We have presented a protocol that describes a detailed procedure for cisterna magna cannulation (CMc), which offers a straightforward method to deliver labeled molecules to the CSF compartment. CMc allows the subsequent visualization of CSF dynamics, both in vivo and ex vivo, using different imaging modalities or histology.
One of the main advantages of the CMc technique lies in its direct access to the subarachnoid space without the need to expose the brain by craniotomy. By not requiring a cranial window or penetration of the brain parenchyma with a needle tip, CMc allows the delivery of molecules into the CSF compartment and the assessment of the glymphatic system by a minimally invasive procedure, with only brief disturbance of intracranial pressure (ICP).
Notably, the injection into the CM is downstream of the main sources of CSF, the choroid plexi located in the ventricular system (lateral, third and fourth ventricles). From the lateral ventricles, CSF flows to the third ventricle via the intraventricular foramina (the foramen of Monro) and from the third to fourth ventricles via the cerebral aqueduct (the aqueduct of Sylvius) to the brain stem and spinal cord (reviewed in3). CSF reaches the subarachnoid space via the CM by flowing through the median aperture (or the foramen of Magendie), and thus CMc injections bypass the entire ventricular system. However, while this may be problematic in some models of CSF/ISF dynamics through the ventricles, direct injection of tracers into the ventricles requires invasive surgical procedures such as drilling of burr holes in the skull windows, and the application of ventricular injections substantially disrupt the ICP13. Likewise, pressure injection of tracers into the subarachnoid space13,14 in our hands abolishes the flux of CSF tracers along the paravascular space. In contrast, even though CMc entails puncture of the dural membrane, ICP is only transiently perturbed and is quickly restored2.
Using the CMc, glymphatic activity can be measured in anesthetized animals after acute CMc, as well as in awake animals, observing a 24-hour recovery period upon cannula implantation. Acute CMc is suited for combination with 2-photon imaging, which provides detailed information about glymphatic activity within cortex to a depth of approximately 200 µm1,2. Importantly, acute CMc also affords the advantage of supporting unbiased MRI studies, where tracer distribution is followed dynamically, relative to an individual baseline image acquired before the initiation of CSF tracer injection15,16,17. For MRI, the dental needle used for CMc should be replaced by a borosilicate capillary (approximately 1 cm length, tip diameter of approximately 20 µm) attached to the PE tubing.
In contrast to acute cannulation, chronic CMc allows the experimenter to perform CSF tracer injection in animals during natural sleep or under anesthesia, as well as in awake, freely moving animals. This is a crucial factor since glymphatic activity is highly state-dependent; tracer influx to the parenchyma is much greater in animals that were injected under anesthesia or asleep than in animals that were injected in the awake state1. In addition, animals with a chronically implanted cannula can receive CSF tracer in their home cage, thus minimizing confounding factors due to effects of stress and arousal on glymphatic activity. For chronic injections under anesthesia, a mixture of ketamine/xylazine (100 mg/kg; 10 mg/kg, respectively) is recommended. Isoflurane at concentrations above 1.5% induces brain swelling and does not enhance glymphatic activity compared to the awake state1. Note that after CMc implantation, animals should be single housed, in order to assure that CMc implanted animals will not damage the cannula of each other. Also, since the CMc chronic implantation is a recovery surgical procedure, it should be performed under sterile conditions and animals should receive post-operational analgesics.
Importantly, CMc can be used as a method to deliver CSF tracers in mice as well as in rats, with minimal modifications to the protocol. Appropriate anesthetics dose should be administered and the maximum volume of CSF tracer that is injected in rats is 30 µL, due to the differences in the size of the ventricular and subarachnoid spaces between the two species.
Despite its procedural simplicity, some training and practice is required for the experimenter to successfully perform CMc. Since the CM varies in size in between species and individual animals, it is advisable to practice the recognition of its structure. Practicing the procedure using Evans Blue (2% in aCSF) allows the experimenter to confirm correct needle insertion. Occasionally, a vessel will be located directly at the midline of the CM, whereupon the needle should be inserted adjacent to the vessel, but as close as possible to the midline. These cases should be noted, for later confirmation that tracers are evenly distributed, despite the off-center placement of the needle tip. Importantly, the atlanto-occipital membrane covering the CM is mechanically tough, and sufficient pressure should be applied to insert the beveled needle tip. However, it is critical that the pressure applied does not result in plunging the needle tip into the medulla or the cerebellum. To facilitate needle insertion into the CM, the head of animals should be tilted downwards at an angle of 120° relative to the body, which stretches the membrane. Importantly, caution should be taken not to obstruct respiration by this head flexion. If the needle tip should enter the cerebellum, tracers will be retained in the tissue and fail to distribute throughout the subarachnoid space. Damage to the medulla is frequently fatal, whereas cerebellum damage in chronic cannulations can result in prostration and general abnormalities in the behavior of the animals. To minimize the risk of this eventuality, needles with a smaller bevel length can be used.
When moving the muscles in the neck region that covers the dura membrane to insert the cannula into the CM, bleeding can occur. Cotton swabs can be used to absorb the bleeding, but alternatively, ferric chloride solution can be applied. Ferric chloride has a hemostatic effect18, and also triggers the stiffening of neck muscles around the incision site, thus helping to obtain correct insertion of the needle into the CM. Ferric chloride also dries out the skull and dural membrane, presenting better surfaces for adhesion of the cannula. For CMc, apply 1 - 2 drops of ferric chloride solution (10%) (approximately 1 mL) into a cotton swab and dab the neck muscles and the occipital crest. However, topical ferric chloride may possibly seep through the membrane into the CSF, with unknown effects on brain homeostasis. If the use of ferric chloride is a matter of concern, one can instead use wound retractors to keep open the incision site. Careful removal of wound retractors after applying the cyanoacrylate glue avoids inadvertent attachment to the incision site.
CMc is a straightforward and reproducible procedure to deliver molecules directly into the CSF compartment. Since CMc is minimally invasive, it is the preferred method for the visualization of the glymphatic system and can be combined with different imaging modalities such as epifluorescence and 2-photon microscopy or MRI. Thus, CMc represents a great tool for studies of fluid dynamics, namely CSF and ISF, and also of brain fluid clearance. Due to the macroscopic coverage of the glymphatic system, CMc has the potential to be used to deliver molecules brain-wide.