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Vascular hyperpermeability as a hallmark of phacomatoses: is the etiology angiogenesis comparable with mechanisms seen in inflammatory pathways? Part I: historical observations and clinical perspectives on the etiology of increased CSF protein levels, CSF clotting, and communicating hydrocephalus: a comprehensive review

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Abstract

Phacomatoses are a special group of familial hamartomatous syndromes with unique neuro-cutaneous manifestations as well as disease characteristic tumors. Neurofibromatosis 2 (NF2) and tuberous sclerosis complex (TSC) are representatives of this family. Vestibular schwannoma (VS) and subependymal giant cell tumor (SGCT) are two of the most common intracranial tumors associated with NF2 and TSC, respectively. These tumors can present with obstructive hydrocephalus due to their location adjacent to or in the ventricles. However, both tumors are also known to have a unique association with an elevated protein concentration in the cerebrospinal fluid (CSF), sometimes in association with non-obstructive (communicating) hydrocephalus (HCP), the causality of which has been unclear. Furthermore, SGCTs have repeatedly been shown to have a predisposition for CSF clotting, causing debilitating obstructions and recurrent malfunctions in shunted patients. However, the exact relation between high protein levels and spontaneous clotting of the CSF is not clear, nor is the mechanism understood by which CSF may clot in SGCTs. Elevated protein levels in the CSF are thought to be caused by increased vascular permeability and dysregulation of the blood–brain barrier. The two presumed underlying pathophysiologic mechanisms for that, in the context of tumorigenesis, are angiogenesis and inflammation. Both mechanisms are correlated to the Pi3K/Akt/mTOR pathway which is a major tumorigenesis pathway in nearly all phacomatoses. In this review, we discuss the influence of angiogenesis and inflammation on vascular permeability in VSs and SGCTs at the phenotypic level as well as their possible genetic and molecular determinants. Part I describes the historical perspectives and clinical aspects of the relationship between vascular permeability, abnormal CSF protein levels, clotting of the CSF, and communicating HCP. Part II describes different cellular and molecular pathways involved in angiogenesis and inflammation in these two tumors and the correlation between inflammation and coagulation. Interestingly, while increased angiogenesis can be observed in both VS and SGCT, inflammatory processes seem more prominent in SGCT. Both pathologies are characterized by different subgroups of tumor-associated macrophages (TAM): the pro-inflammatory, M1 type is predominating in SGCTs while pro-angiogenetic, M2 type is predominating in VSs. We suggest that lack of NF2 protein in VS and lack of TSC1/2 proteins in SGCT determine this fundamental difference between the two tumor types, by defining the predominant TAM type. Since inflammatory reactions and coagulation processes are tightly connected, a “pro-inflammatory state” of SGCT can be used to explain the observed associated enhanced CSF clotting process. These distinct cellular and molecular differences may have direct therapeutic implications on tumors that are unique to certain phacomatoses or those with similar genetics.

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Abbreviations

BBB:

Blood–brain barrier

(c)HCP:

(Communicating) hydrocephalus

CNS:

Central nervous system

CSF:

Cerebrospinal fluid

EC:

Endothelial cell

eNOS:

Endothelial nitric oxide synthase

HGB:

Hemangioblastoma

ICP:

Intracranial pressure

mTOR:

Mammalian target of rapamycin

NF:

Neurofibromatosis

NO:

Nitric oxide

Pi3K:

Phosphatidylinositol-3-kinase

SGCT:

Subependymal giant cell tumor

TSC:

Tuberous sclerosis complex

VEGF:

Vascular endothelial growth factor

vHL:

von Hippel–Lindau

VPS:

Ventriculoperitoneal shunt

VS:

Vestibular schwannoma

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Authors and Affiliations

  1. Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Yosef Laviv & Ekkehard M. Kasper

  2. Department of Neurology/Epilepsy Centre, University of Erlangen, Erlangen, Germany

    Burkhard S Kasper

  3. Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, West Campus, Lowry Medical Office Building, Suite 3B 110 Francis, St. Boston, MA, 02215, USA

    Yosef Laviv

Authors
  1. Yosef Laviv
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  2. Burkhard S Kasper
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  3. Ekkehard M. Kasper
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Correspondence to Yosef Laviv.

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This work was not funded or financially supported.

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Laviv, Y., Kasper, B.S. & Kasper, E.M. Vascular hyperpermeability as a hallmark of phacomatoses: is the etiology angiogenesis comparable with mechanisms seen in inflammatory pathways? Part I: historical observations and clinical perspectives on the etiology of increased CSF protein levels, CSF clotting, and communicating hydrocephalus: a comprehensive review. Neurosurg Rev 41, 957–968 (2018). https://doi.org/10.1007/s10143-017-0839-7

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  • DOI: https://doi.org/10.1007/s10143-017-0839-7

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