The spectrum of age-related small vessel diseases: potential overlap and interactions of amyloid and non-amyloid vasculopathies.

Deep perforator arteriopathy (DPA) and cerebral amyloid angiopathy (CAA) are the commonest known cerebral small vessel diseases (CSVD), which cause ischaemic stroke, intracebral haemorrhage (ICH) and vascular cognitive impairment (VCI). While thus far mainly considered as separate entities, we here propose that DPA and CAA share similarities, overlap and interact, so that “pure” DPA or CAA are extremes along a continuum of age-related small vessel pathologies. We suggest blood-brain barrier (BBB) breakdown, endothelial damage and impaired perivascular β-amyloid (Aβ) drainage are hallmark common mechanisms connecting DPA and CAA. We also suggest a need for new biomarkers (e.g. high-resolution imaging) to deepen understanding of the complex relationships between DPA and CAA.

Schreiber S, Wilisch-Neumann A, Schreiber F,  Assmann A, Scheumann V, Perosa V, Jandke S, Mawrin C, Carare RO, Werring DJ.

Small Vessel Disease Pathological Changes in Neurodegenerative and Vascular Dementias concomitant with Autonomic Dysfunction.

We performed a clinicopathological study to assess the burden of small vessel disease (SVD) type of pathological changes in elderly demented subjects, who had clinical evidence of autonomic dysfunction, either carotid sinus hypersensitivity or orthostatic hypotension or both or had exhibited unexpected repeated falls. Clinical and neuropathological diagnoses in 112 demented subjects comprised dementia with Lewy bodies (DLB), Parkinson’s disease with dementia (PDD), Alzheimer’s disease (AD), Mixed dementia (mostly AD-DLB) and vascular dementia (VaD). Of these, 12 DLB subjects had no recorded unexpected falls in life and therefore no evidence of concomitant autonomic dysfunction. A further 17 subjects were assessed as ageing controls without significant pathology or signs of autonomic dysfunction. We quantified brain vascular pathological changes and determined severities of neurodegenerative lesions including α-synuclein pathology. We found moderate-severe vascular changes and high vascular pathology scores (P<0.01) in all neurodegenerative dementias and as expected in VaD compared to similar age controls. Arteriolosclerosis, perivascular spacing and microinfarcts were frequent in the basal ganglia and frontal white matter (WM) across all dementias whereas small infarcts (<5 mm) were restricted to VaD. In a sub-set of demented subjects, we found that vascular pathology scores were correlated with WM hyperintensity volumes determined by MRI in life (P<0.02). Sclerotic index values were increased by ~50% in both the WM and neocortex in all dementias compared to similar age controls. We found no evidence for increased α-synuclein deposition in subjects with autonomic dysfunction. Our findings suggest greater SVD pathological changes occur in the elderly diagnosed with neurodegenerative dementias including DLB and who acquire autonomic dysfunction. SVD changes may not necessarily manifest in clinically overt symptoms but they likely confound motor or cognitive dysfunction. We propose autonomic dysfunction promotes chronic cerebral hypoperfusion to impact upon ageing-related neurodegenerative processes and characterise their end-stage clinical syndromes. This article is protected by copyright. All rights reserved.

 Hase Y, Polvikoski TM, Firbank MJ, Craggs LJ, Hawthorne E, Platten C, Stevenson W, Deramecourt V, Ballard C, Kenny RA, Perry RH, Ince P, Carare RO, Allan LM, Horsburgh K, Kalaria RN.

3D Reconstruction of the Neurovascular Unit Reveals Differential Loss of Cholinergic Innervation in the Cortex and Hippocampus of the Adult Mouse Brain

Increasing evidence supports a role for cerebrovasculature dysfunction in the etiology of Alzheimer’s disease (AD). Blood vessels in the brain are composed of a collection of cells and acellular material that comprise the neurovascular unit (NVU). The NVU in the hippocampus and cortex receives innervation from cholinergic neurons that originate in the basal forebrain. Death of these neurons and their nerve fibers is an early feature of AD. However, the effect of the loss of cholinergic innervation on the NVU is not well characterized. The purpose of this study was to evaluate the effect of the loss of cholinergic innervation of components of the NVU at capillaries, arteries and veins in the hippocampus and cortex. Adult male C57BL/6 mice received an intracerebroventricular injection of the immunotoxin p75NTR mu-saporin to induce the loss of cholinergic neurons. Quadruple labeling immunohistochemistry and 3D reconstruction were carried out to characterize specific points of contact between cholinergic fibers and collagen IV, smooth muscle cells and astrocyte endfeet. Innate differences were observed between vessels of the hippocampus and cortex of control mice, including a greater amount of cholinergic contact with perivascular astrocytes in hippocampal capillaries and a thicker basement membrane in hippocampal veins. Saporin treatment induced a loss of cholinergic innervation at the arterial basement membrane and smooth muscle cells of both the hippocampus and the cortex. In the cortex, there was an additional loss of innervation at the astrocytic endfeet. The current results suggest that cortical arteries are more strongly affected by cholinergic denervation than arteries in the hippocampus. This regional variation may have implications for the etiology of the vascular pathology that develops in AD.

Nizari S, Carare RO, Romero IA, Hawkes CA.

Dispersion in porous media in oscillatory flow between flat plates: applications to intrathecal, periarterial and paraarterial solute transport in the central nervous system.

Background: As an alternative to advection, solute transport by shear-augmented dispersion within oscillatory cerebrospinal fluid flow was investigated in small channels representing the basement membranes located between cerebral arterial smooth muscle cells, the paraarterial space surrounding the vessel wall and in large channels modeling the spinal subarachnoid space (SSS).

METHODS: Geometries were modeled as two-dimensional. Fully developed flows in the channels were modeled by the Darcy-Brinkman momentum equation and dispersion by the passive transport equation. Scaling of the enhancement of axial dispersion relative to molecular diffusion was developed for regimes of flow including quasi-steady, porous and unsteady, and for regimes of dispersion including diffusive and unsteady.

RESULTS: Maximum enhancement occurs when the characteristic time for lateral dispersion is matched to the cycle period. The Darcy-Brinkman model represents the porous media as a continuous flow resistance, and also imposes no-slip boundary conditions at the walls of the channel. Consequently, predicted dispersion is always reduced relative to that of a channel without porous media, except when the flow and dispersion are both unsteady.

DISCUSSION/CONCLUSIONS: In the basement membranes, flow and dispersion are both quasi-steady and enhancement of dispersion is small even if lateral dispersion is reduced by the porous media to achieve maximum enhancement. In the paraarterial space, maximum enhancement Rmax = 73,200 has the potential to be significant. In the SSS, the dispersion is unsteady and the flow is in the transition zone between porous and unsteady. Enhancement is 5.8 times that of molecular diffusion, and grows to a maximum of 1.6E+6 when lateral dispersion is increased. The maximum enhancement produces rostral transport time in agreement with experiments.

Keith Sharp M, Carare RO, Martin BA.

Knockout of apolipoprotein A‐I decreases parenchymal and vascular β‐amyloid pathology in the Tg2576 mouse model of Alzheimer’s disease

Aims: Apolipoprotein A‐I (apoA‐I), the principal apolipoprotein associated with high density lipoproteins (HDL) in the periphery, is also found at high concentrations in the cerebrospinal fluid. Previous studies have reported either no impact or vascular‐specific effects of apoA‐I knockout on β‐amyloid (Aβ) pathology. However, the putative mechanism(s) by which apoA‐I may influence Aβ deposition is unknown. Methods We evaluated the effect of apoA‐I deletion on Aβ pathology, Aβ production and clearance from the brain in the Tg2576 mouse model of AD.

Results: Contrary to previous reports, deletion of the APOA1 gene significantly reduced concentrations of insoluble Aβ40 and Aβ42 and reduced plaque load in both the parenchyma and blood vessels of apoA‐I knockout x Tg2576 mice compared to Tg2576 animals. This was not due to decreased Aβ production or alterations in Aβ species. Levels of soluble clusterin/apoJ were significantly higher in neurons of apoA‐I KO mice compared to both wildtype and apoA‐I KO x Tg2576 mice. In addition, clearance of Aβ along intramural periarterial drainage pathways was significantly higher in apoA‐I KO mice compared to wildtype animals.

Conclusion: These data suggest that deletion of apoA‐I is associated increased clearance of Aβ and reduced parenchymal and vascular Aβ pathology in the Tg2576 model. These results suggest that peripheral dyslipidaemia can modulate the expression of apolipoproteins in the brain and may influence Aβ clearance and aggregation in AD. This article is protected by copyright. All rights reserved.

Contu L, Carare RO, Hawkes C.

Vascular dysfunction—The disregarded partner of Alzheimer’s disease.

Increasing evidence recognizes Alzheimer’s disease (AD) as a multifactorial and heterogeneous disease with multiple contributors to its pathophysiology, including vascular dysfunction. The recently updated AD Research Framework put forth by the National Institute on Aging–Alzheimer’s Association describes a biomarker-based pathologic definition of AD focused on amyloid, tau, and neuronal injury. In response to this article, here we first discussed evidence that vascular dysfunction is an important early event in AD pathophysiology. Next, we examined various imaging sequences that could be easily implemented to evaluate different types of vascular dysfunction associated with, and/or contributing to, AD pathophysiology, including changes in blood-brain barrier integrity and cerebral blood flow. Vascular imaging biomarkers of small vessel disease of the brain, which is responsible for >50% of dementia worldwide, including AD, are already established, well characterized, and easy to recognize. We suggest that these vascular biomarkers should be incorporated into the AD Research Framework to gain a better understanding of AD pathophysiology and aid in treatment efforts.

Sweeney MD, Montagne A, Sagare AP, Nation DA, Schneider LS, Chui HC, et al

Cerebrovascular smooth muscle cells as the drivers of intramural periarterial drainage of the brain

The human brain is the organ with the highest metabolic activity but it lacks a traditional lymphatic system responsible for clearing waste products. We have demonstrated that the basement membranes of cerebral capillaries and arteries represent the lymphatic pathways of the brain along which intramural periarterial drainage (IPAD) of soluble metabolites occurs. Failure of IPAD could explain the vascular deposition of the amyloid-beta protein as cerebral amyloid angiopathy (CAA), which is a key pathological feature of Alzheimer’s disease. The underlying mechanisms of IPAD, including its motive force, have not been clarified, delaying successful therapies for CAA. Although arterial pulsations from the heart were initially considered to be the motive force for IPAD, they are not strong enough for efficient IPAD. This study aims to unravel the driving force for IPAD, by shifting the perspective of a heart-driven clearance of soluble metabolites from the brain to an intrinsic mechanisms of cerebral arteries (e.g. vasomotion-driven IPAD). We test the hypothesis that the cerebrovascular smooth muscle cells, whose cycles of contraction and relaxation generate vasomotion, are the drivers of IPAD. A novel multiscale model of arteries, in which we treat the basement membrane as a fluid-filled poroelastic medium deformed by the contractile cerebrovascular smooth muscle cells, is used to test the hypothesis. The vasomotion-induced intramural flow rates suggest that vasomotion-driven IPAD is the only mechanism postulated to date capable of explaining the available experimental observations. The cerebrovascular smooth muscle cells could represent valuable drug targets for prevention and early interventions in CAA.

Aldea R, Weller RO, Wilcock DM, Carare RO, Richardson G.


Military-related risk factors for dementia

In recent years, there has been growing discussion to better understand the pathophysiological mechanisms of traumatic brain injury and post-traumatic stress disorder and how they may be linked to an increased risk of neurodegenerative diseases including Alzheimer’s disease in veterans. Building on that discussion, and subsequent to a special issue of Alzheimer’s & Dementia published in June 2014, which focused on military risk factors, the Alzheimer’s Association convened a continued discussion of the scientific community on December 1, 2016. During this meeting, participants presented and evaluated progress made since 2012 and identified outstanding knowledge gaps regarding factors that may impact veterans’ risk for later life dementia. The following is a summary of the invited presentations and moderated discussions of both the review of scientific understanding and identification of gaps to inform further investigations.

Snyder HM, Carare RO, DeKosky ST, de Leon MJ, et al.

A control mechanism for intra-mural periarterial drainage via astrocytes: How neuronal activity could improve waste clearance from the brain.

The mechanisms behind the clearance of soluble waste from deep within the parenchyma of the brain remain unclear. Experimental evidence reveals that one pathway for clearance of waste, termed intra-mural peri-arterial drainage (IPAD), is the rapid drainage of interstitial fluid along basement membranes (BM) of the smooth muscle cells of cerebral arteries; failure of IPAD is closely associated with the pathology of Alzheimer’s disease (AD), but its driving mechanism remains unclear. We have previously shown that arterial pulsations generated by the heart beat are not strong enough to drive IPAD. Here we present computational evidence for a mechanism for clearance of waste from the brain that is driven by functional hyperaemia, that is, the dilatation of cerebral arterioles as a consequence of increased nutrient demand from neurons. This mechanism is based on our model for the flow of fluid through the vascular BM. It accounts for clearance rates observed in mouse experiments, and aligns with pathological observations and recommendations to lower the individual risk of AD, such as mental and physical activity. Thus, our neurovascular hypothesis should act as the new working hypothesis for the driving force behind IPAD.

Diem KA, Carare RO, Weller RO, Bressloff NW.

Lymphatic Drainage of the CNS and Its Role in Neuroinflammation and Neurodegenerative Disease.

CSF in ventricles and subarachnoid spaces and interstitial fluid (ISF) in the extracellular spaces of the CNS parenchyma both drain to lymph nodes but by largely separate routes. CSF drains along lymphatic vessels that allow traffic of antigen presenting cells (APC) to lymph nodes. ISF, on the other hand, drains to lymph nodes along 100–150 nm thick basement membranes in the intramural periarterial pathways that do not allow traffic of APC from the CNS parenchyma to lymph nodes. This is one factor that may account for immune privilege in the CNS; the other factor is the highly controlled entry of T lymphocytes into CNS tissues. Lymphatic drainage of CSF and ISF and draining lymph nodes play a role in neuroimmunological diseases. Lymphatic drainage of ISF maintains homeostasis of the CNS but fails with age and this is associated with failure of elimination and accumulation of amyloid β in the brain in Alzheimer’s disease. Understanding lymphatic drainage of the CNS may aid the development of therapies for neuroimmunological disorders and Alzheimer’s disease.

Weller RO, Carare RO.

The association between hypertensive arteriopathy and cerebral amyloid angiopathy in spontaneously hypertensive stroke-prone rats.

We aimed to test the hypothesis that in spontaneously hypertensive stroke-prone rats (SHRSP), non-amyloid cerebral small vessel disease/hypertensive arteriopathy (HA) results in vessel wall injury that may promote cerebral amyloid angiopathy (CAA). Our study comprised 21 male SHRSP (age 17-44 weeks) and 10 age- and sex-matched Wistar control rats, that underwent two-photon (2PM) imaging of the arterioles in the parietal cortex using Methoxy-X04, Dextran and cerebral blood flow (CBF) measurements. Our data suggest that HA in SHRSP progresses in a temporal and age-dependent manner, starting from small vessel wall damage (stage 1A), proceeding to CBF reduction (stage 1B), non-occlusive (stage 2), and finally, occlusive thrombi (stage 3). Wistar animals also demonstrated small vessel wall damage, but were free of any of the later HA stages. Nearly half of all SHRSP additionally displayed vascular Methoxy-X04 positivity indicative of cortical CAA. Vascular β-amyloid deposits were found in small vessels characterized by thrombotic occlusions (stage 2 or 3). Post-mortem analysis of the rat brains confirmed the findings derived from intravital 2PM microscopy. Our data thus overall suggest that advanced HA may play a role in CAA development with the two small vessel disease entities might be related to the same pathological spectrum of the aging brain.

Solveig J, Garz C, Schwanke D, Sendtner M, Heinze HJ, Carare RO, Schreiber S

Convective influx/glymphatic system: tracers injected into the CSF enter and leave the brain along separate periarterial basement membrane pathways.

Tracers injected into CSF pass into the brain alongside arteries and out again. This has been recently termed the “glymphaticsystem” that proposes tracers enter the brain along periarterial “spaces” and leave the brain along the walls of veins. The object of the present study is to test the hypothesis that: (1) tracers from the CSF enter the cerebral cortex along pial-glial basementmembranes as there are no perivascular “spaces” around cortical arteries, (2) tracers leave the brain along smooth muscle cell basement membranes that form the Intramural Peri-Arterial Drainage (IPAD) pathways for the elimination of interstitial fluid and solutes from the brain. 2 μL of 100 μM soluble, fluorescent fixable amyloid β (Aβ) were injected into the CSF of the cisterna magna of 6-10 and 24-30 month-old male mice and their brains were examined 5 and 30 min later. At 5 min, immunocytochemistry and confocal microscopy revealed Aβ on the outer aspects of cortical arteries colocalized with α-2 laminin in the pial-glial basementmembranes. At 30 min, Aβ was colocalised with collagen IV in smooth muscle cell basement membranes in the walls of cortical arteries corresponding to the IPAD pathways. No evidence for drainage along the walls of veins was found. Measurements of the depth of penetration of tracer were taken from 11 regions of the brain. Maximum depths of penetration of tracer into the brain were achieved in the pons and caudoputamen. Conclusions drawn from the present study are that tracers injected into the CSF enterand leave the brain along separate periarterial basement membrane pathways. The exit route is along IPAD pathways in which Aβ accumulates in cerebral amyloid angiopathy (CAA) in Alzheimer’s disease. Results from this study suggest that CSF may be a suitable route for delivery of therapies for neurological diseases, including CAA.

Albargothy NJ, Johnston DA, MacGregor Sharp M, Weller RO, Verma A, Hawkes CA, Carare RO.

Small vessels, dementia and chronic diseases – molecular mechanisms and pathophysiology.

Cerebral small vessel disease (SVD) is a major contributor to stroke, cognitive impairment and dementia with limited therapeutic interventions. There is a critical need to provide mechanistic insight and improve translation between pre-clinical research and the clinic. A 2-day workshop was held which brought together experts from several disciplines in cerebrovascular disease, dementia and cardiovascular biology, to highlight current advances in these fields, explore synergies and scope for development. These proceedings provide a summary of key talks at the workshop with a particular focus on animal models of cerebral vascular disease and dementia, mechanisms and approaches to improve translation. The outcomes of discussion groups on related themes to identify the gaps in knowledge and requirements to advance knowledge are summarized.

Horsburgh K, Wardlaw JM, van Agtmael T, Allan SM, Ashford MLJ, Bath Philip M, et al.

The meninges as barriers and facilitators for the movement of fluid, cells and pathogens related to the rodent and human CNS.

Meninges that surround the CNS consist of an outer fibrous sheet of dura mater (pachymeninx) that is also the inner periosteum of the skull. Underlying the dura are the arachnoid and pia mater (leptomeninges) that form the boundaries of the subarachnoid space. In this review we (1) examine the development of leptomeninges and their role as barriers and facilitators in the foetal CNS. There are two separate CSF systems during early foetal life, inner CSF in the ventricles and outer CSF in the subarachnoid space. As the foramina of Magendi and Luschka develop, one continuous CSF system evolves. Due to the lack of arachnoid granulations during foetal life, it is most likely that CSF is eliminated by lymphatic drainage pathways passing through the cribriform plate and nasal submucosa. (2) We then review the fine structure of the adult human and rodent leptomeninges to establish their roles as barriers and facilitators for the movement of fluid, cells and pathogens. Leptomeningeal cells line CSF spaces, including arachnoid granulations and lymphatic drainage pathways, and separate elements of extracellular matrix from the CSF. The leptomeningeal lining facilitates the traffic of inflammatory cells within CSF but also allows attachment of bacteria such as Neisseria meningitidis and of tumour cells as CSF metastases. Single layers of leptomeningeal cells extend into the brain closely associated with the walls of arteries so that there are no perivascular spaces around arteries in the cerebral cortex. Perivascular spaces surrounding arteries in the white matter and basal ganglia relate to their two encompassing layers of leptomeninges. (3) Finally we examine the roles of ligands expressed by leptomeningeal cells for the attachment of inflammatory cells, bacteria and tumour cells as understanding these roles may aid the design of therapeutic strategies to manage developmental, autoimmune, infectious and neoplastic diseases relating to the CSF, the leptomeninges and the associated CNS.

Weller RO, MacGregor Sharp M, Christodoulides M, Carare RO, Møllgård K.

The fine anatomy of the perivascular compartment in the brain. Relevance to dilated perivascular spaces in cerebral amyloid angiopathy.

Cerebral white matter hyperintensities (WMH) observed on magnetic resonance imaging (MRI), or low attenuation on computed tomographic scanning (CT), are the most frequent brain imaging finding in patients with small vessel disease or dementia. It has been assumed that WMH are due to arteriosclerosis or blood-brain barrier breakdown, though recently it was demonstrated that WMH have distinct molecular signatures in Alzheimer’s disease (AD) where markers of Wallerian degeneration are present, compared to normal ageing. Dilated perivascular spaces (PVS) are of particular interest for the study of interstitial fluid (ISF) dynamics because they are related to the intramural periarterial drainage (IPAD) of ISF and solutes along arterial basement membranes and can potentially be detected by MRI.

MacGregor Sharp M, Bulters D, Brandner S, Holton J, Verma A, Carare R.O, Werring D.


Inhibition of Aquaporin-4 Improves the Outcome of Ischaemic Stroke and Modulates Brain Paravascular Drainage Pathways.

Pirici I, Balsanu T, Bogdan C, Margaritescu C, Divan T, Vitalie V, et al.

Editorial: Clearance Pathways for Amyloid-β. Significance for Alzheimer’s Disease and Its Therapy.

Carare RO.

The perivascular pathways for influx of cerebrospinal fluid are most efficient in the midbrain.

Dobson H, MacGregor Sharp M, Cumpsty R, Criswell TP, Wellman T, Finucane C, et al.

The structure of the perivascular compartment in the old canine brain: a case study.

Criswell TP, MacGregor Sharp M, Dobson H, Finucane C, Weller RO, Verma A, et al

The increasing impact of cerebral amyloid angiopathy: essential new insights for clinical practice.

Banerjee G, Carare R, Cordonnier C, Greenberg SM, Schneider JA, Smith EE, et al.

Arterial pulsations cannot drive intramural periarterial drainage: Significance for Aβ drainage.

Diem A.K, MacGregor Sharp M, Gatherer M, Bressloff N.W, Carare R.O & Richardson G.

Hypercholesterolemia induced cerebral small vessel disease.

Kraft P, Schuhmann MK, Garz C, Jandke S, Urlaub D, Mencl S, et al.

Loss of clusterin shifts amyloid deposition to the cerebrovasculature via disruption of perivascular drainage pathways.

Wojtas AM, Kang SS, Olley BM, Gatherer M, Shinohara M, Lozano PA, et al.

Vascular basement membrane alterations and β-amyloid accumulations in an animal model of cerebral small vessel disease.

Held F, Morris AWJ, Pirici D, Niklass S, MacGregor Sharp M, Garz C, et al.

The movers and shapers in immune privilege of the CNS.

Engelhardt B, Vajkoczy P, Weller RO.

Quantitative assessment of cerebral basement membranes using electron microscopy.

MacGregor Sharp M, Page A, Morris AWJ, Weller RO, Carare RO.

Investigating the Lymphatic Drainage of the Brain: Essential Skills and Tools.

Albargothy JN, MacGregor Sharp M, Gatherer M, Morris AWJ, Weller RO, Hawkes CA, Carare RO.


Cerebrovascular pathology: the dark side of neurodegeneration.

Carare RO, Kalaria R.

Systems proteomic analysis reveals that Clusterin and Tissue Inhibitor of Metalloproteinases 3 increase in leptomeningeal arteries affected by cerebral amyloid angiopathy.

Manousopoulou A, Gatherer M, Smith C, Nicoll JA, Woelk CH, Johnson M, Kalaria R, Attems J, Garbis SD, Carare RO.

Vascular, glial, and lymphatic immune gateways of the central nervous system.

Engelhardt B, Carare RO, Bechmann B, Flügel A, Laman JD, Weller RO.

Pulsations with reflected boundary waves: a hydrodynamic reverse transport mechanism for perivascular drainage in the brain.

Coloma M, Schaffer JD, Carare RO, Chiarot PR, Huang P.

Vascular basement membranes as pathways for the passage of fluid into and out of the brain.

Morris AWJ, MacGregor Sharp M, Albargothy NJ, Hawkes CA, Verma A, Weller RO, Carare RO.

Hemisphere Asymmetry of Response to Pharmacologic Treatment in an Alzheimer’s Disease Mouse Model.

Manousopoulou A, Saito S, Yamamoto Y, Al-Daghri NM, Ihara M, Carare RO, Garbis SD.

Lymphatic Clearance of the Brain: Perivascular, Paravascular and Significance for Neurodegenerative Diseases.

Bakker E.N, Bacskai B.J, Arbel-Ornath M, Aldea R, Bedussi B, Morris A.W.J, Weller R.O, Carare R.O.

Increased Abeta pathology in aged Tg2576 mice born to mothers fed a high fat diet.

Nizari S, Carare RO, Hawkes CA.

A Simulation Model of Periarterial Clearance of Amyloid-beta from the Brain.

Diem AK, Tan M, Bressloff NW, Hawkes C, Morris AWJ, Weller RO, et al.


Chapter 19 – Pathophysiology of Lymphatic Drainage of the Central Nervous System: Implications for the Pathophysiology of Multiple Sclerosis.

Weller RO, Carare RO, Hawkes CA, Galea I.

Deposition of Amyloid β in the walls of human leptomeningeal arteries in relation to perivascular drainage pathways in cerebral amyloid angiopathy.

Keable A, Fenna K, Yuen HM, Johnston DA, Smyth NR, Smith C, Salman R, Samarasekera N, Nicoll JAR, Attems J, Kalaria RN, Weller RO, Carare RO.

Quantification of molecular interactions between apoE, Amyloid-beta (Aβ) and laminin: Relevance to accumulation of Aβ in Alzheimer’s disease.

Zekonyte J, Sakai K, Nicoll J, Weller RO, Carare RO.

Clearance systems in the brain-implications for Alzheimer disease.

Tarasoff-Conway JM, Carare RO, Osorio RS, Glodzik L, Butler T, Fieremans E, Axel L, Rusinek H, Nicholson C, Zlokovic BV, Frangione B, Blennow K, Ménard J, Zetterberg H, Wisniewski T, de Leon MJ.

Does the difference between PART and Alzheimer’s disease lie in the age-related changes in cerebral arteries that trigger the accumulation of Aβ and propagation of tau?

Weller RO, Hawkes CA, Carare RO, Hardy J.

Peristalsis with oscillating flow resistance: A mechanism for periarterial clearance of amyloid beta from the brain.

Sharp, MK, Diem AK, Weller RO, Carare RO.

White matter changes in dementia: role of impaired drainage of interstitial fluid.

Weller RO, Hawkes CA, Kalaria RN, Werring DJ, Carare RO.

Are you also what your mother eats: Distinct proteomic portrait as a result of maternal high-fat diet in the cerebral cortex of the adult mouse.

Manousopoulou A, Woo J, Hawkes CA, Johnston H, Singhania A, Woelk CH, Garbis SD, Carare RO.

Are the effects of APOE ϵ4 on cognitive function in nonclinical populations age- and gender-dependent?

Rusted J & Carare RO.


Prenatal high fat diet alters the cerebrovasculature and clearance of beta-amyloid in adult offspring.

Hawkes CA, Gentleman S, Nicoll JAR, Carare RO.

The cerebrovascular basement membrane: role in the clearance of β-amyloid and Cerebral Amyloid Angiopathy.

Morris A.W, Carare RO, Schreiber S, Hawkes CA.

Failure of perivascular drainage of beta-amyloid in cerebral amyloid angiopathy.

Hawkes CA, Jayakody N, Johnston DA, Bechmann I, Carare RO.

Impact of N-acetylcysteine on cerebral parenchymal Aβ plaques and kidney damage in spontaneously hypertensive stroke-prone rats.

Bueche CZ, Garz C, Stanaszek L, Niklass S, Kropf S, Bittner D, Härtig W, Reymann KG, Heinze HJ, Carare RO, Schreiber S.

Aß immunotherapy for Alzheimer’s disease: effects on apoE and cerebral vasculopathy.

Sakai K, Boche D, Carare RO, Johnston D, Holmes C, Love S, Nicoll JAR.

Amyloid and tau in the brain in sporadic Alzheimer’s disease: defining the chicken and the egg.

Hawkes C, Carare RO, Weller RO.

Hypertension drives parenchymal ß-amyloid accumulation in the brain parenchyma.

Bueche CZ, Hawkes C, Garz C, Vielhaber S, Attems J, Knight RT, Reymann K, Heinze H, Carare R, Schreiber S.


MK886 reduces cerebral amyloid angiopathy severity in TgCRND8 mice.

Hawkes CA, Shaw JE, Brown MS, Anthony P, McLaurin J, Carare RO.

Immune complex formation impairs the elimination of solutes from the brain: implications for immunotherapy in Alzheimer’s disease.

Carare RO, Teeling J, Hawkes CA, Püntener U, Weller RO, Nicoll JAR, Perry V.

Regional differences in the morphological and functional effects of aging on cerebral basement membranes and perivascular drainage of amyloid-β from the mouse brain.

Hawkes CA, Gatherer M, Sharp MM, Dorr A, Yuen HM, Kalaria R, Weller RO, Carare RO.

Apolipoprotein E epsilon 4 (apoE4) may impair perivascular elimination of amyloid-beta (A beta).

Hawkes CA, Zekonyte J, Howard K, Nicoll JAR, Weller RO, Carare RO.


Hawkes, Cheryl A., Shaw, James E., Brown, Mary, Sampson, Anthony P., McLaurin, JoAnne and Carare, Roxana O. (2013) MK886 reduces cerebral amyloid angiopathy severity in TgCRND8 mice. Neurodegenerative Diseases, 1-7. (doi:10.1159/000351096). PMID: 24021653

Carare, Roxana, Teeling, Jessica, Hawkes, Cheryl A, Püntener, Ursula, Weller, Roy O, Nicoll, James AR and Perry, Victor. (2013) Immune complex formation impairs the elimination of solutes from the brain: implications for immunotherapy in Alzheimer’s disease. Acta Neuropathologica, 1, (1), 48-[11pp]. (doi:10.1186/2051-5960-1-48). PMID: 24252464

Hawkes, C.A., Gatherer, M., Sharp, M.M., Dorr, A., Yuen, H.M., Kalaria, R., Weller, R.O. and Carare, R.O. (2013) Regional differences in the morphological and functional effects of aging on cerebral basement membranes and perivascular drainage of amyloid-β from the mouse brain. Aging Cell, 12, (2), 224-236. (doi:10.1111/acel.12045). PMID  23413811 

Hawkes, C.A., Zekonyte, J., Howard, K., Nicoll, James A.R., Weller, Roy O. and Carare, Roxana O. (2013) Apolipoprotein E epsilon 4 (apoE4) may impair perivascular elimination of amyloid-beta (A beta). Neuropathology and Applied Neurobiology, 39, supplement 1, 8. (doi:10.1111/j.1365-2990.2013.12029.x).


Hawkes, C.A., Sullivan, P.M., Hands, S., Weller, R.O., Nicoll, J.A.R. and Carare, Roxana O. (2012) Disruption of arterial perivascular drainage of amyloid-ß from the brains of mice expressing the human APOE e4 allele. PLoS ONE, 9, (8), 890-901. (doi:10.1371/journal.pone.0041636). PMID: 22848551

Teeling, Jessica L., Carare, Roxana O., Glennie, Martin J. and Perry, V. Hugh. (2012) Intracerebral immune complex formation induces inflammation in the brain that depends on Fc receptor interaction. Acta Neuropathologica, 124, (4), 479-490. (doi:10.1007/s00401-012-0995-3). PMID: 22618994


Hawkes, Cheryl A., Härtig, Wolfgang, Kacza, Johannes, Schliebs, Reinhard, Weller, Roy O., Nicoll, James A.R. and Carare, Roxana O. (2011) Perivascular drainage of solutes is impaired in the ageing mouse brain and in the presence of cerebral amyloid angiopathy. Acta Neuropathologica, 121, (4), 431-443. (doi:10.1007/s00401-011-0801-7). (PMID:21259015). PMID:  21259015

Coleman, Peter G., Carare, Roxana O., Petrov, Ignat, Forbes, Elizabeth, Saigal, Anita, Spreadbury, John H., Yap, Andrea and Kendrick, Tony. (2011) Spiritual belief, social support, physical functioning and depression among older people in Bulgaria and Romania. Aging & Mental Health, 15, (3), 327-333. (doi:10.1080/13607863.2010.519320). PMID: 21491217

2010 – 2000:

Clapham, R., O’Sullivan, E., Weller, Roy and Carare, Roxana Octavia. (2009) Cervical lymph nodes are found in direct relationship with the internal carotid artery: Significance for the lymphatic drainage of the brain. Clinical Anatomy, 23, (1), 43-47. (doi:10.1002/ca.20887). PMID: 19918869

Carare, Roxana-Octavia, Preston , S.D., Subash, M. and Weller, R.O. (2009) Cerebral amyloid angiopathy in the aetiology and immunotherapy of Alzheimer disease. Alzheimer’s Research & Therapy, 1, (2) (doi:10.1186/alzrt6). PMID: 19822028

Weller, Roy O., Djuanda, Effie., Yow, Hong-Yeen and Carare, Roxana O. (2009) Lymphatic drainage of the brain and the pathophysiology of neurological disease. Acta Neuropathologica, 117, (1), 1-14. (doi:10.1007/s00401-008-0457-0). PMID: 19002474

Weller, R.O., Boche, D. & Nicoll, J.A. Microvasculature changes and cerebral amyloid angiopathy in Alzheimer’s disease and their potential impact on therapy. Acta Neuropathol, 87-102 (2009).

Keage, H.A., et al. Population studies of sporadic cerebral amyloid angiopathy and dementia: a systematic review. BMC Neuro, 3 (2009).

Campbell, S.J., Carare-Nnadi, R.O., Losey, P.H. and Anthony, D.C. (2007) Loss of atypical inflammatory response in juvenile and aged rats. Neuropathology and Applied Neurobiology, 33, (1), 108-120. (doi:10.1111/j.1365-2990.2006.00773.x). PMID 17239013

Schley, D., Carare-Nnadi, R., Please, C.P., Perry, V.H. and Weller, R.O. (2006) Mechanisms to explain the reverse perivascular transport of solutes out of the brain. Journal of Theoretical Biology, 238, (4), 962-974. (doi:10.1016/j.jtbi.2005.07.005). PMID: 16112683

O’Sullivan, E., Carare-Nnadi, R., Greenslade, J. and Bowyer, G. (2005) Clinical significance of variations in the nterconnections between flexor digitorum longus and flexor hallucis longus in the region of the knot of Henry. Clinical Anatomy, 18, (2), 121-125. (doi:10.1002/ca.20029). PMID: 15696523

Li, R., et al. Glial fibrillary acidic protein mutations in infantile, juvenile, and adult forms of Alexander disease. Ann Neurol 57, 310-326 (2005).

Salzman, K.L., et al. Giant tumefactive perivascular spaces. AJNR Am J Neuroradiol, 298-305 (2005).

Weller, R.O. & Nicoll, J.A. Cerebral amyloid angiopathy: both viper and maggot in the brain. Ann Neurol 58, 348-350 (2005).

Weller, R.O. Microscopic morphology and histology of the human meninges. Morphologie 89, 22-34 (2005).

Weller, R.O., Cohen, N.R. & Nicoll, J.A. Cerebrovascular disease and the pathophysiology of Alzheimer’s disease. Implications for therapy. Panminerva Med, 239-251 (2004).

Horstmann, S., et al. Genetic and expression profiles of cerebellar liponeurocytomas. Brain Pathol 14, 281-289 (2004).

Sun, D., Newman, T.A., Perry, V.H. & Weller, R.O. Cytokine-induced enhancement of autoimmune inflammation in the brain and spinal cord: implications for multiple sclerosis. Neuropathol Appl Neurobiol 30, 374-384 (2004).

Nicoll, J.A., Yamada, M., Frackowiak, J., Mazur-Kolecka, B. & Weller, R.O. Cerebral amyloid angiopathy plays a direct role in the pathogenesis of Alzheimer’s disease. Pro-CAA position statement. Neurobiol Aging 25, 589-597; discussion 603-584 (2004).

Preece, N.E., Houseman, J., King, M.D., Weller, R.O. & Williams, S.R. Development of vigabatrin-induced lesions in the rat brain studied by magnetic resonance imaging, histology, and immunocytochemistry. Synapse 53, 36-43 (2004).

Fowler, M.I., Weller, R.O., Heckels, J.E. & Christodoulides, M. Different meningitis-causing bacteria induce distinct inflammatory responses on interaction with cells of the human meninges. Cell Microbiol 6, 555-567 (2004).

R.O. & Nicoll, J.A. Cerebral amyloid angiopathy: pathogenesis and effects on the ageing and Alzheimer brain. Neurological research 25, 611-616 (2003).

Nicoll, J.A. & Weller, R.O. A new role for astrocytes: beta-amyloid homeostasis and degradation. Trends Mol Med 9, 281-282 (2003).

Hien, T.T., et al. Neuropathological assessment of artemether-treated severe malaria. Lancet 362, 295-296 (2003).

Roher, A.E., et al. Cortical and leptomeningeal cerebrovascular amyloid and white matter pathology in Alzheimer’s disease. Mol Med 9, 112-122 (2003).

Zhang, B., et al. Molecular pathogenesis of subarachnoid haemorrhage. Int J Biochem Cell Biol 35, 1341-1360 (2003).

Preston, S.D., Steart, P.V., Wilkinson, A., Nicoll, J.A. & Weller, R.O. Capillary and arterial cerebral amyloid angiopathy in Alzheimer’s disease: defining the perivascular route for the elimination of amyloid beta from the human brain. Neuropathol Appl Neurobiol 29, 106-117 (2003). 

Nicoll, J.A., et al. Neuropathology of human Alzheimer disease after immunization with amyloid-beta peptide: a case report. Nat Med 9, 448-452 (2003).

Weller, R.O., Yow, H.Y., Preston, S.D., Mazanti, I. & Nicoll, J.A. Cerebrovascular disease is a major factor in the failure of elimination of Abeta from the aging human brain: implications for therapy of Alzheimer’s disease. Ann N Y Acad Sci 977, 162-168 (2002).

Christodoulides, M., et al. Interaction of Neisseria meningitidis with human meningeal cells induces the secretion of a distinct group of chemotactic, proinflammatory, and growth-factor cytokines. Infect Immun 70, 4035-4044 (2002).

The evolution of A beta peptide burden in the APP23 transgenic mice: implications for A beta deposition in Alzheimer disease. Mol Med 7, 609-618 (2001).

Hilton, D.A. & Weller, R.O. Autopsy investigation of disorders of skeletal muscle and peripheral nerves. Curr Top Pathol 95, 207-238 (2001).

Weller, R.O. & Preston, S.D. The spectrum of vascular disease in dementia. From ischaemia to amyloid angiopathy. Adv Exp Med Biol 487, 111-122 (2001).

Weller, R.O. How well does the CSF inform upon pathology in the brain in Creutzfeldt-Jakob and Alzheimer’s diseases? J Pathol 194, 1-3 (2001).

Weller, R.O. XlVth International Congress of Neuropathology, 3-6 September, 2000, Birmingham, United Kingdom. Brain Pathol 11, 250-258 (2001).

Sun, D., et al. Role of chemokines, neuronal projections, and the blood-brain barrier in the enhancement of cerebral EAE following focal brain damage. J Neuropathol Exp Neurol 59, 1031-1043 (2000).

Kuo, Y.M., et al. Elevated A beta and apolipoprotein E in A betaPP transgenic mice and its relationship to amyloid accumulation in Alzheimer’s disease. Mol Med 6, 430-439 (2000).

Hardy, S.J., Christodoulides, M., Weller, R.O. & Heckels, J.E. Interactions of Neisseria meningitidis with cells of the human meninges. Mol Microbiol 36, 817-829 (2000).

Weller, R.O., Massey, A., Kuo, Y.M. & Roher, A.E. Cerebral amyloid angiopathy: accumulation of A beta in interstitial fluid drainage pathways in Alzheimer’s disease. Ann N Y Acad Sci 903, 110-117 (2000).