imaging in humans allows dural lymphatics to be studied clinically in neurological diseases ranging from multiple sclerosis to dementia. Many obstacles remain before there is a full understanding of the functions of dural lymphatics in relation to the central nervous system. The dura is separated from the CSF in the subarachnoid space by a waterproof, impenetrable layer of arachnoid. The first question therefore is how CSF reaches dural lymphatics, which it undoubtedly does. Once this problem has been solved, it may be possible to expand the use of imaging of dural lymphatics to study the dynamics of CSF drainage by this route and how it is altered in neurological disease.

    The second question that remains to be resolved is the relationship between dural lymphatics and lymphatic drainage of the brain. Studies involving the injection of tracers into the brain itself show that lymphatic drainage pathways are along the walls of cerebral capillaries and arteries. This is supported by observations in the human brain whereby amyloid is deposited in the intramural peri-arterial drainage (IPAD) pathways as cerebral amyloid angiopathy (Morris et al., 2016). 

    These are exciting times, with the promise of visualising routes of lymphatic drainage by MRI not only in the dura but in the central nervous system. In vivo imaging in patients would greatly enhance our knowledge of the pathophysiology of intractable diseases such as multiple sclerosis and dementia and may aid in their management and therapy.


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    View all comments by Roy Weller
  2. In 1787, anatomist Paolo Mascagni published an atlas of all lymphatic vessels in the human body, which included the brain, where he described the presence of lymphatics in the cerebral dura mater (Mascagni, 1787, Vasorum Lymphaticorum Corporis Humani Historia et Ichonographia). In the late 19th century, Gustav Schwalbe injected Prussian blue into the subarachnoid space and found that cervical lymph vessels were stained (Schwalbe, 1869, Der Arachnoidealraum, ein Lymphraum und sein Zusammenhang mit dem Perichorioidealraum). Throughout the 20th century, there were many studies investigating brain lymphatic system drainage. The Fӧldi group described the presence of “prelymphatics” in the brain, as they obstructed the lymphatic vessels in the necks of several animals, including dog, cat, and rabbit, and observed edema in the brains and enlargement of perivascular spaces (Casley-Smith et al., 1976; Csanda et al., 1963, 1968; Földi et al., 1966). Furthermore, studies using intracerebral injections of radioiodinated albumin into rabbit caudate nucleus (Bradbury et al., 1981) and large molecular weight tracers (India ink or albumin labeled with colloidal gold, Evans blue, or rhodamine) into the perivascular space of an artery on the brain surface, or within the cerebral cortices or the subarachnoid spaces of anesthetized rats (Ichimura et al., 1991), demonstrated that solutes carried by the perivascular interstitial fluid (ISF) flow reach the cerebrospinal fluid (CSF) compartment and drain into deep cervical lymph (Bradbury et al., 1981; Ichimura et al., 1991). 

    Two recent studies revealed the presence and role of the meningeal lymphatic vascular system in clearance of ISF and macromolecules from the mouse brain into the deep cervical lymph nodes (Aspelund et al., 2015; Louveau et al., 2015). Using Prox1-GFP transgenic mice, and injection of an inert 20-kDa poly(ethylene glycol) conjugate of the bright near-infrared dye IRDye 680 into brain parenchyma, Aspelund et al. tracked dural lymphatic vessels and the drainage of the dye into the deep cervical lymph nodes. Furthermore, they found that a transgenic mouse model with impaired vascular endothelial growth factor-C/D–vascular endothelial growth factor receptor 3 signaling lack dural lymphatic vessels, and have impaired clearance of macromolecules from brain into deep cervical lymph nodes (Aspelund et al., 2015). Louveau et al. identified several molecular hallmarks of mouse lymphatic endothelial cells in a whole-mount dissection of the dura mater, and also performed in vivo functional studies tracking flow of dye through lymphatic vessels by simultaneously injecting adult mice with fluorescein intravenously and with fluorescent tracer dye (QDot655) intracerebroventricularly, and imaging by multiphoton microscopy through a thinned skull. Furthermore, they identified vessels expressing similar lymphatic endothelial markers (Lyve-1+podoplanin+CD68–) by immunohistochemistry in postmortem human brain dura.

    These previous studies demonstrated that the brain indeed has a lymphatic system, which here Absinta et al. confirmed in living brains in five young healthy human volunteers and three healthy adult non-human primates (marmosets) using magnetic resonance imaging (MRI) with a combination of regular Gadolinium-based contrast agent (Gadovist) and blood-pool contrast agent (Vasovist). Indeed, on T2-weighted fluid-attenuated inversion recovery (FLAIR) and T1-weighted black-blood imaging, lymphatic vessels enhance with Gadovist, but not with Vasovist. They also confirmed the vessels imaged by MRI to be lymphatic by immunohistochemistry using classical lymphatic endothelial markers (i.e., lymphatic vessel endothelial hyaluronan receptor 1 [LYVE-1], podoplanin [D2-40], prospero homeobox protein 1 [PROX1], COUP transcription factor 2 [COUP-TFII], and CCL21) versus vascular endothelial marker CD31 in both humans and marmosets.

    In addition to its potential role in regulating brain immune responses, the meningeal lymphatic system could also play a role in removing metabolic waste and proteinaceous toxic accumulates from brain. It would be very interesting to determine whether there is any dysfunction in lymphatic drainage in neurological diseases, especially neurodegenerative diseases which have aberrant protein accumulation. For example, recent work from Kovacs et al. reported amyloid accumulation in the dura of Creutzfeldt-Jakob disease patients using postmortem histology (Kovacs et al., 2016), which in light of the present findings hints at the possibility of amyloid accumulation by or due to dysfunction of lymphatic vessels. Although the majority of Aβ is cleared from the murine brain under physiological conditions by transvascular receptor-mediated transport across the blood-brain barrier via clearance receptors including low-density lipoprotein receptor-related protein 1 (LRP1) and P-glycoprotein (PgP), about 15–20 percent is cleared from brain by perivascular flow of ISF (Shibata et al., 2000; Xie et al., 2013), likely draining into meningeal lymphatic vessels and deep cervical lymph nodes. Since in Alzheimer’s disease transvascular clearance systems fail relatively early due to damage of blood vessels associated with low expression of LRP1 and PgP (Montagne et al., 2017), it would be interesting to determine if the perivascular Aβ clearance system is also disrupted, leading to accumulation of Aβ along arterial blood vessels and within the lymphatic system. Moreover, whether the perivascular lymphatic system can be used to drain Aβ from brain remains an open question.



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    View all comments by Berislav Zlokovic

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