The lymphatic drainage systems in the brain:a novel target for ischemic stroke?

Recent studies have proposed three lymphatic drainage systems in the brain,that is,the glymphatic system,the intramural periarterial drainage pathway,and meningeal lymphatic vessels,whose roles in various neurological diseases have been widely explored.The glymphatic system is a fluid drainage and waste clearance pathway that utilizes perivascular space and aquaporin-4 protein located in the astrocyte endfeet to provide a space for exchange of cerebrospinal fluid and interstitial fluid.The intramural periarterial drainage pathway drives the flow of interstitial fluid through the capillary basement membrane and the arterial tunica media.Meningeal lymphatic vessels within the dura mater are involved in the removal of cerebral macromolecules and immune responses.After ischemic stroke,impairment of these systems could lead to cerebral edema,accumulation of toxic factors,and activation of neuroinflammation,while restoration of their normal functions can improve neurological outcomes.In this review,we summarize the basic concepts of these drainage systems,including drainage routes,physiological functions,regulatory mechanisms,and detection technologies.We also focus on the roles of lymphatic drainage systems in brain injury after ischemic stroke,as well as recent advances in therapeutic strategies targeting these drainage systems.These findings provide information for potential novel strategies for treatment of stroke.

Combination of manual lymphatic drainage and Kinesio taping for treating pigmented villonodular synovitis:A case report

BACKGROUND Pigmented villonodular synovitis(PVNS)is a benign proliferative disorder that affects the synovial joints,bursae,and tendon sheaths.To date,few studies have reported on the treatment of postoperative pain and edema in patients with PVNS.Herein,we present the case of a woman who developed pain and edema in the left lower limb 1 wk after synovectomy and arthroscopic partial meniscectomy and was unable to walk due to limited flexion and extension of the left knee.CASE SUMMARY A 32-year-old woman underwent synovectomy and arthroscopic partial meniscectomy successively and was treated with a combination of manual lymphatic drainage(MLD)and kinesio taping(KT)in our hospital to alleviate postoperative pain and edema.The following parameters were assessed at 2 wk post-treatment and 1 wk post-discharge follow up:suprapatellar circumference,infrapatellar circumference,visual analog scale score,knee range of motion,pittsburgh sleep quality index score,hamilton anxiety rating scale(HAMA)score,and hamilton depression rating scale(HAMD)score.After treatment,the postoperative pain and edema in the patient’s left knee were effectively relieved,resulting in improved sleep quality and remarkably attenuated HAMA and HAMD scores.CONCLUSION Combined MLD and KT may be an effective approach for relieving postoperative pain and edema in patients with PVNS.

Efficacy of Manual Lymphatic Drainage for Breast Cancer-Related Lymphedema

Purpose: The effect of manual lymphatic drainage in patients with breast cancer is controversial. The purpose of this study is to evaluate the role of manual lymphatic drainage (MLD) in breast cancer-related lymphedema treatment. Methods: The electronic databases of EMBASE, PubMed, Web of Science, and The Cochrane Library were searched to find English articles on MLD which were published before January 2020. After two evaluators selected the studies and independently evaluated literature quality, meta-analysis was carried out with RevMan 5.3 software. The outcome index of lymphedema treatment changed in edema volume. Results: The study included six RCTs of 364 patients and the meta-analysis showed no significant difference in the effect of MLD for BCRL compared with other treatments (mean difference, 3.76;95% confidence interval, -35.09 to 42.62;Z, 0.19;p = 0.850). Conclusion: MLD can relieve the body tissue, rapidly improve local condition, and enhance complete decongestive therapy (CDT) efficacy. MLD can prevent BCRL and improve the symptoms of stage I lymphedema. It should be widely applied to prevent BCRL from entering an irreversible state.

Commentary:The central lymphatic drainage in pharmacological,surgical and physical therapies of Alzheimer’s disease

Alzheimer’s disease(AD)is a prevalent neurodegenerative disease in the aged population1.Etiology of AD remains largely unknown and no effective drugs are available in clinical settings to reverse or delay the disease progress2.In recent years,the brain’s lymphatic systems,including glymphatic3 that exists in the brain interstitial space and meningeal lymphatic vessels4 that presents within the dural sinuses,have been found to play an important role in the AD pathogenesis.

Role of mesenteric component in Crohn’s disease:A friend or foe?

Crohn’s disease(CD)is a complex and relapsing gastrointestinal disease with mesenteric alterations.The mesenteric neural,vascular,and endocrine systems actively take part in the gut dysbiosis-adaptive immunity-mesentery-body axis,and this axis has been proven to be bidirectional.The abnormalities of morphology and function of the mesenteric component are associated with intestinal inflammation and disease progress of CD via responses to afferent signals,neuropeptides,lymphatic drainage,adipokines,and functional cytokines.The hypertrophy of mesenteric adipose tissue plays important roles in the pathogenesis of CD by secreting large amounts of adipokines and representing a rich source of proinflammatory or profibrotic cytokines.The vascular alteration,including angiogenesis and lymphangiogenesis,is concomitant in the disease course of CD.Of note,the enlarged and obstructed lymphatic vessels,which have been described in CD patients,are likely related to the early onset submucosa edema and being a cause of CD.The function of mesenteric lymphatics is influenced by endocrine of mesenteric nerves and adipocytes.Meanwhile,the structure of the mesenteric lymphatic vessels in hypertrophic mesenteric adipose tissue is mispatterned and ruptured,which can lead to lymph leakage.Leaky lymph factors can in turn stimulate adipose tissue to proliferate and effectively elicit an immune response.The identification of the role of mesentery and the crosstalk between mesenteric tissues in intestinal inflammation may shed light on understanding the underlying mechanism of CD and help explore new therapeutic targets.

Sentinel lymph node biopsy in renal malignancy: The past, present and future

Sentinel lymph node biopsy （SLNB） is now an establishedtechnique in penile and pelvic cancers, resulting in alower mortality and morbidity when compared withthe traditional lymph node dissection. In renal cancer however, despite some early successes for the SLNB technique, paucity of data remains a problem, thus lymph node dissection and extended lymph node dissection remain the management of choice in clinically node positive patients, with surveillance of lymph nodes in those who are clinically node negative. SLNB is a rapidly evolving technique and the introduction of new techniques such as near infra-red fuorescence optical imaging agents and positron emission tomography/computed tomography scans, may improve sensitivity. Evidence in support of this has already been recorded in bladder and prostate cancer.Although the lack of large multi-centre studies and issues around false negativity currently prevent its widespread use, with evolving techniques improving accuracy and the support of large-scale studies, SLNB does have the potential to become an integral part of staging in renal malignancy.

Pleural effusion and ascites in extrarenal lymphangiectasia causedby post-biopsy hematoma: A case report

BACKGROUNDThe renal system has a specific pleural effusion associated with it in the form of“urothorax”, a condition where obstructive uropathy or occlusion of thelymphatic ducts leads to extravasated fluids (urine or lymph) crossing thediaphragm via innate perforations or lymphatic channels. As a rare disorder thatmay cause pleural effusion, renal lymphangiectasia is a congenital or acquiredabnormality of the lymphatic system of the kidneys. As vaguely mentioned in areport from the American Journal of Kidney Diseases, this disorder can be causedby extrinsic compression of the kidney secondary to hemorrhage.CASE SUMMARYA 54-year-old man with biopsy-proven acute tubulointerstitial nephropathyexperienced bleeding 3 d post hoc, which, upon clinical detection, manifested as amassive perirenal hematoma on computed tomography (CT) scan withoutconcurrent pleural effusion. His situation was eventually stabilized byexpeditious management, including selective renal arterial embolization. Despite good hemodialysis adequacy and stringent volume control, a CT scan 1 mo laterfound further enlargement of the perirenal hematoma with heterogeneoushypodense fluid, left side pleural effusion and a small amount of ascites. Thesefluid collections showed a CT density of 3 Hounsfield units, and drained fluid ofthe pleural effusion revealed a dubiously light-colored transudate withlymphocytic predominance (> 80%). Similar results were found 3 mo later, duringwhich time the patient was free of pulmonary infection, cardiac dysfunction andovert hypoalbuminemia. After careful consideration and exclusion of otherpossible causative etiologies, we believed that the pleural effusion was due to theocclusion of renal lymphatic ducts by the compression of kidney parenchymaand, in the absence of typical dilation of the related ducts, considered our case asextrarenal lymphangiectasia in a broad sense.CONCLUSIONAs such, our case highlighted a morbific passage between the kidney and thoraxunder an extraordinarily rare condition. Given the paucity of pertinentknowledge, it may further broaden our understanding of this rare disorder.

Consideration of the Self-Care Supporting Program Including Simple Exercise for Patients with Early Stages of Secondary Lower-Limb Lymphedema

Aim: We devised a self-care supporting program targeting patients with early stages of secondary lower-limb lymphedema. The program incorporates “Simple exercises to replace lymphatic drainage” based on lymphatic flow. The purpose of this study was to consider the feasibility of continuing this program. Methods: The participants were patients in the early stages of secondary lower-limb lymphedema after gynecological cancer surgery and lymphedema therapists with more than five years of experience. Patients continued self-care at home after being briefed on the program, and they were analyzed on their self-care continuity status one month later based on a self-administered questionnaire survey and self-care notes. We interviewed the lymphedema therapists about this program to discuss the feasibility of continuing it and obtain feedback. Results: The patients who participated in the study were six women who underwent surgery with lymph node dissection for gynecological cancer. The therapists were five nurses and one occupational therapist. The patient understood the importance of all items in the self-care. “Observation,” “Touching,” and “Skin care” were relatively easy to continue. “Lymph drainage” and “Exercise” were continued with “Simple exercises to replace lymphatic drainage”. “Other exercises” were able to continue by adding distance and time to daily activities. Furthermore, “Measurement” and “Recording” became a burden and were difficult to continue. Nonetheless, this program was generally approved by the lymphedema therapists. They also pointed out the content and format of the self-care notes as improvements. Conclusions: We found that the self-care supporting program that incorporated “Simple exercises to replace lymphatic drainage” might be feasible to continue self-care for patients with early stages of secondary lower-limb lymphedema. Furthermore, we found that we needed to improve the “Measurement” and “Recording” sections of this program.