A unique androgen excess signature in idiopathic intracranial hypertension is linked to cerebrospinal fluid dynamics Michael W. O'Reilly, … , Wiebke Arlt, Alexandra J. Sinclair JCI Insight. 2019. https://doi.org/10.1172/jci.insight.125348. In-Press Preview Idiopathic intracranial hypertension (IIH) is a condition of unknown etiology, characterized by elevated intracranial pressure frequently manifesting with chronic headaches and visual loss. Similar to polycystic ovary syndrome (PCOS), IIH predominantly affects obese women of reproductive age. In this study, we comprehensively examined the systemic and cerebrospinal fluid (CSF) androgen metabolome in women with IIH in comparison to sex-, body mass index- and age-matched control groups with either simple obesity and PCOS, i.e. obesity and androgen excess. IIH women showed a pattern of androgen excess distinct to that observed in PCOS and simple obesity, with increased serum testosterone, and increased CSF testosterone and androstenedione. Human choroid plexus expressed the androgen receptor, alongside the androgen-activating enzyme aldoketoreductase type 1C3. We show that in a rat choroid plexus cell line testosterone significantly enhanced the activity of Na + /K + ATPase, a surrogate of CSF secretion. We demonstrate that IIH patients have a unique signature of androgen excess and provide evidence that androgens can modulate CSF secretion via the choroid plexus. These findings implicate androgen excess as a potential causal driver and therapeutic target in IIH. Research Endocrinology Neuroscience Find the latest version: http://jci.me/125348/pdf
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idiopathic intracranial hypertension is linked to · 3 52 INTRODUCTION 53 Idiopathic intracranial hypertension (IIH) is a chronic and disabling condition characterized by 54 elevated
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A unique androgen excess signature inidiopathic intracranial hypertension is linked tocerebrospinal fluid dynamics
Michael W. O'Reilly, … , Wiebke Arlt, Alexandra J. Sinclair
Idiopathic intracranial hypertension (IIH) is a condition of unknown etiology, characterizedby elevated intracranial pressure frequently manifesting with chronic headaches and visualloss. Similar to polycystic ovary syndrome (PCOS), IIH predominantly affects obese womenof reproductive age. In this study, we comprehensively examined the systemic andcerebrospinal fluid (CSF) androgen metabolome in women with IIH in comparison to sex-,body mass index- and age-matched control groups with either simple obesity and PCOS,i.e. obesity and androgen excess. IIH women showed a pattern of androgen excess distinctto that observed in PCOS and simple obesity, with increased serum testosterone, andincreased CSF testosterone and androstenedione. Human choroid plexus expressed theandrogen receptor, alongside the androgen-activating enzyme aldoketoreductase type 1C3.We show that in a rat choroid plexus cell line testosterone significantly enhanced the activityof Na+/K+ ATPase, a surrogate of CSF secretion. We demonstrate that IIH patients have aunique signature of androgen excess and provide evidence that androgens can modulateCSF secretion via the choroid plexus. These findings implicate androgen excess as apotential causal driver and therapeutic target in IIH.
Images were acquired with MetaMorph (Molecular devices, CA). An image sequence is 291
initially analysed on ImageJ (V1.48), where individual random cells are selected as a region of interest, 292
motile cells are excluded from the analysis. Following this, the multimeasure function was selected to 293
determine the mean intensity of individual cells at each frame. Subsequent to this the F/Fmin is 294
determined for each frame, where F is the intensity for the cell in that particular frame and Fmin is the 295
lowest fluorescence intensity in the baseline period. This normalises the change intensity to baseline, 296
taking into account any quantitative difference in ATP/ADP ratio between cells or differences in 297
Perceval protein expression. Ouabain administration was utilised to initiate a change ATP/ADP ratio 298
or ‘Δ’ (Supplemental Figure 1). This ‘Δ’ is the maximum value F/Fmin following ouabain 299
administration minus the maximum F/Fmin in the pre ouabain administration (baseline). 300
Statistics 301
Statistical analysis was performed using SPSS (Version 22, Chicago, Ill., USA). All 302
comparisons were performed using Student’s t test (two-tailed), Mann-Whitney U test or Kruskal 303
Wallis testing. P-values <0.05 were deemed significant. 304
Study approval 305
For PCOS and healthy controls under the South Birmingham (LREC5835), Edgbaston 306
(12/WM/0206) and Adelaide and Meath Hospital Dublin (2006/10/02) Research Ethics Committees. 307
Ethical approval for recruitment of IIH patients was granted by the Dudley (06/Q2702/64), Yorkshire 308
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and the Humbar-Leeds West (13/YH/0366) and Black Country (14/WM/0011) Local Research Ethics 309
Committees. Ethical approval for CSF samples from patients with neurological disease was granted by 310
Solihull Research Ethics Committee (04/Q2706/65). The Parkinson’s UK Brain Bank has ethical 311
approval from the Wales Research Ethics Committee as a Research Tissue Bank, which covers the use 312
of tissue from the Brain Bank by researchers. 313
AUTHOR CONTRIBUTIONS 314
AJS, MWOR and WA conceptualized and designed the clinical study. All authors were 315
involved in aspects of study conduct as well as drafting and approving the final manuscript. 316
ACKNOWLEDGEMENTS 317
This study was funded by the National Institute of Health Research (NIHR) UK (NIHR 318
Clinician Scientist Fellowship (NIHR-CS-011-028), to AJS), the Medical Research Council UK 319
(project grant MR/K015184/1 to AJS and MR/N00275X/1 to DJH), and the Wellcome Trust (Clinical 320
Research Training Fellowship 099909, to MWOR; Investigator Grant 209492/Z/17/Z, to WA). The 321
views expressed in this publication are those of the author(s) and not necessarily those of the National 322
Health Service, the National Institute for Health Research, or the Department of Health UK. Catherine 323
Hornby was funded by a British Association of Neurologist Intercalated scholarship and a Midlands 324
Neuroscience teaching and Research Fund grant. This project has received funding from the European 325
Research Council (ERC) under the European Union’s Horizon 2020 research and innovation 326
programme (Starting Grant 715884 to D.J.H.). 327
We would like to thank the nurses of the National Institute of Health Research/Wellcome Trust 328
Clinical Research Facility, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK 329
for their help with patient recruitment and running of the study. We are also indebted to all the patients 330
and healthy volunteers who participated in this study. 331
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Figure 3: Functional effect of testosterone on rodent choroid plexus. (A-D) mRNA expression in 456
female rats normalized to ribosomal 18S, n=3 biological replicates (mean+SEM). Z310 are 457
immortalized choroid plexus epithelial cells. (E-G) Z310 cells incubated with 100nM testosterone for 458
two days increased the ∆ATP:ADP ratio at 15 minutes and area under curve (AUC) of the ratio over 15 459
minutes indicating increased Na+/K+ ATPase activity a surrogate of CSF production (n=39 cells from 460
3 pooled coverslips. (E) Data presented as mean ± SD; (F, G) Box and whisker plots: data presented as 461
median and interquartile range, minimum and maximum values. (H) mRNA expression of carbonic 462
anhydrases II and III (Car2 and Car3) and Na+K+ATPase (Atp1a1) at 48 hours in testosterone-treated 463
(vs vehicle) Z310 cells (n=3 repeats, mean ± SEM). Mann-Whitney test for E-H, * p<0.05, ** p<0.01, 464
and **** p<0.0001. (I) Concept figure linking systemic and CSF androgen activation and impact on 465
CSF secretion at the choroid plexus. 466
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Table 1: Baseline characteristics and biochemical data. 467
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Median and interquartile range. Analysis of variance with post hoc Tukey testing: a, p<0.05, b, p<0.01, 470 c, p<0.001 for the comparison of PCOS or IIH v simple obesity; d, p<0.05; e, p<0.01; f, p<0.001 for 471 the comparison PCOS v IIH. 472
Abbreviations: 5-THF, 5alpha-tetrahydrocortisol; 11OHA4, 11-hydroxyandrostenedione; 11KA4, 473 11-ketoandrostenedione; 11OHT, 11-hydroxytestosterone; 11KT, 11-ketotestosterone; A4, 474 androstenedione; An, androsterone; BMI, body mass index; DHEA, dehydroepiandrosterone; DHEAS, 475 dehydroepiandrosterone sulfate; Et, etiocholanolone; T, testosterone; THF, tetrahydrocortisol. 476
*Steroid metabolite ratios indicative of systemic 5-reductase activity, a major androgen-activating 477 reaction 478 479