BRIEF REPORT | NEUROSCIENCE OPEN ACCESS

The effect of prolonged spaceflight on cerebrospinal fluid and

perivascular spaces of astronauts and cosmonauts
Giuseppe Barisanoa,1 , Farshid Sepehrbanda , Heather R. Collinsb, Steven Jillingsc, Ben Jeurissend, James A. Taylorb , Catho Schoenmaekersc,
Chloe€ De Laetc, Ilya Rukavishnikove, Inna Nosikovae, Liudmila Litvinovaf , Alena Rumshiskayaf, Jitka Anneng , Jan Sijbersd, Steven Laureysg,
Angelique Van Ombergenc, Victor Petrovichevf, Valentin Sinitsynh , Ekaterina Pechenkovai , Alexey Grishinj, Peter zu Eulenburgk , Meng Lawl,
Stefan Sunaertm , Paul M. Parizeln , Elena Tomilovskayae,2 , Donna R. Robertsb,1,2, and Floris L. Wuytsc,1,2

Edited by Thomas Albright, Salk Institute for Biological Studies, La Jolla, CA; received December 3, 2021; accepted March 3, 2022

Long-duration spaceflight induces changes to the brain and cerebrospinal fluid compart-
ments and visual acuity problems known as spaceflight-associated neuro-ocular syndrome
(SANS). The clinical relevance of these changes and whether they equally affect crews of
different space agencies remain unknown. We used MRI to analyze the alterations occur-
ring in the perivascular spaces (PVS) in NASA and European Space Agency astronauts
and Roscosmos cosmonauts after a 6-mo spaceflight on the International Space Station
(ISS). We found increased volume of basal ganglia PVS and white matter PVS (WM-
PVS) after spaceflight, which was more prominent in the NASA crew than the Roscos-
mos crew. Moreover, both crews demonstrated a similar degree of lateral ventricle
enlargement and decreased subarachnoid space at the vertex, which was correlated with
WM-PVS enlargement. As all crews experienced the same environment aboard the ISS,
the differences in WM-PVS enlargement may have been due to, among other factors, dif-
ferences in the use of countermeasures and high-resistive exercise regimes, which can
influence brain fluid redistribution. Moreover, NASA astronauts who developed SANS
had greater pre- and postflight WM-PVS volumes than those unaffected. These results
provide evidence for a potential link between WM-PVS fluid and SANS.

spaceflight j microgravity j perivascular space j brain j spaceflight-associated neuroocular syndrome

Author affiliations: aLaboratory of Neuro Imaging,
University of Southern California, Los Angeles, CA 90033;
A human mission to Mars and the building of a lunar outpost are two main goals sev- b
Department of Radiology and Radiological Science,
eral space agencies are aiming to achieve. This requires understanding how the human Medical University of South Carolina, Charleston, SC
29425; cLab for Equilibrium Investigations and
brain adapts to long-term exposure to reduced-gravity environments. Aerospace, University of Antwerp, B-2610 Antwerp,
Widespread changes in brain structure and cerebrospinal fluid (CSF) redistribution Belgium; dImec-Vision Lab, University of Antwerp, B-2610
Antwerp, Belgium; eInstitute of Biomedical Problems,
were observed on postflight MRI in space flyers, including ventricular enlargement with Russian Academy of Sciences, Moscow 123007, Russia;
f
Department of Radiology, National Medical Research
no parenchymal atrophy (1–6), brain upward displacement with narrowing of the sub- Treatment and Rehabilitation Centre of the Ministry of
arachnoid space at the vertex (VSA) (1, 3, 5), and alterations in water diffusivity (7). Health of Russia, Moscow 125367, Russia; gComa Science
Group, University of Lie  ge, 4000 Lie ge, Belgium;
These changes correlate with spaceflight duration (8, 9), persist for several months after h
Department of Radiology, Lomonosov Moscow State
i
return to Earth (1–4), and suggest altered CSF homeostasis associated with spaceflight. University, Moscow 119991, Russia; Laboratory for
Cognitive Research, HSE University, Moscow 101000,
The clinical relevance of these alterations is unknown, but they might be related to Russia; jGagarin Cosmonauts Training Center, Star City
141160, Russia; kInstitute for Neuroradiology, Ludwig-
spaceflight-associated neuro-ocular syndrome (SANS), a disorder characterized by ocular Maximilians-University Munich, 80539 Munich, Germany;
structural changes affecting ∼40 to 60% of NASA astronauts undergoing long-duration l
Department of Radiology, Alfred Health, Melbourne, VIC,
3181, Australia; mDepartment of Imaging and Pathology,
missions aboard the International Space Station (ISS) (10). While visual changes have Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
been noted in Roscosmos (ROS) cosmonauts after spaceflight (1, 11, 12), there are no and nDepartment of Radiology, Royal Perth Hospital,
Perth, WA, 6000, Australia
published reports characterizing them using the SANS classification developed by NASA.
Here, we aim to determine if spaceflight induces volumetric changes to the perivas-
cular spaces (PVS), a brain-wide network of perivascular channels along which CSF– Author contributions: G.B., S.J., J.S., S.L., S.S., P.M.P.,
interstitial fluid (ISF) exchange occurs (13); to investigate the relationship between E.T., D.R.R., and F.L.W. designed research; G.B., H.R.C.,
S.J., C.S., C.D.L., I.R., M.L., E.T., D.R.R., and F.L.W.
PVS dilation and spaceflight-associated alterations in VSA and lateral ventricles (LVs); performed research; G.B., F.S., H.R.C., J.A.T., D.R.R., and
F.L.W. analyzed data; B.J., C.S., C.D.L., I.R., I.N., L.L., A.R.,
and to analyze the relationship between these alterations and SANS. Furthermore, as J.A., A.V.O., V.P., V.S., E.P., A.G., and P.z.E. performed
differences in the adoption of microgravity countermeasures may influence the degree data curation; and G.B., H.R.C., D.R.R., and F.L.W. wrote
the paper.
of the spaceflight-associated changes, we exploratively compared the alterations in these The authors declare no competing interest.
compartments for American, European, and Russian crews in a joint international Copyright © 2022 the Author(s). Published by PNAS.
study of pre- and postspaceflight brain MRI. This open access article is distributed under Creative
Commons Attribution License 4.0 (CC BY).
1
To whom correspondence may be addressed. Email:
Results [email protected], [email protected],
or fl[email protected].
We analyzed brain MRI scans acquired before and within 2 wk after long-duration 2
E.T., D.R.R., and F.L.W. contributed equally to this
spaceflight on the ISS (∼180 d) in 24 NASA astronauts (48.6 ± 5.4 y old), 13 ROS work.

cosmonauts (47.4 ± 5.2 y old), and a small group of European Space Agency (ESA) This article contains supporting information online at
http://www.pnas.org/lookup/suppl/doi:10.1073/pnas.
astronauts (the number is not reported to protect the astronauts’ identity). Since on 2120439119/-/DCSupplemental.

Earth, physiological changes occur over time in PVS, VSA, and LV, we also analyzed Published April 12, 2022.

PNAS 2022 Vol. 119 No. 17 e2120439119 https://doi.org/10.1073/pnas.2120439119 1 of 3

 A Earth − WM−PVS B Earth − BG−PVS C Earth − VSA D Earth − LV
cosmonauts (Fig. 1N). Since postflight scans in NASA astronauts
2000 20000
20000 were acquired closer to landing compared with postflight scans in
Volume mm3

Volume mm3

Volume mm3

Volume mm3
1500 200 15000
15000
1000
500
100
10000
5000
10000 ROS cosmonauts and the spaceflight-associated alterations in LV
5000
0 0 0 0 and VSA usually reverse months after return to Earth (1), we
E
MRI 1
ISS − WM−PVS
**
MRI 2

F
MRI 1
ISS − BG−PVS
**
MRI 2
G MRI 1
ISS − VSA
**
MRI 2

H 20000
MRI 1
ISS − LV
**
MRI 2

tested whether the changes in PVS were correlated with the inter-
15000
val between landing and the postflight scan; a significant inverse
Volume mm3

Volume mm3

Volume mm3

Volume mm3
1500 150 15000
1000 100 10000
10000
500 50 5000 5000 correlation was found for BG-PVS but not for WM-PVS, suggest-
0 0 0 0
Preflight Postflight Preflight Postflight Preflight Postflight Preflight Postflight
ing that the higher WM-PVS increase in NASA astronauts is not
I 1000
Shuttle − WM−PVS J Shuttle − BG−PVS K 15000
Shuttle − VSA L 15000
Shuttle − LV
explained by a shorter landing–postflight MRI interval.
75
Volume mm3

Volume mm3

Volume mm3

Volume mm3
750
500
50

25
10000

5000
10000

5000
Ophthalmologic records were available for the NASA astro-
250
0
Preflight Postflight
0
Preflight Postflight
0
Preflight Postflight
0
Preflight Postflight
nauts who traveled on the ISS; eight (33.3%) developed clinical
M WM-PVS BG-PVS VSA LV
signs of SANS and presented greater pre- and postflight
Preflight
WM-PVS volumes than those unaffected, but similar pre- and
ISS
postflight BG-PVS, VSA, and LV volumes (Fig. 2 A–D). The
postflight percentage increases of PVS and reduction of VSA
volumes were comparable in the two groups, but a significantly
Postflight
ISS
larger postflight increase in LV volume occurred in the non-
SANS group (Fig. 2 E–H), as previously reported (9).
N WM−PVS BG−PVS VSA LV
40 Discussion
Pre− to post−flight change (%)

* *

20
We showed that long-duration, but not short-duration, space-
0
flight is associated with PVS enlargement. The larger pre- and
−20
postflight WM-PVS volumes observed in NASA astronauts
ROS NASA ISS ROS NASA ISS ROS NASA ISS ROS NASA ISS
who developed SANS suggest that fluid accumulation in
Fig. 1. Controls on Earth do not show significant changes in PVS, VSA, or WM-PVS might play a pathophysiological role in SANS and
LV volumes after a 1-y follow-up (A–D). After long-duration spaceflight on that a higher WM-PVS volume at baseline might correspond to
the ISS, we observed a significant increase in PVS and LV and a decrease in
VSA volumes (E–H). Short-duration spaceflight on the space shuttle was not
an increased risk of SANS. Higher body weight was found to
associated with significant changes in PVS, VSA, or LV volumes (I–L). Exam- be associated with an increased risk of SANS in astronauts
ples of 3D masks (cyan) of WM-PVS, BG-PVS, VSA, and LV before and after (14); likewise, WM-PVS burden in healthy individuals is corre-
long-duration spaceflight on the ISS (M). The postflight changes in PVS, but
not in VSA and LV, were significantly higher in NASA astronauts than ROS
lated with body mass index (15), which is also associated with
cosmonauts (N). All data represent mean ± SEM. Paired (A–L) or indepen- higher intracranial pressure (ICP) (16). We speculate that the
dent samples t tests (N). *P ≤ 0.01; **P < 0.001. inverse correlation between WM-PVS and VSA changes could
potentially indicate that the brain upward shift may contribute
to WM-PVS dilation by obstructing major CSF–ISF efflux
scans acquired with 1-y intervals in 13 age-matched healthy routes (e.g., arachnoid granulations, superior sagittal sinus,
volunteers (46.2 ± 4.8 y old) who stayed on Earth; their white bridging veins), as previously observed (5). Space flyers’ sleep
matter perivascular spaces (WM-PVS), basal ganglia perivascu- deprivation (17) and the elevated CO2 on the ISS (18) may
lar spaces (BG-PVS), VSA, and LV volume changes between also contribute to the PVS changes observed, as on Earth, PVSs
the first and second scans (Fig. 1 A–D) were not significant are associated with poor sleep quality (19) and carbogen inhala-
(5.3, 1.0, 0.9, and 0.7%, respectively). To correct for the tion (95% O2/5% CO2) (20). On Earth, PVS enlargement is
time differences between the preflight scan and the launch day considered a nonspecific indicator of impaired brain health,
in all space flyers, these percentage changes were used to estimate being associated with several neurological conditions, including
the WM-PVS, BG-PVS, VSA, and LV volumes at launch day Alzheimer disease and small vessel disease (13). Our findings
(indicated as “preflight” from now on) (SI Appendix). indicate that long-duration exposure to microgravity on the ISS
The results of the statistical analysis are in Dataset S1. may alter the CSF–ISF circulation in PVS, possibly impairing
No lesions were found in any of the scans. We observed signif- cerebral drainage systems like the paravascular/glymphatic path-
icantly increased WM-PVS and BG-PVS volume, decreased way (21) and/or the intramural periarterial drainage pathway
VSA, and LV enlargement after long-duration spaceflight on the (22), and highlight the importance of a gravitationally main-
ISS (Fig. 1 E–H and M). No significant changes in these com- tained brain fluid homeostasis. PVSs were also identified in the
partments occurred in seven NASA astronauts (46.1 ± 2.8 y old) optic nerve (23), and their dilation was speculated to be related
who participated in 2-wk missions on the space shuttle (Fig. 1 to optic disk swelling in astronauts (24).
I–L). The pre- to postflight WM-PVS increase was significantly While LV expansion and VSA reduction were similar in
correlated with VSA reduction; both WM-PVS and VSA changes ROS and NASA crews, the postflight WM-PVS enlargement
were significantly correlated with mission duration. Age and pre- was more prominent in NASA astronauts. Since age, mission
flight brain and WM-PVS volumes were not related to any of the duration, and environmental conditions were similar in NASA
postflight changes observed. Since experienced space flyers adapt astronauts and ROS cosmonauts aboard the ISS, other factors
differently to microgravity than first-time flyers (1), we also inves- must play a role in this difference. We hypothesize that differ-
tigated the relationship between previous spaceflight experience ences in the adoption of microgravity countermeasures and/or
and the PVS changes; BG-PVS, but not WM-PVS, changes were exercise protocols may have influenced the extent of WM-PVS
inversely correlated with previous spaceflight experience. enlargement. For example, ROS cosmonauts undergo six lower
After long-duration spaceflight, the percentage increases in body negative pressure (LBNP) sessions starting 2 wk prior to
WM-PVS and BG-PVS volumes, but not VSA or LV volumes, landing, while NASA and ESA astronauts do not typically do
were significantly higher in NASA astronauts than ROS it. LBNP induces caudal displacement of fluids from the upper

2 of 3 https://doi.org/10.1073/pnas.2120439119 pnas.org
 A WM−PVS
*
B BG−PVS
*
C VSA D LV
2500 20000 ** ** 30000
*
** ** **
2000 * 100
Fig. 2. Preflight and postflight WM-PVS vol-
PVS Volume mm3

PVS Volume mm3

VSA Volume mm3

15000

LV Volume mm3
20000
1500 **

1000
10000 umes (A) were significantly higher in NASA
50
5000
10000
astronauts who developed SANS than those
500
unaffected. A significant PVS (A and B) and LV
0 0 0 0
Preflight Postflight Preflight Postflight Preflight Postflight Preflight Postflight Preflight Postflight Preflight Postflight Preflight Postflight Preflight Postflight (D) enlargement and VSA reduction (C) were
NASA ISS non−SANS NASA ISS SANS NASA ISS non−SANS NASA ISS SANS NASA ISS non−SANS NASA ISS SANS NASA ISS non−SANS NASA ISS SANS
observed in both groups (post hoc compari-
E WM−PVS F BG−PVS G VSA H LV sons, mixed model ANOVA). The spaceflight-
40 40 40 40 associated PVS dilation (E and F) and VSA
Pre− to post−flight change (%)

*
20 20 20 20
reduction (G) were not significantly different
between the groups, but a significantly
0 0 0 0 greater LV enlargement (H) was observed in
the non-SANS group (time by SANS interac-
−20 −20 −20 −20
tion, mixed model ANOVA). Data represent
NASA ISS non−SANS NASA ISS SANS NASA ISS non−SANS NASA ISS SANS NASA ISS non−SANS NASA ISS SANS NASA ISS non−SANS NASA ISS SANS mean ± SEM. *P < 0.05; **P ≤ 0.001.

body by placing the legs and pelvis in a semiairtight chamber Ethics (Institute of Biomedical Problems, Russian Academy of Sciences), and the
with negative pressure. An advanced resistive exercise device Human Research Multilateral Review Board. The study comprising brain MRI
(ARED) is regularly used by space flyers to perform free weight data review of NASA crews was approved by the institutional review boards at
exercises on the ISS, but the load and frequency of use are the NASA Johnson Space Center and the Medical University of South Carolina.
lower for ROS cosmonauts compared with NASA and ESA All participants provided written informed consent.
astronauts. Lifting heavy loads during resistive exercise is often Full methods are in SI Appendix. Briefly, three-dimensional (3D) high-
accompanied by a brief Valsalva maneuver, inducing increased resolution (1-mm3) T1-weighted images were acquired on 3-Tesla MRI machines.
ICP and decreased cerebral blood flow and cerebrovascular Preprocessing and LV segmentation were performed using FreeSurfer’s recon-all.
PVSs were segmented via an automated quantification pipeline (26). VSA was
transmural pressure (25), which can result in PVS fluid accu-
segmented with Advanced Normalization Tools.
mulation (13, 15). Although the effects of LBNP and ARED
on the brain during spaceflight are unknown, they could partly Data Availability. The NASA astronaut data are available upon application to
explain the different WM-PVS changes detected in astronauts the NASA Life Sciences Data Archive at the NASA Johnson Space Center (Hous-
and cosmonauts. We cannot exclude that other factors (e.g., ton, TX). Please contact D.R.R. ([email protected]) for questions concerning
diet) might play a role in this difference. Further studies are NASA astronaut data, or F.L.W. (fl[email protected]) and E.T.
required to confirm these hypotheses. ([email protected]) for questions concerning ESA astronaut and ROS
cosmonaut data. All other data are included in the manuscript and/or supporting
Our results reveal changes of WM-PVS following long- information.
duration spaceflight, which differentially affect NASA and ROS
crews and are linked to SANS, with implications for designing ACKNOWLEDGMENTS. We thank Wafa Taiym and Sara Mason (Lifetime Sur-
countermeasure strategies to support human health on future veillance of Astronaut Health Program, NASA Johnson Space Center) for provid-
long-duration spaceflights and on Earth. ing imaging and clinical data and Lucia Ichino for her critical evaluation of the
manuscript. This study was funded by Russian Academy of Sciences Grant 63.1
Materials and Methods (to E.T., I.R., and I.N.), NASA Grant 20-EPSCoR2020-0069 (to D.R.R.), ESA Grant
ISLRA-2009-1062 (to F.L.W.), the Belgian Science Policy Prodex (to F.L.W., S.J.,
The study comprising brain MRI data acquisition in ESA and ROS crews and con- and C.D.L.), FWO Flanders (to C.S.), and the National Institute of Mental Health
trols was approved by the ESA Medical Board, the Committee of Biomedicine of the NIH Grant RF1MH123223 (to F.S.).

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