Neuroscience and Biobehavioral Reviews 144 (2023) 104974

Contents lists available at ScienceDirect

Neuroscience and Biobehavioral Reviews

journal homepage: www.elsevier.com/locate/neubiorev

Exosome-based approaches in the management of Alzheimer’s disease

Raghuram Kandimalla a, Mohd Saeed b, Neetu Tyagi c, Ramesh C. Gupta a, d, Farrukh Aqil a, e, *
a
Brown Cancer Center, University of Louisville, Louisville, KY 40202, USA
b
Department of Biology, College of Sciences, University of Hail, PO Box 2240, Hail, Saudi Arabia
c
Department of Physiology, University of Louisville, Louisville, KY 40202, USA
d
Department of Pharmacology and Toxicology, University of Louisville, Louisville, KY 40202, USA
e
Department of Medicine, University of Louisville, Louisville, KY 40202, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Alzheimer’s disease (AD) has been the most extensively studied neurological disorders that affects millions of
Exosome individuals globally and is associated with misfolding of proteins in the brain. Amyloid-β and tau are predom­
Alzheimer’s disease inantly involved in the pathogenesis of AD. Therapeutic interventions and nanotechnological advancements are
Blood brain barrier
useful only in managing the AD symptoms and the cure for this disease remains elusive. Exosomes, originating
Drug delivery
Gene therapy
from most cell and tissue types are regarded as a double-edged sword, considering their roles in the progression
and treatment of AD. Exosomes can be manipulated as drug delivery vehicles for a wide range of therapeutic
cargos—both small molecules and macromolecules. Herein, we review the roles of exosomes in the pathology,
diagnosis, and treatment of AD and highlight their application as a drug carrier to the brain for AD treatment.

1. Introduction urine. Owing to their size in the nanometer range and intrinsic ability to
facilitate cell-to-cell communication, exosomes could serve as a poten­
The prevalence of Alzheimer’s disease (AD) and related dementias is tial drug delivery vehicle in rodent models to deliver the drugs to
alarmingly rising among the elderly population worldwide. According to different organs including the brain for various diseases including can­
the World Alzheimer’s Report, there are 46.8 million AD sufferers cer (Elliott and He, 2021). Additionally, the presence of readily target­
worldwide and this number is anticipated to triple by 2050 as the able surface protein markers on exosomes and their ability to undergo
population ages (Gauthier et al., 2021). There is no treatment for AD; the endocytosis aid the distribution of their payload (Simeone et al., 2020).
prescribed medicines only manage the symptoms, may change disease Exosomes are major mediators of intercellular crosstalk within the
progression and reduce discomfort. Advances in nanotechnology pro­ neurovascular unit, which is formed in the CNS by the BBB and neigh­
vide some respite from the symptoms of AD, but a definitive cure re­ boring cells including pericytes, perivascular astrocytes, microglia, and
mains elusive. Therefore, speedy development of efficient novel neurons (Andras and Toborek, 2016; Chivet et al., 2014; Kalani et al.,
therapies and drug delivery systems is required for the management of 2014; Ramirez et al., 2018). Exosomes have also been shown to contain
these diseases. Delivery of therapeutics to the brain, which is shielded by transferrin and insulin receptors that allow uptake via BBB (Podratz and
the blood-brain barrier (BBB), has always been a challenge in the Cliby, 1994). Unique surface proteins, such as CD47, protect the exo­
advancement of therapeutic strategies for neurological disorders (ND). somes from phagocytosis through binding to signal regulatory protein
BBB prevents invasion of pathogens and diseases into the brain envi­ alpha (SIRPα) and initiating the “Don’t eat me” signal (Kamerkar et al.,
ronment. Several approaches for transporting therapeutic drugs across 2017). Exosomes have been subjected to systematic alterations, which
the BBB have been tested; however, most of them have either failed or had led to a number of discoveries that can improve their uptake and
cause structural damage to this barrier (Gabathuler, 2010). Nano­ effectiveness by improving BBB penetration (Gao et al., 2018). One of
biotechnological approaches are among the most viable approaches for these alterations involves the fusion and receptor-mediated trans­
targeting drugs to the brain. portation in which exosomes can be manipulated to deliver therapeutic
Exosomes are nanosized vesicles derived from various cell types and agents to the target sites (Heidarzadeh et al., 2021). Exosomes play a
are abundant in almost all biological fluids, including milk, blood, and role in the pathophysiology of AD and can also be employed to deliver

* Correspondence to: University of Louisville, Farrukh Aqil, Room 304B, 580S. Preston Street, Louisville, KY, 40202, USA.
E-mail address: farrukh.aqil@louisville.edu (F. Aqil).

https://doi.org/10.1016/j.neubiorev.2022.104974
Received 2 August 2022; Received in revised form 21 November 2022; Accepted 22 November 2022
Available online 23 November 2022
0149-7634/© 2022 Elsevier Ltd. All rights reserved.
R. Kandimalla et al. Neuroscience and Biobehavioral Reviews 144 (2023) 104974

therapeutics to hard-to-reach targets. In this review, we highlight the brains, but Aβ1–42 (a 42-amino acid isoform) is extremely neurotoxic,
roles of exosomes in the pathophysiology, diagnosis, and drug delivery, and is mostly found in the brain tissue of AD patients, accounting for less
with a focus on their potential in the treatment of AD. than 10% of the total Aβ content (Wang et al., 2021). These monomers
are rapidly broken down in astrocytes and microglia through
2. Neurological disorders and Alzheimer’s disease receptor-mediated internalization and phagocytosis.
In AD, the balance between the production and scavenging of Aβ is
The two main organs affected by ND are the brain and spinal cord. disrupted. Aβ monomers are released into the synaptic cleft and form Aβ
The main variables contributing to the pathogenesis of different ND oligomers, which are further aggregated to form senile plaques (Pal
include genetics, infection, aging, environmental condition, dietary et al., 2021). These senile plaques block the movement of neurotrans­
choices, and lifestyle changes. Lifestyle factors, such as aging, brain mitters and communication between the neurons. On the contrary, tau
damage, oxidative stress, high-fat diets, addiction to alcohol and ciga­ protein helps in stabilizing the microtubule tracks inside the neurons
rette smoking, high-sugar diets, and neuroinflammation, have a detri­ and maintains the anterograde (soma to axon terminal) and retrograde
mental effect on the onset, severity, and prognosis of ND (Popa-Wagner (axon terminal to soma) neuronal transport (Combs et al., 2019; Iqbal
et al., 2020). Brain cells require a steady flow of oxygen and nutrients to et al., 2010). In AD, Aβ stimulates intraneuronal kinases that phos­
perform their functions. Disorders, such as stroke, disrupt the blood phorylates tau protein and then tau protein cleaves off from microtu­
supply to the brain, resulting in the loss of neurological function. In the bules and is segregated to form neurofibrillary tangles, destabilizing the
US, stroke is one of the main causes of mortality and disability. In microtubular highway neuronal transport leading to neuronal dysfunc­
addition to stroke, neurodegenerative conditions, such as AD and Par­ tion (Iqbal et al., 2010). These dysfunctional neurons are unable to
kinson’s disease (PD), damage the brain. Herein, to remain focused, we secrete choline acetyltransferase (ChAT) and reduce the formation of
have mainly reviewed the role of exosomes in the pathogenesis, diag­ acetylcholine neurotransmitter, which is responsible for many cognitive
nosis, and treatment of AD. and motor functions of the brain. Currently, there is no cure for AD;
CNS gathers and analyzes sensory data and delivers motor impulses drugs used in clinical settings merely treat the symptoms. In this context,
to other organs through connections between different neuronal cells the development of novel therapeutic approaches is necessary for the
and other glial cells like microglia, astrocytes, and oligodendrocytes improvement of AD therapy.
(Huo et al., 2021). AD is a type of dementia characterized by brain at­
rophy caused by neuronal death, which reduces the capacity of the brain 3. Approaches for drug delivery—BBB and other challenges
for thought, movement, and behavior. AD mainly damages the temporal
lobes of the brain, and the damage eventually spreads to other areas. AD Physiologically, brain is the most challenging area in the body for
patients exhibit shrinkage of the hippocampus and cerebral cortex, drug transport. The entry of toxins, infectious agents, neurotherapeutics,
which are involved in memory and language processing. Additionally, and other foreign molecules is restricted by the BBB (Pardridge, 2002).
the brain of AD patients exhibits wider sulci, enlarged brain ventricles, BBB is a vascular structure made up of endothelial cells, pericytes, and
and narrower gyri. The alterations in the brain anatomy are caused by astrocytes. It has a surface area of about 20 m2 and the length of human
neurodegeneration consequent to the buildup of extracellular poly­ brain capillaries is approximately 400 miles (Kadry et al., 2020). Brain
morphous β-amyloid protein (senile plaques) and intracellular tau pro­ capillary endothelial cells weld together to form a tight junction and are
tein (fibrillary tangles). Amyloid precursor protein (APP) is necessary responsible for 100-fold reduction in pinocytosis across the endothelial
for the development and maintenance of neurons in the brain. APP is membrane (Pardridge, 2002). Several transcellular mechanisms, such as
generally cleaved into smaller pieces by the secretases, β and ɣ, forming efflux transport, diffusion, carrier-mediated transport, adsorptive
amyloid beta (Aβ) monomers (Fig. 1). The length of Aβ peptide frag­ transcytosis, paracellular transport, and receptor (folate, glutamine,
ments ranges from 36 to 46 amino acids. Aβ1–40 (a 40-amino acid insulin, IL-13 receptor alpha 2, lipoprotein, scavenging,
isoform) is soluble and less toxic and is frequently found in healthy transferrin)-mediated transcytosis are involved in the transportation of

Fig. 1. Pathophysiology of Alzheimer’s disease and role of

exosomes in its development. Enzymatic degradation of
amyloid precursor protein generates amyloid beta (Aβ),
which is taken up by early endosomes and accumulates on
the exosome surface. The release of exosomes containing
Aβ into the synaptic cleft helps in the formation of senile
plaques and blocks neurotransmission, leading to the
development of AD. On the contrary, instability of micro­
tubules in recipient neurons results in the release of tau and
in the development of neurofibrillary tangles, which, in
turn, cause damage to the neurons and receptors. Damaged
neurons are unable to produce choline acetyltransferase
(ChAT) and inhibit acetylcholine production by preventing
the interaction of acetyl-CoA and choline. By preventing
neurotransmission and causing damage to neuronal cells,
Aβ and neurofibrillary tangles affect the functioning of the
brain and lead to the progression of AD. Created with
Biorender.com.

2
R. Kandimalla et al. Neuroscience and Biobehavioral Reviews 144 (2023) 104974

various molecules into the brain (Heidarzadeh et al., 2021; Matsumoto quercetin (Kuo and Tsao, 2017; Rifaai et al., 2020), rivastigmine (Mutlu
et al., 2017; Tang et al., 2019) (Fig. 2). Passive transport across the et al., 2011), and celecoxib (Guo et al., 2017), as well as macromole­
endothelial cells is regulated by size and physicochemical properties of cules, such as nucleic acids (Arora et al., 2021), to the brain for the
the molecules to cross the BBB. Molecules should possess appropriate treatment of AD.
hydrophilicity and lipophilicity balance with a size < 500 Daltons to To enhance the bioavailability of drugs and to ensure their protection
cross the BBB employing this mechanism (Pardridge, 2005, 2012). from enzymatic degradation, polymeric nanoparticles have been used to
There are three main approaches for drug delivery across BBB, deliver drugs to the brain. Various polymers, such as chitosan, N-butyl-
namely i) invasive approaches; ii) pharmacological approaches; and iii) 2-cyanoacrylate (BCA), and polylactic acid (PLA), have been used in the
physiological approaches (Gabathuler, 2010). development of brain-targeting nanoparticles and for delivering anti-
Invasive approaches deliver drug to the brain by mechanically amyloid beta antibodies (Jaruszewski et al., 2012) and proteins
breaching the BBB. These include inserting a catheter, using hydraulic (Zhang et al., 2014), for AD treatment. Other approaches, such as those
pressure or implants, and intracerebral injection. Invasive approaches using metal nanoparticles (Sonawane et al., 2019), cubosomes (Elnaggar
are expensive and can injure the neurons. In pharmacological ap­ et al., 2015), magnetic nanoparticles (Do et al., 2016), nanocomposites
proaches, the chemical structure of drug molecules is modified to (Chen et al., 2018), antibody-tagged nanoparticles (Carradori et al.,
enhance their penetration across the BBB. In some cases, drugs are 2018), nanoemulsions (Kaur et al., 2020), and dendrimers (Igartua et al.,
enclosed within lipid carriers or polymeric micelles for better movement 2018), have been explored for brain targeting and treatment of AD. The
across the BBB. However, such approaches are limited by the loss of nanodelivery systems showed promising results in preclinical studies
pharmacological activity of drugs due to structural modification. The (Cano et al., 2021), but most of them failed to reach the clinical phase
exact mechanism of drug uptake through different carriers is not known due to scalability issues and toxicity concerns. Therefore, there is a need
and their efficacy has not been explored for hydrophilic drugs. for efficient, nontoxic, and scalable drug carriers to fulfill the unmet
Physiological approaches are widely accepted by the scientific need of brain drug delivery for treating AD and other ND. In the past few
community for the delivery of drugs to the brain. In this approach, drugs years, there has been an increasing interest in the brain delivery using
mimic the native transport of brain surviving nutrients across BBB exosomes.
through their conjugation with ligands that are expressed on the BBB.
The uptake of the resulting drug–ligand complexes across BBB via re­ 4. Exosomes: Sources and isolation
ceptors is mediated by transcytosis. The possible mechanisms underly­
ing the different approaches involved in transport across BBB have been Exosomes or small extracellular vesicles (EVs) are natural nano­
reviewed previously (Gabathuler, 2010). particles, ranging in size from 30 to 150 nm, produced by most cell types
A growing body of research indicates the effectiveness of different in the body. They are widely distributed in biological fluids, such as
nanotechnological approaches in overcoming the hindrance in drug blood serum, plasma, saliva, urine, cerebrospinal fluid (CSF), and milk.
delivery to brain across the BBB for the treatment of AD. Among these Exosomes comprise of a lipid bilayer, embedded with transmembrane
approaches, liposomes have been widely studied as carriers for the de­ proteins and other characteristic protein markers, and a core that is
livery of drugs to the brain. Liposomes are prepared from a variety of packed with enzymes, extracellular matrix proteins, lipids, nucleic acids
lipids and other components, such as cholesterol, polyethylene glycol (DNA and RNA), and transcription factors (Kandimalla et al., 2021b) as
(PEG), egg phosphatidylcholine (EPC), 1,2-distearoyl-sn-glycero-3- shown in Fig. 3. The main techniques used for the isolation of exosomes
phosphoethanolamine (DSPE), dioctadecyl dimethyl ammonium bro­ are ultracentrifugation (Munagala et al., 2016), ultra-filtration,
mide (DDAB), 1,2-dimyristoyl-sn-glycero-3-phosphocholine (DMPC), size-exclusion chromatography, polymer-based precipitation, isoelec­
1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC), 1,2-distearoyl-sn- tric precipitation, and microfluidic technologies. However, based on the
glycero-3-phosphocholine (DSPC), poly(lactic-co-glycolic acid) (PLGA), Minimal information for studies of extracellular vesicles 2018 guide­
soybean phosphatidylcholine (SPC), and stearic acid. Liposomes have lines, the use of a combination of methods for exosome isolation is
been successfully used to deliver small molecules, such as curcumin preferred (Thery et al., 2018). The different methods used in the isola­
(Kuo and Lin, 2015; Kuo et al., 2017; Mourtas et al., 2011, 2014), tion of exosomes have been recently reviewed (Kandimalla et al.,

Fig. 2. Structure of the blood–brain barrier (BBB) and

cargo transport mechanism across blood and brain via the
BBB. Brain neuronal cells are guarded against the entry of
substances from the blood by the BBB. The BBB is made up
of tight endothelial junctions surrounded by pericytes and
astrocytes. The entry of drugs into the brain via the BBB is
mediated through various pathways, such as adsorptive
transcytosis, carrier-mediated transport, diffusion, efflux
transport, paracellular transport, and receptor-mediated
transcytosis. Created with Biorender.com.
Partially adapted with permission from (Tang et al., 2019).

3
R. Kandimalla et al. Neuroscience and Biobehavioral Reviews 144 (2023) 104974

Fig. 3. Biogenesis, source, and composition of

exosomes. Exosomes, a class of small extracel­
lular vesicles (EVs), originate from most cell
types and are abundantly available in cell cul­
ture media and body fluids, such as plasma/
serum, urine, and milk. Multivesicular bodies
(MVBs) are generated from early endosomes by
inward budding of the plasma membrane into
the lumen. The exosomes are released into the
extracellular space upon fusion of late MVBs
with the plasma membrane. The exosomes once
released into cell culture medium or body fluid
can be isolated and utilized for disease man­
agement. Exosomes are made up of a lipid
bilayer with distinctive protein identifiers, such
as CD9, CD63, CD81, ALIX, and TSG101, and
their cores are packed with various proteins,
growth factors, enzymes and different nucleic
acids.
Partially adapted with permission from (Kan­
dimalla et al., 2021b).

2021b). pathogenesis of different neurodegenerative diseases, including AD

Because the lipid and surface protein composition differ among (Graykowski et al., 2020).
exosomes isolated from various sources and is also crucial for their APP and apolipoprotein E (ApoE) were reported to be significantly
functions, identifying new sources of exosomes is of great interest. more prevalent in the early endosomes generated in the brain neurons of
Exosomes have been isolated from several sources, such as mesenchymal AD patients compared with that in normal individuals (Cataldo et al.,
stem cells (Lou et al., 2017; Yu et al., 2014) and dendritic cells (Damo 1997). Early endosomes are regarded as the major sites of APP pro­
et al., 2015; Elashiry et al., 2021), and have been used in different fields cessing and their enlargement coincides with increased levels of Aβ40
of research. Exosomes and exosome-like particles isolated from reliable and Aβ42 peptides and Aβ accumulation in AD patients (Cataldo et al.,
natural sources, such as milk, fruits, and plants, have been explored as 2001, 2004). Aβ42 is localized in multivesicular bodies (MVBs) of
alternative options for clinical use owing to their better safety profiles neurons in the brain of mice, rats, and humans and its levels increase
(Ju et al., 2013; Munagala et al., 2016). However, the functions of with age in both pre- and postsynaptic compartments, which in turn is
exosomes isolated from these sources and the possibility of their bulk associated with synaptic dysfunction and AD progression (Takahashi
isolation have been debatable issues. Therefore, our group has utilized et al., 2002). Exosomes also play a major role in the formation of senile
bovine milk (Munagala et al., 2016) and standardized colostrum powder plaques at neuronal junctions and neurofibrillary tangles inside the
(Kandimalla et al., 2021a; Munagala et al., 2021) for the isolation of neurons. Rajendran et al. (2006) reported that β-cleavage of APP occurs
exosomes in large quantities; these are the most abundant biocompatible in the early endosome phase and fractions of Aβ are embedded into
sources of exosomes. Exosomes have also been engineered or manipu­ MVBs and released into the extracellular space through the plasma
lated for different therapeutic applications, such as for drug delivery and membrane. Exosomal proteins could accumulate along with Aβ plaques,
in AD. In a recent review from our group (Kandimalla et al., 2021b), indicating their role in AD pathogenesis (Rajendran et al., 2006). Alix,
detailed procedures for the isolation of exosome and their therapeutic an exosomal marker, was shown to be present in human amyloid pla­
uses for various biomedical applications have been elaborated. ques, which suggests the contribution of exosomes in the formation of
Aβ plaques in AD patients (Yuyama et al., 2015). In another study, the
5. Exosomes in Alzheimer’s disease possible interaction of exosomes derived from neuro 2 A (N2a) cells with
Aβ was confirmed (Yuyama et al., 2014). Aβ is released into the synaptic
AD is a progressive neurodegenerative disorder, which is manifested cleft through exosome-mediated pathways (Takahashi et al., 2002;
by many functions such as memory loss, movement disorders, learning Vingtdeux et al., 2007). Exosomes isolated from blood, CSF, and urine of
impairment, speech and motor deficits, psychological disturbance, etc. mice with AD have been shown to possess increased amounts of C-ter­
Increasing data suggest that exosomes can play a role in the diagnosis minal fragments of APP (Laulagnier et al., 2018; Miranda et al., 2018).
and treatment of AD. However, the importance of exosomes in the Accumulation of pathological tau protein is a major hallmark of AD.
emergence of AD has not been confirmed. Exosomes demonstrate posi­ Exosomes play a major role in the interneuronal transfer of tau protein
tive effects on AD by scavenging Aβ, supporting neuronal functions; and induce AD (Ruan, 2022). Gradual deposition of hyper­
however, they may have harmful effects through the spreading of Aβ and phosphorylated tau protein in neurons leads to tauopathy in patients
tau, causing neuroinflammation and neuronal dysfunction. with AD (Saman et al., 2012). In a study, wherein EVs isolated from
frozen human brains with AD, prodromal AD, and no AD were injected
5.1. Exosomes in the pathogenesis of Alzheimer’s disease into 18-month-old female wild-type mice, mice receiving EVs from AD
patients showed high levels of phospho-tau protein in the hippocampus
Until recently, it was believed that communications in neuronal cells compared with those receiving EVs from patients with prodromal AD or
occur through the release of neurotransmitters into the synaptic cleft, from no AD control brain. This suggests that EVs have the capability to
and this activates the receptors present on adjacent neurons. However, induce fibrillary tau protein in mouse brains (Ruan et al., 2021).
growing evidence suggests that apart from the conventional neuro­ Microglia, the primary phagocytes in the brain, are positively
transmission, exosomes or sEVs released by neuronal cells play a major correlated with tau pathology. Asai et al. (2015) developed an
role in cell-to-cell communication in the CNS and are involved in the adenovirus-based mouse model, which exhibits tau propagation in 4

4
R. Kandimalla et al. Neuroscience and Biobehavioral Reviews 144 (2023) 104974

weeks (Asai et al., 2015). In this study, exosomes secreted by microglia levels of synaptic protein markers, such as synaptophysin,
were observed to play a major role in the propagation of tau protein. synaptotagmin-2, synaptopodin, synapsin 1, growth-associated protein
Depletion of microglia suppressed this propagation and reduced the 43 (GAP43), post-synaptic adhesion protein neuroligin 1 (NLGN1), and
excitability in the dentate gyrus. This study showed that microglia pre-synaptic neurexin 2α (NRXN2α), and survival cellular proteins, such
spread tau via exosome secretion and, thus, inhibition of exosome syn­ as repressor element 1-silencing transcription factor (REST), low-density
thesis reduces tau propagation both in vitro and in animal model (Asai lipoprotein receptor-related protein 6 (LRP6), and heat-shock factor-1
et al., 2015). EVs isolated from the brains of rTg4510 transgenic mice (HSF1), on exosomes isolated from AD patients compared with those on
were reported to aggregate tau protein at much higher concentrations exosomes isolated from the control group, and can also be used as bio­
compared with control non-transgenic mice. Compared with brain cells, markers for the diagnosis of AD (da Cruz e Silva et al., 2010; Goetzl et al.,
tau was differentially phosphorylated in the EVs isolated from the same 2018, 2016; Soares Martins et al., 2021).
brain cells (Polanco et al., 2016). Besides the protein indicators, exosomal nucleic acids can be used to
The bridging integrator 1 (BIN1) gene is one of the most important diagnose AD. Exosomal microRNA (miRNA) may influence the devel­
risk locus involved in the late onset AD (LOAD). Overexpression of BIN1 opment of AD through apoptosis induction, APP processing, and tau
promotes the release of tau though EVs in in vitro studies as well as in phosphorylation. Cheng et al. reported a serum miRNA signature for the
PS19 mice (Crotti et al., 2019; Tan et al., 2013). The association of AD prognosis. Several miRNAs were found to be differentially modified
exosomes with the release of tau and AD progression has been demon­ between the control and AD groups (Cheng et al., 2015). miR-193b may
strated in a few other reports. Exosomes derived from the brain or suppress the expression of the mRNA and protein levels of APP.
plasma of late-stage AD patients showed up to 20-fold increase in tau Although there was no change in the levels of miR-193b between AD
phosphorylation and higher plasma p-T181-tau levels compared with patients and controls, exosomal miR-193b levels were found to be
the corresponding levels in exosomes derived from normal or early-stage considerably lower in AD patients. In addition, exosomal miR193b and
AD patients (Crotti et al., 2019; Winston et al., 2016). These findings Aβ42 were negatively correlated with AD. These findings imply that
suggest the direct or indirect involvement of exosomes in the progres­ exosomal miR193b levels may be useful as a biomarker for the identi­
sion of AD. fication of AD (Liu et al., 2014). Similarly, the exosomal miR-451a iso­
lated from blood or CSF is another biomarker reportedly whose levels
5.2. Exosomes in AD diagnosis correlate with AD. Numerous studies have shown that exosomal
miR-451a levels in the blood and CSF are lower in AD patients compared
AD is generally diagnosed in elderly people at an advanced stage, with those in control groups (Cogswell et al., 2008; Gamez-Valero et al.,
which makes the treatment difficult. Magnetic resonance imaging 2019; McKeever et al., 2018).
(MRI), computed tomography (CT), and positron emission tomography Most exosome-based methods for diagnosing AD are still in their
(PET) scans are the major tools used in AD diagnosis. Although infancy, and intensive clinical and preclinical research is being done to
numerous biochemical tests have been developed for the diagnosis of devise a reliable one. The outcomes of exosome-based AD diagnosis in
AD, none of these are currently used in clinical settings. The develop­ patients depend on a number of variables, including sample collection,
ment of reliable and accurate biochemical tests for early detection of AD storage, exosome isolation techniques, precipitation processes, and
could help in better treatment of AD during aging. Recent studies sug­ biomarker detection procedures. A universally standardized methodol­
gest that blood levels of phosphorylated-tau (p-tau) isoforms can be used ogy must be developed to validate the diagnosis method and to intro­
to detect the tau and amyloid pathologies. Therefore, p-tau levels in a duce in the clinics. Moreover, it would be useful to develop screening
patient’s blood can serve as a detection marker for AD (Largent et al., methods that can detect AD from easily accessible biofluids, such as
2021). The Lumipulse β-Amyloid ratio (1–42/1–40) in vitro test was blood, urine, and saliva, because collecting CSF involves complex pro­
recently approved by the US FDA for the early identification of AD in cedures and is inconvenient for patients.
cognitively impaired people over the age of 55 years. This test evaluates
the Aβ levels in patient’s CSF. 5.3. Exosomes in the management of AD
Exosomes carry a variety of payloads, such as proteins, lipids, and
nucleic acids, depending on the cell from which they originated, and are Despite the roles of exosomes in the pathogenesis of AD, several
considered one of the most accessible resources for investigating disease beneficial roles have also been attributed to them. Higher levels of Aβ
markers in AD. The exosomes, representing the pathophysiological peptide in the brain are linked to the pathogenesis of AD. Studies have
condition of the cell of origin, are discharged into various bodily fluids. shown the uptake of exosomes containing Aβ by microglia and its
Research on exosomal biomarkers aids the identification of many clearance from the extracellular space, which in turn reduces the Aβ
complicated disorders, including AD. Exosomes have been reported to pathological burden (Yuyama et al., 2014, 2015). It has also been re­
carry AD associated-proteins, such as Aβ1–42 (Maddalena et al., 2003), ported that exosomes isolated from neuroblastoma cells when injected
β-site amyloid precursor protein-cleaving enzyme 1 (BACE-1), soluble into mouse brains trap Aβ and continuous intracerebral administration
amyloid precursor protein (sAPP)β and (sAPP)α, total-tau, p-tau 181, of exosomes into Aβ precursor protein transgenic mice resulted in
p-tau 396, p-tau 231, and glial cell line-derived neurotrophic factor marked reduction in Aβ levels, amyloid deposition, and Aβ-mediated
(GDNF) (Fiandaca et al., 2015; Goetzl et al., 2016; Winston et al., 2016). synapto-toxicity in the hippocampus (Yuyama et al., 2014, 2015). In­
In AD patients, the levels of neuronal exosomal protein markers, such as jection of exosomes derived from N2a cells or human CSF helps in
tau, p-T181-tau, p-S396-tau, and βA1–42, are significantly increased, sequestering Aβ through exosomal surface proteins and reduces the
and can aid the diagnosis of the illness. Several clinical studies showed synaptic-plasticity-disrupting activity (An et al., 2013). Infusion of
increased levels of these protein markers on neuron-derived exosomes exosomes derived from neuronal cells or hypoxic mesenchymal stromal
isolated from the blood of AD patients compared with those on exosomes cells into APP transgenic mice was associated with reduced levels of Aβ
obtained from case controls (Fiandaca et al., 2015; Goetzl et al., 2016; accumulation and amyloid plaque formation (Cui et al., 2018; Yuyama
Winston et al., 2016). The APEX technology, which is an analytical et al., 2015).
technique to distinguish the exosome-bound and unbound circulating Several studies have suggested that exosomes derived from mesen­
Aβ proteins in the blood of AD patients, was described by Lim et al. chymal stem cells (MSCs) transfer their therapeutic factors. Exosomes
(2019). In this method, exosome-bound Aβ provides more accurate data derived from MSCs stimulate neurogenesis in the subventricular zone of
compared with free Aβ on brain amyloid plaques and is comparable to the mice brain and help mice in recovery from cognitive impairment
PET imaging (Lim et al., 2019). In the AD condition, neuronal toxicity (Reza-Zaldivar et al., 2019). Similarly, injection of exosomes isolated
results in the loss of neuronal cells. This is indeed reflected in lower from human umbilical cord MSCs (hucMSC-exosomes) to βPP/PS1

5
R. Kandimalla et al. Neuroscience and Biobehavioral Reviews 144 (2023) 104974

double transgenic mice improved the cognitive functions and cleared Aβ 6. Conclusion and future prospects
deposits from the brain (Ding et al., 2018). Adipose-derived stem cells
(ADSCs) are also a good source of exosomes; these exosomes were re­ The advancements in nanotechnology with regard to drug delivery
ported to exhibit anti-AD activity through reduction in Aβ levels and the offer a potentially promising future direction for AD therapeutics. Exo­
Aβ1–42/1–40 ratio (Lee et al., 2018). As noted previously, exosomes are somes, in particular, have garnered significant attention, owing to their
involved in the pathogenesis of AD as well as in rendering protection small size, substantial role in intercellular communication, biocompat­
against AD progression. More evidence suggest that depending on the ibility, safety, and amenability for use as both putative diagnostic and
need, exosomes can be manipulated for the management of AD (Tian therapeutic tool in various brain disorders, including AD. In the litera­
et al., 2013). ture related to AD, exosomes seem to play a dual role in AD, involved in
the pathogenesis as well as possible amelioration of AD. Exosomes can
accelerate the pathological process by promoting the spread of disease-
5.4. Exosomes-mediated therapies for AD related proteins, causing inflammation, or inducing cell death. On the
contrary, exosomes have also been shown to delay the pathological
Targeting brain with exogenous foreign moieties has always been a process by promoting the clearance of Aβ and tau proteins. Although
challenging task. Advancements in nanomedicine have opened new clearance of proteins involved in pathogenesis has been observed in
avenues for the use of several nanoparticle-mediated delivery options several studies, the exact role of exosomes in AD remains a conundrum,
for brain. Exosomes are considered a potential vehicle for drug delivery requiring systematic research into the mechanistic nature of these par­
to brain. They have the ability to deliver small and macrosize bioactive ticles in the brain.
molecules across the BBB and can be used as effective natural carriers for Lately, research in the field of AD regarding exosomes has focused
the delivery of potential molecules for the AD treatment. Tian et al. largely on their potential as diagnostic markers and carriers of various
reported the real time monitoring of exosome motion in the cells. Exo­ drugs, including both small and macro-sized therapeutic molecules. To
somes enter from the blood circulation into the brain through fusion, better enhance the development of therapeutics, biodistribution studies
receptor-mediated transport, paracytosis, and transcytosis mechanisms using fluorescent dye labeled exosomes and in vivo live imaging to
(Tian et al., 2013). In another study, plasma-derived exosomes were monitor drug transport to the brain would enhance the existing research
found to enhance the bioavailability and delivery of quercetin to the on this subject. Furthermore, given the flexibility of exosomes as
brain. Furthermore, the enhanced delivery of quercetin was supported modifiable particles, the possibility of attaching targeting ligands and
by inhibition of cyclin-dependent kinase 5 (CDK5)-mediated phos­ packing them with a wider range of pharmacologically active com­
phorylation of tau and by reducing the formation of insoluble neurofi­ pounds presents the possibility of a broader range of AD therapeutics.
brillary tangles in AD mice compared with that observed in the case of Another area worth exploring is the development of hybrid exosomes—a
free quercetin (Qi et al., 2020). Similarly, exosomes isolated from concept that has already been tested for other disease models – would
curcumin-treated macrophages (RAW264.7) protect the neuronal cells also diversify available approaches to AD treatment. In summary,
from death and revive the AD symptoms through inhibition of tau despite a lack of complete elucidation of the multiple roles of exosomes
phosphorylation and activation of the AKT/GSK-3β pathway. in the pathogenesis of AD and other neurological disorders, as a product
Curcumin-loaded exosomes also enhance the bioavailability of curcu­ of their ability to cross the blood-brain barrier, carry a wide range of
min and increase its penetration through the BBB via receptor-mediated molecules and be functionalized to target the cells of the brain for de­
transcytosis (Wang et al., 2019). Although, we have not analyzed any livery, exosomes show great possibility for the development of future AD
biological response, we have previously shown that curcumin delivered therapeutics.
to female Sprague-Dawley rats via bovine milk-derived exosomes results
in several fold higher levels of the drug in the brain compared with that Declaration of Competing Interest
achieved with dietary intake of curcumin (Aqil et al., 2017).
Recent studies suggest the use of small interfering RNAs (siRNAs) as We declare that there are no competing interests.
a promising strategy for treating AD. Because exosome carry RNA as
their intrinsic payload, they have been postulated to be capable of Acknowledgements
delivering siRNAs to the brain for the treatment of AD. Exosomes have
several additional advantages as they possess therapeutic efficacy and This work was supported by UofL Brown Cancer Center, Agnes
safety, low immune response, and can be functionalized with tumor- Brown Duggan Endowment funds (FA and RCG), Research and Devel­
targeting ligands. In an interesting study, Alvarez-Erviti and col­ opment Office, KSA Grant # RDO-2003 (FA and MS), and the American
leagues isolated exosomes from self-derived dendritic cells to deliver Heart Association Transformational Project Award #TPA-971566 (NT).
siRNA. In this study, exosomes were functionalized to express Lamp2b RCG holds the Agnes Brown Duggan Chair in Oncological Research. We
with neuron-specific RVG peptide and packed with siRNA using elec­ thank Dr. Margaret Wallen for useful discussions.
troporation. RVG-targeted exosomes administered intravenously in a
mouse model could successfully deliver BACE1 siRNA specifically to References
neurons, microglia, and oligodendrocytes in the brain, resulting in a
specific knockdown of BACE1, a therapeutic target for AD (Alvar­ Alvarez-Erviti, L., Seow, Y., Yin, H., Betts, C., Lakhal, S., Wood, M.J., 2011. Delivery of
siRNA to the mouse brain by systemic injection of targeted exosomes. Nat.
ez-Erviti et al., 2011). The same group successfully delivered exosomes Biotechnol. 29, 341–345.
to the brain, demonstrating the use of exosomes for targeted delivery of An, K., Klyubin, I., Kim, Y., Jung, J.H., Mably, A.J., O’Dowd, S.T., Lynch, T., Kanmert, D.,
small molecules and siRNAs to the brain cells and the elicitation of Lemere, C.A., Finan, G.M., Park, J.W., Kim, T.W., Walsh, D.M., Rowan, M.J., Kim, J.
H., 2013. Exosomes neutralize synaptic-plasticity-disrupting activity of Abeta
biological response. assemblies in vivo. Mol. Brain 6, 47.
In a recent study, MSC-derived exosomes showed homing abilities Andras, I.E., Toborek, M., 2016. Extracellular vesicles of the blood-brain barrier. Tissue
toward specific areas of neuropathology, and specifically to neurons, Barriers 4, e1131804.
Aqil, F., Munagala, R., Jeyabalan, J., Agrawal, A.K., Gupta, R., 2017. Exosomes for the
and that neuroinflammation plays a vital role in these homing mecha­
enhanced tissue bioavailability and efficacy of curcumin. Aaps J. 19, 1691–1702.
nisms. In a study using mouse model, these exosomes when adminis­ Arora, S., Layek, B., Singh, J., 2021. Design and validation of liposomal ApoE2 gene
tered intranasally, were transported to the hippocampus, the central delivery system to evade blood-brain barrier for effective treatment of Alzheimer’s
region associated with AD (Perets et al., 2019). Together, these studies Disease. Mol. Pharm. 18, 714–725.
Asai, H., Ikezu, S., Tsunoda, S., Medalla, M., Luebke, J., Haydar, T., Wolozin, B.,
suggest that exosomes hold significant potential to improve targeted Butovsky, O., Kugler, S., Ikezu, T., 2015. Depletion of microglia and inhibition of
drug delivery and neuronal function recovery in AD therapy. exosome synthesis halt tau propagation. Nat. Neurosci. 18, 1584–1593.

6
R. Kandimalla et al. Neuroscience and Biobehavioral Reviews 144 (2023) 104974

Cano, A., Turowski, P., Ettcheto, M., Duskey, J.T., Tosi, G., Sanchez-Lopez, E., Garcia, M. brain barrier continuity in mice subjected to traumatic brain injury. Exp. Neurol.
L., Camins, A., Souto, E.B., Ruiz, A., Marquie, M., Boada, M., 2021. Nanomedicine- 307, 99–108.
based technologies and novel biomarkers for the diagnosis and treatment of Gauthier, S., Rosa-Neto, P., Morais, J.A., Webster, C., 2021. Journey through the
Alzheimer’s disease: from current to future challenges. J. Nanobiotechnol. 19, 122. Diagnosis of Dementia. Alzheimer’s Disease International, London, England.
Carradori, D., Balducci, C., Re, F., Brambilla, D., Le Droumaguet, B., Flores, O., Goetzl, E.J., Mustapic, M., Kapogiannis, D., Eitan, E., Lobach, I.V., Goetzl, L., Schwartz, J.
Gaudin, A., Mura, S., Forloni, G., Ordonez-Gutierrez, L., Wandosell, F., B., Miller, B.L., 2016. Cargo proteins of plasma astrocyte-derived exosomes in
Masserini, M., Couvreur, P., Nicolas, J., Andrieux, K., 2018. Antibody-functionalized Alzheimer’s disease. FASEB J. 30, 3853–3859.
polymer nanoparticle leading to memory recovery in Alzheimer’s disease-like Goetzl, E.J., Abner, E.L., Jicha, G.A., Kapogiannis, D., Schwartz, J.B., 2018. Declining
transgenic mouse model. Nanomedicine 14, 609–618. levels of functionally specialized synaptic proteins in plasma neuronal exosomes
Cataldo, A., Rebeck, G.W., Ghetri, B., Hulette, C., Lippa, C., Van Broeckhoven, C., van with progression of Alzheimer’s disease. FASEB J. 32, 888–893.
Duijn, C., Cras, P., Bogdanovic, N., Bird, T., Peterhoff, C., Nixon, R., 2001. Endocytic Graykowski, D.R., Wang, Y.Z., Upadhyay, A., Savas, J.N., 2020. The dichotomous role of
disturbances distinguish among subtypes of Alzheimer’s disease and related extracellular vesicles in the central nervous system. iScience 23, 101456.
disorders. Ann. Neurol. 50, 661–665. Guo, J.W., Guan, P.P., Ding, W.Y., Wang, S.L., Huang, X.S., Wang, Z.Y., Wang, P., 2017.
Cataldo, A.M., Barnett, J.L., Pieroni, C., Nixon, R.A., 1997. Increased neuronal Erythrocyte membrane-encapsulated celecoxib improves the cognitive decline of
endocytosis and protease delivery to early endosomes in sporadic Alzheimer’s Alzheimer’s disease by concurrently inducing neurogenesis and reducing apoptosis
disease: neuropathologic evidence for a mechanism of increased beta- in APP/PS1 transgenic mice. Biomaterials 145, 106–127.
amyloidogenesis. J. Neurosci. 17, 6142–6151. Heidarzadeh, M., Gursoy-Ozdemir, Y., Kaya, M., Eslami Abriz, A., Zarebkohan, A.,
Cataldo, A.M., Petanceska, S., Terio, N.B., Peterhoff, C.M., Durham, R., Mercken, M., Rahbarghazi, R., Sokullu, E., 2021. Exosomal delivery of therapeutic modulators
Mehta, P.D., Buxbaum, J., Haroutunian, V., Nixon, R.A., 2004. Abeta localization in through the blood-brain barrier; promise and pitfalls. Cell Biosci. 11, 142.
abnormal endosomes: association with earliest Abeta elevations in AD and Down Huo, L., Du, X., Li, X., Liu, S., Xu, Y., 2021. The emerging role of neural cell-derived
syndrome. Neurobiol. Aging 25, 1263–1272. exosomes in intercellular communication in health and neurodegenerative diseases.
Chen, Q., Du, Y., Zhang, K., Liang, Z., Li, J., Yu, H., Ren, R., Feng, J., Jin, Z., Li, F., Front Neurosci. 15, 738442.
Sun, J., Zhou, M., He, Q., Sun, X., Zhang, H., Tian, M., Ling, D., 2018. Tau-targeted Igartua, D.E., Martinez, C.S., Temprana, C.F., Alonso, S.D.V., Prieto, M.J., 2018. PAMAM
multifunctional nanocomposite for combinational therapy of Alzheimer’s disease. dendrimers as a carbamazepine delivery system for neurodegenerative diseases: a
ACS Nano 12, 1321–1338. biophysical and nanotoxicological characterization. Int J. Pharm. 544, 191–202.
Cheng, L., Doecke, J.D., Sharples, R.A., Villemagne, V.L., Fowler, C.J., Rembach, A., Iqbal, K., Liu, F., Gong, C.X., Grundke-Iqbal, I., 2010. Tau in Alzheimer disease and
Martins, R.N., Rowe, C.C., Macaulay, S.L., Masters, C.L., Hill, A.F., Australian related tauopathies. Curr. Alzheimer Res 7, 656–664.
Imaging, B., Lifestyle Research, G., 2015. Prognostic serum miRNA biomarkers Jaruszewski, K.M., Ramakrishnan, S., Poduslo, J.F., Kandimalla, K.K., 2012. Chitosan
associated with Alzheimer’s disease shows concordance with neuropsychological enhances the stability and targeting of immuno-nanovehicles to cerebro-vascular
and neuroimaging assessment. Mol. Psychiatry 20, 1188–1196. deposits of Alzheimer’s disease amyloid protein. Nanomedicine 8, 250–260.
Chivet, M., Javalet, C., Laulagnier, K., Blot, B., Hemming, F.J., Sadoul, R., 2014. Ju, S., Mu, J., Dokland, T., Zhuang, X., Wang, Q., Jiang, H., Xiang, X., Deng, Z.B.,
Exosomes secreted by cortical neurons upon glutamatergic synapse activation Wang, B., Zhang, L., Roth, M., Welti, R., Mobley, J., Jun, Y., Miller, D., Zhang, H.G.,
specifically interact with neurons. J. Extra Vesicles 3, 24722. 2013. Grape exosome-like nanoparticles induce intestinal stem cells and protect
Cogswell, J.P., Ward, J., Taylor, I.A., Waters, M., Shi, Y., Cannon, B., Kelnar, K., mice from DSS-induced colitis. Mol. Ther. 21, 1345–1357.
Kemppainen, J., Brown, D., Chen, C., Prinjha, R.K., Richardson, J.C., Saunders, A.M., Kadry, H., Noorani, B., Cucullo, L., 2020. A blood-brain barrier overview on structure,
Roses, A.D., Richards, C.A., 2008. Identification of miRNA changes in Alzheimer’s function, impairment, and biomarkers of integrity. Fluids Barriers CNS 17, 69.
disease brain and CSF yields putative biomarkers and insights into disease pathways. Kalani, A., Tyagi, A., Tyagi, N., 2014. Exosomes: mediators of neurodegeneration,
J. Alzheimers Dis. 14, 27–41. neuroprotection and therapeutics. Mol. Neurobiol. 49, 590–600.
Combs, B., Mueller, R.L., Morfini, G., Brady, S.T., Kanaan, N.M., 2019. Tau and axonal Kamerkar, S., LeBleu, V.S., Sugimoto, H., Yang, S., Ruivo, C.F., Melo, S.A., Lee, J.J.,
transport misregulation in tauopathies. Adv. Exp. Med Biol. 1184, 81–95. Kalluri, R., 2017. Exosomes facilitate therapeutic targeting of oncogenic KRAS in
Crotti, A., Sait, H.R., McAvoy, K.M., Estrada, K., Ergun, A., Szak, S., Marsh, G., pancreatic cancer. Nature 546, 498–503.
Jandreski, L., Peterson, M., Reynolds, T.L., Dalkilic-Liddle, I., Cameron, A., Cahir- Kandimalla, R., Aqil, F., Alhakeem, S.S., Jeyabalan, J., Tyagi, N., Agrawal, A., Yan, J.,
McFarland, E., Ransohoff, R.M., 2019. BIN1 favors the spreading of Tau via Spencer, W., Bondada, S., Gupta, R.C., 2021a. Targeted oral delivery of paclitaxel
extracellular vesicles. Sci. Rep. 9, 9477. using colostrum-derived exosomes. Cancers (Basel) 13.
Cui, G.H., Wu, J., Mou, F.F., Xie, W.H., Wang, F.B., Wang, Q.L., Fang, J., Xu, Y.W., Kandimalla, R., Aqil, F., Tyagi, N., Gupta, R., 2021b. Milk exosomes: a biogenic
Dong, Y.R., Liu, J.R., Guo, H.D., 2018. Exosomes derived from hypoxia- nanocarrier for small molecules and macromolecules to combat cancer. Am. J.
preconditioned mesenchymal stromal cells ameliorate cognitive decline by rescuing Reprod. Immunol. 85, e13349.
synaptic dysfunction and regulating inflammatory responses in APP/PS1 mice. Kaur, A., Nigam, K., Srivastava, S., Tyagi, A., Dang, S., 2020. Memantine nanoemulsion:
FASEB J. 32, 654–668. a new approach to treat Alzheimer’s disease. J. Micro 37, 355–365.
da Cruz e Silva, O.A., Henriques, A.G., Domingues, S.C., da Cruz e Silva, E.F., 2010. Wnt Kuo, Y.C., Lin, C.C., 2015. Rescuing apoptotic neurons in Alzheimer’s disease using
signalling is a relevant pathway contributing to amyloid beta- peptide-mediated wheat germ agglutinin-conjugated and cardiolipin-conjugated liposomes with
neuropathology in Alzheimer’s disease. CNS Neurol. Disord. Drug Targets 9, encapsulated nerve growth factor and curcumin. Int J. Nanomed. 10, 2653–2672.
720–726. Kuo, Y.C., Tsao, C.W., 2017. Neuroprotection against apoptosis of SK-N-MC cells using
Damo, M., Wilson, D.S., Simeoni, E., Hubbell, J.A., 2015. TLR-3 stimulation improves RMP-7- and lactoferrin-grafted liposomes carrying quercetin. Int J. Nanomed. 12,
anti-tumor immunity elicited by dendritic cell exosome-based vaccines in a murine 2857–2869.
model of melanoma. Sci. Rep. 5, 17622. Kuo, Y.C., Lin, C.Y., Li, J.S., Lou, Y.I., 2017. Wheat germ agglutinin-conjugated
Ding, M., Shen, Y., Wang, P., Xie, Z., Xu, S., Zhu, Z., Wang, Y., Lyu, Y., Wang, D., Xu, L., liposomes incorporated with cardiolipin to improve neuronal survival in Alzheimer’s
Bi, J., Yang, H., 2018. Exosomes isolated from human umbilical cord mesenchymal disease treatment. Int J. Nanomed. 12, 1757–1774.
stem cells alleviate neuroinflammation and reduce amyloid-beta deposition by Largent, E.A., Wexler, A., Karlawish, J., 2021. The future Is P-Tau-anticipating direct-to-
modulating microglial activation in Alzheimer’s disease. Neurochem Res 43, consumer alzheimer disease blood tests. JAMA Neurol. 78, 379–380.
2165–2177. Laulagnier, K., Javalet, C., Hemming, F.J., Chivet, M., Lachenal, G., Blot, B.,
Do, T.D., Ul Amin, F., Noh, Y., Kim, M.O., Yoon, J., 2016. Guidance of magnetic Chatellard, C., Sadoul, R., 2018. Amyloid precursor protein products concentrate in a
nanocontainers for treating alzheimer’s disease using an electromagnetic, targeted subset of exosomes specifically endocytosed by neurons. Cell Mol. Life Sci. 75,
drug-delivery actuator. J. Biomed. Nanotechnol. 12, 569–574. 757–773.
Elashiry, M., Elsayed, R., Cutler, C.W., 2021. Exogenous and endogenous dendritic cell- Lee, M., Ban, J.J., Yang, S., Im, W., Kim, M., 2018. The exosome of adipose-derived stem
derived exosomes: lessons learned for immunotherapy and disease pathogenesis. cells reduces beta-amyloid pathology and apoptosis of neuronal cells derived from
Cells 11. the transgenic mouse model of Alzheimer’s disease. Brain Res 1691, 87–93.
Elliott, R.O., He, M., 2021. Unlocking the power of exosomes for crossing biological Lim, C.Z.J., Zhang, Y., Chen, Y., Zhao, H., Stephenson, M.C., Ho, N.R.Y., Chen, Y.,
barriers in drug delivery. Pharmaceutics 13. Chung, J., Reilhac, A., Loh, T.P., Chen, C.L.H., Shao, H., 2019. Subtyping of
Elnaggar, Y.S., Etman, S.M., Abdelmonsif, D.A., Abdallah, O.Y., 2015. Novel piperine- circulating exosome-bound amyloid beta reflects brain plaque deposition. Nat.
loaded Tween-integrated monoolein cubosomes as brain-targeted oral nanomedicine Commun. 10, 1144.
in Alzheimer’s disease: pharmaceutical, biological, and toxicological studies. Int J. Liu, C.G., Song, J., Zhang, Y.Q., Wang, P.C., 2014. MicroRNA-193b is a regulator of
Nanomed. 10, 5459–5473. amyloid precursor protein in the blood and cerebrospinal fluid derived exosomal
Fiandaca, M.S., Kapogiannis, D., Mapstone, M., Boxer, A., Eitan, E., Schwartz, J.B., microRNA-193b is a biomarker of Alzheimer’s disease. Mol. Med Rep. 10,
Abner, E.L., Petersen, R.C., Federoff, H.J., Miller, B.L., Goetzl, E.J., 2015. 2395–2400.
Identification of preclinical Alzheimer’s disease by a profile of pathogenic proteins in Lou, G., Chen, Z., Zheng, M., Liu, Y., 2017. Mesenchymal stem cell-derived exosomes as a
neurally derived blood exosomes: A case-control study. Alzheimers Dement 11, new therapeutic strategy for liver diseases. Exp. Mol. Med 49, e346.
600–607 e601. Maddalena, A., Papassotiropoulos, A., Muller-Tillmanns, B., Jung, H.H., Hegi, T.,
Gabathuler, R., 2010. Approaches to transport therapeutic drugs across the blood-brain Nitsch, R.M., Hock, C., 2003. Biochemical diagnosis of Alzheimer disease by
barrier to treat brain diseases. Neurobiol. Dis. 37, 48–57. measuring the cerebrospinal fluid ratio of phosphorylated tau protein to beta-
Gamez-Valero, A., Campdelacreu, J., Vilas, D., Ispierto, L., Rene, R., Alvarez, R., amyloid peptide42. Arch. Neurol. 60, 1202–1206.
Armengol, M.P., Borras, F.E., Beyer, K., 2019. Exploratory study on microRNA Matsumoto, J., Stewart, T., Banks, W.A., Zhang, J., 2017. The transport mechanism of
profiles from plasma-derived extracellular vesicles in Alzheimer’s disease and extracellular vesicles at the blood-brain barrier. Curr. Pharm. Des. 23, 6206–6214.
dementia with Lewy bodies. Transl. Neurodegener. 8, 31. McKeever, P.M., Schneider, R., Taghdiri, F., Weichert, A., Multani, N., Brown, R.A.,
Gao, W., Li, F., Liu, L., Xu, X., Zhang, B., Wu, Y., Yin, D., Zhou, S., Sun, D., Huang, Y., Boxer, A.L., Karydas, A., Miller, B., Robertson, J., Tartaglia, M.C., 2018. MicroRNA
Zhang, J., 2018. Endothelial colony-forming cell-derived exosomes restore blood-

7
R. Kandimalla et al. Neuroscience and Biobehavioral Reviews 144 (2023) 104974

expression levels are altered in the cerebrospinal fluid of patients with young-onset Gendelman, H.E., Kayed, R., Ikezu, S., Luebke, J.I., Ikezu, T., 2021. Alzheimer’s
Alzheimer’s disease. Mol. Neurobiol. 55, 8826–8841. disease brain-derived extracellular vesicles spread tau pathology in interneurons.
Miranda, A.M., Lasiecka, Z.M., Xu, Y., Neufeld, J., Shahriar, S., Simoes, S., Chan, R.B., Brain 144, 288–309.
Oliveira, T.G., Small, S.A., Di Paolo, G., 2018. Neuronal lysosomal dysfunction Saman, S., Kim, W., Raya, M., Visnick, Y., Miro, S., Saman, S., Jackson, B., McKee, A.C.,
releases exosomes harboring APP C-terminal fragments and unique lipid signatures. Alvarez, V.E., Lee, N.C., Hall, G.F., 2012. Exosome-associated tau is secreted in
Nat. Commun. 9, 291. tauopathy models and is selectively phosphorylated in cerebrospinal fluid in early
Mourtas, S., Canovi, M., Zona, C., Aurilia, D., Niarakis, A., La Ferla, B., Salmona, M., Alzheimer disease. J. Biol. Chem. 287, 3842–3849.
Nicotra, F., Gobbi, M., Antimisiaris, S.G., 2011. Curcumin-decorated nanoliposomes Simeone, P., Bologna, G., Lanuti, P., Pierdomenico, L., Guagnano, M.T., Pieragostino, D.,
with very high affinity for amyloid-beta1-42 peptide. Biomaterials 32, 1635–1645. Del Boccio, P., Vergara, D., Marchisio, M., Miscia, S., Mariani-Costantini, R., 2020.
Mourtas, S., Lazar, A.N., Markoutsa, E., Duyckaerts, C., Antimisiaris, S.G., 2014. Extracellular vesicles as signaling mediators and disease biomarkers across
Multifunctional nanoliposomes with curcumin-lipid derivative and brain targeting biological barriers. Int J. Mol. Sci. 21.
functionality with potential applications for Alzheimer disease. Eur. J. Med Chem. Soares Martins, T., Trindade, D., Vaz, M., Campelo, I., Almeida, M., Trigo, G., da Cruz, O.
80, 175–183. A.B., Henriques, A.G., 2021. Diagnostic and therapeutic potential of exosomes in
Munagala, R., Aqil, F., Jeyabalan, J., Gupta, R.C., 2016. Bovine milk-derived exosomes Alzheimer’s disease. J. Neurochem 156, 162–181.
for drug delivery. Cancer Lett. 371, 48–61. Sonawane, S.K., Ahmad, A., Chinnathambi, S., 2019. Protein-capped metal nanoparticles
Munagala, R., Aqil, F., Jeyabalan, J., Kandimalla, R., Wallen, M., Tyagi, N., Wilcher, S., inhibit tau aggregation in Alzheimer’s disease. ACS Omega 4, 12833–12840.
Yan, J., Schultz, D.J., Spencer, W., Gupta, R.C., 2021. Exosome-mediated delivery of Takahashi, R.H., Milner, T.A., Li, F., Nam, E.E., Edgar, M.A., Yamaguchi, H., Beal, M.F.,
RNA and DNA for gene therapy. Cancer Lett. 505, 58–72. Xu, H., Greengard, P., Gouras, G.K., 2002. Intraneuronal Alzheimer abeta42
Mutlu, N.B., Degim, Z., Yilmaz, S., Essiz, D., Nacar, A., 2011. New perspective for the accumulates in multivesicular bodies and is associated with synaptic pathology. Am.
treatment of Alzheimer diseases: liposomal rivastigmine formulations. Drug Dev. J. Pathol. 161, 1869–1879.
Ind. Pharm. 37, 775–789. Tan, M.S., Yu, J.T., Tan, L., 2013. Bridging integrator 1 (BIN1): form, function, and
Pal, A., Rani, I., Pawar, A., Picozza, M., Rongioletti, M., Squitti, R., 2021. Microglia and Alzheimer’s disease. Trends Mol. Med 19, 594–603.
astrocytes in Alzheimer’s disease in the context of the aberrant copper homeostasis Tang, W., Fan, W., Lau, J., Deng, L., Shen, Z., Chen, X., 2019. Emerging blood-brain-
hypothesis. Biomolecules 11. barrier-crossing nanotechnology for brain cancer theranostics. Chem. Soc. Rev. 48,
Pardridge, W.M., 2002. Drug and gene targeting to the brain with molecular Trojan 2967–3014.
horses. Nat. Rev. Drug Disco 1, 131–139. Thery, C., Witwer, K.W., Aikawa, E., Alcaraz, M.J., Anderson, J.D., Andriantsitohaina, R.,
Pardridge, W.M., 2005. The blood-brain barrier: bottleneck in brain drug development. Antoniou, A., Arab, T., Archer, F., Atkin-Smith, G.K., Ayre, D.C., Bach, J.M.,
NeuroRx 2, 3–14. Zocco, D., Zuba-Surma, E.K., et al., 2018. Minimal information for studies of
Pardridge, W.M., 2012. Drug transport across the blood-brain barrier. J. Cereb. Blood extracellular vesicles 2018 (MISEV2018): a position statement of the International
Flow. Metab. 32, 1959–1972. Society for Extracellular Vesicles and update of the MISEV2014 guidelines. J. Extra
Perets, N., Betzer, O., Shapira, R., Brenstein, S., Angel, A., Sadan, T., Ashery, U., Vesicles 7, 1535750.
Popovtzer, R., Offen, D., 2019. Golden exosomes selectively target brain pathologies Tian, T., Zhu, Y.L., Hu, F.H., Wang, Y.Y., Huang, N.P., Xiao, Z.D., 2013. Dynamics of
in neurodegenerative and neurodevelopmental disorders. Nano Lett. 19, 3422–3431. exosome internalization and trafficking. J. Cell Physiol. 228, 1487–1495.
Podratz, K.C., Cliby, W.A., 1994. Second-look surgery in the management of epithelial Vingtdeux, V., Hamdane, M., Loyens, A., Gele, P., Drobeck, H., Begard, S., Galas, M.C.,
ovarian carcinoma. Gynecol. Oncol. 55, S128–S133. Delacourte, A., Beauvillain, J.C., Buee, L., Sergeant, N., 2007. Alkalizing drugs
Polanco, J.C., Scicluna, B.J., Hill, A.F., Gotz, J., 2016. Extracellular vesicles isolated from induce accumulation of amyloid precursor protein by-products in luminal vesicles of
the brains of rTg4510 mice seed tau protein aggregation in a threshold-dependent multivesicular bodies. J. Biol. Chem. 282, 18197–18205.
manner. J. Biol. Chem. 291, 12445–12466. Wang, D., Chen, F., Han, Z., Yin, Z., Ge, X., Lei, P., 2021. Relationship between amyloid-
Popa-Wagner, A., Dumitrascu, D.I., Capitanescu, B., Petcu, E.B., Surugiu, R., Fang, W.H., beta deposition and blood-brain barrier dysfunction in Alzheimer’s disease. Front
Dumbrava, D.A., 2020. Dietary habits, lifestyle factors and neurodegenerative Cell Neurosci. 15, 695479.
diseases. Neural Regen. Res 15, 394–400. Wang, H., Sui, H., Zheng, Y., Jiang, Y., Shi, Y., Liang, J., Zhao, L., 2019. Curcumin-
Qi, Y., Guo, L., Jiang, Y., Shi, Y., Sui, H., Zhao, L., 2020. Brain delivery of quercetin- primed exosomes potently ameliorate cognitive function in AD mice by inhibiting
loaded exosomes improved cognitive function in AD mice by inhibiting hyperphosphorylation of the Tau protein through the AKT/GSK-3beta pathway.
phosphorylated tau-mediated neurofibrillary tangles. Drug Deliv. 27, 745–755. Nanoscale 11, 7481–7496.
Rajendran, L., Honsho, M., Zahn, T.R., Keller, P., Geiger, K.D., Verkade, P., Simons, K., Winston, C.N., Goetzl, E.J., Akers, J.C., Carter, B.S., Rockenstein, E.M., Galasko, D.,
2006. Alzheimer’s disease beta-amyloid peptides are released in association with Masliah, E., Rissman, R.A., 2016. Prediction of conversion from mild cognitive
exosomes. Proc. Natl. Acad. Sci. USA 103, 11172–11177. impairment to dementia with neuronally derived blood exosome protein profile.
Ramirez, S.H., Andrews, A.M., Paul, D., Pachter, J.S., 2018. Extracellular vesicles: Alzheimers Dement (Amst. ) 3, 63–72.
mediators and biomarkers of pathology along CNS barriers. Fluids Barriers CNS 15, Yu, B., Zhang, X., Li, X., 2014. Exosomes derived from mesenchymal stem cells. Int J.
19. Mol. Sci. 15, 4142–4157.
Reza-Zaldivar, E.E., Hernandez-Sapiens, M.A., Gutierrez-Mercado, Y.K., Sandoval- Yuyama, K., Sun, H., Sakai, S., Mitsutake, S., Okada, M., Tahara, H., Furukawa, J.,
Avila, S., Gomez-Pinedo, U., Marquez-Aguirre, A.L., Vazquez-Mendez, E., Padilla- Fujitani, N., Shinohara, Y., Igarashi, Y., 2014. Decreased amyloid-beta pathologies
Camberos, E., Canales-Aguirre, A.A., 2019. Mesenchymal stem cell-derived by intracerebral loading of glycosphingolipid-enriched exosomes in Alzheimer
exosomes promote neurogenesis and cognitive function recovery in a mouse model model mice. J. Biol. Chem. 289, 24488–24498.
of Alzheimer’s disease. Neural Regen. Res 14, 1626–1634. Yuyama, K., Sun, H., Usuki, S., Sakai, S., Hanamatsu, H., Mioka, T., Kimura, N.,
Rifaai, R.A., Mokhemer, S.A., Saber, E.A., El-Aleem, S.A.A., El-Tahawy, N.F.G., 2020. Okada, M., Tahara, H., Furukawa, J., Fujitani, N., Shinohara, Y., Igarashi, Y., 2015.
Neuroprotective effect of quercetin nanoparticles: A possible prophylactic and A potential function for neuronal exosomes: sequestering intracerebral amyloid-beta
therapeutic role in alzheimer’s disease. J. Chem. Neuroanat. 107, 101795. peptide. FEBS Lett. 589, 84–88.
Ruan, Z., 2022. Extracellular vesicles drive tau spreading in Alzheimer’s disease. Neural Zhang, C., Zheng, X., Wan, X., Shao, X., Liu, Q., Zhang, Z., Zhang, Q., 2014. The potential
Regen. Res 17, 328–329. use of H102 peptide-loaded dual-functional nanoparticles in the treatment of
Ruan, Z., Pathak, D., Venkatesan Kalavai, S., Yoshii-Kitahara, A., Muraoka, S., Bhatt, N., Alzheimer’s disease. J. Control Release 192, 317–324.
Takamatsu-Yukawa, K., Hu, J., Wang, Y., Hersh, S., Ericsson, M., Gorantla, S.,