Cell Therapy for Neurological Disorders: History
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Subjects: Cell & Tissue Engineering
Contributor:
Donghui Liu

Neurological disorders are big public health challenges that are afflicting hundreds of millions of people around the world. Although many conventional pharmacological therapies have been tested in patients, their therapeutic efficacies to alleviate their symptoms and slow down the course of the diseases are usually limited. Cell therapy has attracted the interest of many researchers in the last several decades and has brought new hope for treating neurological disorders. Moreover, numerous studies have shown promising results. 

  • cell therapy
  • cell transplantation
  • neurological disorders
  • stem cells
  • clinical trials

1. Introduction

Neurological disorders are defined as diseases of the nervous system. There are more than 600 neurological disorders that can be divided into four categories: (1) sudden onset conditions, such as stroke; (2) intermittent conditions, such as epilepsy; (3) progressive conditions, such as Parkinson’s disease (PD); (4) stable neurological conditions, such as cerebral palsy. These diseases have become a big public health challenge and present a tremendous burden to individuals, their families, and society. Some of the disorders can be common and severe, including stroke, Huntington’s disease (HD), traumatic brain injury (TBI), spinal cord injury (SCI), epilepsy, PD, Alzheimer’s disease (AD), Lyme disease, cerebral palsy, ataxia, amyotrophic lateral sclerosis (ALS), hypoxic-ischemic encephalopathy (HIE) and multiple sclerosis (MS). Currently, although there are many conventional therapies that can alleviate their symptoms, such as levodopa or deep brain stimulation for PD [1], cholinesterase inhibitors, or memantine for AD [2], these treatments have failed to slow or reverse the progression of the diseases, in other words, these diseases are not curable by the conventional therapies.
A common feature of many severe neurological disorders is the loss and/or dysfunction of massive neural cells, especially neurons. Therefore, regenerative medicine, especially cell therapy, has become an intriguing field for researchers in the last several decades. Cell therapy is thought to be an excellent therapy for many neurological disorders acting by replacing dead cells or/and releasing protective factors to the damaged cells or/and modulating the lesion’s microenvironment in the nervous system [3][4][5]. With the rapidly expanding studies in this research area, cell therapy has shown its unique potentials in treating neurological disorders. Currently, various types of cells have been used in cell therapy studies, including embryonic stem cells (ESCs), induced pluripotent stem cells (iPSCs), neural stem/progenitor cells (NSPCs), mesenchymal stromal/stem cells (MSCs), and olfactory ensheathing cells (OECs), etc. However, despite the promising results from numerous animal-based studies, the outcomes from clinical trials are normally not as significant as from animal studies. This may be due to the difference between animal models and the real disease of patients and the differences in nervous systems between animals and humans.

2. Cell Source: Autologous or Allogeneic?

The transplantable cells for patients can be divided into two sources: autologous and allogeneic. Autologous cells are usually more favorable than allogeneic cells in regenerative medicine as they avoid several issues that allogeneic cells may have, such as immune rejection or the use of immunosuppressants, ethical issues, and finding suitable donors [6]. However, allogeneic transplants are necessary for the cells that are therapeutic but hard to obtain from the patients themselves, such as ESCs [7], NSPCs [8], and fetal stem cells (FSCs) that contain various stem cells from fetal blood and tissues (e.g., MSCs, NSPCs, and hematopoietic stem cells) (see Table 1). Nowadays, cell reprogramming provides a new opportunity to generate any type of autologous cells from another type of easily obtainable somatic cells, such as iPSCs from urine [9] and induced neural stem cells from fibroblasts [10]. However, the safety of these cells is highly related to the methods and vectors used in induction protocols [11][12][13], and the safety and therapeutic effects need to be well studied before taking into clinical application.
Table 1. Differences between autologous transplantation and allogeneic transplantation.
  Cell Source Additional Invasive
Procedures		 Immunogenicity Ethical
Issues		 Cell
Availability		 Cell Type
Autologous transplantation Patients themselves Yes No immune rejection No Limited by autologous cell culture Limited, depending on the patient him/herself
Allogeneic transplantation Other donors No Activated immune response, immunosuppressants required Yes (when it involves the use of human embryos) Cryopreserved stocks, suitable for big amount cell preservation Various, depending on the donors (e.g., ESCs and FSCs)
Interestingly, some cells, such as umbilical cord blood mononuclear cells and adipose-derived mesenchymal stem cells (hADSCs), have been reported as immature immune cells; namely, they will not cause immune rejection, even in the absence of immune suppression [14][15], which may make them suitable candidates as allogeneic transplants.

3. Different Cell Types and the Current Progress

3.1. Embryonic Stem Cells (hESCs)

Human ESCs (hESCs) are pluripotent cells that are derived from human embryos and are capable of self-renewing and differentiating into all types of human cells. The first cell line of hESCs was isolated by James Thomson in 1998 [16], which then brought a new hope of developing new hESC lines for cell therapy. The therapeutic potential of ESCs for neurological disorders was proved a long time ago [17][18]. However, several critical issues of hESCs have limited the related studies and clinical applications: (1) ethical issues, as the establishment of hESCs lines involves the exploitation and destruction of human embryos; (2) immune rejection. As hESCs are allogeneic cells, they may cause immune rejection after transplantation [19], or the patient may need a life-long administration of immunosuppressants; (3) tumor formation. Due to the pluripotency of hESCs, they have the potential to generate teratoma after transplantation [20][21]. Several methods have been reported to reduce or eliminate the tumorigenicity of ESCs, such as pre-treating ESCs with mitomycin [22], co-transplantation ESCs with MSCs [23]. Among these methods, pre-differentiating ESCs into target cells prior to transplantation is a favorable way. hESCs are normally taken as a source of different cells in vitro. hESCs derivates, such as hESCs-derived oligodendrocytes, hESCs-derived dopaminergic neurons, have shown their therapeutic effects in animal studies for treating neurological disorders [24][25]. Although several animal studies transplanting hESCs for neurological disorders (such as SCI [26]) have shown some therapeutic effects, hESCs are normally considered unlikely to be directly grafted for cell therapy. Remarkably, however, Geeta Shroff has transplanted hESCs via a similar cell delivery method into patients with Lyme disease, multiple sclerosis, spinal cord injury, stroke, or cerebral palsy, and has proved the effectiveness and safety of the cells (see Table 2), with some ethical concerns [27][28]. Moreover, it has been claimed that these hESCs prepared at their institute are unlikely to cause immune rejection even without immunosuppressants as they were harvested at the very initial stage of blastocyst when the genesis was not activated [7]. To summarize, hESCs are more used as a source of other transplantable cells rather than a direct transplantation candidate in cell therapy studies. However, a certain line of hESCs may become a suitable candidate for cell therapy for neurological disorders if the critical issues can be overcome in the future.
Table 2. Examples of hESC transplantation for neurological disorders in clinical trials (data from PubMed).
Disease Route of
Administration		 Cell Source Cell Amount Number of
Patients		 Longest Follow-Up Time (after 1st Transplantation) Outcome/Conclusion Ref.
Lyme disease Intramuscular, intravenous, and other supplemental routes Human embryo N/A 59 8 weeks 43 patients showed significant improvement, 12 patients showed moderate improvement, 4 patients exhibited mild improvement in their brain perfusion; no deterioration was found [29]
Lyme disease and multiple sclerosis Intramuscular, intravenous, and other supplemental routes Human embryo N/A 2 N/A Patients showed remarkable neurological functional and histological improvement; no adverse events were reported [30]
Spinal cord injury Intramuscular, intravenous, and other supplemental routes Human embryo hundreds of millions of cells in total 5 5 years All patients showed neurological functional improvement, 3/5 showed improved American Spinal Injury Association score (ASIA); no adverse events were reported [31]
Spinal cord injury Intramuscular, intravenous, and other supplemental routes Human embryo hundreds of millions of cells in total 226 N/A 70% of patients improved by at least one ASIA grade after 3 phases of treatment; no adverse events were reported [32]
Stroke Intramuscular, intravenous, and other supplemental routes Human embryo hundreds of millions of cells in total 24 N/A A large population of patients saw significant improvement regarding Nutech Functional Score and European Stroke Scale; no adverse events were reported [33]
Multiplesclerosis Intramuscular, intravenous, and other supplemental routes Human embryo hundreds of millions of cells in total 24 Around 1 year Patients showed an improvement in parameters associated with MS when evaluated with reverse nutech functional score but not with the expanded disability status scale; no adverse events were reported [27]
Cerebral palsy Intramuscular, intravenous, and other supplemental routes Human embryo hundreds of millions of cells in total 91 N/A Most patients showed significant improvement in Gross Motor Function Classification Scores Expanded and Revised (GMFCS-E & R) [34]

3.2. Induced Pluripotent Stem Cells (iPSCs)

The first human iPSCs (hiPSCs) line was generated by Takahashi et al. [35] after they introduced four factors (Oct3/4, Sox2, Klf4, and c-Myc) into human fibroblasts. hiPSCs share similarities with hESCs in many aspects such as proliferation, morphology, gene expression, and differentiation. This iPSCs technique (also called cell reprogramming) provides an opportunity to generate any type of patient-specific cells from other obtainable cells, such as fibroblasts or urine cells. Therefore, there are no ethical issues from hiPSCs. Moreover, autologous cells transplantation from patients themselves has no risk of immune rejection and no need to use immunosuppressants. However, there is still the risk of tumor formation [21]. iPSCs are classically generated by the integration of transcription factors with a viral vector, which may cause tumorigenesis and/or unpredictable mutagenesis in the genome. hiPSCs generated by non-integration methods, such as mRNA [36], plasmid [37], small molecules [38], are safer candidates for transplantation, although they are normally with comparatively low reprogramming efficiency [39].
To date, although several animal studies grafting hiPSCs have shown their therapeutic effects for neurological disorders, such as stroke and SCI [5][40] (see Table S1), similar to hESCs, hiPSCs are also usually taken as a source of other transplantable cells in vitro. Pre-differentiated hiPSCs, including hiPSCs-derived NSPCs, hiPSCs-derived neurons and hiPSCs-derived MSCs have been shown effective for neurological disorders [41][42][43]. Especially, several clinical trials based on hiPSCs derivates have been launched for the treatment of PD and SCI [44][45], and thus have deeply encouraged the use of hiPSCs in treating neurological disorders. However, it is noteworthy that hiPSCs-derived NSPCs may still have the potential to generate tumors [46]. The safety issues, including tumorigenicity and aberrant reprogramming of the cells, need to be clearly addressed before their clinical application.

3.3. Neural Stem/Progenitor Cells (NSPCs)

NSPCs are multipotent cells that can self-renew and generate the main types of cells making up the central nervous system (CNS), including neurons, oligodendrocytes, and astrocytes. NSPCs have a lower risk of tumor formation compared to ESCs and iPSCs as they are more specialized cells and have less self-renewing ability. Therefore, human NSPCs (hNSPCs) are considered a favorable candidate for treating neurological disorders. Although it has been shown that a subset of NSPCs is present in highly restricted regions during adult life, their proliferation declines with aging [47][48], and it is nearly impossible to isolate autologous hNSPCs for cell therapy. The common sources of hNSPCs for research are human fetuses, hESCs, hiPSCs, or hMSCs. Like hESCs, hNSPCs directly isolated from embryos or differentiated from hESCs also have ethical concerns and may cause immune rejection, and hNSPCs from hiPSCs may have the same issues as hiPSCs as mentioned above. hNSPCs can also be obtained by trans-differentiation from hMSCs under specific experimental conditions [49]. In addition, hMSCs-derived hNSPCs are normally preferred in clinical studies as they normally have fewer issues than those from hESCs or hiPSCs. However, it is still important to generate a stable, efficient, and standardized protocol to convert hMSCs to hNSPCs and study the similarity between hMSCs-derived hNSPCs and bona fide hNSPCs.
Currently, hundreds of animal studies have used hNSPCs for treating various neurological disorders, including stroke, SCI, TBI, PD, HD (see Table S2), which are far more than hESCs or hiPSCs transplantation studies. Moreover, their effectiveness has been proved and reported better than human MSCs in some conditions [50][51]. The grafted hNSPCs can not only differentiate into neurons and glia cells and establish a graft-host connection [52][53] but also produce trophic factors and modulate lesion microenvironment to improve behavior recovery [54][55]. Intriguingly, even the injection of hNSPCs secretome alone has been reported to support the functional recovery of 6-hydroxydopamine (6-OHDA) PD rats [56]. Many methods have been applied to enhance the therapeutic effects of hNSPCs, such as genetically modified hNSPCs by overexpressing a selected trophic factor. Brain-derived neurotrophic factor (BDNF)-overexpressing hNSPCs, glial cell line-derived neurotrophic factor (GDNF)-overexpressing hNSPCs, and insulin-like growth factor 1 (IGF-1)-overexpressing hNSPCs have all been shown significant therapeutic effects on neurological disorders [57][58][59]. In addition, pre-treating hNSPCs with a gamma-secretase inhibitor [60], metformin [61] or tumor necrosis factor α (TNFα) [62], co-transplantation of hNSPCs with MSCs [63] or using biomaterial scaffolds as a carrier for hNSPCs [64][65] have also been reported to improve their therapeutic potential for neurological diseases. However, it is worth noting that the subtype of hNSPCs may also influence their therapeutic effects for a specific disease. For example, the human fetal spinal cord-derived NSPCs or spinal cord-type NSPCs from hiPSCs have been shown to improve motor functions after SCI, but not human fetal brain-derived NSPCs or forebrain-type NSPCs from hiPSCs [64][66].
To date, some clinical studies have been accomplished, and a few have shown beneficial outcomes after hNSPCs transplantation for neurological disorders (see Table 3). For allogeneic transplantation, focusing on specific hNSPC lines may help to keep the consistency of the outcomes from bench to beside. Several clinical-grade hNSPC lines have been applied in clinical trials, including NSI-566. NSI-566 cell line has been shown to be safe and potential effective in ALS patients [67][68] and now is in a phase 3 trial for treating ALS. Moreover, the NSI-566 cell line has also been reported to significantly improve the behavioral and histological recovery of ischemic stroke patients [69]. On the other hand, hNSPCs from autologous MSCs are a preferred candidate for clinical therapies of neurological disorders and have been applied for treating cerebral palsy, MS and TBI, in clinical trials [70][71][72][73]. However, most of the trials are in phase 1 or 2 stages, which have proved the safety but not the statistical therapeutic effects of the cells. Further studies need to be performed to better understand the therapeutic effects of the cells for neurological disorders.
Table 3. Examples of hNSPC transplantation for neurological disorders in clinical trials (data from PubMed).
Disease (Model) Route of Administration Cell Source Cell Amount Number of Patients Longest Follow-Up Time (after 1st Transplantation) Outcome/Conclusion Ref.
Ischemic stroke Intracerebral Human fetal spinal cord, cell line: NSI-566 1.2 × 107, 2.4 × 107, or 7.2 × 107 9 24 months All patients showed significant behavioral and histological improvements [69]
ALS Intraspinal Human fetal brain 2.25–4.6 × 106 18 51 months No serious adverse effects. Some patients showed temporary subjective clinical improvement [74]
ALS Intraspinal Human spinal cord 2 to 16 million 15 9 months Intraspinal transplantation of human spinal cord-derived neural stem cells can be safely accomplished at high doses [75]
ALS Intraspinal Human fetal spinal cord, cell line: NSI-566RSC 1.5 million 15 30 months This NSPCs line can be safely transplanted into both lumbar and/or cervical human spinal cord segments [67]
moderate PD Intracerebral Human fetal brain 2 million 7 4 years No adverse effects; enhanced midbrain dopaminergic activity; minor neuropsychological changes; 6/7 showed improved motor function; 5/7 showed better response to medication [76]
Chronic cervical SCI Intraspinal Cells were prepared and released by StemCells Inc. 15 to 40 million 16 1 year Cell transplantation was safe, feasible, and well tolerated.Trends toward improvement in motor function and spasticity were seen [77]
completethoracic SCI Intraspinal Human fetal spinal cord, cell line: NSI-566 N/A 4 27 months No serious adverse events; 3/4 showed early signs of potential efficacy [68]
Chronic cervical and thoracic SCI Intraspinal Human fetal brain, cell line: HuCNS-SC 20 to 40 million 29 1 year Cell transplantation was safe and feasible using a manual injection technique [78]
Traumatic cervical SCI Intraspinal Human fetal telencephalon 1 × 108 34 1 year No serious adverse effects, 5/19 of treated patients showed functional recovery, 1/15 untreated patients showed functional recovery [79]
MS Intrathecal Autologous MSCs 3 × 107 20 Around 1 year No serious adverse effects, improved median Expanded Disability Status Scale (EDSS), 70% and 50% of the subjects demonstrated improved muscle strength and bladder function, respectively [73]
MS Intrathecal Autologous bone marrow MSCs 0.08–17.6 million 6 8.9 years No serious adverse events; 4/6 showed a measurable clinical improvement [71]
non-acute severe TBI Intravenous or intrathecal Autologous MSCs 20 to 40 million 10 6 months No serious adverse events, 7/10 patients presented different degrees of improvement in neurological function [72]
Cerebral palsy subarachnoid cavity Autologous bone marrow MSCs 1–2 × 107 60 6 months No serious adverse events. Treated group showed significant motor function recovery but no significant increases in the language quotients [70]
Induced neural stem/progenitor cells (iNSPCs), such as iPSCs, are generated from other types of somatic cells (such as fibroblasts or urine cells) but bypass the pluripotency stage. Generation of hiNSPCs is an attractive field and is more favorable than hiPSCs in treating neural diseases, as they are easier to differentiate into terminal neural cells and less tumorigenic. Currently, many hiNSPC lines have been generated through different methods [80][81], and several lines have been tested in animal disease models, such as SCI, glioblastoma, and stoke and have shown their significant therapeutic effects [82][83][84][85]. However, the safety and therapeutic potential of hiNSPC are highly related to the induction protocol and need to be further studied. Therefore, it is essential to establish a safe, stable, and efficient protocol to generate hiNSPC for cell therapy studies.

3.4. Neurons, Oligodendrocytes, and Astrocytes

Neurons, oligodendrocytes, and astrocytes are three main cell types that form the CNS and originate from a common lineage of hNSPCs during development. These cells are terminal cells from NSPCs differentiation and can also be obtained from human embryos, hESCs, hiPSCs, or hMSCs in cell therapy studies. Transplantation of these pre-differentiated cells can avoid unexpected or unwanted differentiation or tumor formation of stem cells in vivo, especially in neurological disorders that are associated with the loss or dysfunction of specific types of neural cells, such as transplantation of dopaminergic neurons or dopaminergic progenitors for PD. It has been reported that pre-differentiated GABAergic neurons from hNSPCs have shown greater repopulation of the damaged brain and better neurogenic activity and functional recovery than hNSPCs in a stroke model after transplantation, while hNSPCs have predominantly differentiated into astrocytes [86].
Because neurons are the main functional cells in the nervous system, they are usually more attractive than glia cells for regenerative medicine in neuroscience research. Studies have transplanted neurons or neuron progenitors into different disease models and have shown their therapeutic outcomes (see Table S3). However, it is believed that more mature/differentiated donor cells have less survival capacity after transplantation [87][88][89]. Therefore, for a specific neuron type transplantation (for example, dopaminergic neurons), an immature stage of the cells may lead to better outcomes than mature cells or progenitors [89][90][91]. In addition, as the pre-differentiated cells have less proliferation capacity, they may need more cells for transplantation to reach a therapeutic level. Remarkably, several clinical trials transplanting neurons or neuron-contained tissue have proved the survival and potential therapeutic effects in patients (see Table 4). Moreover, direct reprogramming of human neurons from other somatic cells may also provide a suitable source of therapeutic neurons for cell therapies [92][93].
Table 4. Examples of neuron transplantation for neurological disorders in clinical trials (data from PubMed).
Cell Type Disease (Model) Route of Administration Cell Source Cell Amount Number of Patients Longest Follow-Up Time (after 1st Transplantation) Outcome/Conclusion Ref.
sympathetic neurons PD Intracerebral Autologous sympathetic neurons N/A 4 36 months, Clinical evaluations showed that an increase in the duration of levodopa-induced ‘‘on’’ phase, and the percent time spent in ‘‘off’’ phase exhibited a 30–40% reduction as compared to the pre-grafting values [94]
Dopamine neuron-contained tissue PD Intracerebral Human embryonic mesencephalic tissue N/A 40 1 year human embryonic dopamine neuron transplants survive in patients with severe Parkinson’s disease and result in some clinical benefit in younger but not in older patients [95]
neuronal cells Stroke Intracerebral Human teratocarcinoma N/A 12 18 months No adverse cell-related serologic or imaging-defined effects. The total European Stroke Scale score improved in six patients (3 to 10 points), with a mean improvement of 2.9 points in all patients [96]
Oligodendrocytes and astrocytes are glia cells that are thought of as supportive and protective cells in the nervous system. A recent study has shown that the conditioned medium from hiPSCs-derived glial progenitor cells could result in better therapeutic effects than that from hiPSCs-derived neuronal progenitor cells and show a higher content of neurotrophins, indicating their potentials for cell therapy [97]. The main function of oligodendrocytes is to form myelin sheaths to support and insulate axons. Therefore, oligodendrocytes are highly related to diseases involving demyelination, such as MS and ALS. It has been suggested that transplantation of human oligodendrocyte precursor cells (hOPCs) could result in notable therapeutic outcomes in animals with MS or SCI [98][99][100], whereas transplantation of mature oligodendrocytes has failed to remyelinate naked axons in SCI [101][102]. Therefore, transplantation of hOPCs may be a potential therapy for demyelinating diseases. On the other hand, astrocytes are the most numerous cell type in the brain, playing various functions, including maintaining homeostasis, providing neurotrophic support, and connecting neurons with the bloodstream [103]. The loss or dysfunction of astrocytes is related to many neurological disorders, such as stroke, epilepsy, and MS [104]. Moreover, the astrocyte-formed glial scars are a reason that prevents neuroregeneration after CNS injury [105]. However, a study has also reported functional recovery after grafting hiPSCs-derived astrocytes with overexpressing the major glutamate transporter, GLT1, in an SCI model, suggesting their pro-regenerative function [106]. Notably, it is reported that the therapeutic effects of astrocytes are highly related to the subtypes of the cells. Stephen et al. found that astrocytes generated from human glial precursor cells by exposure to bone morphogenetic protein could promote significant functional recovery after SCI, whereas astrocytes generated by exposing the cells to ciliary neurotrophic factor failed to generate similar results [107]. Overall, the number of transplantation studies targeting oligodendrocytes or astrocytes is much lower than neuron-based studies. However, with better understanding of their functions in CNS, and more accessible sources of human oligodendrocytes or astrocytes (e.g., from hiPSCs), transplantation of oligodendrocytes or astrocytes may be a promising approach for treating specific neurological disorders.

3.5. Mesenchymal Stromal/Stem Cells (MSCs)

MSCs are multipotent cells that can differentiate into various cell types, including bone cells, muscle cells. In addition, it has been reported that MSCs can be transdifferentiated into neural cells under specific conditions, indicating the potential of MSCs for treating neurological diseases [49][108]. Human MSCs (hMSCs) can be easily obtained from many sources, among which the most studied hMSCs are those from bone marrow, umbilical cord, and adipose tissue. Although the detailed differences in their biological characteristics from different sources, the easy acquisition and the common properties, such as the capacity of self-renewing, multi-lineage differentiation, low tumorigenicity, low immunogenicity, and immunoregulatory function, have made hMSCs a promising candidate for cell therapy. Moreover, as mentioned above, hMSCs can also be a source of transplantable neural cells in vitro in models of neurological disorders.
Due to these advantages, hMSCs are currently one of the favorite cell types in cell therapy studies involving treating neurological diseases. Hundreds of animal studies have proved their safety and therapeutic effects for various neurological disorders (see Table S4). Moreover, even hMSC-conditioned medium or hMSCs-derived exosomes have been shown to alleviate the symptoms of experimental stroke or SCI [109][110]. Notably, although it has been reported that hMSCs can differentiate into neural cells in the injured area after transplantation [111][112], other researchers have also found that hMSCs could result in significant functional recovery without neural differentiation or even when hMSC is cleared away at the end of the experiment, suggesting that the main mechanisms of their beneficial functions are neurogenesis and angiogenesis promotion, anti-apoptosis, anti-inflammation, and immunomodulation rather than cell replacement [113][114][115][116][117]. Furthermore, studies have demonstrated that hMSCs can cross the blood-brain barrier (BBB) and home to the injured site through intravenous administration, which is a more suitable route for clinical use compared to direct local delivery to the affected tissue [118][119]. However, it is noteworthy that negative outcomes from hMSCs transplantation have also been shown in several studies, suggesting that administration of hMSCs alone may not be enough to generate significant therapeutic outcomes in some cases [120][121]. Therefore, several methods have been used to improve their therapeutic functions, such as pre-treatment [122], genetic modification [123], co-transplantation with hNSPCs [63], combined with other treatments [124], and using biomaterial scaffolds as a carrier [125]. Interestingly, the therapeutic effects of hMSCs may also be related to the source of the cells or the age of the donor. Jumpei et al. have reported that human cranial bone-derived MSCs could result in significant functional recovery in a rat model of stroke, but not human iliac bone-derived MSCs [126]. Susumu et al. have reported that transplantation of hMSCs from young donors could provide better functional recovery through multiple mechanisms than old hMSCs [127].
To date, many clinical trials using umbilical cord-derived MSCs (UC-MSCs) or autologous bone marrow (BM-MSCs) or adipose-derived MSCs (hADSCs) for treating various neurological disorders have been conducted and published (see Table 5). However, most of the studies have only demonstrated the safety hMSCs administration. Although the therapeutic effects have been seen in many clinical trials, the number of patients in each trial is usually not sufficient for analyzing the efficacy. Therefore, it is necessary to take hMSCs to the next step using more patients and proper controls to study their therapeutic effects and the mode of action in specific neurological disorders.
Table 5. Examples of hMSCs transplantation for neurological disorders in clinical trials (data from PubMed).
Disease (Model) Route of Administration Cell Source Cell Amount Number of Patients Longest Follow-Up Time (after 1st Transplantation) Outcome/Conclusion Ref.
Cerebellar ataxia Intrathecal Bone marrow, (cell line: CS20BR08) 2 × 106/kg 1 10 months No adverse events reported. Improved K-SARA (Korean version of the Scale for the Assessment and Rating of Ataxia) scores [128]
ALS Intrathecal Autologous bone marrow 30 × 106 8 14 months No change in progression rate in patients with an inherently slow course, but some decreased progression rate in patients with an inherently rapid course [129]
SCI Intrathecal Umbilical cord 4 × 106/kg 143 12 months No serious adverse events reported. Significant improvements in neurological dysfunction and recovery of quality of life [130]
Acute complete SCI Intraspinal Umbilical cord 40 million 40 12 months Promoted recovery of neurological function [131]
Chronic SCI Intradural and intravenous Autologous bone marrow 6.6–7.6 × 107 1 5 years No complication or serious adverse effects, improved motoric function [132]
Acute complete SCI Intraspinal Umbilical cord 4 × 107 2 1 year No obvious adverse symptoms reported, the supraspinal control of movements below the injury was regained by functional NeuroRegen scaffolds implantation with hMSCs [133]
SCI Intrathecal Autologous adipose 9 × 107 14 8 months No serious adverse events. Several patients showed mild improvements in neurological function [134]
Cerebral palsy Intravenous Umbilical cord 4.5–5.5 × 107 39 13 months hMSCs transplantation was safe and effective at improving the gross motor and comprehensive function of children with cerebral palsy when combined with rehabilitation [135]
Cerebral palsy Intrathecal and intravenous Umbilical cord 8 × 106/kg 1 18 months No serious adverse effects reported. hMSCs transplantation improved functional recovery, combined with rehabilitation [136]
Cerebral palsy Intravenous Umbilical cord 80 × 107 1 5 years hMSCs transplantation with basic rehabilitation improved the motor and comprehensive function. No serious adverse events [137]
TBI Intrathecal, intramuscular, and intravenous Wharton’s jelly 18 × l06 /kg 1 12 months No important negative effects were reported. The patients’ speech, cognitive, memory, and fine motor skills were improved [138]
Chronic ischemic stroke Intracerebral Bone marrow, cell line: SB623 2.5–10 × 106 18 24 months All experienced at least 1 treatment-emergent adverse event. 7 experienced 9 serious adverse events, which resolved without sequelae. Improved clinical outcomes [139]
Chronic stroke Intravenous Autologous bone marrow 5.3 × 105–2.9 × 106/kg 9 60 weeks No adverse event reported. Improved neurological functions and clinical outcomes [140]
Stroke Intravenous Autologous bone marrow 0.6 to1.6 × 108 12 12 months No significant adverse effects were found. Improved neurological function [141]
HIE Intrathecal, intramuscular, and intravenous Wharton’s jelly 12 × 106/kg 1 12 months Improved neurological recovery [142]
HIE Intravenous Umbilical cord 1 × 108 22 180 days No significant adverse effects were found. Markedly improved recovery of neurological function, cognition ability, emotional reaction, and extrapyramidal function [143]
MS Intravenous Umbilical cord 14 × 107 20 1 year No serious adverse events reported. Improved functional recovery [144]
MS Intravenous Autologous bone marrow 1–2 × 106/kg 24 6 months No serious adverse effects reported. No substantial evidence of inhibition of disease activity, tissue repair, or recovery of function [145]
MS Intravenous Umbilical cord 12 × 106/kg 23 12 months No significant adverse effects were found. Improved neurological function [119]
Drug-resistant epilepsy Intrathecal Autologous bone marrow 7.4–16 × 107 4 2 years CD271+ hMSCs, combined with autologous bone marrow nucleated cells transplantation, showed no serious adverse events but considerable neurological and cognitive improvement [146]
PD Intracerebral Autologous bone marrow N/A 7 36 months No significant adverse effects were found. Several patients showed improved neurological function [147]

3.6. Dental Pulp Stem Cells (DPSCs) and Stem Cells from Human Exfoliated Deciduous Teeth (SHED)

DPSCs and SHED are derived from the dental pulp of adult permanent teeth and baby deciduous teeth, respectively. They are ectoderm-derived stem cells originating from neural crest cells and possess similar characteristics as MSCs, including the capacity of self-renew and multi-lineage differentiation and expression of MSC-related markers. However, it is still controversial to define DPSCs and SHED as MSCs, mainly due to their different potency of differentiating into specific lineages [148]. Because of their easy accessibility by routine dental procedures and their MSC-like properties, DPSCs and SHED have gained more attention in the last decade in the field of regenerative medicine, including treating neurological diseases. Moreover, they can maintain their stemness and multipotency for many years by cryopreservation, therefore, providing an opportunity for cell banking [149][150].
Remarkably, it has been reported that, compared to BM-MSCs or hADSCs, DPSCs have a higher growth rate, stronger neurogenesis, and better neuro-supportive and neuro-protective properties in neurological injuries and pathologies [148], indicating they may have better therapeutic effects for neurological disorders. DPSCs have been used to treat many neurological disorders in animal studies and have led to significant beneficial outcomes (see Table S5), mainly through the secretion of neurotrophic factors and anti-inflammatory functions [151]. It has been reported that the expression of neurotrophic factors in DPSCs is higher than that of hADSCs and BM-MSCs [152]. The conditioned medium from DPSCs can also improve several neuropathological conditions, including ALS [151][153]. On the other hand, the therapeutic effects of SHED for neurological disorders have also been studied in some animal studies, which have shown improved results (see Table S5). It is suggested that SHED are in a more immature state than DPSCs with higher expression of pluripotent markers and a higher proliferation rate, while DPSCs show higher expression of neuroectodermal markers [154][155]. Similarly, the conditioned medium of SHED has also been proved to be therapeutic for animal model of stroke, PD, and TBI etc [156][157][158].
Overall, DPSCs and SHED are also promising candidates for treating neurological disorders and may be beyond hADSCs and BM-MSCs. However, due to the limited volume of the pulp tissue, it usually takes months to obtain enough cells for therapy from the primary isolation, although they have a high proliferation rate [148]. Moreover, the heterogeneity of DPSCs and SHED may affect their therapeutic potentials [159][160]. Moreover, most of the available evidence of their therapeutic function for neurological disorders was acquired using nonhuman xenotransplants. It is still a long way to study their therapeutic and side effects in humans.

3.7. Muse Cells

Muse cells (multilineage-differentiating stress enduring cells) are non-cancerous pluripotent stem cells that were first discovered by Yasumasa et al. in 2010 [161]. Muse cells are sporadically present in the connective tissue of nearly all organs, such as bone marrow and umbilical cord, and can even be collected from commercial cell lines, including human fibroblasts and bone marrow MSCs [161][162][163]. Interestingly, it has been reported that Muse cells are the primary source of hiPSCs in human fibroblasts, but not the non-Muse cells [164][165]. Moreover, as Muse cells are present in cultured MSCs, it is thought that Muse cells are more therapeutic in clinical MSCs therapies regarding tissue regeneration [166]. The characteristics of Muse cells, including non-tumorigenicity, pluripotency, and easy collection, have made Muse cells a promising candidate for cell therapy.
Several animal studies have shown the safety and effectiveness of human Muse cells for treating neurological disorders, such as stroke, intracerebral hemorrhage, encephalopathy, ALS, and SCI (see Table S6). Moreover, Muse cells can engraft and integrate into the damaged regions and differentiate into neuronal cells, and finally, lead to functional and morphological recovery after intravenous administration [167][168][169][170]. However, Muse cells are still a novel type of stem cells that have not been well studied as other stem cells. With more related studies, we will obtain a better understanding of Muse cells and their potentials for treating neurological disorders.

3.8. Olfactory Ensheathing Cells (OECs)

OECs, also known as olfactory ensheathing glia, are terminally differentiated and self-renewable cells that are found in both the peripheral nervous system (PNS) and CNS, supporting the regeneration of the olfactory system throughout life. OECs can be isolated from the olfactory bulb (OB-OECs) through intracranial surgery or from olfactory mucosa (OM-OECs) through a simple, non-invasive nasal biopsy, which is preferred for autologous transplantation. Based on these properties, human OECs (hOECs) are considered a suitable candidate for CNS transplantation, particularly for SCI treatment. Numerous animal studies have shown that hOECs could promote the recovery from SCI through various mechanisms, including neuroprotection, promoting axonal growth/sprouting, improving angiogenesis, and restriction of glial scar [171][172]. Notably, OECs from different sites may act through different mechanisms. It has been reported that OM-OECs could regulate extracellular matrix and improve angiogenesis, while OB-OECs intend to improve axonal regeneration [172]. In addition to the animal studies, hOECs have also been used in clinical trials for SCI since the early 2000s (see Table 6). Although with a relatively small size of patients and variable outcomes in different patients, hOECs transplantation has led to different levels of functional recovery in most cases, indicating their therapeutic roles for SCI. Moreover, hOECs have also been used for treating ALS and cerebral palsy patients and have resulted in functional improvements, suggesting their therapeutic potentials are not only for SCI but also for other neurological disorders [173][174].
Table 6. Examples of OECs transplantation for neurological disorders in clinical trials (data from PubMed).
Disease Route of Administration Cell Source Cell Amount Number of Patients Longest Follow-Up Time (after 1st Transplantation) Outcome/Conclusion (Targeting Behavioral and Histological Change) Ref.
SCI Intraspinal Autologous olfactory bulb 5 × 105 1 19 months Improved neurological and histopathological recovery, no adverse effects were seen [175]
SCI Intraspinal Human fetal olfactory bulbs 1 × 106 7 6 months No serious adverse effects were seen. All treated patients showed functional improvement, 4/5 showed improvement in electrophysiological tests [176]
SCI Intraspinal Human fetal olfactory bulbs 2–5 × 106 15 8 weeks No serious adverse effects were seen. 12/15 showed obvious spinal function improvement, and 3/15 had slight improvement [177]
SCI Intraspinal Autologous nasal mucosa 1.8–21.2 × 106 6 1 year no adverse findings related to olfactory mucosa biopsy or transplantation. All treated patients showed improved functional recovery, 2/3 of treated patients showed improved American Spinal Injury Association class [178]
SCI Intraspinal Human fetal olfactory bulbs 2 × 106 6 24 months No clinical complications were observed. All patients showed improved neurofunctional recovery [179]
SCI Intraspinal Autologous olfactory mucosa Not mentioned 8 24 months No clinical complications were observed. All patients showed improved neurofunctional recovery, 3/8 showed returned substantial sensation and motor activity in various muscles, 2/8 showed restored bladder function [180]
SCI Intraspinal Human fetal olfactory bulbs 5 × 105 11 1.5 years All patients had no complications or deterioration of neurological conditions. Sensation and spasticity improved moderately. Locomotion recovery was minimal [181]
SCI Intraspinal olfactory bulbs 5 × 105 108 5.3 years No serious adverse effects were seen. Improve neurological functions. Sufficient rehabilitation most likely played a critical role [182]
SCI Intraspinal olfactory bulbs 5 × 105 171 12 weeks OECs transplantation can improve the neurological function of spinal cord of SCI patients regardless of their ages [183]
ALS Intracranial and/or intraspinal Human fetal olfactory bulbs 1–2 × 106/treatment, 1–5 treatments 507 N/A multiple doses of cellular therapy serve a positive role in the treatment of ALS [173]
Cerebral palsy Intracranial Human fetal olfactory bulbs 2 × 106 14 6 months OECs transplantation is effective for functional improvement in children and adolescents with cerebral palsy, yet without obvious side effects [174]
However, several bottlenecks are impeding the therapeutic effects of hOECs. hOECs isolated from the olfactory bulb or olfactory mucosa usually contain contamination cells such as fibroblasts that may affect their effects and need to be purified [184][178][176]. Moreover, the difficulty to quickly expand, poor survival after suspension injection, limited migration, and phagocytosis are also considered the major hampers of hOECs treatments [184]. Although various methods have been used to optimize OECs transplantation, it is still far from being a mature treatment for neurological disorders, including SCI [184].

3.9. Hematopoietic Stem Cells (HSCs)

HSCs are multipotent cells that generate all types of blood cells and can be found in peripheral blood, bone marrow (which provides an opportunity for autologous transplantation), and umbilical cord blood. Human HSCs (hHSCs) are one of the earliest cell types that have been used for clinical transplantation for the treatment of certain cancerous diseases, with acceptable safety [185]. Due to their ability to generate new blood and immune cells, hHSCs, especially autologous hHSCs, have also been used to treat autoimmune diseases of the nervous system, including MS, in the last two decades [186]. Currently, thousands of MS patients have been treated with autologous hHSCs, and many of them have shown significant therapeutic outcomes. However, in comparison to other stem cells, hHSCs only work as a supportive blood product following chemotherapy to speed hematopoietic recovery rather than a single treatment for these diseases. Actually, “autologous hematopoietic stem cell transplantation (AHSCT)” has become a clinical term that contains several procedures, including (1) mobilization—releasing hHSCs from the bone marrow into peripheral blood, (2) harvesting—collecting hHSCs from the blood of the patient, (3) conditioning regimen—administration of cytotoxic chemotherapy, and (4) infusion—returning hHSCs to the patient by infusion into the veins. Overall, with more clinical experience, AHSCT has become a promising supportive strategy for treating MS. The current status of using AHSCT for MS is well reviewed in a published paper [187].

This entry is adapted from the peer-reviewed paper 10.3390/biology10111142

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