Multimodal evidence for impaired glymphatic brain clearance as a mediator of "inflammaging" in schizophrenia - integrating insights from in vivo neuroimaging, omics, and post-mortem single nucleus-RNA-Seq data

Abstract

Persistent cognitive impairment and reduced life expectancy in schizophrenia may arise from inflammation-driven accelerated aging ("inflammaging"), yet the underlying mechanisms remain unclear. Impaired glymphatic clearance, dependent on polarized aquaporin-4 (AQP4) localization at astrocytic endfeet, offers a plausible mechanistic link between inflammation and brain aging. Here, we integrate in vivo neuroimaging with post-mortem single-nucleus transcriptomics from distinct patient cohorts to demonstrate glymphatic dysfunction in schizophrenia and define its molecular basis. We identify reduced astrocytic expression of components of the dystrophin-associated protein complex (SNTA1, DAG1) required for AQP4 polarization. Both in vivo neuroimaging and post-mortem gene expression signatures of glymphatic dysfunction are restricted to an inflammatory subgroup characterized by peripheral immune activation and pro-inflammatory glial transcriptional profiles. Moreover, imaging signatures of glymphatic impairment are associated with schizophrenia polygenic risk scores enriched for immune - and oxidative stress - related aging pathways as well as cognitive dysfunction. At the cellular level, glymphatic dysfunction coincides with loss of homeostatic programs in microglia and astrocytes, increased inflammatory signaling, and endothelial signatures of blood-brain barrier disruption. Across modalities, glymphatic impairment is linked to accelerated aging, including increased brain and epigenetic age, and aging-related gene expression signatures.