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Letter to the editor at the journal Medical hypotheses.
Can cerebrospinal fluid diversion be beneficial in the treatment of chronic fatigue syndrome?
Dear Editor,
We read with great interest the paper recently published in Medical Hypotheses by Higgins et al. [1] and would appreciate the opportunity to make a comment.
The authors measured cerebrospinal fluid (CSF) pressure by lumbar puncture in twenty patients diagnosed with chronic fatigue syndrome (CFS), in whom headache was a prominent symptom [1]. CSF pressure was found to be more than 20 cmH2O in five patients, including three with pressures of 25 cmH2O or greater who were relabelled as idio- pathic intracranial hypertension (IIH).
The remaining fifteen patients had CSF pressures between 12 and 20 cmH2O. Even more importantly, the authors found that, when intracranial pressure was reduced by CSF withdrawal, seventeen patients (85%) reported an amelioration of symptoms including fatigue, many of whom had CSF pressures in the normal range. The authors suggested that incomplete forms of IIH, with average CSF pressures much lower than in the syndrome in full, may manifest as CFS.
As a possible explanation for the symptomatic improvement after CSF drainage, we speculate that glymphatic dysfunction may be re- sponsible for at least some cases of CFS, and that CSF withdrawal may unblock stagnation of glymphatic transport. The glymphatic system is a recently discovered brain-wide perivascular network along which a large proportion of subarachnoid CSF recirculates through the brain parenchyma, facilitating the clearance of interstitial waste [2].
Interestingly, recent evidence indicates that dilated perivascular spaces could be the site where chemical processes generate fatigue in multiple sclerosis patients [3]. Moreover, small lesions suggestive of perivascular space involvement are often seen on MRI scans of CFS patients [4]. Disturbances of the CSF and lymphatic drainage pathways have been previously postulated to play a role in CFS [5]. Such disturbances might be responsible for an impaired interstitial fluid drainage, causing toxic build up within the central nervous system, and we speculate that CSF diversion may be beneficial to at least some CFS patients by favoring waste clearance and restoring glymphatic flow.
Sincerely yours, Peter Wostyn
Peter Paul De Deyn
Can cerebrospinal fluid diversion be beneficial in the treatment of chronic fatigue syndrome?
Dear Editor,
We read with great interest the paper recently published in Medical Hypotheses by Higgins et al. [1] and would appreciate the opportunity to make a comment.
The authors measured cerebrospinal fluid (CSF) pressure by lumbar puncture in twenty patients diagnosed with chronic fatigue syndrome (CFS), in whom headache was a prominent symptom [1]. CSF pressure was found to be more than 20 cmH2O in five patients, including three with pressures of 25 cmH2O or greater who were relabelled as idio- pathic intracranial hypertension (IIH).
The remaining fifteen patients had CSF pressures between 12 and 20 cmH2O. Even more importantly, the authors found that, when intracranial pressure was reduced by CSF withdrawal, seventeen patients (85%) reported an amelioration of symptoms including fatigue, many of whom had CSF pressures in the normal range. The authors suggested that incomplete forms of IIH, with average CSF pressures much lower than in the syndrome in full, may manifest as CFS.
As a possible explanation for the symptomatic improvement after CSF drainage, we speculate that glymphatic dysfunction may be re- sponsible for at least some cases of CFS, and that CSF withdrawal may unblock stagnation of glymphatic transport. The glymphatic system is a recently discovered brain-wide perivascular network along which a large proportion of subarachnoid CSF recirculates through the brain parenchyma, facilitating the clearance of interstitial waste [2].
Interestingly, recent evidence indicates that dilated perivascular spaces could be the site where chemical processes generate fatigue in multiple sclerosis patients [3]. Moreover, small lesions suggestive of perivascular space involvement are often seen on MRI scans of CFS patients [4]. Disturbances of the CSF and lymphatic drainage pathways have been previously postulated to play a role in CFS [5]. Such disturbances might be responsible for an impaired interstitial fluid drainage, causing toxic build up within the central nervous system, and we speculate that CSF diversion may be beneficial to at least some CFS patients by favoring waste clearance and restoring glymphatic flow.
Sincerely yours, Peter Wostyn
Peter Paul De Deyn