Traditionally CSF formation has been experimentally altered by interfering with membrane ion transporters or by reducing delivery of substrate. Nevertheless, metabolically upstream molecular manipulations for modulating CSF secretion deserve consideration. A novel approach is to target transcription factors as putative regulators of cellular enzymes in CSF formation. Mice lacking the transcription factors p73, foxJ1 and E2F5 develop non-obstructive hydrocephalus 3031, possibly from CSF over secretion. Epithelial ultrastructure analysis and electron translucence in micrographs are consistent with accelerated fluid formation by CP 32. It is intriguing that E2F5 in CPe is down-regulated as the cells mature (i.e. as they convert from pseudostratified to single cuboidal epithelium) in their ability to produce CSF 30. Such ontogenetic findings on transcription factors in mice and human CP 3031 prompt a new tack to augment CSF formation by manipulating E2F5 expression.

Releasing the natural inhibitory brake on the manufacture of CSF would be a unique way to increase fluid transfer across CP. There is an experimental precedent for this theoretical approach. Resection of the sympathetic nerve from the superior cervical ganglion attenuates the inhibitory autonomic tone on CP. This increases CSF production 32. Enhancing CSF formation and the associated sink action 33 on brain interstitial solutes may find application to aging, normal pressure hydrocephalus (NPH), and Alzheimer's disease (AD) patients who retain extracellular metabolites from sluggish fluid turnover 19.

Most attempts to regulate CSF formation rate have been directed at altering ion movement via transporters in the basolateral (plasma-facing) and apical (CSF-facing) membranes of the CPe 1. Because the CP is a kidney-type organ 34, with epithelial mechanisms 35 similar to those in the renal tubule that transfer a large volume of ions and water, many diuretic agents have been tested for ability to inhibit CSF formation 127. Gaining insight on the many ion transporters and channels in CPe is key to attaining fine control of CSF production, upward as well as downward regulation.

At the basolateral membrane, the uptake of Na⁺ and Cl^- is the primary step in CSF formation (Fig. 5). Inward transport of fixed ions, Na⁺ and Cl^-, is facilitated by carriers functionally dependent upon basolateral transmembrane gradients for Na⁺, Cl^-, H⁺ and HCO₃^-. The basolateral Na⁺-H⁺ exchanger (NHE1) transfers Na into the choroid cell. This process is inhibited by the diuretic agent amiloride 363738, which decreases CSF formation 3638. This action is analogous to the polyuria caused by inhibiting the proximal and distal tubule Na⁺-H⁺ exchanger (NHE3) that normally supports substantial fluid transfer in kidney 39. The Cl^--HCO₃^- exchanger translocates interstitial Cl^- into the cytoplasm. Moreover the basolateral Na⁺-dependent Cl^--HCO₃^- exchanger and the Na⁺-HCO₃^- cotransporter in CPe 404142 may also be potential targets for controlling fluid movement. Na⁺ coupling to HCO₃^- transport is likely integral to nascent CSF generation 4344. Systemic metabolic alkalosis, in comparison to metabolic acidosis, promotes Na⁺ influx into CPe and subsequently into ventricular CSF 38. Therefore basolateral HCO₃^- transport 4042 by one or more mechanisms (Fig. 5) might be manipulated to modify HCO₃^- flux or alter choroid cell pH to modulate fluid formation.

At the apical membrane Na⁺-K⁺-ATPase, the Na pump, is a workhorse that actively secretes Na into the ventricles (Fig. 5) thereby driving CSF formation. The Na pump critically keeps cell Na low 38 to set up a driving force (favorable gradient) for basolateral inward Na movement via the Na-cotransporters. Therefore, pharmacological disruption of the apical Na pump, by distorting transmembrane ion gradients, secondarily disables transport activity at the opposite basolateral face. The apically located Na⁺-K⁺-2Cl^- cotransporter (NKCC1) is significant in regard to bidirectional transport capability. The ability of the cotransporter to transfer ions in both the secretory and reabsorptive modes 45 reflects a versatile transporter for regulating cell ion homeostasis and CSF dynamics. Interference with NKCC1 activity by bumetanide 46 or furosemide reduces CSF formation rate 47. In both congenital 48 and aging 18 disorders, altered expression of NKCC1 in CPe is associated with diminished CSF formation rate. Drugs used in the aging population, e.g., the loop-diuretic furosemide and the cardiac glycosides (that inhibit the choroidal Na⁺ pump 49), reduce CSF formation rate and may therefore exacerbate the deleterious effects of advanced age on the brain. Research is needed to address how apical membrane transporters, as well as ion channels for K⁺, Cl^- and HCO₃^- 50, can be manipulated to increase or decrease CSF formation rate, depending upon specific clinical needs.

In experimental settings, Na⁺-K⁺-ATPase and carbonic anhydrase (c.a.) are the two enzymes in the CPe that have been the most extensively analyzed in inhibitory studies of CSF formation. Na⁺-K⁺-ATPase, or the Na⁺ pump, is atypically (amongst epithelia) located on the luminal or CSF face of the CPe. Therefore ouabain inhibits the Na⁺ pump (which is integral to CSF formation) when placed intraventricularly, but not intravenously. In addition to interfering with CSF production, the Na⁺-K⁺-ATPase inhibition also alters CPe volume, potential difference and ion homeostasis 51; therefore, ouabain and other cardiac glycosides have limited value in regulating human CSF formation. On the other hand, the inhibition of c.a. by acetazolamide is not as harsh on CPe function, and so can be used therapeutically to reduce CSF generation. Because a variety of c.a. isoforms is expressed in CP, there are potentially multiple targets at the blood-CSF interface for regulating fluid dynamics.

Ubiquitous enzymes in the c.a. group integrate cellular acid-base phenomena with CSF formation 52. One of the earliest, but still clinically useful, means for decreasing CSF formation is to reduce the intracellular generation of labile ions (e.g., protons and bicarbonate) that feed fluid transporters at the plasma- and CSF-facing poles of the CPe. Cytosolic c.a. II catalyzes cellular hydration of CO₂ to yield H⁺ and HCO₃^-. Acetazolamide, a sulfonamide drug, slows down this reaction 44. Consequently this elevates choroidal cell pH, thus reducing H⁺ availability to basolateral Na⁺-H⁺ exchange 435354. Membrane-bound isoforms of c.a. (e.g., c.a. VIII) are likely proximate to basolateral HCO₃^- transporters (e.g., anion exchanger 2 or AE2) to which they supply HCO₃^- for exchange with interstitial Cl^- 55. It is worthwhile seeking non-sulfonamide agents to selectively inhibit specific c.a. isoforms, II, VIII and XII 565758. Identifying a drug for a specific line of attack 59 may help to reduce systemic side effects that attend chronic acetazolamide administration.

Disruption of cellular acid-base balance by diminishing c.a. activity with acetazolamide provides deductive insights on the function of transporters and aquaporins. CPe pH_i increases by 0.3 – 0.4 pH units after acute exposure (1 hr) to acetazolamide 4353. Chronic administration of acetazolamide markedly alters CP function and structure 60, including the apical microvilli which contain the AQP1 channels. In the kidney, and in the testis (another barrier tissue), acetazolamide down-regulates AQP1 expression 61626364, possibly by way of pH_i change. With regard to fluid transfer in the kidney, the crucial importance of Na⁺-H⁺ antiport exchange (via NHE3) and pH_i stability for maintaining intact AQP2 and NKCC2 systems is revealed in NHE3-knockout analyses 39. In the physiologically analogous CPe, the coordination of multiple transporter systems (NHE1 and NKCC1) with AQP1 channel function evidently allows CPe ion and volume homeostasis to occur simultaneously with CSF secretion 38.

Yet another potential avenue for regulating CSF formation exploits the expression plasticity of aquaporins (AQP) in CP 6566. Aquaporin channels, which facilitate water diffusion across the blood-CSF interface 676869, appear in the developing CPe 7071 and are retained throughout life. AQP1, initially designated as CHIP28 72, is heavily expressed at the ventricular-facing membrane of CPe 7374 but not in blood-brain barrier (BBB) endothelium. Thus by regulatory phosphorylation or ubiquitination of AQP1 75, it may be possible to selectively modulate water movement from blood into the cerebral ventricles 76. In AQP-1 null mice, there is a substantial reduction in CSF forming-capacity of the CP; and consequently, an associated lowering of the CSFP 7778. Such knock-out studies imply that the number of AQP1 channels in CPe apical membrane importantly determines CSF manufacturing ability.

Of significance to CSF dynamics, nature performs an experiment in which there is AQP1 deficiency in late life 57. Thus, aged (20-mo) Sprague-Dawley rats have substantially less AQP1 expression in CPe than do young adult counterparts 57. Accordingly, senescent rats are less able to form CSF 79. Human CPe expresses AQP1 80. This raises the possibility of therapeutically upregulating or restoring AQP1 expression in aged humans when the CSF turnover rate is compromised by AD and NPH 319. Conversely in congenital hydrocephalus it may be feasible to down-regulate AQP1 expression or channel activity in CPe, thereby lowering CSFP by suppressing CSF formation rate 7778. Atrial natriuretic peptide (ANP), a CSF-modulator, has been implicated as a regulator of AQP1 channel function 69.

Neuropeptides in CSF stimulate peptidergic receptors in CP to alter metabolism of 2nd messengers and the associated ion transport coupled to fluid formation 81. Choroidal arginine vasopressin (AVP) is functionally interactive with various fluid-regulating peptides (Table 3). AVP release from CP, for autocrine inhibitory regulation, is promoted by angiotensin (Ang II) and basic fibroblast growth factor (FGF2). Upon stimulation, choroidal receptors for ANP and AVP both induce dark epithelial cells 8283in vitro as well as in vivo. Dark CPe cells have a neuroendocrine role to down -regulate CSF production. Stimulation of V1 vasopressinergic receptors induces dark cells 83, reduces Cl^- efflux from CPe 83, and decreases CSF formation 84. Moreover, ANP transcripts for three natriuretic receptors 85 that generate cyclic guanylyl monophosphate (cGMP) 86 are expressed in both intact and cultured CP. In some physiological settings ANP curtails CSF formation by CP 87. This inhibition may be mediated by CPe dark cells 82 that are more frequent in hydrocephalus.

Also supporting this fluid homeostasis model are the observations of substantial plasticity of choroidal receptors for water-regulating neuropeptides when CSF dynamics are imbalanced. There is up-regulated or down-regulated density of CP receptors for ANP in hydrocephalus 88, depending upon the pathophysiology (kaolin-induced as well as congenital). CSF neuroendocrine regulation is also reflected by changes in ANP receptor density secondary to altered CSF hydrodynamics or fluid shifts in space flight 89. Moreover there are more choroidal binding sites for AVP in AD 90, a disorder that can present with ventriculomegaly 3 and increased CSF pressure 91. Peptide analogs of ANP and AVP 17 may prove beneficial for therapeutically modulating CSF parameters through action at CP neuropeptide receptors.

ICP is a complex function of hydrodynamic and hemodynamic parameters. In combination they produce, in adult humans, a CSFP of 100–200 mm H₂O measured in the lateral recumbent position by lumbar puncture. This pressure is directly proportional to the CSF production rate and outflow resistance, which typically is 70 mm H₂O/ml/min and greater in the 8^th decade than in young adults 92.

On the hydrodynamics side, feedback down regulation of CSF formation can lower CSFP. Homeostatic adjustments to decrease fluid output by CP are critical because sustained CSFP elevation compromises the vascular supply to the CNS 93. Accordingly, elucidation of neuroendocrine fluid regulation is essential for developing agents to manage CSFP. A key observation for constructing a CSFP regulatory model is that the CSF concentration of most neuropeptides, including ANP, depends upon a central (CNS) source rather than a peripheral (plasma) source 94. Moreover, intraventricularly-administered ANP reduces CSFP elevated by ischemia 95 or congenital hydrocephalus 96. Such findings prompt the pursuit of various elements comprising a central homeostatic system to regulate CSFP.

Growing evidence supports a ventricular servomechanism to stabilize CSFP. One hypothesis posits pressure-sensitive regulatory elements in the CSF-periventricular nexus that respond by synthesizing/releasing peptides that target the CP 97. A prime neuropeptide candidate for acutely regulating CSFP is ANP. Collective experimental and clinical evidence demonstrates that: i) the CSF titer of ANP increases proportionally to CSFP elevation 98, ii) the CSF level of ANP is elevated in high-pressure hydrocephalus 99100, iii) the ANP receptors in CP undergo a Vmax adjustment to compensate for the CSFP increase in hydrocephalus 88101, and iv) the CPe is bioreactive to ANP 82 and modulates CSF formation 102 by a cGMP-dependent mechanism 86103. The putative regulation of CP-CSF by ANP and AVP occurs in acute high-pressure hydrocephalus but evidently not in chronic NPH 104. Interestingly the CP of immature rats (with a relatively low CSFP and incompletely-developed CSF secretion 33) is less sensitive than the adult epithelium to modulation by ANP and AVP 83. This is probably due to infant vs. adult differences in neuropeptide receptor density and coupling to CPe metabolism.

Increasing CSFP during development in rodents is temporally associated with the early phases of fluid formation by CP. CSF pressure in pentobarbitone-anesthetized exteriorized fetal rats (18–21 days p.c.) is about 20 mm H₂O, rising to 34 mm H₂0 at 10 days postnatal and later 105. The 1 – 3-week postnatal interval in the rat is a watershed period in the maturation of CP-CSF secretion 33106. Thus the increasing vascularity and arterial perfusion of the plexus in early postnatal life 107108109 foster the progressively increasing enzymatic and transport capabilities of the CPe 110111. Enhanced blood flow and metabolic rate combine to accelerate Na⁺ and Cl^- transport into ventricles 112. Such incremental fluid production by CP 113 elevates CSFP to a level found in adults 105. Arterial pulsations in CP along with increasing fluid turnover set up a pressure head for moving CSF down the neuraxis 114 and developmentally opening up subarachnoid sites for reabsorption. This increased hemodynamic-hydrodynamic generation of CSF secretion and pressure pulse fosters a spurt in brain growth 106107108109110111112113. Maintaining appropriate CSFP in the developing CNS critically depends upon aqueductal patency and smooth CSF flow. Just as intraocular pressure importantly molds the shape of the developing eye, the typically-moderate rise in CSFP in perinatal stages of life 105 contributes to morphing the expanding CNS.

Untoward effects on brain development, however, result from inordinately elevated CSFP secondary to blockage of the Sylvian aqueduct. Augmented CSFP has been observed in aqueduct-impaired hydrocephalic (H-Tx) rats, increasing 2-fold between 10 and 21 days after birth 115. In other H-Tx studies, CSFP increased from about 20 mm H₂0 at 10 days after birth to as high as 90 mm H₂0 by 3 weeks 116117. Elevated pressure reflects blocked flow out of the lateral ventricle. The consequent CSF stasis in hydrocephalus interferes with cerebral and ventricular system development 118119.

Transgenic mice lacking ependymal-specific expression of hydin 120, which facilitates ciliary functions, have gross distortions in the anatomical relationship between the ventricles and adjacent brain. Certain hydrocephalic malformations stem from metabolic, transport and ciliary deficiencies in the developing CP 121. Systematic investigations should explore how faulty cilia development in the choroido-ependymal lining affects CSF formation, composition, volume and ultimately the CSFP.

CSFP impacts periventricular protein expression and secretion into the ventricles. An optimally-growing CNS depends on delicately-balanced biophysical and biochemical phenomena in CSF 6. In congenital hydrocephalus, however, there is not only increased pressure but also altered CSF composition 118119121. Nerve growth factor concentration is elevated in CSF of children with congenital hydrocephalus 122, but cytokine levels are evidently stable (implying intact BBB function) 123. Whereas some alterations in CSF constituents are due to interrupted CSF flow 119121, other changes in composition are related to byproducts of pressure-induced oxidative damage to cells near the ventricles 124. Other modifications of CSF chemistry in hydrocephalus, possibly homeostatic, may be due to pressure-induced up-regulation of proteins secreted by CPe, ependyma and periventricular tissue. One example is choroidal growth factor synthesis in response to augmented CSFP that follows ischemia 7 or trauma. CPe and ependyma are a plentiful source of growth factors 125126 to repair tissue injured by elevated CSFP and its secondary effects 8.

The interaction between the pressures of the CSF and vascular systems, especially in the onset of hydrocephalus, awaits systematic investigation. Fascinatingly, the elevated arterial pressure in spontaneously hypertensive rats is linked to ventriculomegaly via effects on secretion by the subcommissural organ (SCO) in the aqueductal wall 127. The SCO and its associated Reissner's fiber (RF) secrete into CSF glycoproteins essential for establishing normal CSF flow down the neuraxis for distal reabsorption. Therefore, a disrupted SCO-RF complex results in less efficient CSF flow and consequent hydrocephalus 128129. Compromised function of the SCO 130 as well as CP 121 leads to ventriculomegaly and imbalanced CSF dynamics. These observations point to the significance of the circumventricular organs in secreting factors to optimize developing CSF flow, volume and pressure.

In addition to the pressure effects on the periventricular zone, there are several ways that CSFP impacts the brain globally. Responses to elevated CSFP can be broadly categorized by: i) how neural structure and metabolism are affected by modified CSF dynamics; and ii) how homeostatic transport interfaces that protect the parenchyma respond to neuropeptide up-regulation in CSF hypertension. For the first consideration, there are marked oxidative changes 131132133 in hydrocephalus that are reflected in the way that injured neurons metabolize neurotransmitters 134 and myelin 135. Although beyond the scope of this review, the topic of deleterious anaerobic neuronal metabolism in hydrocephalus has been treated previously 136137138. Concerning the second consideration, i.e., homeostatic mechanisms, the regulatory increases in ANP and AVP concentrations in CSF from elevated CSFP 9899100104 evidently foster vascular perfusion of several regions. Even though up-regulated ANP may decrease CSF formation in ischemia and hydrocephalus, it does support CPe viability by increasing choroidal blood flow 139. CSF-administered ANP and AVP dilate cerebral arteries 140141. ANP- and AVP-dilating effects on large pial arteries thereby counter cerebral vasospasm induced by endothelin following subarachnoid hemorrhage 142. Such perfusion-supporting actions by centrally up-regulated ANP curtail edema 143 by stabilizing the CP and cerebral vasculature threatened by ischemia and augmented CSFP.

In chronic hydrocephalus, even moderate increments in CSFP can compromise CBF and metabolism. Intermittent changes in CSFP need a thorough analysis, particularly in regard to effects on regional hydrodynamics and hemodynamics. Clearly, prospective as well as retrospective studies 91 on CSFP are essential to advance treatment strategies for CSF diseases (Fig. 6).

CSFP wave analysis provides substantial insight on the state of CSF dynamics and is more reliable than assessments of cerebral perfusion pressure and mean ICP, especially when there are differences in baseline pressure 144. CSF has a characteristic pressure pulse that varies in health and disease. Cardiovascular parameters markedly affect CSFP waves by contributing systolic and diastolic components of pulse amplitude and latency 145146147148. Arterial pressure pulsations are transmitted across CPs to ventricular fluid 114 and generate CSF pressure waves. It would be clinically useful in hydrocephalus 149 to characterize these pressure waves in the ventriculo-subarachnoid system.

How is ICP recorded, and does it matter where sensors are placed, i.e., in the CSF, brain parenchyma or epidural space? Continuous ICP signals have been recorded with sensors such as the Camino OLM ICP and Codman ICP MicroSensor 144. A study of brain parenchyma vs. epidural space monitoring revealed marked differences in recorded mean pressure, but not in the parameters of mean ICP wave amplitude and mean ICP wave latency 150. Thus, epidural ICP recording (to estimate parenchymal pressure) is feasible for determining parameters such as single wave pulse pressure amplitude (dP) and single wave latency (dT, or rise time). Moreover, monitoring ICP in the cerebral ventricles, as waveform parameters, gives comparable results to pressure measurements done with the sensor in brain parenchyma 145. Evidence is lacking for an appreciable pressure gradient between the parenchyma and ventricular CSF.

Pulsatile components of CSFP will likely be more helpful than mean CSFP in evaluating intracranial compliance (Fig. 7). Eide introduced a method for continually recording ICP signals at 100 Hz, converting to digital data, and then processing in 6-s time windows 151. An algorithm filters noise prior to accepting cardiac beat-induced single ICP waves for analysis of amplitude and latency. Wave amplitude analysis is also promising in pediatric hydrocephalus 152 because it is a better predictor of intracranial compliance than is mean pressure. Children with intracranial hypertension from hydrocephalus or craniosynostosis had a more successful outcome after surgery if the mean CSF wave amplitude pre-surgery was > 5 mm Hg 152. To assure quality control of the waveforms processed, an algorithmic analysis screens out infarct-induced waves to improve diagnostic information 153.

ICP/CSF waveform analyses have predictive potential for outcome in adult patients with chronic hydrocephalus. Although patients with idiopathic NPH (iNPH) may have normal mean ICP, it is possible that they have altered single ICP waves. Higher values of mean ICP wave amplitudes were found in iNPH patients who eventually improved after shunting 154. In one cohort, the mean CSFP wave amplitude was a better predictor than resistance to CSF outflow (Ro), in regard to positive clinical change a year after shunting 155. Up to 60% of iNPH patients have augmented mean CSF wave amplitudes, and 90% of these individuals respond favorably to shunting 156. Post-shunting cognitive outcomes 157 were better in iNPH patients with relatively high pre-operative mean ICP wave amplitudes (Fig. 7).

The so-called B waves in CSF, especially in NPH patients, can predict post-surgical outcome in adult chronic hydrocephalus. Slow B waves, however, only weakly correlated with improvement after shunt surgery 158. An alternative to B wave examination has been proposed. Accordingly, the relative pulse pressure coefficient (RPPC) combines the effects of pulsatory volume changes and elastance on CSFP 159. RPPC reflects reallocation/storage rather than reabsorption of CSF because it relates pulse amplitude to mean CSFP.

A worthy clinical goal is to ascertain absolute CSFP by methodology minimally disruptive to CSF or brain. CSF is contiguous with fluids in the ear, nose and eyes. The orbit vasculature, for example, is exposed to ambient CSFP. This should enable reliable CSFP determination from transocular sonographic and dynamometric data. An empirical index based on ocular arterial (blood flow) and venous (outflow pressure) measurements highly correlates (r = 0.95) with absolute CSFP 160. Therefore this promising indirect ocular approach deserves refinement.

Technical advances are also being made with directly measured CSFP. A novel technique minimizing CNS invasion utilizes a hollow mandrin. This ventricular probe allows precise cannulation of CSF and determination of opening CSFP without fluid loss along the penetrating catheter 161. This refined mandrin approach consistently accesses the ventricles with a single puncture compared with occasional multiple penetrations in previous cannulation procedures to locate the CSF 161. Overall, the aim of CSFP assessments is reliability by minimally perturbing the CSF-brain.

To expedite CSF and hydrocephalus modeling, attention is being devoted to delineating CSFP signals. Highly precise signals for hemodynamic and hydrodynamic parameters facilitate CSFP analyses. Continuous signal inputs to multiple sensors (blood pressure and CSFP during infusions) are integrated by software 162 to evaluate fluid dynamics and predict steady-state responses to infusion tests. Computerized rheoencephalography non-invasively assesses NPH by analyzing changes in cerebral electrical impedance related to pulsatile blood flow 163. Arterial compliance determined by rheoencephalography is evaluated from the regression of arterial pulse amplitude (aAMP) on mean CSFP. Patients with lower arterial compliance have higher slope values for aAMP vs. CSFP. Increasingly sophisticated analyses of CSFP against arterial pressure will improve predictive shunting. Models of fluid-structure interactions to predict pressure and flow within the ventricles 164 and transmittal of pressure into brain parenchyma 165166 are advancing the theory of pulsatile fluid dynamics.

There is increasing appreciation that reduced CSF flow adversely affects brain metabolism and fluid balance 31819118119. Historically in hydrocephalus investigations, CSF pressure and volume 170171172173, not flow and composition, have been emphasized in animal models and shunt design. Consequently, considerable knowledge has accrued on pressure-volume relationships in the ventriculo-subarachnoid system. Evidence continues to accumulate, however, for the importance of CSF flow on cerebral metabolism. Because the CP-CSF supplies micronutrients and peptides to neuronal networks, and removes many catabolites, impeded CSF flow disturbs metabolism in early life 119 as well as in late stages 174.

Interference with CSF flow through the ventricles and aqueduct in fetal life profoundly retards brain development 118119. This is due partly to compromised transport of growth factors from secretory sites such as CP to subventricular germinative zones where stem cells become neurons. In the H-Tx hydrocephalic rat there is a congenital defect leading to tissue dysgenesis in the aqueductal region 175176. The H-Tx model 117118119 displays prenatal ventriculomegaly and distortions in CSF growth factor delivery via volume transmission even before intraventricular pressure rises. Prenatally-altered CSF flow thus causes maldevelopment in H-Tx due to faulty differentiation of neural precursor cells 118. Because CP function is fundamental for CNS development 2, it is pertinent to assess how perturbed CSF flow and composition harm the growing brain. Non-invasive quantification of aqueductal CSF flow 177 during perinatal life would enhance insights into pediatric hydrocephalus.

CSF flow disruption in adult chronic hydrocephalus also devastates cerebral functions. Throughout aging, the ability of CP epithelium to manufacture CSF undergoes continual decline 235779. As CSF formation rate dwindles by 50% or more in senescence and disease 319, the sink action 33 of slower-flowing CSF is attenuated 9. The concentration of potentially-toxic peptides and organic metabolites in CSF 174 and brain consequently builds up due to sluggish flow. Less favorable concentration gradients for catabolites diffusing from ISF to ventricular CSF, results in reduced clearance of harmful substances from brain. Pharmacological studies in old animals treated with flow inhibitors, e.g., acetazolamide 3653, FGF2 178179, and kaolin 180 are needed to analyze the time course of elevated CSF protein concentration in acute vs. chronic states of curtailed flow.

Due to previous technological limitations, there has been a paucity of investigations to assess CSF flow in animal models. However several non-invasive studies involving magnetic resonance imaging (MRI) to quantify CSF flow have been carried out in humans. One of the earliest such analyses by Ridgway et al. 181 demonstrated that CSF flow is pulsatile, i.e., moving to and fro, alternately in cephalic and caudal directions. Thus, they used the MRI pulse sequence (gated from the R-wave of the electrocardiogram) to calculate CSF flow velocities (e.g., 2.9 cm/sec) and corresponding flow rates (e.g., 0.4–0.6 ml/min). Similarly, dynamic MRI of CSF flow, using a multi-slice spin echo approach, was used to compare aqueductal CSF flow rates before and after ventriculostomy to repair non-communicating hydrocephalus 182. MR phase imaging has also been used to demonstrate a circadian variation in human CSF flow, the latter being twice as great at night as in daytime 183.

Recent advances have been made in the technology and algorithms for quantifying CSF flow non-invasively. Using phase-contrast MRI to calculate CSF and CBF curves over the cardiac cycle, Stoquart-Elsankari et al. 184 extracted data for several CSF parameters: mean and peak flows, latencies and stroke volume. They found that CSF stroke volume was reduced in the elderly, both at the aqueductal and cervical levels. Another new approach is the phase contrast balanced steady-state free precession (PC-bSSFP). It is advantageous over the gradient echo in that signal-to-noise ratio is improved and non-laminar CSF flows can be more efficiently analyzed 185. PC-bSSFP has been more suitable than the gradient echo approach for quantifying turbulent CSF flow in the prepontine cistern and cervical subarachnoid space 184185. Application of refined imaging procedures to small animal models will be helpful in modeling flow pulsatility and the intra-cardiac cycle displacements of CSF volume.

CSF volume importantly adjusts to physiological variations in cerebral blood volume (CBV). Thus an increased amount of blood within the cerebrovascular system leads to a displacement, and to a reduced volume, of CSF. Conversely, a decrease in CBV can result in an augmented volume of CSF. This more-or-less reciprocal relationship between CBV and CSF volume reflects the fact that, according to the Munro-Kelly doctrine 191, the combined volume of blood, CSF and brain remains relatively constant in the intracranial space bounded by the rigid skull. Consequently, in order to regulate pressure within the CNS, the CSF is a useful physical buffer that helps to accommodate changes in brain blood supply.

Physical aspects of choroidal hemodynamics also significantly affect CSF volume. There is a brisk, pulsating blood flow of 3–4 ml/g/min to the plexus 108109. This strong arterial pulse is transmitted across the choroidal epithelial membranes to CSF. Therefore nearly all CSF motion is pulsatile. It has long been known that CSF dynamics are markedly impacted by vascular pressure waves in CP 114. Hyperdynamic upstream CP pulsations dilate the cerebral ventricles when there is increased impedance to the flow of CSF pulsations in the SAS 192. As downstream CSF impedance rises, there is redistribution of CSF pulses from the subarachnoid compartment back to the ventricles and the capillary-venous circulation. Egnor and colleagues propose that communicating hydrocephalus with ventriculomegaly results from pulse redistribution within the cranial cavity 192.

Hypo-secretion of CSF, presumably occurring consequent to disrupted bicarbonate transport in CP of SLC4 knockout mice, drastically reduces ventricular volume 193. On the other hand, hypersecretion of CSF by an actively metabolizing CP papilloma 194, predisposes to ventricular expansion. Thus, altered transport and permeability at the choroidal blood-CSF interface significantly bears on the ventricular volume.

The spontaneously hypertensive rat model (SHR) also reveals the significance of BCSFB transport and fluid formation in regulating fluid volume within the CNS interior. SHR displays a ventriculomegaly 127195 that likely results from markedly transformed CP functions. Ions, water and non-electrolytes more readily penetrate the blood-CSF barrier of SHR compared with non-hypertensive Wistar-Kyoto (WKY) controls 196. The CPe of SHR rats consistently has a greater number of mitochondria, increased Golgi processing and enhanced transport activity 197. The higher permeability of the blood-CSF interface in SHR allows greater penetration of organic solutes such as sucrose from blood to CSF 196. Increased activity of the Na⁺-K⁺-2Cl^- cotransporter 198 which promotes fluid transfer in CP 1, also occurs in SHR. Greater permeability and secretion at the CP in SHR would promote faster transfer of fluid into the ventricles. This is consistent with the ventricular expansion in SHR 127195. According to the Egnor model 192, the larger pulse amplitude of the transmitted arterial pulse in the SHR would also be a factor causing ventriculomegaly.

Other injury models of the blood-CSF barrier shed light on dysregulated ventricular volume. Acute arterial hypertension in adult rats transiently opens the BCSFB allowing plasma proteins to leak into the ventricles 199. Pathological disturbances that enhance CP permeability lead to macromolecule accumulation in the normally low-protein CSF. This increases the osmotic pressure of CSF and draws water into the ventricles. Transient forebrain ischemia also disrupts choroidal ultrastructure and transporters 187, causing a temporary loss of CSF homeostasis. Further analyses of hypertensive and ischemic insults to the choroidal circulation should delineate repair mechanisms 125 that restore homeostasis of the CPe and ventricular volume.

Peptidergically-regulated fluid transfer at the BCSFB and BBB 200201 helps to set the volume and composition of CSF and brain ISF, respectively. Moreover the fine tuning of fluid exchange at the ependymal interface, mediated by neuropeptides 202 and growth factors 125, effects fluid balance between the ventricles and interstitium. When these coordinated homeostatic mechanisms at the transport interfaces are upset, the ventricles can either expand or contract.

At the blood-CSF interface in CP, there is a complex interplay among ANP, AVP and FGF2 and their apical membrane receptors to control ion and water secretion into the ventricles. This trio of peptides down-regulates CSF formation via neuroendocrine effects on CPe 261781828384858687. ANP, AVP and FGF2 levels in the CP-CSF system are mainly under central control 698203204205206207208 and thus largely independent of plasma and peripheral effects. When the CNS is perturbed biochemically or physically, these peptidergic systems are activated to restore normal hydration and osmolality. By these mechanisms, extracellular as well as intracellular fluid volumes in CNS are stabilized 209.

Ventricle size is affected by peptide regulation of CSF output from CP. FGF2 has many physiological roles, but a newly appreciated one is fluid regulation. Exogenously administered FGF2 both in vivo and in vitro reduces CSF formation 178179. This FGF2-induced suppression of fluid generation is evidently promoted by the choroidal release of the CSF inhibitor, AVP 210. FGF2 and AVP expression in the CPe, like that of the hypothalamus-pituitary axis, is sensitive to the water balance of the organism 208211. It is intriguing that in the growing SHR the continually declining FGF2 level in CPe (and perhaps a resultant diminishing inhibitory tone on CSF production) is temporally associated with progressively increasing ventricle size 195. Collective evidence implicates choroidal FGF2 in ventricular volume regulation.

ANP is also regarded as a volume-regulating peptide 212. Several investigators report that choroidal ANP receptors in the ventriculomegalic SHR rat are down regulated 103213214215216. Therefore, the reduced ANP tone lowers the generation of the CSF-inhibiting second messenger, cGMP, in the CPe of SHR 103. A downloader of extracellular fluid volume in peripheral systems, ANP may have a similar function in the CNS. ANP receptor impoverishment in the CP of SHR rats 103213214215216 may cause less inhibition of CSF production and the related ability to maintain normal ventricular volume. Accordingly, the observed increase in CSF formation in the SHR 196, possibly due to attenuated natriuretic modulation, would be consistent with ventriculomegaly. The question is begged as to whether a genetic alteration in the ANP (or related neuroendocrine) systems in SHR rats precludes CSF volume down-regulation.

To construct a global model of CSF-ISF volume homeostasis, more information is needed on how ANP, AVP and FGF2 work in concert to regulate fluid transfer across CP and BBB 200201209. AVP also interacts with angiotensin II in the CP-CSF system to decrease fluid production 217. Neuropeptidergic modulation at fluid reabsorption sites in the CNS importantly awaits elucidation. Gaining insights on peptidergic regulation of CSF flow in various regions may make feasible the use of natural ligands or their analogs and antagonists 17 to therapeutically correct aberrant ventricle size.

Another substantial factor in turnover rate is the volume of CSF. In young adults, there is a CSF space of 150–160 ml and a formation rate of about 0.4 ml/min 3. The result is a normal turnover rate in man of about 4 volumes of CSF per 24 hours (Table 4). CSF volume or space however is augmented in senescence and dementia, often as an ex vacuo hydrocephalus secondary to atrophic loss of brain mass. Large ventricles inherently impair the CSF's ability to efficiently renew itself because turnover rate is inversely related to CSF volume (ventricles, cisterns and subarachnoid spaces). Accordingly, in aging, NPH and AD (Table 4), the CSF turnover rate can fall by 3–4-fold. Consequently as the ventricles enlarge in aging and disease 3, the purity of CSF is gradually lost due to less rapid turnover causing stagnation of extracellular fluid.

CSF disorders in both the young and old CNS often involve impoverished fluid turnover. CSF sink action to remove catabolites is a function of fluid formation and CSF volume relative to brain volume. In perinatal development when BCSFB transport capacity is less, the CP forms fluid at a slower rate per mass of tissue than in adults 33106107110111112113. Moreover, in early life the ratio of CP-CSF volume to brain volume is relatively high 34. These factors lessen the capability of immature brain to eliminate unneeded catabolites. The growing anabolic brain requires an optimally functioning CP-CSF to remove catabolites as well as provide micronutrients. Congenital hydrocephalus, with expanding ventricles, further reduces the already low degree of CSF sink action in the fetus 33113. Consequently, the low CSF turnover in infantile hydrocephalus makes the maturing CNS especially vulnerable to damage.

In later life, CSF turnover rate is also markedly curtailed 239181979. In senescence, NPH and AD, there is progressively lower CSF formation rate and expanded ventricular volume. The net result for all three states is diminished CSF turnover rate (Table 4). Such attenuated CSF sink action in aging, NPH and AD 319 alters CSF composition (see below) with deleterious consequences for brain. In aging, when dwindling fluid percolation and interstitial deposits hamper clearance of brain solutes, the curtailed flux of neurotransmitter metabolites (such as homovanillic acid) from interstitium to ventricles 218 likely reflects diminished bulk flow and diffusion between ISF and CSF. In a rat model that mimics NPH 219, beta amyloid peptide (Aβ) accumulates centrally as in NPH patients. In both cases Aβ clearance pathways are impaired (Fig. 8), by reduced transport of low-density lipophilic protein receptor related protein (LRP-1) at the BBB 219 and slower bulk flow from attenuated CSF dynamics 379. Pharmacological intervention 1112151617 in geriatric patients to maintain CSF formation and minimize ventricular dilation might prevent curtailed CSF turnover. A worthy goal is to provide trophic drugs or CP transplants 1215 to minimize neurodegeneration by stabilizing CSF volume and content.

The brain vitally depends upon the stability of CSF composition 220, similar to the way the body is dependent on plasma chemistry that is stabilized within tolerable limits. Acting like a kidney inside the CNS 34, the CP has a major role in homeostatically adjusting the brain extracellular fluid 11827. CSF constituents are exquisitely regulated by a complex array of transporters in the CP epithelium 1184668220221. Substantial deviations in CSF concentration of ions and peptides require restoration to normality 17. When CSF homeostasis fails, neuronal function becomes vulnerable 1819222. A major translational challenge is to correct CSF solute distortions in aging, NPH and AD when both CP and BBB transport capacities are diminished 391879219223. Stabilizing the CSF composition is predicated largely on pharmacological manipulation of the barrier transporters and on restoration of a breached BCSFB or BBB 223224225. To help manage certain CSF disorders, aberrant concentrations of proteins 226 and catabolites 174 in CSF need to be profiled and categorized for various stages of NPH and AD.

Biochemical analysis of the CSF has immense potential for diagnostics and prognostics 227. In disease states the CSF composition is transformed by invading immune cells, plasma cytokines and pathogens 5; as well as by modified active secretions from CP. Therefore the CSF is clinically useful to evaluate: i) the nutritional and trophic status of the brain in patients with hydrocephalus or dementia 228; ii) the purifying capacity of central anion and peptide reabsorptive systems in aging and AD 229, iii) the therapeutic or cytotoxic concentration of certain CSF-borne agents targeted to neurons or meninges 230, and iv) the presence of abnormal solutes 231, or normal molecules in atypical concentrations. Solute concentration profiles can define certain disease states and be used to evaluate the benefit of therapeutic intervention.

To sustain the brain, the CSF provides a full complement of vitamins, peptides, nucleosides and growth factors 121027222232. Adequate nutritional/trophic support of neurons via CSF is compromised in senescence 79. This may result from dietary deficiency coupled with reduced micronutrient delivery to brain by inefficient CP-CSF transport mechanisms 1857223. Vitamins B and C are transported specifically across CP to CSF and adjacent neural tissue 222223224225226227228229230231232233234. In aging, massive interstitial fibrosis of CP (Fig. 9) and oxidative damage to the epithelium 223 impair this essential transport route. Structural and biochemical disruptions may reduce not only CSF formation rates, but also the secretion of organic substances into CSF of AD subjects 228. Overall then, CSF concentration data for the elderly should be interpreted in light of reduced bulk flow as well as altered metabolism 218.

Proteins in CSF can also become deficient in late life. Transthyretin (TTR) is extensively synthesized and secreted by CP into CSF. TTR is a useful CSF marker because it is manufactured mainly by CP 235 and only slightly if at all, by brain parenchyma 236. One function of TTR is to bind Aβ, thus stabilizing it in a soluble form and preventing CNS peptide toxicity 223 that may occur when Aβ self-assembles into neurotoxic oligomers. CSF levels of TTR decrease in both aging and AD 237238. A CSF deficiency of TTR may predispose the brain interstitium to Aβ oligomer toxicity and plaque formation 223. Strategies are needed to sustain TTR secretion by CP in the elderly, e.g., by nicotinic modulation 239. Moreover the array of growth factors secreted by CP helps to repair injuries from forebrain ischemia or neurodegeneration 717125126. Brain fitness requires a sustained choroidal secretion of a cocktail of peptides and proteins that effect a balanced metabolic homeostasis of the CSF and neuronal-glial networks.

In addition to receiving productive secretions from the CP, the CSF is also a repository for catabolites diffusing out of brain. Excessive metabolite efflux from ISF to ventricles can toxify the CSF. Toxic catabolites in CSF, generated by peroxidative phenomena, increase with age and neurodegeneration 174. Glycated proteins in CSF are elevated in AD 231. The CP tissue that protects and nourishes the CSF-brain nexus, suffers from oxidative injury and disrupted metabolism in advanced age and AD 18223240241. A vicious cycle ensues as toxic neuronal products (e.g., Aβ) enter CSF from brain and inflict further harm to the CP already debilitated by aging 5779. The steady build up of Aβ in CP epithelium may disturb leptin transport from blood to CSF 242. Such altered transport at the BCSFB could perturb neuroendocrine balance by interfering with hormone signal transfer to hypothalamus via the CSF.

Maintaining ISF and CSF compositional purity is of prime importance and depends upon efficient clearance mechanisms. Because the CNS lacks lymphatic capillaries, the CSF-mediated removal of metabolites and toxins is essential for efficient neuronal function. The CP-CSF system, proximally and distally, plays a major role in removing harmful substances. This occurs three ways. First, reabsorptive transporters in the apical membrane of CP epithelium actively remove organic anions and peptides from ventricular CSF 117243. This choroidal clearance complements active reabsorption of unneeded metabolites from ISF into cerebral capillaries 229; for a given catabolite, the proportional clearance across BBB vs. BCSFB 244 should be determined in both health and particular diseases. Secondly, the continually-elaborated nascent CSF streams through the brain interior acting as a sink for metabolites diffusing down concentration gradients into the ventricles 12333. These substances pass through the ventriculo-subarachnoid system by bulk flow to distal drainage sites 118. A third aspect of toxin clearance is the downstream extrusion of metabolites via outward CSF flow at the arachnoidal-lymphatic-venous interfaces 17245. In healthy CSF these three disposal mechanisms work in concert to effect fluid homeostasis. Therefore, in chronic hydrocephalus (NPH) with decreased CSF turnover 319, distorted CSF chemistry may be rectified by enhancing CSF formation, flow and drainage. Metabolite clearance defects and toxicity must be considered along with known ischemic insults in NPH to obtain a complete picture of chronic hydrocephalus.

Comprehensive analysis of CSF biochemistry helps to manage NPH, AD and other complications of senescence. Several animal models demonstrate inhibitory effects of neuropeptides and growth factors on CSF formation and reabsorption 178246. A logical extension is to analyze systematically the biochemistry of human CSF at stages of chronic hydrocephalus with and without neurodegeneration. CSF profiling of protein, peptides and organic metabolites (e.g., sphingomyelin derivatives) in aging patients will likely provide insight on how the failing barriers and brain metabolism are linked to deficient CSF dynamics. Elevated levels of ventricular CSF albumin, neuropeptide Y, vasoactive intestinal peptide and sulfatide (an ischemia marker for subcortical arteriosclerotic encephalopathy) have negative implications for surgical outcome by shunting 247248. Systematic analyses of CSF constituents in progressive iNPH and aqueductal stenosis 247 will likely improve predictive power for shunting benefits.

Pharmacological manipulation of CSF and brain ISF composition may prove feasible. One goal is to improve CSF flow and content through actions of drugs delivered across the BCSFB into the brain interior 1617. Reparative agents are needed in periventricular regions (e.g., the subventricular zone, hippocampus and white matter) damaged by elevated CSFP 91, ischemia 7126186187 and distorted CSF chemistry. Another compelling need is to develop CSF-cleansing procedures for geriatric patients in whom brain fluid turnover is seriously compromised. This would be analogous to renal dialysis in patients with kidney failure. Novel technology for CSF dialysis or low-flow shunting, in particular subgroups of patients with dementia, may improve cognition. Therefore, the use of new drugs 16 and biotechnological devices 15 deserves consideration, to slow down degeneration or promote healing of NPH/AD. CPs and ventricles 1617 show promise as regulatory sites to attain desired drug concentrations and optimize CSF composition 249.

CSF and ISF dynamically exchange water and solutes across the ependymal (interior) and pia-glial (exterior) surfaces of brain 127. Brain ISF has distinctive circulatory features 22. Continual ISF turnover, even at a relatively slow rate 250251, maintains an optimal microenvironment for neurons. In aging there is less efficient active transport at the brain capillary endothelium and choroidal epithelium. Consequently, the slower turnover of ISF and CSF causes CNS accumulation of potentially injurious organic acids and peptides. Neurons are harmed in senescence when metabolites accumulate interstitially 9.

Metabolic waste is discarded through ISF and CSF clearance routes. Brain ISF conducts metabolites away from neurons and glia to excretory sites. ISF has multiple input and output components that keep the fluid mixed and delivered to excretory loci. On the input side of ISF volume and flow is a CSF-like fluid likely secreted by the astroglial-endothelial complex in microvessels 252. The putative BBB fluid production is much less than by CP. Another input to ISF is water generated by parenchymal metabolism 252. A third input to ISF is a fraction of t