Molecular Biology

Aquaporins and Brain Edema

Donald E.G. Griesdale, M.D.,* and Christopher R. Honey, M.D., D.Phil. *Department of Anesthesia and Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada

Griesdale DEG, Honey CR. Aquaporins and brain edema. Surg Neurol 2004;61:418 21.

Aquaporins are a family of transmembrane proteins that selectively allow the passage of water through the plasma membrane. Their importance is highlighted by their ubiquitous presence from bacteria to mammals. In humans, they are found throughout the body and recent work has highlighted their function within the brain. They are intimately involved in the production of cerebrospinal uid and the control of water movement at the blood-brain barrier. Aquaporin levels are up-regulated in animal models of trauma, stroke and water intoxication as well as around human malignant brain tumors. They have thus been implicated in the formation of brain edema. Knockout mice, without the aquaporin gene, appear to have reduced brain edema compared to their wild type brethren in models of brain edema. Currently, the clinical treatment of brain edema is limited. Increased knowledge of the aquaporins may open new targeted therapies for brain edema. 2004 Elsevier Inc. All rights reserved.
KEY WORDS

Aquaporin, brain edema, AQP1, AQP4.

ncreased tissue water content, or edema, can occur in any damaged tissue in the body. Cerebral edema occurs following a variety of insults: trauma, local and systemic infection or inammation, infarction, and neoplasms. Although edema is tolerated in many tissues, its presence within the brain can result in increased intracranial pressure (ICP), which in turn, can signicantly worsen neurologic outcomes. In adults, the intracranial volume is xed owing to the rigidity of the skull. Normally, the intracranial space contains brain tissue, cerebrospinal uid, arterial and venous blood. In addition, tumors, cerebral edema and traumatic hematomas increase the contents within the xed intracranial cavity. The Monro-Kellie doctrine states that any increase in one component within the intracranial space does so at the expense of

another. For example, a growing brain tumor displaces CSF caudally into the subarachnoid space surrounding the spinal cord. Blood is pushed into the extracranial vascular capacitance beds. However, once a certain size of the mass (tumor, edema, hematoma) is reached, the intracranial pressure (ICP) increases exponentially. Increased ICP places direct pressure on adjacent structures leading to decreased cerebral perfusion, resultant metabolic changes and infarction. This eventually leads to herniation of cerebral tissue and possible death. Therefore, increased ICP worsens neurologic outcomes. As cerebral edema complicates many of the aforementioned conditions, it can lead to drastic increases in ICP. Thus, cerebral edema can signicantly worsen outcomes and lead to death following a variety of insults. There are 2 broad classes of cerebral edema: cytotoxic and vasogenic [13]. Cytotoxic edema is an accumulation of intracellular uid that occurs without disruption of the blood-brain barrier (BBB). Its location is primarily within gray mater where neurons and astrocytes are affected following trauma, ischemia, infarction or hypoxia. In contrast, when the BBB is disrupted, plasma leaks from capillaries into the interstitium and results in vasogenic edema. Vasogenic edema occurs with tumors and infarction, and is located primarily in white mater. Cytotoxic and vasogenic edema most likely represents a continuum as most pathologic processes may result in both types. For example, ischemia initially leads to cellular swelling (cytotoxic edema) with subsequent disruption of the BBB and resultant vasogenic edema [24].

Treatment of Cerebral Edema

Unfortunately, our ability to treat cerebral edema is modest. Osmotic agents such as Mannitol, decrease cerebral edema by creating an osmotic gradient favoring the movement of water from brain tissue to
2004 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010 1710

Address reprint requests to: Christopher R. Honey, M.D., D.Phil., FRCS, Associate Professor, Division of Neurosurgery, University of British Columbia, Suite 325, West 10th Avenue, Vancouver, BC, Canada V5Z 4E5. Received September 16, 2003; accepted October 17, 2003. 0090-3019/04/$see front matter doi:10.1016/j.surneu.2003.10.047

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the intravascular space. In addition, Mannitol can increase cerebral perfusion by improving red blood cell rheology via immediate plasma volume expansion [4] and can reduce ICP by reducing vascular volume following vasoconstriction [15]. However, Mannitols mechanism of action is a double-edged sword. With disruption of the BBB, as seen in vasogenic edema, Mannitol can pass into the brain parenchyma and exacerbate cerebral edema. This is of particular concern with repeated doses [12]. Thus, the usefulness of Mannitol is short lived and probably is best served as a treatment for acute increases in ICP. Corticosteroids are thought to decrease vasogenic edema by decreasing capillary permeability. This is likely a direct mechanism on capillary endothelia through inhibition of phospholipase A-2 [19]. There is clearly a benecial effect of corticosteroids on peritumoral edema [10,28]. Not only does the amount of edema decrease on imaging studies, but this translates into improved patient outcomes. Using steroids as the sole treatment in metastatic brain tumors doubles survival from 1 to 2 months [20]. Unfortunately, there has been no consistent benet of steroids in head injury, thus limiting their use as a broad treatment for cerebral edema [2,6]. Corticosteroids also have systemic effects, which limit their usefulness. Although not born out by a recent meta-analysis, there are concerns that corticosteroids increase risk of infection and gastrointestinal bleeding [1]. In addition to the aforementioned medical treatments, cerebral edema can be treated surgically. Surgery to remove edematous brain tissue usually occurs in the setting of life threatening increases in intracranial pressure following craniocerebral trauma. Although surgery may be lifesaving, it is not targeted treatment and is usually used as a last resort. It is very difcult to know how much tissue should be resected; and regrettably, salvageable cortex is often removed. Thus surgery itself can result in signicant morbidity despite its lifesaving value. Ideally, treatment for cerebral edema would be targeted, have limited side effects, and be applicable to all types of edema. Such treatment does not currently exist. However, a newly discovered class of water channels, aquaporins, provide a new target for therapies directed at cerebral edema.

water through the plasma membrane in uidtransporting cell types throughout the body [16]. They are present from bacteria to mammals. They are small (MW 30,000), and composed of 2 tandem repeats of 3 membrane-spanning alpha helices. The specicity for water appears to be determined by the size of the pore [7,11]. Although primarily permeable to water, some AQPs may allow the passage of small solutes or ions. There have been 11 aquaporins cloned to date [26]. Their distribution is widespread with AQP being located in: renal collecting ducts, secretory glands, skeletal muscle, stomach, liver, testes, and brain. Mutations in different AQP have been implicated in several human diseases. For example, AQP 2 is a vasopressin regulated water channel located within the collected ducts of human kidneys. Mutations in this gene result in hereditary nephrogenic diabetes insipidus [8]. In the eye, a type of cataract formation has been associated with a mutation in AQP0 [25].

Aquaporins in the Brain

Of the 6 aquaporins expressed in the brain, AQP1 and 4 are the most extensively studied and provide potential mechanisms for cerebral edema [3]. Normally, AQP1 expression is limited to the choroid plexus, the cerebrospinal uid (CSF) producing cells within the ventricular system [17]. Thus it is thought to play a role in CSF secretion. Selectively blocking this channel in the choroid plexus may reduce CSF production and could potentially be used clinically to treat communicating hydrocephalus. Although not normally found within brain parenchyma, AQP1 is extensively expressed within the cytoplasm of primary malignant brain tumors (astrocytomas). Furthermore, there appears to be greater AQP1 expression with increasing malignancy. Since increasingly malignant tumors have greater amount of cerebral edema on imaging studies, AQP1 expression may correlate with the extent of peritumoral edema. In contrast to astrocytomas, AQP1 is not found within metastatic carcinomas. However, AQP1 is present in the surrounding vascular endothelium and reactive astrocytes that accompany metastatic tumors [22]. As such, AQP1 expression may play a crucial role in the development of cerebral edema that complicates both primary and metastatic brain tumors. Blocking this channel could have benecial effects on the vasogenic edema that accompanies brain tumors. Unlike AQP1, AQP4 is normally present within

Aquaporins General
Aquaporins (AQP) are a family of transmembrane proteins, which selectively allow the passage of

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Griesdale and Honey

brain parenchyma. AQP4 is primarily expressed in glial cells at the blood-brain and the brain-CSF interfaces [9]. At the BBB, AQP4 is expressed within astrocytic foot processes adjacent to endothelial cells [17]. At the brain-CSF interface, AQP4 is found in the ependymal cells on the basal side of the plasma membrane. Given this preferential expression at uid interfaces, it can be inferred that AQP4 plays an important role in water transport between uid compartments within the brain. Astrocytes may utilize AQP4 to maintain extracellular homeostasis and protect neurons during osmotic challenges. Excess water would preferentially ow into astrocytes (not neurons) during hypotonic conditions. Swollen astrocytes could then return to normal during a regulatory volume decrease (a calcium dependent mechanism with extrusion of osmotically active solutes). AQP4 has been demonstrated to play a role in formation of brain edema in multiple pathologic states including tumors, trauma, water intoxication and infarction. As with AQP1, AQP4 upregulation occurs within malignant astrocytomas (primary brain tumors) and reactive astrocytes near metastatic carcinomas [22]. In addition, the expression of AQP4 correlates with the presence of contrast enhancement on computerized tomography (CT) scans, the latter being an indicator of BBB breakdown, and a conduit for cerebral edema. Thus, AQPs play a central role in the formation of vasogenic edema seen with malignant neoplasms. Therefore, selective blockage of AQP4 may help reduce the vasogenic edema in these clinical settings. There is also excellent evidence that AQP4 plays a signicant role in the formation of cytotoxic models of brain edema seen following trauma. Following traumatic cortical contusions in rats, the amount of AQP4 mRNA was signicantly higher at the site of injury when compared to remote sites within the same brain [27]. Also, the degree of AQP4 expression correlates with the degree of brain edema as seen on magnetic resonance imaging (MRI). Interestingly, there was also a reduction of AQP4 expression in brain tissue adjacent to the site of injury [23]. The authors postulated that this represented a control mechanism to prevent rampant edema following brain injury. Such rampant edema, occasionally termed malignant edema occasionally follows trauma and can signicantly worsen outcomes and even lead to death [5]. Thus, a lack of AQP4 down regulation in brain tissue adjacent to the trauma may be a mechanism for malignant edema. As previously discussed, infarction results in

both cytotoxic and vasogenic edema. A stroke model in rats, demonstrated an increase of AQP4 mRNA expression following middle cerebral artery (MCA) occlusion. The AQP4 levels peaked on Day 3 following MCA occlusion, which paralleled the increased edema observed on MRI [24]. Not only is AQP4 present in the many etiologies of cerebral edema, the inability to produce AQP4 appears to prevent the formation of edema. Transgenic mice with homozygous AQP4 deletion had signicantly decreased brain edema following water intoxication and stroke. More importantly, they have better survival and improved neurologic outcomes than their wild-type brethren [14]. Thus, AQP4 is potentially a powerful target for therapies against cerebral edema.

Conclusion
Cerebral edema is a difcult problem complicating trauma, tumors, infections and infarctions of the brain. It can result in devastating morbidity and even mortality. Unfortunately, we are currently limited in our ability to treat edema, as many of our treatments are either ineffective or result in unacceptable side effects. Aquaporins appear to be intimately linked with the formation of brain edema and may therefore, provide a new potential target for treatment of this condition. REFERENCES
1. Alderson P, Roberts I. Corticosteroids in acute traumatic brain injury: systematic review of randomised controlled trials. BMJ 1997;314:18559. 2. Alderson, P, Roberts, I. Corticosteroids for acute traumatic brain injury. Cochrane Database of Systematic Reviews. 2000;3. 3. Badaut J, Lasbennes F, Magistretti PJ, Regli L. Aquaporins in brain: distribution, physiology, and pathophysiology. J Cerebral Blood Flow Metabol 2002;22: 36778. 4. Barry KG, Berman AR. Mannitol infusions. Part III. The acute effect of the intravenous infusion of mannitol on blood and plasma volume. N Engl J Med 1961;264: 10858. 5. Bingaman WE, Frank JI. Malignant cerebral edema and intracranial hypertension. Neurol Clin 1995;13: 479 509. 6. Bullock R, Chestnut RM, Clifton GL. Guidelines for the management of severe head injury. Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. J Neurotrauma 2000;17:449 627. 7. Cheung A, Van Hoek AN, Yeager M, Verkman AS, Mitra AK. Three-dimensional organization of a human water channel. Nature 1997;387:62730. 8. Deen PM, Verkjik MA, Knoers NV, Wieringa B, Monnens LA, van Os CH, van Oost BA. Requirement of

Aquaporins and Brain Edema

Surg Neurol 421 2004;61:418 21

9.

10. 11.

12. 13. 14.

15.

16. 17.

18.

human renal water channel quaporin-2 for vasopressin dependent concentration of urine. Science 1994; 264:925. Frigeri A, Gropper MA, Umenishi F, Kawashima M, Brown D, Verkman AS. Localization of MIWC and GLIP water channel homologs in neuromuscular, epithelial and glandular tissues. J Cell Sci 1995;108:29933002. Galicich JH, French LA, Melby JC. Use of dexamethasone in the treatment of cerebral edema associated with brain tumors. Lancet 1961;8146 53. Gutierrez AM, Gonzalez E, Echevarria M, Hernandez CS, Whittembury G. The proximal straight tubule (PST) basolateral cell membrane water channel: selectivity characteristics. J Membr Biol 1995;143:189 97. Kaufmann AM, Cardoso ER. Aggravation of vasogenic cerebral edema by multiple dose mannitol. J Neurosurg 1992;77:584 9. Klatzo I. Neuropathological aspects of brain edema. J Neuropathol Exp Neurol 1967;26:114. Manley GT, Fujimura M, Ma T, et al. Aquaporin-4 deletion in mice reduces brain edema after acute water intoxication and ischemic stroke. Nat Med 2000;6:159 63. Muizelaar JP, Wei EP, Kontos HA, Becker DP. Mannitol causes compensatory cerebral vasoconstriction in response to blood viscosity changes. J Neurosurg 1983;59:82288. Neely JD, Christensen BM, Nielsen S, Agre P. Heterotetrameric composition of aquaporin-4 water channels. Biochemistry 1999;38:11156 63. Neilsen S, Smith BL, Christensen EI, Agre P. Distribution of the aquaporin CHIP in secretory and resorptive epithelia and capillary endothelia. Proc Natl Acad Sci 1993;90:72759. Nielsen S, Nagelhus EA, Amiry-Maghaddam M, Bourque C. Agre P. Ottersen OP. Specialized mem-

19.

20. 21.

22.

23. 24. 25. 26. 27.

28.

brane domains for water transport in glial cells: highresolution immunogold cytochemistry of aquaporin-4 in rat brain. J Neurosci 1997;17:17180. Ohnishi T, Sher PB, Posner JB, Shapiro WR. Capillary permeability factor secreted by malignant brain tumor. Role in the peritumoral brain edema and possible mechanism for anti-edema effect of glucocorticoids. J Neurosurg 1990;72:24551. Ruderman NB, Hall TC. Use of glucocorticoids in the palliative treatment of metastatic brain tumors. Cancer 1965;18:298 306. Saadoun S, Papadopoulos MC, Davies DC, Krishna S, Bell BA. Aquaporin-4 expression is increased in oedematous human brain tumours. J Neurol, Neurosurg and Psychiatry 2002;72:2624. Saadoun S, Papadopoulos MC, Davies DC, Bell BA, Krishna S. Increased aquaporin 1 water channel expression in human brain tumours. Br J Cancer 2002; 87:6213. Sun MC, Honey CR, Berk C, Wong NL, Tsui JK. Regulation of aquaporin-4 in a traumatic brain injury model in rats. J Neurosurg 2003;98:5659. Taniguchi M, Yamashita T, Kumura E, et al. Induction of aquaporin-4 water channel mRNA after focal cerebral ischemia in rats. Mol Br Res 2000;78:1317. Verkman AS, Mitra AK. Structure and function of aquaporin water channels. Am J Physiol 2001;78:F13 28. Verkman AS, van Hoek AN, Ma T, et al. Water transport across mammalian cell membranes. Am J Physiol 1996;48:C1230. Vizuete ML, Venero JL, Vargas C, et al. Differential upregulation of aquaporin-4 mRNA expression in reactive astrocytes after brain injury: potential role in brain edema. Neurobiol Dis 1999;6:24558. Wen P, Marks PW. Medical management of patients with brain tumors. Curr Opin Oncol 2002;14:299 307.

ealists try to be as objective as possible. They try not to distort life by forcing it to agree with their own desires or with the formulas of art. However, in the process of selecting and presenting their material, they cannot help being inuenced by what they feel and think. Even the most thoroughgoing Realism, therefore, is the result of observation and personal judgment.

Nathanson, Stephen. Idealism. World Book Online Reference Center. 2004. World Book, Inc. 23 Feb. 2004. <http://www.worldbookonline.com/wb/Article?id ar271560.>