Vascularization of fetal neocortical grafts implanted in brain infarcts in spontaneously hypertensive rats

An update on stem cell therapy for stroke patients: Where are we now?

With a foundation built upon initial work from the 1980s demonstrating graft viability in cerebral ischemia, stem cell transplantation has shown immense promise in promoting survival, enhancing neuroprotection and inducing neuroregeneration, while mitigating both histological and behavioral deficits that frequently accompany ischemic stroke. These findings have led to a number of clinical trials that have thoroughly supported a strong safety profile for stem cell therapy in patients but have generated variable efficacy. As preclinical evidence continues to expand through the investigation of new cell lines and optimization of stem cell delivery, it remains critical for translational models to adhere to the protocols established through basic scientific research. With the recent shift in approach towards utilization of stem cells as a conjunctive therapy alongside standard thrombolytic treatments, key issues including timing, route of administration, and stem cell type must each be appropriately translated from the laboratory in order to resolve the question of stem cell efficacy for cerebral ischemia that ultimately will enhance therapeutics for stroke patients towards improving quality of life.

Cell Therapy for Stroke: A Mechanistic Analysis

Cell therapy has been widely recognized as a promising strategy to enhance recovery in stroke survivors. However, despite an abundance of encouraging preclinical data, successful clinical translation remains elusive. As the field continues to advance, it is important to reexamine prior clinical trials in the context of their intended mechanisms, as this can inform future preclinical and translational efforts. In the present work, we review the major clinical trials of cell therapy for stroke and highlight a mechanistic shift between the earliest studies, which aimed to replace dead and damaged neurons, and later ones that focused on exploiting the various neuromodulatory effects afforded by stem cells. We discuss why both mechanisms are worth pursuing and emphasize the means through which cell replacement can still be achieved.

Bioscaffold-Induced Brain Tissue Regeneration

Brain tissue lost after a stroke is not regenerated, although a repair response associated with neurogenesis does occur. A failure to regenerate functional brain tissue is not caused by the lack of available neural cells, but rather the absence of structural support to permit a repopulation of the lesion cavity. Inductive bioscaffolds can provide this support and promote the invasion of host cells into the tissue void. The putative mechanisms of bioscaffold degradation and its pivotal role to permit invasion of neural cells are reviewed and discussed in comparison to peripheral wound healing. Key differences between regenerating and non-regenerating tissues are contrasted in an evolutionary context, with a special focus on the neurogenic response as a conditio sine qua non for brain regeneration. The pivotal role of the immune system in biodegradation and the formation of a neovasculature are contextualized with regeneration of peripheral soft tissues. The application of rehabilitation to integrate newly forming brain tissue is suggested as necessary to develop functional tissue that can alleviate behavioral impairments. Pertinent aspects of brain tissue development are considered to provide guidance to produce a metabolically and functionally integrated de novo tissue. Although little is currently known about mechanisms involved in brain tissue regeneration, this review outlines the various components and their interplay to provide a framework for ongoing and future studies. It is envisaged that a better understanding of the mechanisms involved in brain tissue regeneration will improve the design of biomaterials and the methods used for implantation, as well as rehabilitation strategies that support the restoration of behavioral functions.

Concise Review: Stem Cell Therapy for Stroke Patients: Are We There Yet?

Four decades of preclinical research demonstrating survival, functional integration, and behavioral effects of transplanted stem cells in experimental stroke models have provided ample scientific basis for initiating limited clinical trials of stem cell therapy in stroke patients. Although safety of the grafted cells has been overwhelmingly documented, efficacy has not been forthcoming. Two recently concluded stroke clinical trials on mesenchymal stem cells (MSCs) highlight the importance of strict adherence to the basic science findings of optimal transplant regimen of cell dose, timing, and route of delivery in enhancing the functional outcomes of cell therapy. Echoing the Stem Cell Therapeutics as an Emerging Paradigm for Stroke and Stroke Treatment Academic Industry Roundtable call for an NIH‐guided collaborative consortium of multiple laboratories in testing the safety and efficacy of stem cells and their derivatives, not just as stand‐alone but preferably in combination with approved thrombolytic or thrombectomy, may further increase the likelihood of successful fruition of translating stem cell therapy for stroke clinical application. The laboratory and clinical experience with MSC therapy for stroke may guide the future translational research on stem cell‐based regenerative medicine in neurological disorders. stem cells translational medicine2019;8:983&988

Biodegradation of ECM hydrogel promotes endogenous brain tissue restoration in a rat model of stroke

The brain is considered to have a limited capacity to repair damaged tissue and no regenerative capacity following injury. Tissue lost after a stroke is therefore not spontaneously replaced. Extracellular matrix (ECM)-based hydrogels implanted into the stroke cavity can attract endogenous cells. These hydrogels can be formulated at different protein concentrations that govern their rheological and inductive properties. We evaluated histologically 0, 3, 4 and 8 mg/mL of porcine-derived urinary bladder matrix (UBM)-ECM hydrogel concentrations implanted in a 14-day old stroke cavity. Less concentrated hydrogels (3 and 4 mg/mL) were efficiently degraded with a 95% decrease in volume by 90 days, whereas only 32% of the more concentrated and stiffer hydrogel (8 mg/mL) was resorbed. Macrophage infiltration and density within the bioscaffold progressively increased in the less concentrated hydrogels and decreased in the 8 mg/mL hydrogels. The less concentrated hydrogels showed a robust invasion of endothelial cells with neovascularization. No neovascularization occurred with the stiffer hydrogel. Invasion of neural cells increased with time in all hydrogel concentrations. Differentiation of neural progenitors into mature neurons with axonal projections was evident, as well as a robust invasion of oligodendrocytes. However, relatively few astrocytes were present in the ECM hydrogel, although some were present in the newly forming tissue between degrading scaffold patches. Implantation of an ECM hydrogel partially induced neural tissue restoration, but a more complete understanding is required to evaluate its potential therapeutic application. STATEMENT OF SIGNIFICANCE: Extracellular matrix hydrogel promotes tissue regeneration in many peripheral soft tissues. However, the brain has generally been considered to lack the potential for tissue regeneration. We here demonstrate that tissue regeneration in the brain can be achieved using implantation of ECM hydrogel into a tissue cavity. A structure-function relationship is key to promote tissue regeneration in the brain. Specifically, weaker hydrogels that were retained in the cavity underwent an efficient biodegradation within 14 days post-implantation to promote a tissue restoration within the lesion cavity. In contrast, stiffer ECM hydrogel only underwent minor biodegradation and did not lead to a tissue restoration. Inductive hydrogels weaker than brain tissue provide the appropriate condition to promote an endogenous regenerative response that restores tissue in a cavity. This approach offers new avenues for the future treatment of chronic tissue damage caused by stroke and other acute brain injuries.

[Restoration of damaged cortical pathways by neural grafting]

The motor cortex plays a central role in the control, planning, and execution of voluntary motor commands in mammals. The loss of cortical neurons is a common feature of many neuropathological conditions such as traumatic and ischemic lesions or several neurodegenerative diseases. Cell transplantation presents a promising therapeutic strategy to overcome the limited abilities of axonal regrowth and spontaneous regeneration of the adult central nervous system. In this review, we will present a historical review of brain transplantation and the current state of research in the field of cortical transplantation.

Review : Glial Boundaries and Scars: Programs for Normal Development and Wound Healing in the Brain

Early studies of glial boundaries, which are composed of immature astrocytes and extracellular matrix mol ecules (which they express), initially offered insight into the partitioning that occurs in the developing nervous system. More recently, however, it has been suggested that similar "boundaries" may have important roles in other processes occurring in the brain, including repair after traumatic brain injury. As more is understood about the expression and function of boundary molecules and glia, their potential importance is becoming apparent in numerous neuropathological conditions, including neurodegeneration and neuroregeneration in Alzheimer's and Huntington's diseases as well as in brain neoplasms. Furthermore, before we can hope to fully understand and facilitate regeneration in the compromised brain, our knowledge of the glial boundary, both during development and in the adult, must be more complete. The Neuroscientist 1:142-154, 1995

Use of stem cells for the treatment of multiple sclerosis

The reported evidence of neurodegeneration in multiple sclerosis (MS) may explain the lack of efficacy of the currently used immunomodulating modalities and the irreversible axonal damage, which results in accumulating disability. To date, efforts for neuroprotective treatments have not been successful in clinical studies in other CNS diseases. Therefore, for MS, the use of stem cells may provide a logical solution, since these cells can migrate locally into the areas of white-matter lesions (plaques) and have the potential to support local neurogenesis and rebuilding of the affected myelin. This is achieved both by support of the resident CNS stem cell repertoire and by differentiation of the transplanted cells into neurons and myelin-producing cells (oligodendrocytes). Stem cells were also shown to possess immunomodulating properties, inducing systemic and local suppression of the myelin-targeting autoimmune lymphocytes. Several types of stem cells (embryonic and adult) have been described and extensively studied in animal models of CNS diseases and the various models of MS (experimental autoimmune encephalomyelitis [EAE]). In this review, we summarize the experience with the use of different types of stem cells in CNS disease models, focusing on the models of EAE and describe the advantages and disadvantages of each stem cell type for future clinical applications in MS.

Survival and early differentiation of human neural stem cells transplanted in a nonhuman primate model of stroke

OBJECT

Neural cell transplantation has been proposed as a treatment after stroke. The purpose of this study was to establish if human neural stem cells (HNSCs) could survive in the nonhuman primate brain after an ischemic event.

METHODS

Three adult cynomolgus monkeys received a unilateral occlusion of the M, segment of the right middle cerebral artery (MCA). One week later each animal received five magnetic resonance (MR) image-guided stereotactic intracerebral injections of HNSC neurospheres labeled with bromodeoxyuridine (BrdU) in the areas surrounding the ischemic lesion as defined in T1- and T2-weighted images. On the day of transplantation and throughout the study the monkeys received oral cyclosporine (10 mg/kg twice a day), and plasma levels were monitored routinely. The animals were killed at 45, 75, or 105 days after transplantation. Magnetic resonance images revealed a cortical and subcortical infarction in the MCA distribution area. Postmortem morphological brain analyses confirmed the distribution of the infarcted area seen in the MR images, with loss of tissue and necrosis in the ischemic region. Cells that were positive for BrdU were present in the three experimental monkeys, mainly along injection tracks. Double-label immunofluorescence for BrdU and betaIII-tubulin (a marker of young neurons) revealed colocalization of few HNSCs, most of which were observed outside the immediate injection site. Colocalization with nestin was also observed, indicating an early neural/glial fate.

CONCLUSIONS

In a model of stroke in nonhuman primates, HNSCs can survive up to 105 days when transplanted 1 week after an ischemic event and can partly undergo neuronal differentiation.

Is there a future for neural transplantation?

Traditionally neural transplantation has had as its central tenet the replacement of missing neurons that have been lost because of neurodegenerative processes, as exemplified by diseases such as Parkinson disease (PD). However, the effectiveness and widespread application of this approach clinically has been limited, primarily because of the poor donor supply of human fetal neural tissue and the incomplete neurobiological understanding of the circuit reconstruction required to normalize function in these diseases. So, in PD the progress from promising neural transplantation in animal models to proof-of-principle, open-labeled clinical transplants, to randomized, placebo-controlled studies of neural transplantation has not been straightforward. The emergence of previously undescribed adverse effects and lack of significant functional advantage in recent clinical studies has been disappointing and has served to cast a new, and perhaps more realistic, perspective on this treatment approach. In fact, there have been calls by some involved in neural transplantation to return to the drawing board before pressing on with further clinical trials, and the return to basic experimentation. This therefore precipitates the question - is there a future for neural transplantation? It is important to remember that there are a number of possible explanations for the disappointing results from the recent clinical trials in PD, ranging from the mode of transplantation to patient selection. Nevertheless, almost irrespective of these reasons for the current trial results, there have always been significant practical and ethical problems with using human fetal tissue, and so a number of alternative cell sources have been investigated. These alternative sources include stem cells, which are attractive for cell-based therapies because of their potential ease of isolation, propagation and manipulation, and their ability in some cases to migrate to areas of pathology and differentiate into specific and appropriate cell types. Furthermore, the availability of stem cells derived from non-embryonic sources (e.g. adult stem cells derived from the sub-ventricular zone) has removed some of the ethical limitations associated with the use of embryonic human tissue. These potentially beneficial aspects of stem cells means that there is a future for neural transplantation as a means of treating patients with a range of neurological disorders, although whether this will ever translate into a truly effective, widely available therapy remains unknown.

Microvascular plasticity in aging

Understanding the bases of aging-related cognitive decline remains a central challenge in neurobiology. Quantitative studies reveal little change in the number of neurons or synapses in most of the brain but their ongoing replacement is reduced, resulting in a significant loss of neuronal plasticity with senescence. Aging also may alter neuronal function and plasticity in ways that are not evident from anatomical studies of neurons and their connections. Since the nervous system is dependent upon a consistent blood supply, any aging-related changes in the microvasculature could affect neuronal function. Several studies suggest that, as the nervous system ages, there is a rarefaction of the microvasculature in some regions of the brain, as well as changes in the structure of the remaining vessels. These changes contribute to a decline in cerebral blood flow (CBF) that reduces metabolic support for neural signaling, particularly when levels of neuronal activity are high. In addition to direct effects on the microvasculature, aging reduces microvascular plasticity and the ability of the vessels to respond appropriately to changes in metabolic demand. This loss of microvascular plasticity has significance beyond metabolic support for neuronal signaling, since neurogenesis in the adult brain is regulated coordinately with capillary growth.

Restorative neurosurgery: opportunities for restoration of function in acquired, degenerative, and idiopathic neurological diseases

Historically, neurosurgery has improved the environment of the nervous system to promote maximal spontaneous recovery of function. The population of patients whom we treat at present is a small portion of those who suffer from disabling neurological illnesses. Based on a combination of new technology, and advances in neuroscience, restorative neurosurgery is advancing the frontiers of our specialty, and providing the potential to restore lost function. Significant advancements in gene therapy, the discovery and delivery of neurotrophic factors, and cell transplantation now require neurosurgeons to broaden the scope of our practice so that it includes the restoration of function in an enormous number of patients with acquired, degenerative and idiopathic neurological diseases. In order to meet the present challenge, neurosurgeons must broaden our vision, our role, and our future educational goals. In this review, we summarize the landmark advances in the basic and clinical neurosciences and the results of clinical trials that are driving our evolution from passive reaction to disease to active attempts to restore lost central nervous system function.

Differentiation and angiogenesis of central nervous system stem cells implanted with mesenchyme into ischemic rat brain

After cerebral infarction, necrosis in neural tissues is not usually repaired or reconstructed by the injured brain. We therefore examined the effects on postinfarction repair of implanting central nervous system (CNS) stem cells together with mesenchyme, because CNS stem cells can be expected to adapt and survive in the adult brain. Cerebral infarction was induced by the Koizumi-Longa method, using the adult male spontaneous hypertensive rat model. Reperfusion was performed an hour after middle cerebral artery occlusion. The rat mesencephalic neural plate at the early somite stage (embryonic day 10.5) together with the adjacent ventral mesenchymal tissues was dissected out under the microscope and immediately implanted into the ischemic rat striatum. One month later, the cognitive function was evaluated by the Morris water maze method. Histologic and immunohistochemical examinations of the graft were made with hematoxylin-eosin (H&E), neurofilament-200, and tyrosine hydroxylase (TH) stains. In the water maze study, mean latency times required to reach an escape platform in the implanted animals with surviving grafts were found to be shorter than in those without grafts, but longer than in normal animals. In the spatial probe trial, the number of animals seen to cross the area in the pool where the platform had been located was greater in the implanted rats with surviving grafts than in other groups. Multiple vascularization in the grafted area was observed histologically in H&E-stained tissues, and neurofilament-200-positive cells were recognized in the graft. TH staining revealed within the graft many immunoreactive neuron-like cell bodies with long dendrites. It was suggested that grafted CNS stem cells with mesenchyme may survive and differentiate into mature CNS tissue within the adult ischemic rat brain, constructing vessels in and around the grafts, and may therefore have the potential to be effective in the recovery of the cognitive function of the rat model.

Fetal neocortical grafts placed in brain infarcts do not improve paw-reaching deficits in adult spontaneously hypertensive rats

The aim was to study if neural grafts placed brain infarcts could improve functional recovery. The middle cerebral artery was occluded (MCAO) in 19 spontaneously hypertensive rats. Nine rats were sham operated. Twelve to 16 days after the ischemic insult, 9 of the MCAO rats received transplants of dissociated fetal neocortical tissue (MCAO-T) and 1, 3 and 6 months after transplantation surgery, the rats were behaviorally evaluated by a test for forelimb function. Infarct and transplant sizes were measured morphometrically. The remaining volume of the infarcted hemisphere was 66 +/- 7% (mean +/- SD) in the MCAO group and 71 +/- 9% in the MCAO-T group of the non-operated hemisphere. All grafted rats had surviving transplants. Contralateral to the lesion, paw-reaching was highly impaired in both infarcted groups compared with sham-operated controls with no significant difference between MCAO and MCAO-T. The lesion size correlated significantly with contralateral paw-reach performance at all test periods. We conclude that neocortical grafts did not alleviate the impaired forepaw function.

Analysis of neocortical grafts placed into focal ischemic lesions in adult rats

This study investigated the viability of fetal neocortical block grafts transplanted into adult ischemic cortical lesions. Recipient rats sustained focal ischemic lesions by permanent occlusion of the middle cerebral artery 4-7 days prior to transplantation. Twenty days later, the animals were sacrificed and the brains examined using triphenyltetrazolium chloride, routine Nissl or acetylcholinesterase histochemistry. Ischemic infarctions were localized to the ipsilateral sensorimotor cortex and transplants were integrated with the host cerebral cortex or striatum. Cholinergic fibers were found crossing the host-transplant interface, presumably innervating the graft. This study demonstrates that fetal neocortical block grafts placed into adult focal ischemic lesions following permanent arterial occlusion can survive and establish connections with the host brain.

Neovascularization of rat fetal neocortical grafts transplanted into a previously prepared cavity in the cerebral cortex: a three-dimensional morphological study using the scanning electron microscope

Neovascularization within syngeneic rat fetal neocortical grafts transplanted into a previously prepared cavity in the cerebral cortex was studied 1 to 3 months after transplantation, utilizing scanning electron microscopy of vascular corrosion casts. The grafts were easily identified and the outer surface of the grafts, especially at the host-graft interface, was surrounded by large regenerated vessels of leptomeninges and connective tissue (e.g. dura). Large vessels originating from the choroid plexus also coated the grafts in animals whose lateral ventricles had been opened at the time of cavitation. These large regenerated vessels were mainly observed on the surface of the grafts, and they ramified markedly to form capillary networks in the vicinity of the host-graft interface. Occasionally several relatively large regenerated vessels were noted to extend into the grafts, and to ramify and connect with graft capillary networks having the same features as that of the host brain. Moreover, direct vascular connections between host capillaries and those within the grafts were observed. In some animals, arteries and arterioles which fed the grafts were identified in the perimeter of the grafts with their characteristic morphology. The interior microvasculature structure of the grafts was largely composed of the capillary network of graft origin, and of several relatively large penetrating vessels originating from the regenerated leptomeningeal vessels or the vessels of the choroid plexus. The present study demonstrated that the blood supply to the solid grafts transplanted into the previously prepared cavities originated primarily from the regenerated host vessels. These host vessels perfused the intrinsic graft vessels via new anastomoses which formed predominantly at the host-graft interface.

Three-dimensional morphological study of microvascular regeneration in cavity wall of the rat cerebral cortex using the scanning electron microscope: implications for delayed neural grafting into brain cavities

The present study was carried out to quantify the subsequent vascular regeneration around a lesion cavity made in the rat cerebral cortex and to decide the origin of the regenerated microvessels. A quantitative study utilizing computerized image analysis after microvascular perfusion with India ink indicated approximately 25 and 160% increase of the vascular density adjacent to the cavity compared to the contralateral cortex at 4 and 21 days, respectively, after lesioning. The microvasculature around the cavity was also evaluated by scanning electron microscopy of vascular corrosion casts. Newly formed leptomeningeal vessels began to grow down toward the floor of the cavity 4 days after lesioning and nearly covered the walls of the cavity 21 days after lesioning. A neovascular network of leptomeninges and connective tissue (e.g., dura) was formed as a roof over the cavity. Numerous branches of these newly formed vessels and prominent anastomoses with the capillary network in the walls and floor of the cavity were observed. Newly formed vessels also originated from the choroid plexus in cases where the lateral ventricle had been opened at the time of lesioning. These results document the plasticity of the vascular system in the cerebral cortex after a mechanical injury. The regenerated vascular network may offer a suitable condition for survival of transplanted tissues.

Functional recovery after brain infarction: plasticity and neural transplantation

In the past, little attention has been given to the role of brain plasticity for the long term functional outcome in experimental stroke although there is substantial evidence for plasticity in other experimental models of neurological disorders. Under clinical conditions, functional improvement occurs in most stroke survivors during the initial months after the ischemic incidence. Recent PET studies in stroke patients, investigated two months or later after stroke, indicate a considerable potential for functional plasticity in the adult human cerebral cortex. Research aimed at the identification of the mechanisms underlying functional recovery should be given high priority, particularly with regard to environmental factors and pharmacological interventions. Pilot experiments of environmental enrichment significantly improved the functional outcome of laboratory animals after brain infarction. Fetal neocortical tissue grafted into the infarcted area in adult rats received afferent fibres from the intact brain and responded to contralateral sensory stimulation with increased metabolic activity, indicating functional integration between neocortical grafts and host afferent systems. However, reciprocal connections from the graft to the host tissue were rare, and it remains to be shown whether grafting will be able to restore the complex cortical organization of the infarcted tissue.

Functional integration of cortical grafts placed in brain infarcts of rats

Five to 6 days after a right middle cerebral artery occlusion, a cell suspension of fetal neocortex was grafted into the infarcted area of adult spontaneously hypertensive rats. Three to 17 months later, functional integration of the grafts into the afferent somatosensory pathway was tested using the 2-[14C]deoxyglucose method for estimation of glucose utilization. Grafted rats (n = 8) and control rats (n = 5) with no arterial occlusion were stimulated in the left vibrissal region resulting in an increased glucose utilization in the left trigeminal sensory nucleus and the right ventroposterior nucleus of the thalamus, whereas the same regions in a group (n = 5) of nonstimulated grafted rats were not activated. Glucose uptake in the right somatosensory cortex of control rats was 96 +/- 5 (mean +/- SEM) mumol/100 gm/min. Neocortical grafts consumed less glucose than cortex in control rats but the vibrissae-stimulated group displayed a 110% higher value than the nonstimulated grafted group (32 +/- 5 vs 15 +/- 2, p < 0.05). We conclude that graft glucose metabolism is increased following stimulation of the host somatosensory pathway, which demonstrates that transplanted neurons can be functionally integrated with neural circuitries of the host after an ischemic insult.

Paw-reaching, sensorimotor, and rotational behavior after brain infarction in rats

BACKGROUND AND PURPOSE

Functional tests that are stable and consistent over time are an advantage for long-term evaluation of treatment in experimental stroke research. Because little information on this subject is available in rodents with focal cerebral ischemia, we investigated the outcome of three behavioral tests for a period of 3 months after the insult.

METHODS

Spontaneously hypertensive rats were sham-operated (n = 27) or underwent an occlusion (n = 36) of the right middle cerebral artery. Before surgery all rats were tested for amphetamine-induced rotational behavior, and half of the rats were trained in a paw-reaching task. One, 2, and 3 months after surgery the tests were repeated, together with a test for sensorimotor function. Infarct size was measured morphometrically.

RESULTS

In the lesion group, total hemisphere area was reduced by 22%, caudate putamen by 47%, and the thalamus by 24%. Contralateral to the lesion, paw-reaching was highly impaired, regardless of whether or not the rats had been pretrained, and lesion size correlated significantly to paw-reach performance. Ipsilateral rotation increased and sensorimotor function recovered with time in infarcted rats.

CONCLUSIONS

In contrast to amphetamine-induced rotation and sensorimotor behavior, the paw-reaching test provides a stable behavioral parameter after a middle cerebral artery occlusion. Moreover, the lesion-induced deficit in paw-reaching is highly correlated to the extent of the infarct, suggesting that this test is useful in evaluating treatment effects for a longer period of time.