• Nathan A Shlobin, Brandon L Staple, Michelle Sclafani, and David H Harter.
• Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. Electronic address: nas2227@cumc.columbia.edu.
• World Neurosurg. 2024 Oct 1; 190: 147156147-156.

BackgroundCerebrospinal fluid (CSF) circulates throughout the ventricles, cranial and spinal subarachnoid spaces, and central spinal cord canal. CSF protects the central nervous system through mechanical cushioning, regulation of intracranial pressure, regulation of metabolic homeostasis, and provision of nutrients. Recently, investigators have characterized the glial-lymphatic (glymphatic) system, the analog of the lymphatic system in the central nervous system, and described a fourth meningeal layer; the subarachnoid lymphatic-like membrane (SLYM)relevant to the CSF.MethodsA narrative review was conducted.ResultsIn this review, we summarize these advances. We describe the development of the original model, controversies, a revised model, and a new conceptual framework. We characterize the biological functions, influence of sleep-wake cycles, and effect of aging with relevance to the glymphatic system. We highlight the role of the glymphatic system in Alzheimer's disease, idiopathic normal pressure hydrocephalus, ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury. Next, we characterize the structure and role of the SLYM. Finally, we explore the relevance of the glymphatic system and SLYM to neurosurgery.ConclusionsThis manuscript will inform clinicians and scientists regarding preclinical and translational advances in the understanding of the structure, dynamics, and function of the CSF.Copyright © 2024 Elsevier Inc. All rights reserved.

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