Indonesia International (Bio)Medical Students Congress

2017

Intravenous delivery of bone marrow-derived

mesenchymal stem cells (BM-MSCs) enhances
functional recovery and brain repair markers in
ischemic stroke
Afina Thara Pitaloka*, Ramadhanti Salma Ulwanda** and Nuzula Fikrin
Nabila***

* Third Year Medical Student, Universitas Airlangga, (finapitaloka@gmail.com)

** Third Year Medical Student, Universitas Airlangga, (ulwanda@gmail.com)

*** Third Year Medical Student, Universitas Airlangga,

(fkrnnabila@gmail.com)

Correspondent author : Afina Thara Pitaloka (+628983887521, Faculty of

Medicine, Airlangga University, Mayjen Prof. Dr. Moestopo 47, Surabaya,
finapitaloka@gmail.com)

Abstract

Stroke is a major contributor to the noncommunicable diseases worldwide. As one of

the neurodegenerative diseases, stroke causes loss of brain parenchyma and neurons,
astrocytes, oligodendrocytes and endothelial cells. Ischemic strokes as one of the
types of stroke account for about 80-85% of all strokes. Nowadays, there is a lack of
effective treatment to promote tissue repair and functional recovery after the
ischemic attack. Thus, strategies such as cell-based therapies with mesenchymal
stem cells (MSCs) pave the way for new treatment options for stroke. Bone marrow-
derived mesenchymal stem cells (BM-MSCs) therapy is one of the most promising
methods to treat and promote recovery from ischemic stroke. This literature review
aims to evaluate the therapeutic potential of BM-MSCs in ischemic stroke. Studies
showed that intravenous administration of BM-MSCs significantly improved
function and also increased the level of vascular endothelial growth factor (VEGF),
synaptophysin, oligodendrocyte (Olig-2) and neurofilament. Furthermore, MSCs
have many advantages. MSCs can be obtained, amplified, and stored for immediate
use after stroke. MSCs also do not express Major histocompatibility complex II
(MCH-II), so it could minimize the risk of rejection in patients.

Keywords: bone marrow; intravenous; ischemic stroke; mesenchymal stem cells.

Introduction
Stroke is a major contributor to the
global non-communicable diseases.
About 15 million people suffer from
stroke, with approximately six millions
of deaths annually. In the US, 87%
strokes account as ischemic stroke.
Combining the expectation that the
number of people over the age of 65
will double by 2030, and that the risk
of suffering a stroke doubles for each
decade over the age of 55, will even
lead to a further increase in patient
numbers with permanent disabilities
and socioeconomic burden.1 Stroke
causes loss of brain parenchyma and
neurons, astrocytes, oligodendrocytes
and endothelial cells.2,3
Ischemic stroke is most frequently
caused by thromboembolisms while
hemorrhagic stroke most often results
from vessel wall pathology associated
with hypertension and
microaneurysms. This review will only
focus on ischemic stroke as the main
pathology. The specific therapies
currently used for ischemic stroke
management are intervention to prevent
inappropriate coagulation, surgical
procedures to repair vascular
abnormalities, and thrombolytic
therapy.2,4 Despite the high burden of
stroke, there is still a lack of effective
treatment to promote tissue repair and
functional recovery after the ischemic
attack.2,3
Stem cell therapy is one of the most
promising methods to treat and
promote recovery from ischemic
stroke. Many studies regarding the
treatment of ischemic stroke have been
using bone marrow-derived
mesenchymal stem cells (BM-MSCs).
BM-MSCs are promising therapy after
ischemic stroke because of their
advantageous characteristic, such as
their ability to differentiate into cell
types relevant to repair, modulate the
immune system, promote neurogenesis,
and secrete neuroprotective factors.1,3,4
Another research also suggests that the
reduction of inflammatory component
complement 3 (C3) expression by
MSCs can help to alleviate ischemic
brain damage, and can be used for a
new neuroprotective strategy in stroke
therapy.4,5
This literature review aims to discuss
the usage of BM-MSCs given
intravenously for the treatment of
ischemic stroke.
Materials and Methods
We have done a systematic literature
search for relevant clinical researches
and reviews published between 2008
and 2017 using Pubmed, ScienceDirect
and Google Scholar. The search
strategy consisted of MeSH (medical
subject heading) words and keywords
related to the disease. Search words
were 'bone marrow', 'intravenous' or
'iv', 'ischemic stroke', and
'mesenchymal stem cells'. All studies
about bone marrow mesenchymal stem
cells were included. We excluded
publications which were not in English.
Result and Discussion
Many studies, from preclinical to
clinical, have evaluated the potency of
BM-MSCs in many degenerative brain
diseases, including ischemic stroke.
BM-MSCs contribute to the formation
of hematopoietic stem cells niche that
supports hematopoiesis. Within the
bone marrow, MSCs can be isolated
from other BM cells due to their
potency to adhere to tissue culture
plastic. These cells have a spindle-
shaped fibroblast-like morphology and
can be expanded and enriched by
culturing for 3 to 5 weeks.3,6,7
A study evaluated the effect of
intravenously administered BM-MSCs
(2 106 cells) 30 minutes after
permanent middle cerebral artery
occlusion (pMCAO) to rats as the
model of ischemic stroke at 24 hours
and 14 days. It showed that BM-MSCs
therapy reduced the number of
TUNEL+ cells in the peri-infarct area
which means decreased cell death.
According to this study, at 14 days, the
untreated group showed significantly
more TUNEL+ cells than the BM-
MSCs group, with number of
TUNEL+ cells 41 6.4 and 26 5.5
respectively.1,7,8
BM-MSCs also increased cellular
proliferation after pMCAO.
Quantitative analysis showed that the
infarct group displayed a significantly
smaller decrease in the peri-infarct
zone at 14 days after focal cerebral
ischemia than did the BM-MSCs.1,7
A study demonstrated that infarct size
measured by MRI in rats with pMCAO
does not change after administration of
intravenous BM-MSCs, but some
previous studies showed a decrease.1,7,8
The study also revealed that the BM-
MSCs treated groups showed good
functional recovery at 24 hours and 14
days compared with the untreated
infarct group (Figure 1).1
This result is in line with other studies
which also showed that administration
of BM-MSCs in animal models
improved sensorimotor function.
Another study also found that BM-
MSCs enhanced synaptogenesis and
nerve regeneration, while decreased
tissue plasminogen activator (tPA)-
induced brain damage.6,9
Studies found that BM-MSCs secrete a
wide array of neurotrophins, growth
factors, cytokines and other soluble
factors such as VEGF or BDNF, in
response to repair processes, and this
could amplify trophic factor levels in
the brain. A study found that BM-
MSCs increased cellular proliferation
and modified brain repair markers
levels.1,7,8
Vascular endothelial growth factor
(VEGF) levels were significantly
higher in the rat brain after BM-MSCs
therapy compared with the control
group by 4.84 (A.U.) and 2.75 (A.U.)
respectively. The levels of Olig-2
labeling were also considerably higher
than in the control group after the BM-
MSCs treatment with the number 2.05
(A.U.) and 2.89 (A.U.) respectively.1,7
Recovery after stroke is a dynamic
process, and the growth and trophic
factors produced by BM-MSCs may
affect synaptogenesis in the ischemic
brain. Compared with the control
group, synaptophysin (SYP) levels
were also significantly increased after
BM-MSCs administration with the
number 2.15 (A.U.) and 3.14 (A.U.)
respectively. Lastly, neurofilament (NF)
levels were significantly increased
after the BM-MSCs treatment
compared with the control group by
2.10 (A.U.) and 1.18 (A.U.)
respectively. The BDNF levels were
also higher after BM-MSCs therapy,
but this increase did not reach
statistical significance. The GFAP
levels were decreased significantly
after BM-MSCs administration in
comparison with the infarct group.1,7,8
In ischemic stroke, BM-MSCs
establishes neuronal protection through
inflammatory and immune response
modulation. BM-MSCs has been
shown to upregulate interleukin-6 (IL-
6) expression in a mouse model, which
probably accounts for neuroprotective
effect. Soluble factors secreted from
BM-MSCs, such as IL-6, IL-8,
chemokine ligand 2 (CCL2), VEGF,
hepatocyte growth factor, and bone
morphogenetic protein-4 (BMP-4) also
increase maturation and survival of
neuron. The same research also
suggests that neuroprotective effect of
MSCs in cerebral ischemia is
associated with the down-regulation of
C3 expression.5,7
In particular, intravenously injected
BM-MSCs enter the brain and
stimulate local production of growth
factors from endogenous cells like
astrocytes and endothelial cells. These
growth factors lead to angiogenesis
and vascular stabilization. Intravenous
administration of BM-MSCs leads to a
time-dependent release
neurotrophins and angiogenic growth
factors. The production of these
molecules all contributes to and likely
coordinates the improvement in
neurological function post stroke.1,7,8
The use of BM-MSCs for therapies are
advantageous because they are easy to
harvest, can be quickly isolated,
expanded and stored for a period, can
be administered in various ways, are
relatively immune-privileged, and they
may be administered through different
methods.9,10,11
Furthermore, it is known that BM-
MSCs do not express major
histocompatibility complex II (MCH-
II), thus minimizing the risk of
rejection in patients and facilitates their
allogeneic administration. It possibly
allows BM-MSCs from healthy donors
to be stored in biobanks for the
treatment of stroke patients during the
acute phase of the disease.7,9,10
Clinical trials in ischemic stroke
patients showed that administration of
intravenous BM-MSCs is safe and no
significant side effects were observed
during the treatment.11,12 A study also
found that BM-MSCs therapy
improves clinical outcome measured
by modified Rankin scale (mRS)
(Figure 2). This clinical improvement
is believed to be associated with serum
levels of stromal cell-derived factor-
1.12
Conclusion
The use of BM-MSCs intravenously as
a therapy after an ischemic attack can
reduce ischemic damage, significantly
improved functional recovery, and
increase brain repair markers. Its
effects on the ischemic tissues can also
promote angiogenesis and
synaptogenesis through the increase of
VEGF, SYP, Olig-2 and NF levels.
of Neuroprotective effects are achieved
through the modulation of
inflammatory and immune response.
MSCs is also advantageous for their
obtainability and can be easily
amplified and stored for immediate use
when needed after an attack. They also
have minimal risk of rejection because
of the unexpressed MCH-II.
Further studies are necessary to explain
the beneficial effects, efficacy, and
safety related to MSCs therapy,
especially in the human model. But,
the intravenous MSCs therapy remains
as one of the most promising methods
to treat and promote recovery from
ischemic stroke.
Acknowledgement
We would like to acknowledge the
support and guidance from all
mentoring lecturers.
Conflict of Interest
The authors declare that there is no
conflict of interest in this work.
References
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Fig. 1. Acute intravenous (i.v.)

administration of bone marrow-derived
mesenchymal (BM-MSC) cells
improved functional recovery at 24 h
and 14 d after permanent middle
cerebral artery occlusion (pMCAO). 1
(Gutirrez-Fernndez M, Rodrguez-Frutos B, Ramos-
Cejudo J, Teresa Vallejo-Cremades M, Fuentes B, Cerdn
S et al. Effects of intravenous administration of allogenic
bone marrow- and adipose tissue-derived mesenchymal
stem cells on functional recovery and brain repair markers
in experimental ischemic stroke. Stem Cell Research &
Therapy. 2013;4(1):11.)

Fig. 2. Proportion of patients in the

control and MSC group according to
the mRS at day 7 of admission and last
evaluation. 12 (Lee J, Hong J, Moon G, et al. A