Introduction
Intraventricular hemorrhage (IVH) frequently occurs after intraparenchymal or subarachnoid hemorrhage (SAH). Thus, 30–50% of intracerebral hemorrhage (ICH) patients exhibit intraventricular extension, and nearly half of these cases develop hydrocephalus [
1]. Currently, there are no pharmacological interventions approved for treating post-hemorrhagic hydrocephalus (PHH) [
2]. It is typically managed neurosurgically with cerebrospinal fluid (CSF) diversion (shunt placement or endoscopic third ventriculostomy).
Blood components contribute to secondary brain injury after cerebral hemorrhage including IVH. Iron, a product from the lysis of erythrocytes and the subsequent degradation of hemoglobin, contributes to hydrocephalus development in rats [
3,
4]. Peroxiredoxin-2 (Prx-2) is the third most common protein in red blood cells. Extracellular Prx-2 acts as a proinflammatory damage-associated molecular pattern (DAMP), facilitating the release of proinflammatory factors by microglia/macrophage [
5,
6]. Intraventricular injection of Prx-2 induces hydrocephalus and the effects of IVH can be attenuated by the administration of Conoidin A, a Prx-2 inhibitor [
7,
8].
While the role of inflammation in PHH pathogenesis has been widely studied [
2], there has been limited focus on the choroid plexus (ChP) immune cell response following IVH. This is despite the proximity of the ChP to the IVH and a growing understanding of the role of the ChP in neuroinflammatory conditions [
9,
10] and a potential role of ChP inflammation in regulating CSF production [
11,
12]. Consequently, there is a critical need to explore the pathophysiological mechanisms of inflammation at the ChP in both IVH and PHH.
The central nervous system (CNS) hosts a distinct population of immune cells known as border-associated macrophages (BAMs), which encompass meningeal macrophages, perivascular macrophages and ChP macrophages [
13]. Recent research has shed light on the role of meningeal and perivascular macrophages in various neurological diseases, including SAH and ischemic stroke [
14,
15]. Our prior publications have underscored the potential involvement of ChP macrophages in the pathogenesis of hydrocephalus. Depletion of ChP stromal macrophages reduced the hydrocephalus induced by iron [
3] and Prx-2 [
8]. Furthermore, intraventricular injection of Prx-2 [
7] and thrombin [
16] resulted in ChP neutrophil accumulation. However, our understanding of the PHH-induced changes in ChP immune cells (including epiplexus macrophages, stromal macrophages, dendritic cells, natural killer (NK) cells, lymphocytes and neutrophils), remains limited.
Liposomes, which are lipid vesicles synthetically created, serve as carriers for encapsulating hydrophilic drug molecules, including clodronate. Macrophages have the capacity to internalize clodronate liposomes, a process that ultimately leads to their own cell death [
17]. Depleting macrophages via clodronate liposomes has been employed as a strategy in various animal models, including ICH [
18], ischemic stroke [
19], allergic encephalomyelitis [
20], and spinal cord injury [
21]. While some investigations have explored the potential mechanisms of clodronate liposomes in the context of blood component-induced hydrocephalus in rats [
3,
8], there remains a limited understanding of the therapeutic effects and underlying mechanisms of clodronate in the PHH. Further research is required to fully elucidate these aspects.
CX
3CR-1
GFP mice are characterized by a knock-in/knock-out design that leads to the expression of enhanced green fluorescent protein (EGFP) in monocytes, dendritic cells, NK cells and microglia under the control of the endogenous CX
3CR1 locus. These mice have been used to examine leukocyte migration and trafficking [
22] and the immune cell response to ischemic stroke, spinal cord injury, traumatic brain injury, laser burn and maternal immune activation [
23‐
27]. However, to date, there has been no documented utilization of CX
3CR-1
GFP mice as a resource for investigating the response of ChP immune cells following IVH and the subsequent PHH development.
The current study used CX
3CR-1
GFP mice to examine activation and alterations in ChP immune cells after hydrocephalus induced by IVH or blood components (iron and Prx2). Additionally, it evaluated the impact of clodronate liposome treatment on hydrocephalus and its effects on ChP immune cells. Clodronate liposomes kill macrophages after internalization [
17].
Discussion
The key findings of this study were: (a) in naïve CX3CR-1GFP mice, approximately 75% of GFP(+) cells in ChP are macrophages, with the majority located in the stroma; (b) after IVH and intraventricular injection of iron or Prx-2, both of which induce ventriculomegaly, ChP GFP(+) immune cells increase in number and size; (c) ChP epiplexus (but not stromal) macrophages show significant increases after IVH, iron injection and Prx-2 injection; (d) IVH, iron injection and Prx-2 injection all markedly increase the number of ChP T lymphocytes and neutrophils; (e) when iron was co-injected with clodronate liposomes, ventriculomegaly, ChP immune cell activation and the number of ChP macrophages were all reduced. These results are discussed further below.
Before discussing IVH-induced changes in the ChP immune cell landscape, it is important to consider IVH-related modeling in rodents. The current study used a 30 µl autologous blood injection in mice to mimic an IVH. It also used 12.5 µl injections of saline with and without FeCl
3 (0.5 mmol/L) and Prx-2 (1 mg/ml), two important erythrocyte components released during cell lysis. 12.5 µl injections were used to reflect the approximate volume of erythrocytes in a 30 µl autologous blood injection. It is important to note that volume of saline injected does not appear to be an important component in the ventricular dilation with FeCl
3 or Prx-2. In the current study, naïve mice had ventricular volumes of 6.2 ± 0.3 mm³, whereas those given a 12.5 µl intraventricular injection of saline had a ventricular volume of 6.7 ± 0.4 mm³ at 1 day. In a separate unpublished study, we have found a ventricular volume of 6.8 ± 0.2 mm³ at 1 day after a 30 µl intraventricular injection of saline. Thus, by one day, any saline injected has migrated from the ventricles and doesn’t result in ventricular dilation. In contrast, there is evidence that ‘toxic’ effects of erythrocyte components released on lysis contribute to ventricular dilation in IVH. Thus, intraventricular injection of lysed but not intact red blood cells caused ventricular dilation at 1 day in rats, an effect inhibited by an iron chelator deferoxamine [
4] and a Prx-2 inhibitor, Conoidin-A [
7]. The ventricular dilation induced by IVH (autologous whole blood) was also reduced by deferoxamine in rats [
30].
While increasing the volumes of saline up to 30 µl does not cause ventricular dilation in mice, in IVH modeling the amount of blood injected appears important. Thus, in the current study, 30 µl of blood caused an approximate doubling in ventricle size, whereas a recent study by Cao et al. [
31] injected 50 µl and trebled ventricular volume. However, it is difficult to dissociate direct volume effects (e.g., injecting different volumes of blood when the aqueduct outflow may be blocked) from there being a greater amount of potential toxic blood components (such as Fe and Prx-2).
Overall, understanding the changes in the ChP immune landscape (including macrophages, neutrophils and T-lymphocytes) after IVH is important for multiple reasons. Macrophages, via phagocytosis, play an important role in hematoma clearance after a cerebral hemorrhage. While this process has been studied extensively in ICH, where monocyte-derived macrophages and resident microglia play important roles [
32], much less is known about hematoma phagocytosis in IVH and the role of ChP macrophages. The ChP may either be a source of macrophages or a site of macrophage migration between blood and CSF. Neutrophils are generally thought to enhance CNS injury, including in ICH, via neurotoxic proteins released during degranulation [
33]. However, one protein, lactoferrin, released may be beneficial in cerebral hemorrhage because of its iron-binding properties [
34]. The role of T-lymphocytes in IVH is unknown but there is evidence that they play an important modulatory role in brain injury after cerebral ischemia, either promoting protection or injury [
35]. Leukocytes are a crucial element in the response to pathogens and it is possible that the ChP immune response after IVH may guard against possible pathogen entry into CSF/brain that could occur along with an IVH. Interestingly, Nakano et al. [
36] found that one pathogen, Streptococcus mutans, can actually cause cerebral hemorrhage via its expression of a collagen binding protein. In addition, immune cells regulate the function of many cell types via the release of cytokines and chemokines, including recent evidence that they regulate ChP function including CSF secretion [
12].
CX
3CR-1
GFP mice, expressing EGFP in macrophages, dendritic cells, NK cells and microglia, are a valuable tool for studying inflammation in various neurological diseases [
22]. In this study, using those mice combined with conventional immunohistochemistry, we found macrophages (epiplexus and stromal), dendritic cells, NK cells and lymphocytes, but not neutrophils, in naïve ChP. We observed activation of GFP(+) cells in CX
3CR-1
GFP mouse following IVH without immunofluorescence staining. IVH resulted in an increase in the number (∼ 40%) and size of ChP GFP(+) cells indicating ChP immune cell activation. This activation may be influenced by blood components, such as iron and Prx-2, generated after erythrocytes lysis. Iron has been shown to activate ChP macrophages [
3] and Prx-2 can activation ChP macrophages [
7] and dendritic cells [
8]. Intraventricular injection of iron/Prx-2 mimicked the effects of IVH, increasing the number of ChP GFP(+) immune cells (∼ 30–40%) and their soma size suggesting they may play important roles in ChP immune cell activation after IVH. The ChP functions as an immunological hub, housing various types of peripheral immune cells within its stroma, such as dendritic cells, macrophages, and T cells. Together with the epithelial cells, these immune cells engage in immunosurveillance, identifying pathogens and alterations in the cytokine environment. Upon activation, they secrete homing molecules that stimulate the chemotaxis of circulating immune cells, thereby orchestrating an immune response at the ChP [
10].
In using CX
3CR-1
GFP mice to study the PHH it is important to make sure that these mice have a similar response to IVH and blood components. The degree of ventriculomegaly after IVH and ventricular iron and Prx-2 injection in CX
3CR-1
GFP mice was similar to that previously reported in rodents [
3,
8,
28].
To further investigate the changes to the ChP immune cell landscape after IVH and blood component injection, the ChP of CX
3CR-1
GFP mice was further probed with traditional immunohistochemistry. Iba-1 antibody was used to distinguish macrophages from other ChP GFP(+) immune cells. GFP(+)/Iba-1(+) cells were defined as macrophages and subdivided into epiplexus and stromal macrophages based on their location relative to the ChP epithelium [
28,
37,
38]. Macrophages were the predominant (∼ 75% of GFP(+) cells) cell type at the ChP expressing GFP in naïve mice with the majority being stromal. There were fewer dendritic and NK cells. After IVH, an even greater % percentage of GFP(+) cells were macrophages (∼ 90%) and this was also the case after intraventricular iron or Prx-2 injection.
Macrophages play a crucial role in inflammatory responses and can produce various proinflammatory cytokines, including interleukin-1β (IL-1β), -6, -12, -23, -10 and tumor necrosis factor-a [
39,
40]. Proinflammatory cytokines, especially IL-1β, are potent drivers of leukocyte recruitment to the CNS. The number of epiplexus macrophages increased significantly following IVH and intraventricular injection of iron/Prx-2. Interesting, IVH and intraventricular injection of iron/Prx-2 did not significantly change stromal macrophage numbers. Our prior study, however, illustrated that intraventricular iron injection led to hydrocephalus and an increased number of stromal macrophages in both aged and young rats [
3]. This discrepancy might be attributed to species or model differences. Being on the apical surface of the ChP epithelium, epiplexus cells are situated to respond the intraventricular blood or factors released from the hemorrhage (such as iron and Prx-2) into CSF.
There are several possible explanations for the increase in epiplexus macrophages following IVH and intraventricular iron/Prx-2 injection. The first is blood-derived monocyte migration. Ge et al., found that blood-derived monocyte infiltrated from blood into ChP and CSF after ischemic stroke [
41]. Second, stromal macrophages and dendritic cells can migrate to the apical surface of epithelium [
8]. Third, macrophage proliferation could underlie the increase in epiplexus cells. An increase Ki67 (proliferation marker) positive ChP macrophages has been reported in PHH rats [
12].
T lymphocytes were identified using CD4 immunohistochemistry in this study. In naïve mice, they were rare compared to total ChP cells (ratio 1:1000). However, IVH resulted in a marked (∼ 16-fold) increase in ChP T lymphocyte numbers, and intraventricular injections of iron and Prx-2 replicated this effect. These findings suggest that iron and Prx-2 may be involved in T lymphocyte infiltration into ChP and possibly CSF following IVH. Lymphocyte trafficking across blood-choroid plexus barrier has been reported in various conditions, including ischemic stroke [
42], feline immunodeficiency virus infection [
43] and ventricular injection of tumor necrosis factor-alpha [
44]. The blood-brain barrier regulates lymphocyte traffic into the CNS, maintaining its barrier properties and selectively permitting the passage of activated T lymphocytes through cerebral vessels in vivo [
45]. Activated auto-aggressive CD4 (+) T lymphocytes, which are initially activated outside the CNS, can migrate into the CNS and trigger cellular events that result in edema, inflammation, and demyelination within the CNS white matter [
46]. In vivo studies provide evidence that immunocompetent cells, such as T lymphocytes, can infiltrate the healthy CNS regardless of their antigen specificity [
47]. The ChP can also promote T cell trafficking in response to inflammation, influencing adaptive immunity in the CNS [
48]. To our knowledge, this study is the first to report T lymphocyte infiltration into the ChP after IVH, and further research is needed to elucidate the function of these lymphocytes in IVH and PHH.
Neutrophils within ChP were identified using MPO antibody. ChP neutrophils were absent in naïve mice. However, IVH and intraventricular injection of iron or Prx-2 resulted in a marked increase in ChP neutrophils (neutrophils: total ChP cells ratios of ∼ 3–5:100). These results suggest that iron and Prx-2 may play a role in neutrophil infiltration following IVH. Previous studies have demonstrated that intraventricular injection of Prx-2 [
7] and thrombin [
16] results in the accumulation of neutrophil within the ChP. Neutrophils serve as a primary defense mechanism within the innate immune system, combatting external microbial threats [
49]. The origin of the neutrophils found in the ChP, whether they migrate across the ChP blood vessel or the ventricular wall, remains unclear. Nonetheless, accumulating evidence suggests that neutrophils can also contribute detrimentally to intracerebral injury through the release of extracellular traps [
50,
51]. However, the signaling mechanisms and specific pathways through which blood components (iron, Prx-2, thrombin) activate neutrophils and recruit them to the ChP and potentially CSF require future investigation.
Evidence indicates that the activation of inflammatory pathways at the ChP can induce CSF hypersecretion, which may contribute to hydrocephalus formation after IVH [
11]. Recent study has revealed that PHH and post-infectious hydrocephalus is characterized by TLR4-mediated ChP immune cell signaling and SPAK-dependent ChP transepithelial ion transport [
12]. Reduction of macrophages adhering to the ChP epithelium and stroma attenuates ChP inflammation, suggesting that macrophages reduction may reduce CSF secretion by the ChP epithelium and ultimately decrease ventricle dilation. The present study supports this hypothesis by using clodronate liposomes to deplete ChP macrophages. Liposomes containing clodronate induce apoptosis in macrophages, leading to their self-elimination, and have been utilized for macrophage depletion in various tissues [
52]. When macrophages engulf these clodronate-loaded liposomes, the liposomes are broken down by lysosomal phospholipases, releasing clodronate into the cells’ interior, which then triggers apoptosis through inhibits the adenosine triphosphate production enzyme adenine nucleotide translocase [
53]. Clodronate liposome treatment reduced ventriculomegaly induced by intraventricular iron injection by reducing the number of ChP macrophages (both epiplexus and stromal macrophages). In contrast to macrophage reduction, clodronate liposomes did not impact the number of ChP T lymphocytes and neutrophils within ChP. Targeting macrophages with clodronate liposomes has also reduced ventriculomegaly induced by intraventricular injection of Prx-2 in rats [
8]. Together, this suggests that targeting ChP macrophage activation might be a therapeutic target in PHH.
Several limitations should be noted in this study. It primarily serves as a proof-of-concept study that identifies alterations in ChP immune cells (macrophages, lymphocytes and neutrophils) following IVH and intraventricular injection of blood components (iron and Prx-2), as well as the associated inflammatory responses in PHH and iron/Prx-2-induced acute (24 h) ventriculomegaly. Long-term changes were not examined and functional outcomes were not assessed. The results may not be applicable to both sexes, as only male CX3CR-1GFP mice were studied. While the results indicate the clodronate liposomes deplete ChP macrophages but not lymphocytes and neutrophils, it remains uncertain whether the nonspecific uptake of clodronate liposomes by other cells might influence hydrocephalus formation and the inflammatory response.
In summary, IVH and blood components (iron, Prx-2) cause marked changes in ChP immune landscape. Reduction of ChP macrophages through clodronate liposome treatment depletes ChP macrophages and attenuates iron-induced ventriculomegaly. This suggests that the ChP immune cells response may be a potential therapeutic target in IVH-induced hydrocephalus.