Childs Nerv Syst (2014) 30:3746

DOI 10.1007/s00381-013-2304-4

REVIEW PAPER

Stem cells for brain repair in neonatal hypoxiaischemia

L. Chicha & T. Smith & R. Guzman

Received: 7 October 2013 / Accepted: 8 October 2013 / Published online: 1 November 2013
# Springer-Verlag Berlin Heidelberg 2013

Abstract Neonatal hypoxicischemic insults are a significant

cause of pediatric encephalopathy, developmental delays, and
spastic cerebral palsy. Although the developing brains
plasticity allows for remarkable self-repair, severe disruption
of normal myelination and cortical development upon
neonatal brain injury are likely to generate life-persisting
sensory-motor and cognitive deficits in the growing child.
Currently, no treatments are available that can address the
long-term consequences. Thus, regenerative medicine appears
as a promising avenue to help restore normal developmental
processes in affected infants. Stem cell therapy has proven
effective in promoting functional recovery in animal models
of neonatal hypoxicischemic injury and therefore represents
a hopeful therapy for this unmet medical condition.
Neural stem cells derived from pluripotent stem cells
or fetal tissues as well as umbilical cord blood and
mesenchymal stem cells have all shown initial success
in improving functional outcomes. However, much still
remains to be understood about how those stem cells can
safely be administered to infants and what their repair
mechanisms in the brain are. In this review, we discuss
updated research into pathophysiological mechanisms of
neonatal brain injury, the types of stem cell therapies currently
being tested in this context, and the potential mechanisms
through which exogenous stem cells might interact with and
influence the developing brain.
L. Chicha : R. Guzman
Department of Biomedicine, University of Basel, Basel, Switzerland
L. Chicha : T. Smith : R. Guzman
Department of Neurosurgery, University of Basel, Basel, Switzerland
R. Guzman
Department of Neurosurgery, Stanford University
School of Medicine, Stanford, CA, USA
R. Guzman (*)
Department of Neurosurgery and Biomedicine, University Hospital
Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland
e-mail: raphael.guzman@usb.ch

Keywords Neonatal hypoxiaischemia . Stem cell

transplantation . White matter injury . Brain repair .
Myelination

Introduction
Despite major advances in monitoring technology and
knowledge of fetal and neonatal pathologies, hypoxic
ischemic (HI) strokes remain the most common form of
damage to the neonate brain [51], causing significant
mortality and persistent neurobiological morbidity. In most
cases, exact timing and underlying causes of the injury are
unknown. Etiologies are complex and most often
multifactorial. Reported precipitating insults include placental
abnormalities [21], intrauterine growth restriction [115],
preeclampsia [115], maternal infections [15, 33, 72],
circulation disorders [34, 61, 114], and perinatal asphyxia
[87]. Genetic makeup, sex, and degree of brain development
also affect vulnerability and the mechanisms of brain injury [44,
105]. Neonatal HI occurs in 13 per 1,000 live full-term births
and dramatically increases to 40 per 1,000 in preterm children
with very low birth weight [33, 47]. Of affected newborns,
25 % develop severe and persistent neuropsychological
impairments, including mental retardation, motor deficits,
cerebral palsy, and epilepsy [104].
Upon neonatal HI insult, oxygen and glucose supplies are
transiently depleted from the brain, causing an energy failure
and initiating a cascade of biochemical events leading to cell
dysfunction and oxidative stress [97]. Depending on the
strength and duration of this initial insult, secondary injuries
are likely to follow which include mitochondrial dysfunction,
apoptosis, and excitotoxicity [97]. Tertiary effects may persist
in the brain such as sensitization to inflammation, impaired
oligodendrocyte maturation/myelination, persistent gliosis,
and epigenetic changes [14, 26, 97]. Although those enduring
damages might predispose patients to developmental
disruption and sensitization to further injury, this also creates
an extended window of opportunity for further treatment.

38

White matter damages in the developing brain

Brain white matter consists of glia and myelinated axons and
plays a crucial role in fast signal transmission throughout the
CNS. The process of active myelination reflects the progression
of functional brain maturation and connectivity in the first years
of life and renders the infant brain particularly vulnerable to
injuries such as pediatric stroke and epilepsy [73]. Consequently,
white matter injury and disruption of normal myelination is a
hallmark of neonatal HI. Clinical diffusion tensor imaging (DTI)
studies have shown that the majority of children with spastic
types of cerebral palsy present white matter injuries and the
importance of myelin loss correlates with the severity of motor
impairments and learning disabilities [65, 80]. Together with
perinatal inflammation, hypoxiaischemia is considered the
principal initiating mechanism for pathogenesis of
periventricular leukomalacia (PVL), a condition characterized
by coagulation and necrosis of white matter near the lateral
ventricles, accompanied by gliosis/necrosis evolving from
diffuse to focal cyst formation [45]. Non-cystic diffuse PVL
accounts for most of the cerebral white matter injury in the
newborn and is associated with loss of pre-myelinating
oligodendrocytes, astrogliosis, and microglial infiltration [72].
Studies indicate that pre-myelinating late oligodendrocyte
progenitors (pOPC) are crucial in renewing the pool of
oligodendrocyte progenitor (OPC) and driving their
differentiation towards myelinating oligodendrocytes. These
pOPC are particularly vulnerable to the hypoxic stress generated
during ischemic insults, and hence, rapidly undergo apoptosis in
the injured environment [4, 85]. Systemic upregulation of proinflammatory cytokines associated with astrogliosis and
microglial infiltration as well as resulting oxidative stress are
also likely to restrict white matter development and affect
existing and forming myelin fibers [47, 109].
While experimental models have been proposed to prevent
or ameliorate white matter injury-associated mechanisms
separately [45], therapies targeting the overall neurogenic
niche are likely to be the most effective in restoring
progression of white matter formation and alleviate longterm disabilities following neonatal HI injuries.

Childs Nerv Syst (2014) 30:3746

neonatal HI and neurobehavioral outcomes reminiscent of

cerebral palsy. Multiple variations of this model have been
explored including global hypoxia without carotid artery
ligation, bilateral carotid occlusion, and temporary carotid
occlusions using aneurysm clips. The neonatal hypoxia model
has been applied in rats, mainly Sprague Dawley and Wistar rats.
It has been shown that a more consistent injury was achieved in
Wistar rats as compared to Sprague Dawley rats probably
because of differences in collateral circulation [69]. Other
adjunct interventions have been explored such as the
combination with low doses of lipopolysaccharidea potent
trigger of the innate immune systemwhich dramatically
increased injury response to HI challenge [53, 110] and
suggested that inflammation may further sensitize the immature
central nervous system.

Stem cell therapy

First studies on cell therapy for neonatal HI were designed to
evaluate the ability of transplanted cells in replacing damaged
tissue and utilized fetal cortical grafts or polymer scaffolds
seeded with neural stem cells [22, 43, 71]. However, several
reports subsequently demonstrated that transplanted stem cells
promote CNS tissue repair not merely through cell replacement
but by providing trophic and immunomodulatory support for
endogenous repair mechanisms [60]. Different types of stem
cells have been considered to mediate brain repair including
stem cells derived from umbilical cord blood, bone marrow,
fetal central nervous system, embryonic tissues as well as
reprogrammed somatic [99] cells. Because each stem cell type
have unique characteristics, it is likely that they use distinct
machineries to interact with the ischemic environment and
trigger regenerative mechanisms. On the other hand, some
mechanisms are common to all stem cell types, and those might
be particularly relevant for the induction of repair mechanisms
in the brain. In the following paragraphs, we will review cell
type-specific characteristics that might be relevant to
regeneration in the injured neonatal brain. We will also discuss
current concepts of the potential mechanisms of action that
induce repair/regeneration of the injured CNS.

Preclinical approach

Umbilical cord blood-derived mesenchymal stem cells

Animal models

The human umbilical cord is a rich source of stem and

progenitor cells including mesenchymal stem cells (MSC)
and hematopoietic stem/progenitor cells (HPC). Umbilical
cord cells are easily available via noninvasive procedures
and considered less immunogenic than alternative adult stem
cell sources such as bone marrow. MSC derived from cord
blood have shown to generate neural stem cells in vitro [19,
28] and to lead to functional improvement in rodent models of
perinatal brain injury [55, 116]. Thus, there is a growing

Because of the large heterogeneity in factors potentially

contributing to cerebral palsy, it has been difficult to achieve a
reliable animal model. The Levine and Rice-Vannucci model of
neonatal HI[54, 78, 103], involving unilateral temporary or
permanent ligation of the common carotid artery and subsequent
exposure to hypoxic condition (810% O2) on postnatal day 7
(P7) animals, is the most commonly used paradigm to model

Childs Nerv Syst (2014) 30:3746

interest in studying the potential of umbilical cord-derived

stem cells for the treatment of brain diseases [60, 99, 101].
MSC have demonstrated potent trophic support [8] and
immunomodulatory properties in vitro [98, 112], and therefore,
appear as particularly interesting candidates to modulate glial
activation and pro-inflammatory mechanisms that accompany
neonatal ischemic injuries. Furthermore, as those cells are
isolated at birth following clamping and elimination of the
umbilical cord, they present the considerable advantages of
being autologous and freshly available after sorting and
expansion. Short-term exposure to mild hypoxia has shown
to optimize MSC functions [40], which might further
emphasize their therapeutic relevance in the context of HI
injury. Besides MSC, other cells can be isolated from the
mononuclear fraction of umbilical cord blood, with a relative
immature and naive phenotype. Those include HPC and
endothelial progenitors, which derive from a common
precursor cell called the hemangioblast [52]. Interestingly,
while intravenous injection of HPC in the ischemic brain has
demonstrated neuroprotective and immunomodulatory
effects[84], transplantation of a cord blood fraction enriched
in hemangioblastic cells induced neovascularization in a mouse
model of stroke [64, 93]. This might further argue that different
stem cell types support distinct repair mechanisms depending
on their respective lineage, and combinational therapies might
be appropriate in major injuries.
Fetal/adult neural stem/progenitor cells
Neural stem/progenitor cells (NPC) can be found in
endogenous neurogenic areas such as the subventricular zone
or the dentate gyrus of the hippocampus. In the case of human
NPC, the primary source can either be donated fetal tissue [25,
92, 95, 107, 108] or adult post-mortem brains [70]. Fetalderived NPC are typically isolated from the brain tissue by
fluorescent-activated cell sorting and then grown as
neurospheres under proliferative conditions [95]. Adult
human neural stem cells have been isolated from brain tissue
obtained from patients undergoing surgical procedures
involving removal of brain tissue for the treatment of epilepsy,
tumors, or trauma [3, 9, 32]. These studies demonstrate that
the adult human brain contains a renewable source of NPC,
which can be successfully isolated through various surgical
techniques. Regardless of source, these cells can differentiate
into oligodendrocytes, astrocytes, and neurons. NPC
demonstrated potent ability to migrate in response to
endogenous chemokines [41] and can move at a rate of 100
125 m/day towards the area of injury in the neonatal brain
where they can survive for up to 52 weeks following
transplantation [67]. As for MSC, mild hypoxia has shown
to enhance proliferation and differentiation of a human NPC
line towards neuronal and oligodendroglia lineages,
emphasizing the potential of fetal NPC to mediate brain repair

39

in HI conditions [83]. Most stem cell therapy studies in

neonatal HI utilized rodent NPCs. The only study to date
using human NPCs found a change in activation of resident
microglia, and most interestingly, a change in gene expression
in the brain after cell engraftment, suggesting a potent crosstalk between transplanted and intrinsic cells [13]. In this study,
the increase in transcripts for growth factors GDNF, IGF-1, and
FGF2; neuronal marker doublecortin; and oligodendrocyte
markers Olig2 and myelin basic protein suggest that
widespread changes in the brain could be driving the functional
improvements seen following NPC engraftment [13].
Embryonic stem cell-derived neural stem cells
Embryonic stem cells (ESC) are derived from the microscopic
cluster of cells populating the blastocyst cavity a couple of days
following fertilization [96]. ESC have been reported to
differentiate into various cell types including NPC and
oligodendroglial progenitors [10, 46] and are therefore
considered as a potential source for cell replacement therapy in
CNS diseases. Among all stem cell types, ESC are the most
truly self-renewable and pluripotent populations. These
properties confer them the considerable advantages of providing
an almost unlimited supply of cells and differentiating toward a
whole spectrum of distinct cell types. For instance, human
embryonic stem cells have proven to differentiate in vitro
towards oligodendrocyte progenitor cells, motoneurons,
dopaminergic neurons, astrocytes, and peripheral sensory
neurons (reviewed in [24]). However, counterparts to those
properties are increased risks of neoplastic transformation (graft
overgrowth) and multigerm layer teratoma formation following
transplantation, events which are likely to be supported by
factors released by the injured brain, thus raising major safety
issues [42, 79, 86]. Furthermore, relative immaturity of ESCderived lineages might confer protracted development requiring
several months of further in vitro or in vivo maturation before
demonstrating therapeutic potential [7, 63]. Last but not least,
human ESC research is a rather controversial issue, as creation
of an ESC line requires the destruction of a human embryo [96].
Induced pluripotent stem cells
Induced pluripotent stem cells (iPSC) are adult somatic cells
that have been reprogrammed to an embryonic stem cell-like
state by enforced expression of pluripotency transcription
factors, mainly Oct3/4, Sox2, Klf4, and c-myc [94]. As iPSC
capture the genetic diversity of the donor, provide access to the
earliest stages of development, and virtually generate unlimited
numbers of patient-specific cells, they are particularly
considered as a valuable tool to model human genetic diseases
in vitro [59, 74, 91]. In the field of stem cell transplantation,
they present the advantages to overcome ethical limitations and
to allow for generation of autologous cellular products, while

40

behaving similar to ESC in morphology, gene expression, and

differentiation potential. Although this new field has generated
quite some excitement within the scientific community, major
safety issues remain associated with the use of iPSC. First, the
ectopic expression of the chosen set of pluripotency factors can
lead to neoplastic transformation of cells derived from these
iPSC [6, 31, 38, 68]. Furthermore, in most existing procedures,
these genes are introduced via DNA integrating viruses, which
are likely to maintain or reactivate their transcriptional activity
in the pluripotent cells or their progeny [68]. Also of major
safety concern, there is a growing body of evidence
demonstrating genetic and epigenetic instability in human
iPSC, likely to originate during in vitro selection of the
reprogrammed clones [66] and the reprogramming procedure
per se [31]. If iPSC are to be used for clinical regenerative
purposes, careful genetic integrity controlling is an absolute
requirement. Considerable efforts are currently being made to
develop safer and more efficient methods to generate iPSC. For
instance, recent promising procedures focus on the use of nonintegrating Sendai viruses that can further be removed through
temperature shift [5].
Future should confirm the potential use of iPSC in stem cell
therapies in the context of stroke. On an optimist note, a recent
study in a rat experimental stroke model has reported that iPSCderived NPC are effective in reducing stroke-induced
inflammatory response, gliosis, and apoptosis, contributing to
endogenous neurogenesis and inducing behavioral recovery [11].

Potential therapeutic mechanisms of action

Neuroprotection and neuroplasticity
Although stem cell-induced endogenous repair mechanisms are
largely unknown, it is likely that transplanted cells and resident
neuronal and glial lineages will mutually interact to support
therapeutic effect. In support for the present hypothesis, we have
recently demonstrated that NPC-secreted vascular-endothelial
growth factor (VEGF) is necessary and sufficient to regulate
endogenous microglial proliferation, activation, and phagocytic
properties [62]. Although this study was performed with mouse
NPC, it strongly suggests that exogenous stem cells assume a
role in maintaining tissue integrity and immune function in the
CNS apart from their purpose to merely produce and replace
neural cells. Neonatal brain injury is accompanied by activation
of pathways of oxidative stress, inflammation, and excitotoxicity
that can lead to damages progressing over a long period of time
and causing persisting disabilities in the growing child. In
addition to neuronal damages, injury to non-neuronal types such
as oligodendrocytes [4, 85, 89] and astrocytes [89] might also
impair neurodevelopment. Neuroprotective and antiapoptotic
effects mediated by NPC and stem cells in general have been
recognized and largely reviewed in the context of different CNS

Childs Nerv Syst (2014) 30:3746

disorders including neonatal stroke [16, 48, 76, 99]. Based on

previous data, it sounds reasonable to postulate that the
transplants induce a greater survival of intrinsic brain
populations. For instance, it has been shown that intravenously
administrated marrow stem cells increase the expression of
critical neurotrophic growth factors in the rat brain after
traumatic injury [58]. Transplantation of human neural stem
cells in a rat model of adult stroke has also shown to modulate
dendritic plasticity and axonal transport, mostly through non-cell
autonomous secretion of VEGF and thrombospondins [2].
Oligodendrogenesis and white matter regeneration
Brain anatomy is characterized by a dramatic growth from the
end of the second trimester through the neonatal stage, with
whole brain volume increasing almost 17 times [39]. Brain
structures have shown to develop disproportionately during this
period, and this might partly explain the extensive
inhomogeneity of white matter injuries and their outcomes
observed in cerebral palsy patients. Together with the reported
increased sensitivity of pOPC to HI insults [4, 85], these
observations place oligodendrogenesis and myelination as core
processes underlying early brain injuries and life-persisting
symptoms. A number of molecules have been critically involved
in oligodendrogenesis, including neurotrophic factors such as
platelet-derived growth factor-alpha (PDGF) [27], insulin-like
growth factor-1 (IGF-1) [50], brain-derived neurotrophic factor
[102], and erythropoietin [117]. Even though different stem cell
types have not been compared side by side for their expression of
neurotrophic factors, it is likely that secretion of some of those
critical factors by NPC will partly explain the bystander effects of
stem cell therapies [2, 48, 56]. In a model of multiple sclerosis
recapitulating demyelination, it has been demonstrated that NPC
induced OPC proliferation and maturation via secretion of
PDGF and FGF2 specifically [20]. In a rat model of neonatal
hypoxiaischemia, a study reported that human NPC graft
specifically enhanced axonal transport and sprouting [13]
through upregulation of oligodendrogenesis, myelination as well
as an increase in neurotrophic factors. Once again, this strongly
argues for cross-talk mechanisms between exogenous NPC and
intrinsic cells, here the oligodendrocytes, in mediating brain
repair and functional recovery through multiple modalities.
Immunomodulation
Several independent observations suggest a pivotal role for the
immune system in shaping the central nervous system and
contributing to its recovery upon injuries. Firstly, it has been
recently demonstrated that immune myeloid cells home to the
central nervous system before neurogenesis occurs [30].
Second, brain architecture and myelination are severely
compromised in microglia-depleted animals [23]. Third, most
of the reported stem cell-secreted factors are potent triggers of

Mexico
April 13
IV
37 weeks42 weeks
20
Neonatal asphyxia
AUCB
NCT01506258

Safety/Efficacy

USA
December 15
IV
6 weeks6 years
10
Arterial ischemic stroke (AIS)
AUCB
NCT01700166

Safety/Efficacy

USA
December 13
IV
<14 days
25
Neonatal encephalopathy

Safety
AUCB
NCT00593242

Cerebral palsy
AUCB
NCT01072370

Safety/efficacy

40

112 years

IV

February 14

USA

A Randomized Study of Autologous Umbilical

Cord Blood Reinfusion in Children With
Cerebral Palsy
Safety and Effectiveness of Cord Blood Stem
Cell Infusion for the Treatment of Cerebral
Palsy in Children
Cord Blood for Neonatal Hypoxic-ischemic
Encephalopathy
Umbilical Cord Blood in the Treatment of
Stroke in Children (Pedi Stroke)
Autologous Stem Cells in Newborns With
Oxygen Deprivation
USA
January 16
IV
12 m0nths6 years
Cerebral palsy

Efficacy

120

Location Clinical trial title

Delivery Completion
Patients Age

AUCB

Aside from the type of stem cells used for transplantation in

neonatal HI, the route of administration and timing are likely
to play crucial roles in the efficacy of the treatment. Stem cells
can be delivered systemically or directly into the brain. Our
laboratory previously demonstrated that delivery of stem cells
to the injured brain via intravascular treatment allows for a
widespread distribution of cells in the brain by means of a

NCT01147653

Cell delivery and timing

Endpoint
classification

Methodologies

Clinical trial ID Cell type Specific pathology

immune-related pathways, including molecules directly

involved in chemo-attraction and modulation of inflammation
and phagocytosis [1, 13, 62, 77]. It appears that there are direct
NPC-mediated immunomodulatory effects on the brain
resident immune cells as well as modulation of the systemic
immune system. Using NPC transplantation, several groups
have demonstrated that induced recovery is partly mediated
through modulation of microglial phagocytic activities [13,
62]. Studies in multiple sclerosis and spinal cord injury also
emphasize the role of the innate immune system, principally
macrophages/microglia, in supporting remyelination
processes via phagocytosis of myelin debris [49, 82, 88].
Interestingly, transplantation of HPC, the progenitors of the
immune and endothelial lineages, has also proven beneficial
in animal models of stroke without reported cell fusion events
[84]. In the field of neurodevelopmental disorders, recent
studies have also started to unravel the beneficial role of bone
marrow transplantation. For instance, in a genetic rodent
model of Retts syndrome, a group strikingly identified
microglial phagocytic activity as a major mediator of
functional recovery [18]. Interestingly, different types of stem
cells have intrinsic phagocytic properties [57, 100], and this
might contribute to their beneficial effects in the injured brain.
A second immunomodulatory effect appears to be
systemic. Cord blood stem cell infusion in a model of acute
stroke has shown to mediate brain protection through specific
modulation of the splenic release of inflammatory cells [106].
The same has been shown for stem cell-induced recovery in
traumatic brain injury [111]. In this study, stem cell injection
led to a preservation of blood brain barrier integrity through
modulation of the immune cell response in the spleen. A
pharmacologic correlate to this phenomenon relies on the
use of sphingosine-1 phosphate receptor agonist fingolimod
(FTY720)a multiple sclerosis market drug. Its main action
is to segregate inflammatory cells within the spleen, and it has
also demonstrated long-term protection in rodent models of
cerebral ischemia [113]. Taken together, these findings
support the concept of NPC-mediated local and systemic
modulation of the immune response as a potentially important
mechanism of action.

41

Table 1 Clinical trials using stem cells for treatment of neonatal stroke-related disorders. AUCB: autologous umbilical cord blood stem cells, IV: intravenous

Childs Nerv Syst (2014) 30:3746

42

Childs Nerv Syst (2014) 30:3746

Cell Replacement
Neurons, glia
Microglia

Remyelination
HPC
NPC

Oligodendrogenesis support
Myelin debris clearance

MSC

Exogenous Stem Cells

Neonatal HI

Intravascular or intranasal treatment

Neuroprotection
Phagocytosis

Immunomodulation
Trophic support

Stem cell intrinsic properties?

Enhance microglia functions

Microglia

White matter recovery

Functional improvement
Clinical safety?
Risk/benefit ratio?

activated
microglia

Fig. 1 Potential stem cell-induced brain repair mechanisms. Schematic illustrating main candidate mechanisms of action in stem cell-mediated white
matter repair following neonatal hypoxicischemic injuries. For detail, cf. text

highly feasible, safe, repeatable, and minimally invasive

approach [12, 35, 36, 75]. Our studies suggest an active
mechanism of cell recruitment to the brain through cellular
expression of adhesion molecules [36] and chemokine
receptors [1, 81]. While previous studies involved
transplantation of human stem cell grafts 24 h after neonatal
hypoxiaischemia injury [13], we established that intra-arterial
transplantation of NPC 3 days after the insult resulted in higher
cell engraftment and survival when compared with earlier (6
24 h) or later (714 days) time-points [81]. Interestingly, day 3
post-injury correlated with the highest expression of signaling
molecules such as VCAM-1, CCL2, and CXCL12, here again
supporting a cross-talk hypothesis, where the injured
environment is likely to dictate efficiency of exogenous stem
cell treatment. Current clinical trials will be using early (48 h
and 2 weeks after birth) and chronic time points (up to 12 years
of age) for intravenous cell delivery (Table 1).
Imaging
Noninvasive approaches to monitor stem cells upon
transplantation are pivotal to therapeutic success and to
prediction of graft viability and potential complications.
High field magnetic resonance imaging (MRI) remains the
modality of choice to evaluate pathogenesis, severity, and
evolution of neonatal HI [17]. To evaluate white matter tract
integrity and repair, MRI-based DTI has become the main
imaging modality [90]. MRI can not only monitor evolving
neonatal cerebral injury but also track migration and location
of iron oxide nanoparticle (SPIO) labeled exogenous stem
cells for prolonged time periods [13, 37, 67, 75]. Other

preclinical stem cell imaging approaches have included

reporter genes for bioluminescence, proton emission
tomography, single photon emission tomography, radioactive
tracers, and fluoride labeling for fluoride MR-based imaging
(for review, see [29]). To date, however, there is no modality
for clinical stem cell imaging.

Conclusions and perspectives

Increased understanding in the pathophysiology of perinatal
injuries leading to cerebral palsy has placed white matter
injury and myelin loss at the core of the disorder. With their
unique regenerative properties, stem cells appear as a
promising and versatile tool for therapeutic approaches in
pediatric neurology. Moreover, repair mechanisms might be
facilitated by the immaturity and plasticity of the neonatal
developing brain.
Proof of principle for stem cell-mediated brain repair and
functional recovery has been shown with different types of
cells in the Rice-Vannucci animal model of neonatal
hypoxiaischemia. Most of those studies argue in favor of a
strong communication between transplanted cells and intrinsic
brain lineages. More than cell replacement, it becomes more
and more obvious that exogenous stem cells are acting as
bystander cells, providing a favorable niche for neuroprotection
and immunomodulation (Fig. 1). However, knowledge
obtained from preclinical models is unable to totally predict
clinical outcomes in pediatric patients. Several clinical trials are
underway to evaluate the safety and efficacy using autologous
cord blood intravenous transplantation (Table 1), and results of

Childs Nerv Syst (2014) 30:3746

those should partly address safety of cell transplantation in the

acute and chronic phase, as well as efficacy of the procedure for
the growing child.

References
1. Andres RH, Choi R, Pendharkar AV, Gaeta X, Wang N, Nathan JK,
Chua JY, Lee SW, Palmer TD, Steinberg GK, Guzman R (2011)
The CCR2/CCL2 interaction mediates the transendothelial
recruitment of intravascularly delivered neural stem cells to the
ischemic brain. Stroke 42(10):29232931. doi:10.1161/
STROKEAHA.110.606368
2. Andres RH, Horie N, Slikker W, Keren-Gill H, Zhan K, Sun G,
Manley NC, Pereira MP, Sheikh LA, McMillan EL, Schaar BT,
Svendsen CN, Bliss TM, Steinberg GK (2011) Human neural stem
cells enhance structural plasticity and axonal transport in the
ischaemic brain. Brain 134(Pt 6):17771789. doi:10.1093/brain/
awr094
3. Ayuso-Sacido A, Roy NS, Schwartz TH, Greenfield JP, Boockvar
JA (2008) Long-term expansion of adult human brain
subventricular zone precursors. Neurosurgery 62(1):223229. doi:
10.1227/01.NEU.0000311081.50648.4C, discussion 229-231
4. Back SA, Han BH, Luo NL, Chricton CA, Xanthoudakis S, Tam J,
Arvin KL, Holtzman DM (2002) Selective vulnerability of late
oligodendrocyte progenitors to hypoxia-ischemia. J Neurosci
22(2):455463
5. Ban H, Nishishita N, Fusaki N, Tabata T, Saeki K, Shikamura M,
Takada N, Inoue M, Hasegawa M, Kawamata S, Nishikawa S
(2011) Efficient generation of transgene-free human induced
pluripotent stem cells (iPSCs) by temperature-sensitive Sendai virus
vectors. Proc Natl Acad Sci U S A 108(34):1423414239. doi:10.
1073/pnas.1103509108
6. Ben-Porath I, Thomson MW, Carey VJ, Ge R, Bell GW, Regev A,
Weinberg RA (2008) An embryonic stem cell-like gene expression
signature in poorly differentiated aggressive human tumors. Nat
Genet 40(5):499507. doi:10.1038/ng.127
7. Brederlau A, Correia AS, Anisimov SV, Elmi M, Paul G, Roybon L,
Morizane A, Bergquist F, Riebe I, Nannmark U, Carta M, Hanse E,
Takahashi J, Sasai Y, Funa K, Brundin P, Eriksson PS, Li JY (2006)
Transplantation of human embryonic stem cell-derived cells to a rat
model of Parkinsons disease: effect of in vitro differentiation on
graft survival and teratoma formation. Stem Cells 24(6):14331440.
doi:10.1634/stemcells.2005-0393
8. Caplan AI, Dennis JE (2006) Mesenchymal stem cells as trophic
mediators. J Cell Biochem 98(5):10761084. doi:10.1002/jcb.
20886
9. Chaichana K, Zamora-Berridi G, Camara-Quintana J, QuinonesHinojosa A (2006) Neurosphere assays: growth factors and
hormone differences in tumor and nontumor studies. Stem Cells
24(12):28512857. doi:10.1634/stemcells.2006-0399
10. Chambers SM, Fasano CA, Papapetrou EP, Tomishima M, Sadelain
M, Studer L (2009) Highly efficient neural conversion of human ES
and iPS cells by dual inhibition of SMAD signaling. Nat Biotechnol
27(3):275280. doi:10.1038/nbt.1529
11. Chang DJ, Lee N, Park IH, Choi C, Jeon I, Kwon J, Oh SH, Shin
DA, Do JT, Lee DR, Lee H, Moon H, Hong KS, Daley GQ, Song J
(2012) Therapeutic potential of human induced pluripotent stem
cells in experimental stroke. Cell Transplant. doi:10.3727/
096368912X657314
12. Chua JY, Pendharkar AV, Wang N, Choi R, Andres RH, Gaeta X,
Zhang J, Moseley ME, Guzman R (2011) Intra-arterial injection of
neural stem cells using a microneedle technique does not cause

43

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

microembolic strokes. J Cereb Blood Flow Metab 31(5):1263

1271. doi:10.1038/jcbfm.2010.213
Daadi MM, Davis AS, Arac A, Li Z, Maag AL, Bhatnagar R, Jiang
K, Sun G, Wu JC, Steinberg GK (2010) Human neural stem cell
grafts modify microglial response and enhance axonal sprouting in
neonatal hypoxic-ischemic brain injury. Stroke 41(3):516523. doi:
10.1161/STROKEAHA.109.573691
Dammann O (2007) Persistent neuro-inflammation in cerebral
palsy: a therapeutic window of opportunity? Acta Paediatr 96(1):
67. doi:10.1111/j.1651-2227.2007.00097.x
Dammann O, Leviton A (1997) Maternal intrauterine infection,
cytokines, and brain damage in the preterm newborn. Pediatr Res
42(1):18. doi:10.1203/00006450-199707000-00001
De Feo D, Merlini A, Laterza C, Martino G (2012) Neural stem cell
transplantation in central nervous system disorders: from cell
replacement to neuroprotection. Curr Opin Neurol 25(3):322333.
doi:10.1097/WCO.0b013e328352ec45
de Vries LS, Jongmans MJ (2010) Long-term outcome after
neonatal hypoxic-ischaemic encephalopathy. Arch Dis Child Fetal
Neonatal Ed 95(3):F220F224. doi:10.1136/adc.2008.148205
Derecki NC, Cronk JC, Lu Z, Xu E, Abbott SB, Guyenet PG,
Kipnis J (2012) Wild-type microglia arrest pathology in a mouse
model of Rett syndrome. Nature 484(7392):105109. doi:10.1038/
nature10907
Ding DC, Shyu WC, Chiang MF, Lin SZ, Chang YC, Wang HJ, Su
CY, Li H (2007) Enhancement of neuroplasticity through
upregulation of beta1-integrin in human umbilical cord-derived
stromal cell implanted stroke model. Neurobiol Dis 27(3):339
353. doi:10.1016/j.nbd.2007.06.010
Einstein O, Friedman-Levi Y, Grigoriadis N, Ben-Hur T (2009)
Transplanted neural precursors enhance host brain-derived myelin
regeneration. J Neurosci 29(50):1569415702. doi:10.1523/
JNEUROSCI.3364-09.2009
Elbers J, Viero S, MacGregor D, DeVeber G, Moore AM (2011)
Placental pathology in neonatal stroke. Pediatrics 127(3):e722
e729. doi:10.1542/peds.2010-1490
Elsayed MH, Hogan TP, Shaw PL, Castro AJ (1996) Use of fetal
cortical grafts in hypoxic-ischemic brain injury in neonatal rats. Exp
Neurol 137(1):127141. doi:10.1006/exnr.1996.0013
Erblich B, Zhu L, Etgen AM, Dobrenis K, Pollard JW
(2011) Absence of colony stimulation factor-1 receptor results
in loss of microglia, disrupted brain development and olfactory
deficits. PLoS One 6(10):e26317. doi:10.1371/journal.pone.
0026317
Erceg S, Ronaghi M, Stojkovic M (2009) Human embryonic stem
cell differentiation toward regional specific neural precursors. Stem
Cells 27(1):7887. doi:10.1634/stemcells.2008-0543
Flax JD, Aurora S, Yang C, Simonin C, Wills AM, Billinghurst LL,
Jendoubi M, Sidman RL, Wolfe JH, Kim SU, Snyder EY (1998)
Engraftable human neural stem cells respond to developmental
cues, replace neurons, and express foreign genes. Nat Biotechnol
16(11):10331039. doi:10.1038/3473
Fleiss B, Gressens P (2012) Tertiary mechanisms of brain damage: a
new hope for treatment of cerebral palsy? Lancet Neurol 11(6):556
566. doi:10.1016/S1474-4422(12)70058-3
Fruttiger M, Karlsson L, Hall AC, Abramsson A, Calver AR,
Bostrom H, Willetts K, Bertold CH, Heath JK, Betsholtz C,
Richardson WD (1999) Defective oligodendrocyte development
and severe hypomyelination in PDGF-A knockout mice.
Development 126(3):457467
Fu YS, Shih YT, Cheng YC, Min MY (2004) Transformation of
human umbilical mesenchymal cells into neurons in vitro. J Biomed
Sci 11(5):652660. doi:10.1159/000079678
Gera A, Steinberg GK, Guzman R (2010) In vivo neural stem cell
imaging: current modalities and future directions. Regen Med 5(1):
7386. doi:10.2217/rme.09.79

44
30. Ginhoux F, Greter M, Leboeuf M, Nandi S, See P, Gokhan S,
Mehler MF, Conway SJ, Ng LG, Stanley ER, Samokhvalov IM,
Merad M (2010) Fate mapping analysis reveals that adult microglia
derive from primitive macrophages. Science 330(6005):841845.
doi:10.1126/science.1194637
31. Grad I, Hibaoui Y, Jaconi M, Chicha L, Bergstrom-Tengzelius R,
Sailani MR, Pelte MF, Dahoun S, Mitsiadis TA, Tohonen V,
Bouillaguet S, Antonarakis SE, Kere J, Zucchelli M, Hovatta O,
Feki A (2011) NANOG priming before full reprogramming may
generate germ cell tumours. Eur Cell Mater 22:258274, discussio
274
32. Greenfield JP, Ayuso-Sacido A, Schwartz TH, Pannullo S,
Souweidane M, Stieg PE, Boockvar JA (2008) Use of human neural
tissue for the generation of progenitors. Neurosurgery 62(1):2137.
doi:10.1227/01.NEU.0000311059.87873.46, discussion 27-30
33. Grether JK, Nelson KB (1997) Maternal infection and
cerebral palsy in infants of normal birth weight. JAMA 278(3):
207211
34. Gunther G, Junker R, Strater R, Schobess R, Kurnik K, Heller C,
Kosch A, Nowak-Gottl U (2000) Symptomatic ischemic stroke in
full-term neonates : role of acquired and genetic prothrombotic risk
factors. Stroke 31(10):24372441
35. Guzman R, Choi R, Gera A, De Los Angeles A, Andres RH,
Steinberg GK (2008) Intravascular cell replacement therapy for
stroke. Neurosurg Focus 24(34):E15. doi:10.3171/FOC/2008/24/
3-4/E14
36. Guzman R, De Los Angeles A, Cheshier S, Choi R, Hoang S,
Liauw J, Schaar B, Steinberg G (2008) Intracarotid injection of
fluorescence activated cell-sorted CD49d-positive neural stem cells
improves targeted cell delivery and behavior after stroke in a mouse
stroke model. Stroke 39(4):13001306. doi:10.1161/
STROKEAHA.107.500470
37. Guzman R, Uchida N, Bliss TM, He D, Christopherson KK,
Stellwagen D, Capela A, Greve J, Malenka RC, Moseley ME,
Palmer TD, Steinberg GK (2007) Long-term monitoring of
transplanted human neural stem cells in developmental and
pathological contexts with MRI. Proc Natl Acad Sci U S A
104(24):1021110216. doi:10.1073/pnas.0608519104
38. Hochedlinger K, Yamada Y, Beard C, Jaenisch R (2005) Ectopic
expression of Oct-4 blocks progenitor-cell differentiation and
causes dysplasia in epithelial tissues. Cell 121(3):465477. doi:10.
1016/j.cell.2005.02.018
39. Huang H, Zhang J, Wakana S, Zhang W, Ren T, Richards LJ,
Yarowsky P, Donohue P, Graham E, van Zijl PC, Mori S (2006)
White and gray matter development in human fetal, newborn and
pediatric brains. Neuroimaging 33(1):2738. doi:10.1016/j.
neuroimage.2006.06.009
40. Hung SC, Pochampally RR, Hsu SC, Sanchez C, Chen SC, Spees J,
Prockop DJ (2007) Short-term exposure of multipotent stromal cells
to low oxygen increases their expression of CX3CR1 and CXCR4
and their engraftment in vivo. PLoS One 2(5):e416. doi:10.1371/
journal.pone.0000416
41. Imitola J, Raddassi K, Park KI, Mueller FJ, Nieto M, Teng YD,
Frenkel D, Li J, Sidman RL, Walsh CA, Snyder EY, Khoury SJ
(2004) Directed migration of neural stem cells to sites of CNS injury
by the stromal cell-derived factor 1alpha/CXC chemokine receptor
4 pathway. Proc Natl Acad Sci U S A 101(52):1811718122. doi:
10.1073/pnas.0408258102
42. Issa R, AlQteishat A, Mitsios N, Saka M, Krupinski J, Tarkowski E,
Gaffney J, Slevin M, Kumar S, Kumar P (2005) Expression of basic
fibroblast growth factor mRNA and protein in the human brain
following ischaemic stroke. Angiogenesis 8(1):5362. doi:10.
1007/s10456-005-5613-8
43. Jansen EM, Solberg L, Underhill S, Wilson S, Cozzari C, Hartman
BK, Faris PL, Low WC (1997) Transplantation of fetal neocortex
ameliorates sensorimotor and locomotor deficits following neonatal

Childs Nerv Syst (2014) 30:3746

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.
55.

56.

57.

58.

59.

60.

ischemic-hypoxic brain injury in rats. Exp Neurol 147(2):487497.

doi:10.1006/exnr.1997.6596
Johnston MV, Hagberg H (2007) Sex and the pathogenesis of
cerebral palsy. Dev Med Child Neurol 49(1):7478. doi:10.1111/j.
1469-8749.2007.0199a.x
Khwaja O, Volpe JJ (2008) Pathogenesis of cerebral white matter
injury of prematurity. Arch Dis Child Fetal Neonatal Ed 93(2):
F153F161. doi:10.1136/adc.2006.108837
Kim H, Walczak P, Kerr C, Galpoththawela C, Gilad AA, Muja N,
Bulte JW (2012) Immunomodulation by Transplanted Human
Embryonic Stem Cell- Derived Oligodendroglial Progenitors in
Experimental Autoimmune Encephalomyelitis. Stem Cells. doi:10.
1002/stem.1218
Kirby RS (2012) Cerebral palsy and birth defects: what is the frame
of reference? Dev Med Child Neurol 54(8):677678. doi:10.1111/j.
1469-8749.2012.04331.x
Kokaia Z, Martino G, Schwartz M, Lindvall O (2012) Cross-talk
between neural stem cells and immune cells: the key to better brain
repair? Nat Neurosci 15(8):10781087. doi:10.1038/nn.3163
Kotter MR, Li WW, Zhao C, Franklin RJ (2006) Myelin impairs
CNS remyelination by inhibiting oligodendrocyte precursor cell
differentiation. J Neurosci 26(1):328332. doi:10.1523/
JNEUROSCI.2615-05.2006
Kuhl NM, De Keyser J, De Vries H, Hoekstra D (2002) Insulin-like
growth factor binding proteins-1 and -2 differentially inhibit rat
oligodendrocyte precursor cell survival and differentiation in vitro.
J Neurosci Res 69(2):207216. doi:10.1002/jnr.10293
Kurinczuk JJ, White-Koning M, Badawi N (2010) Epidemiology of
neonatal encephalopathy and hypoxic-ischaemic encephalopathy.
Early Hum Dev 86(6):329338. doi:10.1016/j.earlhumdev.2010.
05.010
Lacaud G, Robertson S, Palis J, Kennedy M, Keller G (2001)
Regulation of hemangioblast development. Ann N Y Acad Sci
938:96107, discussion 108
Larouche A, Roy M, Kadhim H, Tsanaclis AM, Fortin D, Sebire G
(2005) Neuronal injuries induced by perinatal hypoxic-ischemic
insults are potentiated by prenatal exposure to lipopolysaccharide:
animal model for perinatally acquired encephalopathy. Dev
Neurosci 27(24):134142. doi:10.1159/000085985
Levine S (1960) Anoxic-ischemic encephalopathy in rats. Am J
Pathol 36:117
Lim JY, Park SI, Kim SM, Jun JA, Oh JH, Ryu CH, Jeong CH, Park
SH, Park SA, Oh W, Chang JW, Jeun SS (2011) Neural
differentiation of brain-derived neurotrophic factor-expressing
human umbilical cord blood-derived mesenchymal stem cells in
culture via TrkB-mediated ERK and beta-catenin phosphorylation
and following transplantation into the developing brain. Cell
Transplant. doi:10.3727/096368910X557236
Lu P, Jones LL, Snyder EY, Tuszynski MH (2003) Neural stem cells
constitutively secrete neurotrophic factors and promote extensive
host axonal growth after spinal cord injury. Exp Neurol 181(2):115
129
Lu Z, Elliott MR, Chen Y, Walsh JT, Klibanov AL, Ravichandran
KS, Kipnis J (2011) Phagocytic activity of neuronal progenitors
regulates adult neurogenesis. Nat Cell Biol 13(9):10761083. doi:
10.1038/ncb2299
Mahmood A, Lu D, Chopp M (2004) Intravenous administration of
marrow stromal cells (MSCs) increases the expression of growth
factors in rat brain after traumatic brain injury. J Neurotrauma 21(1):
3339. doi:10.1089/089771504772695922
Marchetto MC, Winner B, Gage FH (2010) Pluripotent stem cells in
neurodegenerative and neurodevelopmental diseases. Hum Mol
Genet 19(R1):R71R76. doi:10.1093/hmg/ddq159
Martino G, Bacigaluppi M, Peruzzotti-Jametti L (2011) Therapeutic
stem cell plasticity orchestrates tissue plasticity. Brain 134(Pt 6):
15851587. doi:10.1093/brain/awr115

Childs Nerv Syst (2014) 30:3746

61. Mercuri E, Cowan F, Gupte G, Manning R, Laffan M, Rutherford
M, Edwards AD, Dubowitz L, Roberts I (2001) Prothrombotic
disorders and abnormal neurodevelopmental outcome in infants
with neonatal cerebral infarction. Pediatrics 107(6):14001404
62. Mosher KI, Andres RH, Fukuhara T, Bieri G, Hasegawa-Moriyama
M, He Y, Guzman R, Wyss-Coray T (2012) Neural progenitor cells
regulate microglia functions and activity. Nat Neurosci 15(11):
14851487. doi:10.1038/nn.3233
63. Muotri AR, Nakashima K, Toni N, Sandler VM, Gage FH (2005)
Development of functional human embryonic stem cell-derived
neurons in mouse brain. Proc Natl Acad Sci U S A 102(51):
1864418648. doi:10.1073/pnas.0509315102
64. Murohara T (2001) Therapeutic vasculogenesis using human cord
blood-derived endothelial progenitors. Trends Cardiovasc Med
11(8):303307
65. Nagae LM, Hoon AH Jr, Stashinko E, Lin D, Zhang W, Levey E,
Wakana S, Jiang H, Leite CC, Lucato LT, van Zijl PC, Johnston MV,
Mori S (2007) Diffusion tensor imaging in children with
periventricular leukomalacia: variability of injuries to white matter
tracts. AJNR Am J Neuroradiol 28(7):12131222. doi:10.3174/ajnr.
A0534
66. Nguyen HT, Geens M, Spits C (2013) Genetic and epigenetic
instability in human pluripotent stem cells. Hum Reprod Update
19(2):187205. doi:10.1093/humupd/dms048
67. Obenaus A, Dilmac N, Tone B, Tian HR, Hartman R, Digicaylioglu
M, Snyder EY, Ashwal S (2011) Long-term magnetic resonance
imaging of stem cells in neonatal ischemic injury. Ann Neurol
69(2):282291. doi:10.1002/ana.22168
68. Okita K, Ichisaka T, Yamanaka S (2007) Generation of germlinecompetent induced pluripotent stem cells. Nature 448(7151):313
317. doi:10.1038/nature05934
69. Oliff HS, Coyle P, Weber E (1997) Rat strain and vendor differences
in collateral anastomoses. J Cereb Blood Flow Metab 17(5):571
576. doi:10.1097/00004647-199705000-00012
70. Palmer TD, Schwartz PH, Taupin P, Kaspar B, Stein SA, Gage FH
(2001) Cell culture. Progenitor cells from human brain after death.
Nature 411(6833):4243. doi:10.1038/35075141
71. Park KI, Teng YD, Snyder EY (2002) The injured brain interacts
reciprocally with neural stem cells supported by scaffolds to
reconstitute lost tissue. Nat Biotechnol 20(11):11111117. doi:10.
1038/nbt751
72. Patrick LA, Smith GN (2002) Proinflammatory cytokines: a link
between chorioamnionitis and fetal brain injury. J Obstet Gynaecol
Can 24(9):705709
73. Paus T, Collins DL, Evans AC, Leonard G, Pike B, Zijdenbos A
(2001) Maturation of white matter in the human brain: a review of
magnetic resonance studies. Brain Res Bull 54(3):255266
74. Peitz M, Jungverdorben J, Brustle O (2013) Disease-specific iPS
cell models in neuroscience. Curr Mol Med 13(5):832841
75. Pendharkar AV, Chua JY, Andres RH, Wang N, Gaeta X, Wang H,
De A, Choi R, Chen S, Rutt BK, Gambhir SS, Guzman R (2010)
Biodistribution of neural stem cells after intravascular therapy for
hypoxic-ischemia. Stroke 41(9):20642070. doi:10.1161/
STROKEAHA.109.575993
76. Pimentel-Coelho PM, Rosado-de-Castro PH, da Fonseca LM,
Mendez-Otero R (2012) Umbilical cord blood mononuclear cell
transplantation for neonatal hypoxic-ischemic encephalopathy.
Pediatr Res 71(4 Pt 2):464473. doi:10.1038/pr.2011.59
77. Pluchino S, Zanotti L, Rossi B, Brambilla E, Ottoboni L, Salani G,
Martinello M, Cattalini A, Bergami A, Furlan R, Comi G,
Constantin G, Martino G (2005) Neurosphere-derived multipotent
precursors promote neuroprotection by an immunomodulatory
mechanism. Nature 436(7048):266271. doi:10.1038/nature03889
78. Rice JE 3rd, Vannucci RC, Brierley JB (1981) The influence of
immaturity on hypoxic-ischemic brain damage in the rat. Ann
Neurol 9(2):131141. doi:10.1002/ana.410090206

45
79. Rickhag M, Teilum M, Wieloch T (2007) Rapid and long-term
induction of effector immediate early genes (BDNF, Neuritin and
Arc) in peri-infarct cortex and dentate gyrus after ischemic injury in
rat brain. Brain Res 1151:203210. doi:10.1016/j.brainres.2007.03.005
80. Righini A, Doneda C, Parazzini C, Arrigoni F, Matta U, Triulzi F
(2010) Diffusion tensor imaging of early changes in corpus callosum
after acute cerebral hemisphere lesions in newborns. Neuroradiology
52(11):10251035. doi:10.1007/s00234-010-0745-y
81. Rosenblum S, Wang N, Smith TN, Pendharkar AV, Chua JY, Birk
H, Guzman R (2012) Timing of intra-arterial neural stem cell
transplantation after hypoxia-ischemia influences cell engraftment,
survival, and differentiation. Stroke 43(6):16241631. doi:10.1161/
STROKEAHA.111.637884
82. Ruckh JM, Zhao JW, Shadrach JL, van Wijngaarden P, Rao TN,
Wagers AJ, Franklin RJ (2012) Rejuvenation of regeneration in the
aging central nervous system. Cell Stem Cell 10(1):96103. doi:10.
1016/j.stem.2011.11.019
83. Santilli G, Lamorte G, Carlessi L, Ferrari D, Rota Nodari L, Binda
E, Delia D, Vescovi AL, De Filippis L (2010) Mild hypoxia
enhances proliferation and multipotency of human neural stem cells.
PLoS One 5(1):e8575. doi:10.1371/journal.pone.0008575
84. Schwarting S, Litwak S, Hao W, Bahr M, Weise J, Neumann H
(2008) Hematopoietic stem cells reduce postischemic inflammation
and ameliorate ischemic brain injury. Stroke 39(10):28672875.
doi:10.1161/STROKEAHA.108.513978
85. Segovia KN, McClure M, Moravec M, Luo NL, Wan Y, Gong X,
Riddle A, Craig A, Struve J, Sherman LS, Back SA (2008) Arrested
oligodendrocyte lineage maturation in chronic perinatal white
matter injury. Ann Neurol 63(4):520530. doi:10.1002/ana.21359
86. Seminatore C, Polentes J, Ellman D, Kozubenko N, Itier V, Tine S,
Tritschler L, Brenot M, Guidou E, Blondeau J, Lhuillier M, Bugi A,
Aubry L, Jendelova P, Sykova E, Perrier AL, Finsen B, Onteniente
B (2010) The postischemic environment differentially impacts
teratoma or tumor formation after transplantation of human
embryonic stem cell-derived neural progenitors. Stroke 41(1):153
159. doi:10.1161/STROKEAHA.109.563015
87. Shah PS, Perlman M (2009) Time courses of intrapartum asphyxia:
neonatal characteristics and outcomes. Am J Perinatol 26(1):3944.
doi:10.1055/s-0028-1095185
88. Shechter R, London A, Varol C, Raposo C, Cusimano M, Yovel G,
Rolls A, Mack M, Pluchino S, Martino G, Jung S, Schwartz M
(2009) Infiltrating blood-derived macrophages are vital cells
playing an anti-inflammatory role in recovery from spinal cord
injury in mice. PLoS Med 6(7):e1000113. doi:10.1371/journal.
pmed.1000113
89. Sizonenko SV, Camm EJ, Dayer A, Kiss JZ (2008) Glial responses
to neonatal hypoxic-ischemic injury in the rat cerebral cortex. Int J
Dev Neurosci 26(1):3745. doi:10.1016/j.ijdevneu.2007.08.014
90. Sotak CH (2002) The role of diffusion tensor imaging in the
evaluation of ischemic brain injurya review. NMR Biomed
15(78):561569. doi:10.1002/nbm.786
91. Stewart MH (2013) Pluripotency and targeted reprogramming:
strategies, disease modeling and drug screening. Curr Drug Deliv
92. Svendsen CN, Caldwell MA, Ostenfeld T (1999) Human neural
stem cells: isolation, expansion and transplantation. Brain Pathol
9(3):499513
93. Taguchi A, Soma T, Tanaka H, Kanda T, Nishimura H, Yoshikawa
H, Tsukamoto Y, Iso H, Fujimori Y, Stern DM, Naritomi H,
Matsuyama T (2004) Administration of CD34+ cells after stroke
enhances neurogenesis via angiogenesis in a mouse model. J Clin
Invest 114(3):330338. doi:10.1172/JCI20622
94. Takahashi K, Yamanaka S (2006) Induction of pluripotent stem
cells from mouse embryonic and adult fibroblast cultures by defined
factors. Cell 126(4):663676. doi:10.1016/j.cell.2006.07.024
95. Tamaki S, Eckert K, He D, Sutton R, Doshe M, Jain G, Tushinski R,
Reitsma M, Harris B, Tsukamoto A, Gage F, Weissman I, Uchida N

46

96.

97.

98.

99.

100.

101.

102.

103.
104.
105.
106.

107.

Childs Nerv Syst (2014) 30:3746

(2002) Engraftment of sorted/expanded human central nervous
system stem cells from fetal brain. J Neurosci Res 69(6):976986.
doi:10.1002/jnr.10412
Thomson JA, Itskovitz-Eldor J, Shapiro SS, Waknitz MA, Swiergiel
JJ, Marshall VS, Jones JM (1998) Embryonic stem cell lines derived
from human blastocysts. Science 282(5391):11451147
Thornton C, Rousset CI, Kichev A, Miyakuni Y, Vontell R,
Baburamani AA, Fleiss B, Gressens P, Hagberg H (2012)
Molecular mechanisms of neonatal brain injury. Neurol Res Int
2012:506320. doi:10.1155/2012/506320
Tipnis S, Viswanathan C, Majumdar AS (2010) Immunosuppressive
properties of human umbilical cord-derived mesenchymal stem cells:
role of B7-H1 and IDO. Immunol Cell Biol 88(8):795806. doi:10.
1038/icb.2010.47
Titomanlio L, Kavelaars A, Dalous J, Mani S, El Ghouzzi V,
Heijnen C, Baud O, Gressens P (2011) Stem cell therapy for
neonatal brain injury: perspectives and challenges. Ann Neurol
70(5):698712. doi:10.1002/ana.22518
Tso GH, Law HK, Tu W, Chan GC, Lau YL (2010) Phagocytosis of
apoptotic cells modulates mesenchymal stem cells osteogenic
differentiation to enhance IL-17 and RANKL expression on CD4+
T cells. Stem Cells 28(5):939954. doi:10.1002/stem.406
van Velthoven CT, Kavelaars A, van Bel F, Heijnen CJ (2010)
Mesenchymal stem cell treatment after neonatal hypoxic-ischemic
brain injury improves behavioral outcome and induces neuronal and
oligodendrocyte regeneration. Brain Behav Immun 24(3):387393.
doi:10.1016/j.bbi.2009.10.017
Vant Veer A, Du Y, Fischer TZ, Boetig DR, Wood MR, Dreyfus CF
(2009) Brain-derived neurotrophic factor effects on oligodendrocyte
progenitors of the basal forebrain are mediated through trkB and the
MAP kinase pathway. J Neurosci Res 87(1):6978. doi:10.1002/jnr.
21841
Vannucci RC (1993) Experimental models of perinatal hypoxicischemic brain damage. APMIS Suppl 40:8995
Vannucci RC, Perlman JM (1997) Interventions for perinatal
hypoxic-ischemic encephalopathy. Pediatrics 100(6):10041014
Vannucci SJ, Hagberg H (2004) Hypoxia-ischemia in the immature
brain. J Exp Biol 207(Pt 18):31493154. doi:10.1242/jeb.01064
Vendrame M, Gemma C, Pennypacker KR, Bickford PC, Davis
Sanberg C, Sanberg PR, Willing AE (2006) Cord blood rescues
stroke-induced changes in splenocyte phenotype and function. Exp
Neurol 199(1):191200. doi:10.1016/j.expneurol.2006.03.017
Vescovi AL, Gritti A, Galli R, Parati EA (1999) Isolation and
intracerebral grafting of nontransformed multipotential embryonic
human CNS stem cells. J Neurotrauma 16(8):689693

108. Vescovi AL, Parati EA, Gritti A, Poulin P, Ferrario M, Wanke E,

Frolichsthal-Schoeller P, Cova L, Arcellana-Panlilio M, Colombo A,
Galli R (1999) Isolation and cloning of multipotential stem cells from
the embryonic human CNS and establishment of transplantable
human neural stem cell lines by epigenetic stimulation. Exp Neurol
156(1):7183. doi:10.1006/exnr.1998.6998
109. Volpe JJ (2008) Neonatal encephalitis and white matter injury: more
than just inflammation? Ann Neurol 64(3):232236. doi:10.1002/
ana.21466
110. Volpe JJ (2008) Postnatal sepsis, necrotizing entercolitis, and the
critical role of systemic inflammation in white matter injury in
premature infants. J Pediatr 153(2):160163. doi:10.1016/j.jpeds.
2008.04.057
111. Walker PA, Shah SK, Jimenez F, Gerber MH, Xue H, Cutrone R,
Hamilton JA, Mays RW, Deans R, Pati S, Dash PK, Cox CS Jr
(2010) Intravenous multipotent adult progenitor cell therapy for
traumatic brain injury: preserving the blood brain barrier via an
interaction with splenocytes. Exp Neurol 225(2):341352. doi:10.
1016/j.expneurol.2010.07.005
112. Wang M, Yang Y, Yang D, Luo F, Liang W, Guo S, Xu J (2009) The
immunomodulatory activity of human umbilical cord blood-derived
mesenchymal stem cells in vitro. Immunology 126(2):220232. doi:
10.1111/j.1365-2567.2008.02891.x
113. Wei Y, Yemisci M, Kim HH, Yung LM, Shin HK, Hwang SK, Guo
S, Qin T, Alsharif N, Brinkmann V, Liao JK, Lo EH, Waeber C
(2011) Fingolimod provides long-term protection in rodent models
of cerebral ischemia. Ann Neurol 69(1):119129. doi:10.1002/ana.
22186
114. Wu YW, Hamrick SE, Miller SP, Haward MF, Lai MC, Callen PW,
Barkovich AJ, Ferriero DM (2003) Intraventricular hemorrhage in
term neonates caused by sinovenous thrombosis. Ann Neurol 54(1):
123126. doi:10.1002/ana.10619
115. Wu YW, March WM, Croen LA, Grether JK, Escobar GJ, Newman
TB (2004) Perinatal stroke in children with motor impairment: a
population-based study. Pediatrics 114(3):612619. doi:10.1542/
peds.2004-0385
116. Xia G, Hong X, Chen X, Lan F, Zhang G, Liao L (2010)
Intracerebral transplantation of mesenchymal stem cells derived
from human umbilical cord blood alleviates hypoxic ischemic brain
injury in rat neonates. J Perinat Med 38(2):215221. doi:10.1515/
JPM.2010.021
117. Zhang J, Li Y, Cui Y, Chen J, Lu M, Elias SB, Chopp M (2005)
Erythropoietin treatment improves neurological functional recovery
in EAE mice. Brain Res 1034(12):3439. doi:10.1016/j.brainres.
2004.11.036