Source Journal of Neurological Disorders and Therapies

Review

Neural Tissue Engineering: Combating Alzheimer’s disease

Luke C. Gordon1,2*

Received Date: 01-05-2018,

Alzheimer’s disease is the most common neurodegenerative disorder, with prevalence accumulating
alarmingly. An effective disease modifying therapy remains elusive, as current clinical treatments
Accepted Date: 22-05-2018
only deliver minimal, symptomatic relief whilst cellular death continues unperturbed. Pathologically,
Published Date: 04-06-2018
Alzheimer’s disease is characterized by extracellular amyloidal proteins and intracellular
Editor: R M Damian Holsinger neurofibrillary tangles. However, the intricacies of the neuropathological mechanisms are not
http://sourcejournals.com/ explicitly defined. The collective absence of understanding regarding disease progression is the
probable reason for the lack of preventative measures or effective treatments. Tissue engineering
solutions show promise in the mitigation of Alzheimer’s disease utilizing a myriad of experimental
techniques that are not centric around the pathophysiology of the disease, but rather the regeneration
of neuronal tissue to improve functionality. As disease mechanisms are still unconfirmed with
oppositional theories still dominating literature, tissue engineering solutions are hugely diverse in
regard to their targets of treatment, modality of delivery and time of intervention. This review will
aim to investigate the current landscape of putative tissue engineering solutions, evaluate the efficacy
of present symptomatic treatments, and propose challenges obstructing future applications specific
to clinical translation in Alzheimer’s disease.
Keywords: Alzheimer’s disease, tissue engineering, neurodegeneration, stem cells, scaffol
Anatomy and Pathophysiology of Alzheimer’s
disease Aβ is a peptide of 40 or 42 amino acids resultant from
systematic cleavage of amyloid precursor protein (APP)
The central nervous system (CNS) comprises of the by β- and γ-secretases. Monomeric amyloid present
brain and spinal cord, which are actively protected by during brain development is considered as
the blood-brain barrier (BBB) from a multitude of neuroprotective due to its quantifiable presence in brain
biomolecules [1]. Neural tissue consists of and cerebral spinal fluid (CSF) samples of healthy
predominantly two cell types: neural and glial cells, each populations, and the alleged supportive role it has in
with their own complex generative processes [2]. neuronal development [6]. Rather, it is hypothesized that
Neurons are the fundamental unit in the brain’s electrical an oligomeric derivate of amyloid is the neurotoxic
circuitry, capable of transmitting sensory and motor form6. Aβ accumulates predominantly in the
signals responsible for the detection of external stimuli hippocampus and entorhinal cortex [7] to form
and generation of movement in muscular entities oligomers and dense core plaques that are collectively
respectively. Neuronal cell bodies and glia are synaptotoxic to neuronal transmissions [8]. These
susceptible to a myriad of neurodegenerative conditions depositions of Aβ constituents are hypothesized to halter
capable of unsettling brain architecture and eliciting action potentials in regions primarily responsible for
subsequent abnormal functionality [3]. memory consolidation [8,9], development [9], learning
[8,9], and deterrence of synaptic plasticity [9,10]. Thus,
Aβ accumulation can be accredited with provoking
The most common neurodegenerative condition is symptomatic hallmarks including short-term memory
Alzheimer’s disease (AD) [4]. Clinically, AD symptoms loss, difficulty with language, disorientation, mood
arise from the loss of cholinergic neurons resulting in swings, loss of motivation, inability to manage self-care
progressive cognitive deterioration [2]. Histologically, and societal withdrawal which are analogous with these
AD is characterized by the deposition of amyloid beta brain centres [9]. These symptoms can accelerate with
(Aβ) plaques and tau-immunoreactive neurofibrillary progression of the disease leaving patients completely
tangles (NFT), which concurrently shape diagnostic dependent [9].
criterion for the continuum that differentiates ‘normal’
aging from AD dementia [5].
Despite amyloid deposition being a well-established
indicator and contributor of AD within literature (i.e.
1
Department of Physiology F13, University of Sydney, “The amyloid cascade hypothesis” [11]), NFT
Sydney, NSW 2006, Australia aggregation has been shown to more tightly dictate the
2
Biomedical Engineering J13, School of Aerospace, degree of dementia impairment in comparison to Aβ
Mechanical and Mechatronic Engineering, The University of [12-14]. NFTs are comprised of hyper-phosphorylated
Sydney, NSW 2006, Australia, E-mail:
lgor3244@uni.sydney.edu.au

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distribution and reproduction in any medium.
forms of the microtubule-associated tau protein. Tau
protein is abundant in CNS neurons as it is primarily
required to modulate stability of axonal microtubules
and thus is considered functionally innate. Deregulation
of modulatory protein kinases and phosphatases leads to
hyperphosphorylation of tau which aggressively
aggregate to form intermediate bodies of paired helical
filaments (PHFs) approximately 10nm in diameter [5].
PHFs will further pair to construct an intracellular
helical tridimensional conformation. The resultant
aggregate will displace the nucleus towards the
periphery of the soma distending the neuron and
eventuating in cellular apoptosis [15]. Once the cell has
perished the extraneuronal “ghost” tangle or NFT is
formed [5]. NFTs are originally reported in the
entorhinal territory of the brain in the case of AD, and
as the disease progresses will undergo a non-random
degenerative pathway throughout the cerebral cortex
and brainstem [16].
To support these two biomolecules as possibly
independent or additive contributors of AD, transgenic
mutations in both APP and tau have been found to
generate dementing illness in animal models [17-19].
The debate presently continues on the primary
biomolecule ensuing AD [20] meaning that great
scepticism should be used when evaluating treatments
that are based on these pathophysiological profiles.
In addition to these primary biomolecules, microvascular
dysfunction has also been linked to neurodegeneration and
AD. Comorbidity of cardiovascular disease (CVD) and AD
has been highlighted suggesting an association between
these two complex age-associated diseases [21,22]. The link
between these two disease states is suggested to be due to
shared risk factors including hypertension [23–25], diabetes
mellitus [26–28], Apolipoprotein E genotype [29,30] and
high cholesterol [31].
While these risk factors are primarily responsible for cardiac
malady, it has been suggested that the resultant CVD from
these factors can lead to impaired Aβ and NFT clearance in
the brain due to reduced cerebral blood flow [32,33]. While
a clear causation relationship between CVD and AD is
absent, evidence is mounting to suggest CVD may play a
dominant role in the generation or propagation of dementia
and AD. Increased Aβ deposits have been found in the brains
of coronary artery disease subjects (75%) while subjects not
suffering from CVD-related disease rarely demonstrated
AD-like Aβ deposits (12%) [34]. Hypoxic events due to
cardiac arrest have additionally been shown to generate time-
dependent elevations in serum Aβ42, with most patients
seeing a 7-fold increase following a 10-hour (h) period as
compared to 1h post-cardiac arrest. The magnitude of
elevation was further shown to correlate with clinical
outcome [32]. The effects of hypoxia from cardiac arrest is
not confined to Aβ, elevations in tau have also been reported
24h following cardiac arrest [35]. The serum tau elevation
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resultant from cardiac arrest has even been demonstrated as
a novel biomarker to predict neurological outcome in
patients [36], the accuracy of which outperforms clinical
information currently collected (age, time to return of
spontaneous circulation and bystander cardiopulmonary
resuscitation) and serum neuron-specific enolase [37], a
novel biomarker currently recommended in multiple
treatment guidelines.
The correlation between CVD and AD-related biomolecule
elevations advocates that cardiac dysfunction may play a
larger role in AD pathogenesis that previous postulated. For
this reason, treatments which improve the vascular faction of
the neurovascular unit (NVU; the intimate anatomical
relationship in the brain between neurons, astrocytes,
myocytes, pericytes, extracellular matrix components and
endothelial cells of the BBB) may improve neurological
outcome in AD patients.
Despite the knowledge regarding potential biomolecules and
microvascular dysfunction that may potentiate AD, the
overall aetiology remains unknown. Despite current
emergent treatments primarily aimed at minimising these
biomolecular depositions, it should be noted there remains a
lack of knowledge regarding the roles of these factors within
the pathological processes of AD.
Current Treatments for Alzheimer’s disease
Protracted life expectancy in recent decades has yielded a
significant escalation in the prevalence of AD, the most
common age-related neurodegenerative disease. The
population is aging alarmingly with figures demonstrating
that the worldwide fraction of individuals >60 years is
projected to rise from 11.7% in 2013 to 21.1% by 2050,
placing an onus on researchers to address age-corelated
dementing illness, such as AD [38]. AD is an affliction
affecting approximately 47 million people worldwide with
an estimated global cost of US$818 billion. Current
projections estimate this number of sufferers will be in
excess of 131 million individuals by 2050 [39]. By the end
of 2018 the financial burden will be in excess 1 trillion [39].
Due to this significantly increasing prevalence rate and
associated cost, a viable intervention to mitigate this terminal
and debilitating disease is critically required. To date, no
clinical treatment exists that has had the ability to
reproducibility halter AD pathology.
The functional consequences of AD are further exacerbated
by the brain’s ineptitude to regenerate neuronal tissue
following chronic neurodegenerative conditions [40]. This is
dissimilar to other bodily systems which are able to self-heal
following injury [40]. Thus, a treatment for AD must include
the capability of stimulating remedial healing. Furthermore,
complex inflammatory responses to AD routinely include
glial scarring, microglial infiltration, astrocyte proliferation
and mobilization of inflammatory cytokines. These
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collectively affect injury endpoints of the disease and vary
patient-to-patient [41,42].
This attenuated neuronal regeneration in conjunction with
glial scarring and an improper inflammatory response limits
the ability of CNS neurons to repopulate during AD and
results in cyclical damage. Current interventions are unable
to halter this degenerative process leading to admission of
AD patients into palliative care with negligible hope of
recovery. This further exacerbates the emotional and
financial toll placed upon patients and family [38]. Current
interventions include Cholinesterase Inhibitors (CI), N-
methyl-D-aspartate antagonists (NMDA-I), combination
therapies, antidepressants and anti-psychotics. These
methods remain symptomatic for the treatment of AD as they
merely attempt to neutralize neurotransmitter disturbances
resultant from the disease, whilst the underlying biochemical
mechanisms ensue [43].
Cholinesterase Inhibitors
Three CIs are currently marketed (donepezil, rivastigmine,
galantamine) which combat the loss of acetylcholine (ACh)
neurons of the basal forebrain. This disease hallmark occurs
relatively early in the progression of AD and results in a
deficiency of enzymatic function expediting memory loss
and deterioration of cognitive faculties [44].
Ordinarily ACh is released from presynaptic neuronal
terminals, into the synaptic cleft and binds to post-synaptic
muscarinic and nicotinic receptors. However,
Acetylcholinesterases (AChE) present on the post-synaptic
neuron are responsible for modulation of ACh levels and
actively terminate signal transduction of ACh via hydrolysis.
A choline molecule resultant from this process is then
recycled into the pre-synaptic neuron and ACh is regenerated
via combination with acetyl-CoA due to the efforts of
choline acetyltransferase [45].
The majority of CIs will bind irreversibly to AChE,
immobilizing and preventing its binding to post-synaptic
receptors [45]. Some clinically marketed irreversible CIs
(including Trichlorfon) are also available, but this class of
pharmaceutical is associated with increased toxicity risk
[45]. CIs reduce cholinesterase activity responsible for the
lysing of choline-esters including the fundamental
neurotransmitter, ACh. CIs through this mechanism increase
endogenous cholinergic transmission across the synaptic
cleft and optimize neuronal action potentials improving
memory retention, cognitive function and activities of daily
living45. Regrettably, CIs don’t halter the relentless
cholinergic neuronal damage but rather delay cognitive
decline by enhancing efficiency of neurotransmission across
synapses of surviving ACh neurons [45]. As a result, CI
treatments have been shown to have tapering effects as AD
pathophysiology ensues [45,46]. Moreover, CI treatment has
been shown to be ineffective in patients with severe AD (as
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defined by a mini-mental state examination score (MMSE)
of 5 to 17), due to only minute effect sizes within clinical
trials [46]. As behavioral deficits are normally recognized at
later stages of disease progression [47,48], it is hypothesized
that for the majority of severe AD cases, CI interventions are
unable to mitigate already established neurodegeneration.
Patients using CI interventions have also been reported to
experience significant adverse events compared to placebo
in clinical trialling including nausea, vomiting, diarrhea,
anorexia, headache and abdominal pain occasionally
resulting in trial withdrawal. Furthermore, patient outcomes
are highly variable and predictions of drug success are
impossible prior to treatment, with sub-groups deemed
commonly as ‘non-responders’ [46]. With significant
variability, null treatment sub-groups, small effect sizes and
significant adverse events, CI intervention efficacy remains
in question as a viable treatment for AD and efforts are
continuing to offer a superior alternative.
N-Methyl-D-Aspartate Antagonists
A non-competitive, moderate–affinity NMDA receptor
antagonist, memantine is suggested to improve neuronal
survival through reduced excitotoxicity. Excessive
glutamatergic activation, partly through activation of NMDA
receptors, results in neurotoxicity, occasioning cell death
[43,49]. Memantine exerts its therapeutic effects by blocking
glutamatergic NMDA receptors, which results in
normalization of the glutamate system that in turn
ameliorates cognitive and memory deficits [49]. Memantine
has comparatively high tolerability and low adverse event
profiles due to its low affinity and rapid off-rate kinetics.
This aids in the preservation of the physiological function of
the receptor [49,50]. Unlike other NMDA antagonists, the
relatively fast off-rate kinetics of memantine prevents its
accumulation in the neuronal channel as well as interference
with normal synaptic transmission, which is essential when
moderating glutamatergic pathways [51].
Memantine is an increasingly effective antagonist during
conditions of high glutamate concentrations or over-
activation of NMDA receptors, whilst relatively inactive in
normal neurological conditions [52]. In AD, blocking of
NMDA receptors with memantine also mitigates Aβ-induced
degeneration of cholinergic neurons in the nucleus basalis of
Meynert and hippocampal regions in rat [53-55].
Furthermore, Memantine exhibits an ability to minimize
levels of secreted APP and Aβ in multiple models of
transgenic AD mice [56,57]. Via these two additive
mechanisms, memantine is suggested to elicit
neuroprotection in AD. Clinical trials have established that
memantine can significantly moderate clinical deterioration
in AD, however like CIs, only provoke small effect sizes on
cognition, mood and behaviour [58-61] without affecting
pathophysiology.
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Combined Therapy of NMDA-I and CI
Clinical trial evidence has demonstrated significant benefit
in cognition and language for moderate to severe AD patients
following combined treatment of NMDA-I (memantine) and
CI (donepezil) compared to memantine alone [43,62-64].
However, this effect is not reproducible in mild to moderate
groups of AD, thus benefit is only existent in the latter stages
of AD and effect sizes are minimal.
Alleviation of Psychological and Behavioural Symptoms
Commonly Associated with Alzheimer’s Disease
Compounding significant memory and cognitive deficits are
the debilitating non-cognitive neuropsychiatric symptoms of
AD. These include (with their respective prevalence in AD
patients) apathy (72%), psychosis (38%), anxiety and
depression (59%), dysphoria (40%), aberrant motor function
(38%), aggression and belligerence (64%) and hallucinations
(10%) [65]. Whilst anti-dementia drugs such as CIs and
NMDA-Is have been shown to mitigate some behavioural
symptoms [46,66,67], they have tapering efficacy in severe
cases. The adoption of clinically accepted antipsychotics and
antidepressants are then employed as a final effort to rescue
quality of life during the late stages of disease.
Antidepressants trialled for AD include serotonin and
noradrenaline reuptake inhibitors (SNRIs), selective
serotonin reuptake inhibitors (SSRIs) and tricyclic agents.
SSRIs have been demonstrated as the most effective
antidepressant to treat comorbid depression in AD patients
[65] and have demonstrated efficacy in decreasing
depressive episodes, behavioural disturbances and
improving activities of daily life. However cognitive decline
has remained unaltered by these treatments [65,68].
Antipsychotic use in dementia is contentious, as this class of
medication is associated with higher risk of mortality,
pneumonia, cerebrovascular morbidity and accelerated
cognitive decline as compared to anti-dementia treatments
[65].
Disease Modifying Treatments: Interference of Amyloid
β Deposition
Amyloid-modifying approaches are currently occupying the
majority of clinical trial endeavours for AD. Early trial
results with amyloid depletion drugs are disappointing, with
the majority of patients gaining little to no functional
recovery even when administration precedes symptoms or
within the early stages of the disease. Clinical trials have
even reported damaging effects. AN1792, the first Aβ
vaccination attempt, resulted in 6% of phase 2 clinical trial
patients exhibiting evidence of meningoencephalitis, a lethal
inflammation of the bran and meninges [69]. Conversely, a
more recent attempt using aducanumab, a monoclonal
antibody for a conformational epitope found on Aβ, has
elicited significant reduction in amyloid deposition, however
measures of functional and cognitive recovery (as measured
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using MMSE) were insignificant at 24 weeks and even 52
weeks of treatment failed to establish a dose-dependent
result [70]. Results of this double blind, placebo-controlled
trial are indicative of amyloid not being the centric pathology
of AD and this is well established in literature [71,72].
Despite this, phase III trials of aducanumab are underway in
order to determine efficacy of amyloid-modulatory
amelioration of AD.
In summary, all of the aforementioned current treatments are
merely symptomatic and offer only weak beneficial effects
for cognition or the behavioural and psychological
symptoms of AD. Early disease modifying interventions are
necessary to ease AD pathogenesis and improve long-term
outcomes for patients. As delay in treatment is associated
with a non reversible pathogenic advancement [69], these
disease modification treatments need to coincide with
prompt diagnosis and exhibit the capability of slowing or
halting pathophysiology, neither of which are achieved with
present-day medications or protocols.
Tissue Engineering Strategies for Alzheimer’s Disease
Tissue engineering is an emergent technology to aid in the
fight against AD. Tissue engineering for AD aims to
regenerate neural tissue mitigating further degeneration
rather than merely abetting symptoms. Tissue engineering
encompasses a multidisciplinary field, which culminates
engineering and medical sciences in the development of
biological substitutes to reinstate, conserve or improve tissue
functionality impacted by disease or injury [49]. The human
brain is arguably the most elaborate organ in regards to
composition, circuitry and the myriad of largely
undetermined functions. This makes the brain a difficult
target for tissue engineering endeavors. This review will
analyze current tissue engineering methodologies including
stem cells, scaffolds and growth factors. This review will
also evaluate pertinent attempts to create neuronal tissue
models with tissue engineering strategies including brain
microplatforms and ex vivo organotypic cultures. The
culmination of these will be employed in coming years to
improve clinical outcomes for patients with AD. Whilst
microvascular dysfunction has been suggested to
demonstrate a role in AD pathophysiology, this review will
not encompass vascular tissue engineering but rather focus
on techniques of synthesising and supporting neuronal tissue
only.
Stem Cells
Cell-based therapies for AD aim to replace or promote
survival of damaged neuronal cells. This is facilitated by the
transplantation of multiple stem cell modalities including
mesenchymal stromal cells (MSCs) [73,74], neural stem
cells [75], embryonic stem cells (ESCs) [76,77] and induced
pluripotent stem cells (iPSCs) [77]. These cells enable the
regeneration of damaged host tissue via direct cell
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replacement or indirect secretion factors stimulating
neuroprotection or neurogenesis [78,79]. Stem cells are
capable of self-renewal and differentiation into dedicated
progenitor cells decided by the environment where they
preside. For AD, stem cells need to differentiate and mature
into neural stem cells, specifically cholinergic neurons of the
nucleus basalis [80] or hippocampal region [81]. In addition
to the replacement of injured neurons, stem cells can
stimulate neural precursors, promote structural
neuroplasticity, inhibit proinflammatory cytokines, suppress
neuronal apoptosis, and generate various growth factors
[72,82]. Presently, stem cell research remains in its infancy
for AD. Identification of the ideal stem cell type and the most
appropriate route of administration for this
neurodegenerative disease are required before tissue
engineering can offer a ‘cure’.
Neural tissue engineering methodology is being trialled
extensively in CNS disorders including stroke [83,84],
traumatic brain injury (TBI) [85-87], Huntington’s disease
(HD) [88-90], Parkinson’s disease (PD) [91-94] and
Alzheimer’s disease (AD) [94,95].
For most methodologies, the neural stem cell (NSC) is
pivotal to the success of these techniques. NSCs are
multipotent, immature, uncommitted cells that exist
predominantly in the brain during developmental stages and
less prolifically in the adult nervous system [72]. NSCs will
differentiate into neurons, astrocytes and oligodentrocytes,
which collectively support the complex circuitry of the CNS
Table 1 - Advantages and limitations of stem cells subtypes for applications in Alzheimer's disease
This journal is © The Source Journal of Neurological Disorders and Therapies 2018
[72]. Unfortunately, these cells are rare in the adult brain,
require intrusive surgical procedures for harvest and
proliferate only to a limited capacity in current culturing
mediums [96,97]. They are located in the lateral walls of the
ventricles and the dentate gyrus of the hippocampus [98,99].
NSC treatments for AD have several requirements to ensure
success following transplantation. For example, transplanted
stem cells must survive in the adult brain once injected,
migrate from a focal injection site to populate the targeted
regions, differentiate with high fidelity to produce the
required sub-type of neuron and form suitable synaptic
interfaces [100]. For AD, as opposed to other
neurodegenerative conditions like Parkinson’s disease,
lesioned tissue is widespread throughout multiple regions
making treatment with NSCs extremely complex. In order to
combat this, the hippocampal, entorhinal cortex and basal
forebrain can be targeted, as they are the most profoundly
affected. Blurton-Jones and colleagues found that bilateral
transplantation of NSC into the hippocampus of aged 3xTg-
AD mice (which exhibit both amyloid and tau pathology)
was able to rescue learning and memory compared to non-
treated transgenic animals [101]. The proposed mechanism
was a robust enhancement in hippocampal synaptic density
facilitated by brain-derived neurotrophic factor (BDNF).
BDNF is implicated in the differentiation of new neurons and
synapses, vital for learning, memory and higher-order
thinking [85], and is secreted by NSCs [101]. Thus, Blurton-
Jones and colleagues suggested that NSC-derived BDNF via
implantation was able to intensify endogenous synaptic
connectivity and has potential to improve memory and
cognition.
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NSCs have also been demonstrated to be neuroprotective for
cortical neurons in transgenic P301S mice [102,103], a mouse
model of AD that displays overt tau pathology and neuronal
loss [104]. The putative mechanism of action is via
neurotrophic up-regulation of glial cell-derived neurotrophic
factor (GDNF) and activity-dependent neuroprotective protein
(ADNP) in conjunction with NSC differentiation to astrocytes
[104]. It is thus suggested that NSC-derived neurotrophic
factors mitigate neurodegeneration in murine models of AD.
Trials of human NSCs and identification of a clinical grade
NSC source are required before clinical trials can proceed
[100]. MSCs are multipotent stromal stem cells derived
predominantly from bone marrow, adipose tissue and
umbilical cord blood [105]. Literature dictates that MSCs have
been able to differentiate into neural cells whilst also reducing
Aβ aggregates in vitro and in vivo and could possess
therapeutic benefit for AD [105,106]. Aβ aggregate clearance
is attributed to MSC-induced microglial cell activation
[107,108]. Immunologically, microglia are suggested to
regulate growth factors, which can stimulate neurogenesis and
cytokines that modulate neuroinflammation [88]. This
synergistic approach of neurogenesis and neuroprotection
could be beneficial for patients with AD and has been
demonstrated to increase hippocampal neurogenesis in APP
transgenic mice following intracerebral injection [109].
ESCs boast pluripotency, the ability to self-renew indefinitely
and an aptitude to differentiate into virtually all cell types of
the CNS [110]. Due to their high proliferative abilities, these
cells are being used in experiments as inexhaustible sources of
neurons to test candidate drugs in neurodegenerative diseases
[110]. Nistor and colleagues found that human neuronal
progenitor cells could be generated in large quantities and high
purity from ESCs [111]. This progenitor population was shown
to elicit neuron-specific markers and could differentiate into
various neuronal subtypes including cholinergic and
dopaminergic cells [111]. However, translation of ESCs for
clinical therapies must be conducted with extreme caution; the
persistence of non-differentiated cells from this cell source can
be tumorigenic due to genetic instability or malignant
transformation when cultured [112,113].
Recently developed iPSC technology involves the
reprogramming of adult somatic cells to gain self-renewal and
pluripotency capabilities similar to ESCs [114-116]. As iPSCs
can be derived autologously and are able to proliferate
indefinitely, somatic cells from a patient can be a sufficient cell
source for transplantation therapy. Furthermore, this
autologous source can prevent immunological rejection issues
and quashes the ethical issues raised from ESC use [117,118].
In recent years, research has utilised iPSCs derived from AD
patients to model the neurodegenerative disease and produce
patient-specific pathogenic species, potentially removing the
need for animal and human testing [117].
Despite the considerable interest and research using stem cell
technology to mitigate AD, knowledge of the ideal stem cell
source capable of targeting the multifocal lesions associated
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with AD remain unclear (see Table 1 for summary). Despite
this, stem cell injections do have strengthening evidence of
efficacy signifying its potential in future treatments for AD.
Animal models continue to make up the majority of evidence
to ratify tissue engineering therapies, leaving multiple concerns
regarding ethics and safety in humans. Until improvements in
cell survival and long-term results are observed, extrapolation
cannot be conducted in humans.
Scaffolds
Stem cell transplantation demonstrates efficacy for AD animal
models, however poor cell survival remains a significant
challenge as host immunity cells attempt to eradicate injected
cells [119,120]. Autologous cells, such as iPSCs, whilst they
do recruit an immune response, are comparably minimal to
allogenic and xenogeneic sources [119]. A sizeable
immunological barrier remains in the path of clinical trials for
stem cell transplantation, as functional rescue of
neurodegenerative conditions will not arise if the majority of
injected cells cannot survive to regenerate. Literature routinely
reports <1% cell survival for conventional stem cell
transplantations [118,119]. Engraftment is a requirement of
lone stem cell injections to ensure proliferation; otherwise the
prognosis of cell survival will be dire. An additional challenge
includes spatial organization of injected cells as the cells
become frequently dissociated. To combat these tribulations,
employment of micro-scaffolding can generate cells in three-
dimensional configurations which will provide guidance for
tissue regeneration, structural support, engraftment and
ultimately cell survival.
Recent advancements by Carlson and colleagues demonstrated
successful grafting of injected scaffold-supported
reprogrammed neuronal networks into hippocampal brain
slices and mice brain striatum in vivo using an iPSC cell source
[121]. The scaffold utilized an electrospun 100μm synthetic
poly (desaminotyrosyl tyrosine ethyl ester carbonate) (pDTEc)
polymer fibre, which was injected with seeded IPSCs capable
of differentiation into human induced neuronal (iN) cells.
Differentiation of IPSCs into iN cells was completed using
ectopic expression factors (Brn2, Ascl1, and Myt1l) and single
transcription factors (Ascl1, NeuroD1 or Ngn2) [122-125].
Literature describes pDTEc as the leading candidate polymer
from all tyrosine-derived polycarbonates [126], is supportive
of pluripotent stem cell cultures when microscaled and is
biocompatible. Results of micro-scaffolding injections were
promising. Neurite outgrowth was shown to improve 3.5-fold
in hippocampal brain slices and cell survival had a 38-fold
improvement during transplantation into mice striatal tissue in
vivo using the scaffolds. This was comparative to isolated cells
alone [121].
Scaffold fibre diameter was an important consideration as
diameter changes induced profound effects upon cellular
proliferation. Thick scaffolds of 3.23 μm permitted greater
scaffold permeability to cellular infiltration, whilst the thinner
fibre scaffolds (1.25 μm) were comparatively impermeable.
This was attributed to the decreased void space between the
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thicker 3.23 μm scaffold fibres [121]. To improve induction of
neuronal cells, the addition of doxycycline to the cellular
scaffold stimulated the loss of undifferentiated morphology,
the development of early, bipolar neuronal cells and generated
robust expression of βIII-tubulin and microtubule-associated
protein 2 (MAP2). These proteins are almost exclusively
neuronal cytoskeletal proteins [121,127] demonstrating that
the iPSCs had indeed differentiated into iNs.
It has been recently found that teratoma formation is a
significant risk associated with injections of isolated
pluripotent stem cells [121]. This risk is theoretically reduced
with the use of scaffolding materials. Colonies of dissociated
iNs with intercellular distances of <6.4μm reportedly succumb
to motility-induced aggregation, inability to differentiate,
asymmetrical colonies, subsequent improper proliferation of
cells [128] and subsequent increased risk of teratoma formation
[121]. Micro-scaffolding suggestively reduces teratoma-
formation propensity via establishing a third substrate
dimension, constraining migration paths of cells and dictates a
minimal intercellular distance resultant from the scaffold’s
large surface area. This combination can improve the
assortment of cells and thus reduce teratoma formation.
The completed scaffold with these configurations, increased
excitability and exhibited robust ability to fire action potentials
throughout the micro-scaffold construct, demonstrated by
patch-clamp electrophysiology, when seeded with iN cells ex
vivo compared to injected cells alone [121]. When injected in
vivo, cell survival was estimated at 7.58% utilizing the injected
scaffold-seeded iN cells compared to 0.11% when injected
with dissociated iN cells alone. This demonstrated efficacy had
no overt change in inflammatory response and also
demonstrated some ingrowth of endogenous tissues into the
scaffolds. This experimentation depicts the beneficial
implications of scaffolding in neuronal tissue. However, this is
novel data with minimal evidence at present. Scaffolding has
not reached trial stages but demonstrates exciting potential for
the treatment of AD with stem cell sources, as currently
dissociated stem cell methodology cannot generate the
required confluence of cells.
Growth Factors
Various growth factors are being tested in an attempt to
ameliorate AD pathogenesis. Neurogenesis in adults is dictated
by several physiological and pathological factors resulting
from the proliferation of NSCs. Up-regulatory factors of
neurogenesis include estrogen [129,130], antidepressants
[131,132] and growth factors, most notably are BDNF [133],
insulin growth factor I (IGF-1) [134-136], incretins [136] and
nerve growth factor (NGF) [137].
Type 2 diabetes mellitus (T2DM) has been identified as a risk
factor for AD, suggesting that insulin-signalling impairment
could be an initiator or accelerator to this disease [136-138] and
this is reinforced in various epidemiology studies [139-170].
Insulin receptors are expressed on neurons which dictate
dendritic sprouting, neuronal stem cell activation, cell growth,
repair and neuroprotection via oxidative stress [143-146].
This journal is © The Source Journal of Neurological Disorders and Therapies 2018
Current clinical trials are being conducted to evaluate nasal
application of insulin. This delivery method has insulin enter
the brain directly and induces minimal effects on peripheral
glucose levels, which can lead to insulin desensitization [136].
A randomized, double blinded and placebo-controlled phase II
trial of 104 patients demonstrated that nasal applications for 4
months of 20IU and 40IU of insulin improved memory, general
cognition and the ability to conduct day-to-day tasks, which
were also correlated with important biomarkers of AD
including Aβ42 level and tau/Aβ42 ratios [146]. This is
reinforced in various other clinical trials using intranasal
delivered anti-diabetic drugs [147,149] and is currently
recruiting for phase III clinical trials [150].
BDNF is responsible for the longevity and functionality of the
entorhinal cortical and hippocampal neurons [151,152]. It has
been demonstrated that declining BDNF occurs in early stages
of AD, via signalling through the TrkB receptor [153]. BDNF
itself has incompetent pharmacokinetics for systemic
administration as it has a brief half-life in the plasma and poor
BBB penetrance [153].
Various methods are employed to modulate BDNF levels
including transplantation of NSCs, lentivirus gene transfer
[154], attachment of BDNF to a monoclonal antibody capable
of BBB transportation [155] or nasal administration of a BDNF
mimetic [156]. As mentioned above, Blurton-Jones, et al.
exhibited the beneficial effects of NSC implantation, which is
resultant from increased BDNF levels. Furthermore, Nagahara
and colleagues, successfully evaluated neuroprotection from
increased BDNF in various animal models [154]. Amyloid-
transgenic mice upon BDNF gene delivery were able to reverse
synaptic loss, partially stabilize abnormal gene expression and
restore learning and memory. It should also be noted that these
outcomes were all independent of amyloid plaque load. For
aged rats, BDNF infusions mitigated cognitive decline and
entorhinal neuronal death, which occurred in control-aged rats.
Finally, in an aged primate model with bilateral radiofrequency
lesions, BDNF-lentiviral vectors ameliorated age-related
cognitive decline and neuronal atrophy, which was
demonstrated in sham-control experiments [154]. These
models demonstrated neuroprotective effects on fundamental
circuitry involved in AD, indicating success of therapeutic
BDNF delivery.
Studies have recently demonstrated the pivotal role that NGF
plays in aging and the occurrence of age-related abnormalities
such as AD. NGF has demonstrated regenerative and
neuroprotective effects on cholinergic neurons of the basal
forebrain in various animal models [157-159], highlighting the
protein as a candidate dementia treatment. Uncertainty remains
on the role NGF could play in mitigating the pathogenesis of
AD. NGF levels in the serum, CSF, hippocampal and parietal
cortices remain similar in AD and normal-aged patients [160].
Conversely, NGF levels in the plasma and dentate gyrus have
been reported as abnormally high for AD patients [161].
Contrasting evidence is also found in preclinical studies, with
intracerebroventricular administration of Aβ in mice models
being inductive of reduced NGF protein expression, which is
suggested to elicit cognitive impairment [162]. Despite the
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convoluted data on NGF’s complex role in AD, Ferreira, et al.
conducted an interesting phase I clinical trial in 2015 [159]. Six
patients were implanted with encapsulated NGF in the basal
forebrain for 12 months. Results were encouraging with lower
levels of Aβ in CSF, however there was evidence of brain
atrophy accompanied by increased NFT and tau levels. A
second phase I clinical trial by Tuszynski and colleagues
investigated 10 patients with early stage AD using both ex vivo
and in vivo NGF gene therapy techniques [163]. NGF resultant
trophic responses were demonstrated including axonal
sprouting toward local sources of NGF and cholinergic cell
hypertrophy. As trophic responses, like those aforementioned,
have been shown to ameliorate cognitive deficits in a range of
animal models of neurodegeneration [164-166], phase II
clinical trials of NGF gene therapy in AD is underway to
translate these findings to humans [167].
Brain Microplatforms
AD pathophysiology is highly complex, with multiple
hypotheses of its synthesis. Testing to better understand AD is
conducted in animal-based and in vitro models but there are
significant limitations. Animal testing exhibits high costs, low-
throughput, intensive labour regimes, and experimental
variations. Conversely, in vitro models currently present
simplified systems, which often lead to bias or false results
[168]. Brain microplatforms aim to be biomimetic of the 3D
structure, abundant vasculature, BBB and cerebrospinal fluid
(CSF) to better emulate the natural tissue in vitro. These
heterogeneously cellular 3D environments aim to improve the
current 2D monolayer in vitro cultures by using concave
microwells, which can produce large quantities of microscopic
spherical tissue of unique type, shape and size. Developments
recently in microfluidics and microelectromechanical systems
have established an ability to emulate in vivo conditions using
in vitro methodology, which previously could not be replicated
[169].
Specifically for AD, techniques to imitate the disease using
microplatforms include propagation of Aβ or tau through
neuronal networks and axonal transfer [170-174], Aβ or tau
resultant toxicity [175-178] and glial cell function [179,180].
These models are additionally viable for drug testing and
disease modelling to accelerate understanding of this
debilitating condition. Park, et al. were able to produce a 3D
culture-based microfluidic chip with neurospheroids and a
constant flow of interstitial fluid [181]. Neurospheroid cells
were generated by neural progenitor cells, which were isolated
from rat embryonic cerebral cortical regions. The cells were
then suspended and micropipetted into concave wells and
cultured for 10 days to generate multiple almost identical
neurospheroids. By replicating the pathophysiology of AD
with the addition of Aβ to the culturing substrate, the authors
were able to use various immunofluorescent stains to illustrate
the interaction of Aβ with the neural tissues architecture. It was
demonstrated that thioflavin S immunoflourescence (specific
marker for Aβ) was increased, showing successful adherence
of Aβ to the neurospheres and β-III tubulin expression was
reduced indicative of a decline of neuronal density within the
neurospheres. This supports the hypothesis that Aβ is
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neurotoxic but also demonstrates the ability for in vitro
neurodegenerative disease modelling using tissue-engineering
methodologies. These techniques mitigate the numerous costly
and time-consuming attributes of animal testing which still
remains the benchmark for neurodegenerative studies.
Ex vivo culturing Models of Alzheimer’s Disease: Past to
the Present
While the majority of evidence described in this review has
been related to in vivo stem cell transplantations due to the
importance of various physiological processes affecting cell
survival, ex vivo models have also been utilised for the
purposes of investigating stem cell tissue engineering
strategies. The first reports of cell cultures capable of observing
neuronal cells were in 1907. Harrison published an account
wherein frog ectoderm nerve cells were removed and placed in
a drop of lymph for observation [182]. During this time,
Harrison observed neuronal cell aggregation and the branching
of filaments. It was concluded that this development was an
example of self-differentiation. He also observed nerve fibres
which were capable of growing outwards at approximately 15-
60μm/h [183]. Upon termination of the filaments, an amoeboid
end was created which was observed to extend further fibres.
These were postulated to be surveying the media around the
nerve cell.
In 1911, Shorey took this concept further, creating a culture
medium that was successful in culturing neuroblasts taken
from a Necturus, a genus of salamander. Utilising a medium
containing water, peptone, NaCl, beef extract and gelatin,
Shorey was able to produce nerve fibres from late stage
neuroblasts taken from the medullary canal [184]. The
constituents of the tissue culture media were found to be
important, claiming that the beef extract (a metabolic product
of muscle) was required for axonal growth. The complexities
of culturing nerve cells from undifferentiated stem cells and
neuroblasts continued to be explored further.
During this period of the early twentieth century, various
conditions were deemed necessary to ensure successful
culturing of nerve tissues. The first was rigorous asepsis, as the
culture medium routinely contained plasma and embryotic
material, it was an exceptional environment for the
colonization of bacteria [183]. Another feature previously
overlooked, was the mechanical features of the culture. In
recent years, mechanical features such as the elasticity of
culturing matrices, have been fully appreciated as capable of
altering stem cell lineages [185]. In the 1930s, the mechanical
features and ultrastructures of the media were likewise found
to be important; for example various authors demonstrated that
free floating tissues prompted the cessation of growth and
subsequent degeneration of cell populations [183,186,187]. In
1934, Weiss further investigated the effects of mechanical
forces on the orientation of nerve processes specifically. Prior
to this knowledge, electrical currents were suggested to be the
main orientating factor for nerve processes [188], a finding that
has been quoted extensively within literature [189–191].
Simply, by applying a small electrical field (eg 125 mW/mm)
to cultured neurons the speed and orientation of nerve fibres
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would be modulated. Many conflicting reports have been
published since with findings disputing [192–194] and
advocating [189,190,195,196] an electrically induced
orientation effect for nerve fibre sprouting.
The mechanical and electrical hypotheses explained above
demonstrate the complexities of deriving accurate ex vivo
models of neurological environments. In the early 1940s,
Roger Sperry added further perplexing evidence for the
required conditions of neuron populations in vitro. He found
that neurons in culture had sensitivities to chemical gradients
which could ensue regenerative processes. Sperry’s work built
upon various reports from other groups that lower vertebrates
demonstrated an ability to recover vision after a transection of
the optic nerve [197–199]. Sperry conducted a variety of
experiments on the retinotectal system of the newt and frog to
investigate how the transection of this system could be
reversed. In a newt, he demonstrated that if the eye was rotated
180° and transected the newt, once the optical nerve had
regenerated, would behave as though the visual world had been
respectively revolved [200]. For example, if food was
presented above the newt, it twisted its head to look down.
Similarly in frogs, Sperry demonstrated that uncrossing the
optic nerves by transecting them and allowing for ipsilateral
regeneration would manifest left-right visual reversal [201].
The influences of mechanical guidance upon nerve fibre
regeneration were rejected as Sperry postulated that the nerves
would have taken systematic paths through the fibre, which
would have preserved a linear hierarchy between the transected
fibres, however this was not the case. Using silver stained
sections of the optical nerve, he found that the fibres, once
regenerated, were highly disordered describing the scene as a
bird’s nest. As the fibres did not act according to a mechanical
cue for the regenerative process, he proposed that the optical
fibres according to their origins in the retina, followed
chemical cues when re-establishing retinotectal connections.
Following the theories of embryology, Sperry hypothesized
that throughout neuronal differentiation, retinal ganglion cells
and tectal cells acquired two categories of cytochemical labels.
The first label denotes the neuron type as either retinal ganglion
or tectal, whilst the second denotes a positional label denoting
the topographical position of the retinal ganglion cell within
the retina. In this postulation, known as the chemoaffinity
theory, he suggested that along the length of the optical
pathway existed cytochemical gradients which dictated the
suitable brachial connections in the optic tract [202].
With evidence for more than a century that neurons exhibit
sensitivity to chemical, mechanical and electrical
environmental factors, to date there is no ex vivo neuronal
models for tissue engineering purposes which are capable of
refabricating analogous in vivo settings. To add a further
dimension of complexity, within each of the brain regions
specifically affected in AD, the impacted cholinergic neurons
are intrinsically different when harvested from different
affected regions (e.g. septal-diagonal band region, nucleus
basalis magnocellularis region, striatum, the pontomesechalic
tegmentum region of the brainstem and the spinal cord) of the
brain in terms of volume, fibre outgrowth, innervation patterns
and morphology [203,204]. For this reason, creating a
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cholinergic neuronal population from a single source to model
AD for tissue engineering practices is far too simplified to be
accurately compared to in vivo models. Despite this,
organotypic cultures of the late twentieth century have made
milestones in the mission to close the gap between in vivo and
ex vivo models of the brain.
Organotypic cultures, which are defined as explanted tissues
that continue to develop in an ex vivo environment, have been
developed in order to study the neurodegeneration of
cholinergic neurons as in AD. In 1983, Keller, et al. reported
the presence of cholinergic neurons and nerve fibres in
organotypic cultures derived from the septum and
hippocampus of rat brains [205] which had previously been
required to be studied in situ [206,207]. Gähwiler, et al. further
characterized this model in 1990, demonstrating the first
neuronal culture supported with NGF. He established that NGF
was capable of enhancing the number of AChE-positive
neurons and the activities of AChE and choline
acetyltransferase, enzymes that are responsible for the
breakdown and synthesis of ACh respectively. NGF is an
example of a revolutionary step for neuronal in vitro
experimentation [208] and has demonstrated reproducibly, the
ability to neuroprotect cholinergic neurons in organotypic
brain slice cultures. For example, Humpel and colleagues have
demonstrated an ability to increase the number of neurons per
cultured brain slice by 10-fold by adding 10ng/ml of NGF to a
culture of cholinergic neurons of the nucleus basalis of
Meynert [209,210].
At present, many groups have utilized ex vivo organotypic slice
models to study many aspects of AD. Such cultures have been
used to study AD-related cytochemical changes [211,212],
apoptotic cell death following Aβ-induced neurotoxicity [213]
and tau phosphorylation [214]. Whilst ex vivo models such as
those described are useful, they remain primarily a tool to
investigate mechanistic pathways, which must still be further
ratified in in vivo animal models. A difficult question that still
remains is whether slices derived from postnatal donors,
cultured for a matter of months can be used to represent mature
adult situations such as those attributable to AD patients? With
culturing protocols becoming more advanced with time, the
gap is closing between neuronal in vivo and ex vivo models but
appropriate testing prior to clinical trials cannot rely entirely
on ex vivo models. Despite this, ex vivo organotypic slice
models have some advantages over in vivo models at the
present, most notably they have higher throughput and the
ability to co-culture various cell types in the brain [210].
As demonstrated by the historical development of neuronal
cultures, difficulties of neuron survival and the unknown
influences affecting brain cells have clouded the potential of
simulating accurate in vivo environments. Despite this, as more
is learnt about the intricacies of the physiological environment
of AD, ex vivo models and the tissue engineering techniques
used to create them will exponentially advance. This will
hopefully lead to appropriate ex vivo neuronal cultures to
accelerate research of tissue engineering strategies in the fight
against AD and other neurodegenerative conditions.
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Challenges Facing Tissue Engineering Solutions for
Alzheimer’s Disease
Each of the mentioned tissue engineering applications
designed for the treatment of AD pose unique challenges. As
this is a new therapeutic paradigm, tissue engineering
outcomes are difficult to predict especially when translating
animal results to human clinical trials. Predictability is further
impaired in AD-specific tissue engineering solutions as they
act upon mechanisms which are poorly understood. Common
complications to all tissue engineering methodologies include
mitigation of immune responses, ethical considerations
surrounding animal and human testing, regulatory obstacles,
cost of development and commercialization. This review
highlights below the challenges at the pinnacle of each tissue
engineering strategy and evaluates potential solutions for their
future.
Stem Cells: Ensuring Cellular Survival
Stem cell transplantation demonstrates great promise through
two mechanisms. First, transplantation can delay the onset of
symptoms and directly regenerate tissue. Second, stem cell
grafts can facilitate trophic support for the survival and
propagation of endogenous cells whilst positively modulating
inflammatory responses [215].
Post-transplantation cellular death remains a significant barrier
to stem cell transplantation as animal models routinely
demonstrated poor cell survival rates of <1% for dissociated
cells [216,217]. Disruptions of local immune signaling from
transplantations reduce cellular survival but can additionally
exacerbate disease progression via aggravation of
inflammatory responses [218,219]. For dissociated stem cell
transplants, anti-inflammatory drugs may provide respite
[220], however this can be dampening to important
inflammatory responses. For example, acute inflammation has
been shown to elicit hormesis (i.e. tissue is protected in the
short-term by neuroprotective effects) [221] while chronic
inflammation is explicitly damaging. Differentiating this
threshold between acute and chronic responses is difficult.
Stem cells, namely MSCs, have been shown to be
unpredictable immunomodulators of a range of inflammatory
cytokines. In a model of TBI in mice, transplanted MSCs were
shown to down-regulate pro-inflammatory cytokines
interleukin-6 (IL-6) and anti-inflammatory IL-10 mRNA post-
injection and increase IL-6 mRNA [222]. These non-
synchronous responses to stem cell transplantation are
commonly reported [222]. These complex immunological
reactions to stem cell transplantation are not fully understood
and have greatly varied implications for patients. To mitigate
these problems of unpredictability, withdrawal from allogenic
sources should be considered. Adoption of autologous cellular
sources, such as iPSCs, will improve immunological disarray
and improve host response predictability [223].
Engraftment is highly dependent on host-immunity responses
to injections, as without cellular attachment, cell survival is
improbable. Strategies to increase engraftment and cell
survival predominately involve the use of
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immunosuppressants. High doses are normally required to
elicit increased engraftment and can lead to toxicity as
demonstrated in both human [224,225] and animal models
[226,227]. Additionally studies show that immunosuppressive
drugs can further augment various cell populations, their
proliferative profiles and ultimately their cell survival [228-
231]. Comprehensive analysis of immunological reactions in
response to transplantation of candidate cell sources needs to
be conducted when profiling and estimating engraftment of
cells. If required, the interaction of stem cell populations with
co-administered immunosuppressants should be additionally
studied.
An additional complication is fibrotic scar formation. This
intermediate stage of the regeneration can lead to a haltering in
the regenerative tissue if cells are exposed to imperfect micro-
environments [232]. In the AD brain, glial scars are supposed
to escalate Aβ genesis [233], which further progresses the
disease state. It is for this reason that competent stem cell
infiltration is required so scarred tissue can be replaced
subsequent to neurodegenerative insult234. Upon replacement,
the functional and electrical characteristics should mimic that
of innate tissue.
In summary, the most pertinent problem with dissociated stem
cell solutions in AD is the profound death of injected cells,
leading to minimal levels of cell rescue. While methods do
exist to alleviate this, including the use of
immunosuppressants, they can lead to serious consequences
including toxicity. Improvement of cell survival has been
shown in scaffolding techniques utilized in neural tissue
engineering, which could hold validity in future AD tissue
engineering solutions.
Seeded Scaffolds: Minimizing Tissue Damage
Seeded scaffolds for neural engineering include the challenges
listed above including; cell survival, engraftment and
immunological responses but the introduction of polymeric
structures elicits new issues. These include the
biodegradability, biocompatibility, electro-activity and cell-
material interactions of the scaffold and ensuring mode of
implantation does not damage neural tissue.
Biodegradability is vital as prolonged exposure to scaffolding
constructs can lead to chronic inflammatory reactions [235].
Materials, like pDTEc have tunable hydrophobicity and
degradation profiles, which is optimal as they can be tailored
to the treatment regime. By allowing degradation of the
scaffold, regenerated cells can produce their own extracellular
matrix [236].
Biocompatibility is fundamental to the success of the
treatment. The scaffold and collapsed constituents should
generate negligible immune reactions to allow healing, post-
treatment. Cells both seeded and innate should ultimately
migrate through the scaffold and proliferate before laying
down new matrix [236]. Structurally for the brain, soft
scaffolds have been suggested to be mimetic of innate brain
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tissue and this favors the proliferation of neural stem cells
instead of glial cells [236].
A new consideration only now being addressed in neural
engineering is electro-activity of scaffolds. The use of
graphene as a surface scaffold modification is currently being
trialed in preclinical studies of rats. This has been shown to
improve electrical interactions whilst actually reducing
microglial recruitment compared to non-graphene structures
[237].
The generation of brain mimetic scaffolds will occupy future
endeavors of the technology in attempts to remedy lesions
generated in AD and other neurodegenerative conditions.
Growth Factors: Overcoming the Brains Defences to Elicit
Trophic Responses
A number of growth factors, namely neurotrophins are
inherently poor at transporting past the BBB. To combat this
issue, monoclonal antibodies can be developed to move these
neurotrophins across the BBB via receptor–mediated transport.
Investigation is also underway to optimize transport through
the BBB utilizing a variety of nanoparticles. A study in 2009
demonstrated this ability using poly(butyl cyanoacrylate)
nanoparticles which were able to act as a carrier following
intravenous injection238. Future application of growth factors
must either use this nanoparticle method or the use of stem cell-
induced neurotrophins as described above to produce clinical
effect.
Conclusion
Without cure or even an adequate disease modifying treatment
for AD, literature is generating traction in the field of tissue
engineering. Whilst this body of evidence is its infancy for
applications within this highly intricate and undetermined
condition, current preclinical evidence is promising with
treatments on the precipice of clinical trials. Each tissue
engineering technology has unique challenges that must be
overcome, but for each successful treatment, thorough
preclinical testing is required to ensure safety during human
translation. The brain’s inability to regenerate healthy
functional tissue leaves currently diagnosed AD patients
without hope. Tissue engineering aims to create a future in
which impending cognitive decline does not plague the future
of AD patients.
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