International Journal of

Molecular Sciences

Review
Role of Exosomes in the Pathogenesis and Theranostic of
Alzheimer’s Disease and Parkinson’s Disease
Aojie He 1,† , Meiling Wang 1,† , Xiaowan Li 1 , Hong Chen 1 , Kahleong Lim 2 , Li Lu 1, * and Chengwu Zhang 1, *

1 School of Basic Medical Sciences, Shanxi Medical University, 56 Xinjiannan Road, Taiyuan 030001, China;
heaojie@sxmu.edu.cn (A.H.); wangmeiling@sxmu.edu.cn (M.W.); lxw@b.sxmu.edu.cn (X.L.);
chenhong22@sxmu.edu.cn (H.C.)
2 Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road,
Singapore 308232, Singapore; kahleong.lim@ntu.edu.sg
* Correspondence: lilu@sxmu.edu.cn (L.L.); chengwu_zhang@sxmu.edu.cn (C.Z.)
† These authors contributed equally to this work.

Abstract: Alzheimer’s disease (AD) and Parkinson’s disease (PD) are the most common neurodegen-
erative diseases (NDDs) threatening the lives of millions of people worldwide, including especially
elderly people. Currently, due to the lack of a timely diagnosis and proper intervention strategy, AD
and PD largely remain incurable. Innovative diagnosis and therapy are highly desired. Exosomes
are small vesicles that are present in various bodily fluids, which contain proteins, nucleic acids,
and active biomolecules, and which play a crucial role especially in intercellular communication. In
recent years, the role of exosomes in the pathogenesis, early diagnosis, and treatment of diseases
has attracted ascending attention. However, the exact role of exosomes in the pathogenesis and
theragnostic of AD and PD has not been fully illustrated. In the present review, we first introduce the
biogenesis, components, uptake, and function of exosomes. Then we elaborate on the involvement of
exosomes in the pathogenesis of AD and PD. Moreover, the application of exosomes in the diagnosis
and therapeutics of AD and PD is also summarized and discussed. Additionally, exosomes serving
as drug carriers to deliver medications to the central nervous system are specifically addressed. The
potential role of exosomes in AD and PD is explored, discussing their applications in diagnosis and
treatment, as well as their current limitations. Given the limitation in the application of exosomes,
Citation: He, A.; Wang, M.; Li, X.;
we also propose future perspectives for better utilizing exosomes in NDDs. Hopefully, it would
Chen, H.; Lim, K.; Lu, L.; Zhang, C.
Role of Exosomes in the Pathogenesis
pave ways for expanding the biological applications of exosomes in fundamental research as well as
and Theranostic of Alzheimer’s theranostics of NDDs.
Disease and Parkinson’s Disease. Int.
J. Mol. Sci. 2023, 24, 11054. https:// Keywords: exosomes; Alzheimer’s disease; Parkinson’s disease; pathogenesis; theranostic
doi.org/10.3390/ijms241311054

Academic Editors: Zhi Dong Zhou

and Alexandre Hiroaki Kihara
1. Introduction
Received: 22 May 2023 AD and PD are the two most common neurodegenerative diseases, for which the etiol-
Revised: 25 June 2023
ogy remains to be elucidated. AD and PD share comparable pathological features, such as
Accepted: 27 June 2023
the progressive loss of specific neurons, and the presence of aggregated proteins [1,2]. The
Published: 4 July 2023
exact mechanisms underlying the pathogenesis of AD and PD are not yet fully understood.
Mitochondrial dysfunction, oxidative stress, and compromised protein degradation and in-
flammation are all involved in the pathogenesis of both AD and PD. There are also distinct
Copyright: © 2023 by the authors.
participants for each disease. Regarding AD, the Aβ/tau hypothesis is widely accepted,
Licensee MDPI, Basel, Switzerland. and accumulation of Aβ/tau is thought to be the initiator as well as the biomarker of AD.
This article is an open access article Cerebrovascular dysfunction is also reported to participate in the development of AD [3].
distributed under the terms and In terms of PD, it is believed that the aberrant accumulation of α-synuclein (α-syn) is the
conditions of the Creative Commons key mediator of the apoptosis of dopaminergic neurons. Pesticides are one environmental
Attribution (CC BY) license (https:// factor that could potentially lead to PD [4,5]. In recent years, with the prevalent usage of
creativecommons.org/licenses/by/ electronics such as cellphones, the impact of microwaves on neurodegeneration has also
4.0/). attracted the attention of researchers. Sohail Mumtaz and his colleagues addressed this

Int. J. Mol. Sci. 2023, 24, 11054. https://doi.org/10.3390/ijms241311054 https://www.mdpi.com/journal/ijms

Int. J. Mol. Sci. 2023, 24, 11054 2 of 19

issue and reported that specific frequencies of microwave radiation can potentially lead
to hippocampal damage and impair cognitive function [6]. Furthermore, when it comes
to explaining the mechanisms behind neurodegenerative diseases, there exists a relatively
innovative idea suggesting that the manifestation of AD and PD is a loss of memory and
learning ability and a movement disorder, respectively [1,2]. So far, AD and PD remain
incurable. In the clinic, the diagnosis of AD and PD predominantly depends on clinical
manifestations together with bioimaging such as computed tomography (CT) and magnetic
resonance imaging (MRI) [7–9]. Treatment of AD and PD mainly involves symptomatic
approaches, rather than approaches aimed at terminating or rescuing pathological pro-
cesses involved in neurodegeneration. Inhibitors of acetyl-cholinesterase (AChE), including
donepezil, rivastigmine, and galantamine, are first-class medications for AD, which can
temporarily or partially restore memory but not reverse the loss of neurons [10,11]. Admin-
istration of L-DOPA, catechol-O-methyltransferase (COMT) inhibitors, monoamine oxidase
inhibitors, amantadine, and dopamine agonists can effectively relieve the symptoms of
PD, but it barely delays the loss of dopaminergic neurons [12,13]. The onset of AD and PD
is latent. When patients visit a doctor for treatment, the loss of neurons has occurred for
decades, and intervention hardly achieves anticipated effects. Accordingly, novel strategies
for the diagnosis and treatment of AD and PD are in high demand.
Exosomes are microvesicles with a diameter of about 40–150 nm secreted by various
types of cells such as neurons, immune cells, and mesenchymal stem cells (MSCs), which
function as the “cargo” for intercellular materials and information transferring [14–16].
In 1983, exosomes were first identified in sheep reticulocytes, and in 1987 Johnstone et al.
named them “exosomes” [17,18]. Accumulating studies reveal that exosomes possess more
functions than deposing metabolites. Exosomes contain proteins, lipids, and nucleic acids,
which can be released into the extracellular space and transferred to peripheral tissues [14].
One crucial biological basis for exosomes to fulfill their function is their ability to smoothly
traverse various physiological barriers, including cell membranes and the blood-brain
barrier (BBB). The lipid bilayer membranes of exosomes facilitate its fusion with membrane-
like structures in the body such as the BBB [19]. Once exosomes enter neighboring or distal
cells, the “cargo” released by exosomes alter the status and functions of those cells [20,21].
It is widely acknowledged that the status of the immune system and communication
among immune cells play vital roles in the development of diseases. Exosomes are believed
to participate in immune regulation. Exosomes present in the bloodstream facilitate the
transmission of inflammatory cytokines, chemokines, transcription factors, and proteins
from the stressed microenvironment to the brain, and activate microglial cells and astrocytes,
which subsequently lead to the occurrence of NDDs [22]. Moreover, the “cargo” in the
exosomes can also serve as biomarkers for diseases [23]. In recent years, exosomes have
been engineered to endow them with more functions. However, the role of exosomes in the
pathogenesis and therapeutics of NDDs has not yet been elaborately addressed.

2. Exosomes
Exosomes were initially thought of as one way for cells to dispose of waste, trash,
and unneeded cellular components [24]. Yet with the progress of intensive research, more
functions of exosomes have been discovered. Valadi et al. reported that exosomes contain
messenger RNAs (mRNAs) and non-coding RNAs (e.g., miRNAs), which might be one
new mechanism for the exchange of genetic material between cells [25]. Moreover, other
researchers demonstrated that exosomes carry not only RNA but also proteins, lipids, and
other biomolecules, which play an essential role in intercellular material and information
transmitting. The presence of “cargo” within exosomes underlies its potential utility as
diagnostic biomarkers. Furthermore, exosomes have been discovered to harbor a diverse
range of organelles, such as mitochondria, components of the endoplasmic reticulum,
and fragments of the Golgi apparatus, further amplifying the function of exosomes [26].
Ljubava D. Zorova et al. utilized real-time quantitative PCR to verify the existence of
mitochondria DNA (mtDNA) in exosomes [27]. Xiaowan Wang et al. proved that exosomes
Int. J. Mol. Sci. 2023, 24, 11054 3 of 19

from NT2 cells also contain mtDNA, which aligned with the finding of Ljubava D. Zorova’s
group [27,28]. The presence of mitochondria in exosomes awaits support from more studies.
Exosomes can be found in diverse bodily fluids, such as blood, cerebrospinal fluid
(CSF), sweat, urine, and saliva. Given its wide presence and transference in body fluids,
exosomes exhibit promising applications in the diagnosis and therapeutics of various
diseases [29,30]. It should be noted that exosomes belong to a family of extracellular
vesicles (EVs). EVs could be classified into different subtypes based on their diameter and
biogenesis as shown here in Table 1 [31,32].

Table 1. Major types of EVs.

Markers 1 EV Calss Name Size

CD63 2sEV Exosome (Classical) 40–150 nm
Exosome CD81
sEV Exosome (Non-Classical) 40–150 nm
CD9
3 Microvesicel
Annexin A1 lEV ~150–1000 nm
Microvesicel (Classical microvesicle)
ARRDC1
sEV Microvesicel (ARMM) ~40–100 nm
Apoptotic EV
lEV 1–5 µm
(Apoptotic body)
Apoptotic EV Annexin V
Apoptotic EV
sEV~lEV ~100–1000 nm
(Apoptotic vesicle)
LC3B-PE Autophagic extracellular vesicle
Autophagic EV sEV~lEV 40–1000 nm
p62 (Autophagic EV)
oncosomes Annexin A1 lEV oncosomes 1–10 µm
1 2 3
EV, extracellular vesicle; sEV, small EVs are <200 nm in diameter; lEV, small EVs are >200 nm in diameter.

2.1. Biogenesis and Composition of Exosomes

Exosomes are sequentially formed via the endosomal pathway (Figure 1), which
includes the early sorting endosome (ESE), late sorting endosome (LSE), and finally, the
multivesicular bodies (MVBs) that fuse with the cell membrane and are released [14].
Exosomes have a lipid bilayer membrane consisting of glycerol diacids, phospholipids,
glycerophospholipids, polyglycerophospholipids, cholesterol, and sphingolipids, which
are more rigid than the plasma membrane, ensuring the stability of exosomes in the external
environment [14,33].
The components of exosomes determine their biofunction. Exosomes are first thought
to be “garbage bags” for cells to get rid of useless cellular components [24]. Recent studies
reveal that the “cargo” carried by exosomes possess multiple biological functions [29,33].
The “cargo” includes proteins, metabolic enzymes, and nucleic acids. To be noted, the
“cargo” in exosomes might be diverse depending on the cell types from which they are
derived [29,34]. The featured exosomal proteins are a four-transmembrane protein super-
family, including CD63, CD9, CD81, and CD82, which were widely utilized to identify
exosomes [35,36]. However, Mathilde Mathieu et al. pointed out that CD63 is an exosome-
specific protein, while CD9 and CD81 might not be [37]. There are other functional proteins
in exosomes, such as the endosomal sorting complex-related proteins required for transport
(e.g., Tsg101), lysosome-associated membrane glycoproteins (e.g., LAMP-1 and LAMP-2B),
multivesicular body-associated proteins (e.g., Alix-1), heat shock proteins (e.g., hsp60,
hsp79, and hsp90), adhesion molecules (e.g., CD45 and CD11b), histocompatibility-related
MHC-I and II, Rabs family proteins, and membrane-linked proteins and integrins [38].
The enzymes carried by exosomes mainly include GTPase and metabolic enzymes [14,16].
Alongside proteins, exosomes also contain nucleic acids such as mRNAs, non-coding RNAs,
long non-coding RNAs, and circular RNAs that help to transmit genetic information and
influence the function of target cells [14]. It was reported that exosomes from living cells
and dying tumor cells could release DNA. Nevertheless, the presence of DNA in exosomes
 ecules (e.g., CD45 and CD11b), histocompatibility-related MHC-I and II, Rabs family
proteins, and membrane-linked proteins and integrins [38]. The enzymes carried by exo-
somes mainly include GTPase and metabolic enzymes [14,16]. Alongside proteins, exo-
somes also contain nucleic acids such as mRNAs, non-coding RNAs, long non-coding
Int. J. Mol. Sci. 2023, 24, 11054 4 of 19
RNAs, and circular RNAs that help to transmit genetic information and influence the
function of target cells [14]. It was reported that exosomes from living cells and dying
tumor cells could release DNA. Nevertheless, the presence of DNA in exosomes is still
iscontroversial,
still controversial, and further
and further studystudy is needed
is needed [39,40].
[39,40]. OmicsOmics on exosomes
on exosomes could
could helphelp to
to de-
define theirexact
fine their exact“cargo”,
“cargo”,and
andmore
morenovel
novelcomponents
componentsmightmightbebefound.
found.

Figure1.1.Structure,
Figure Structure,biogenesis,
biogenesis,and
andfunction
functionofofexosomes.
exosomes.TheTheright
rightpanel
panelillustrates
illustratesthe
thebiogenesis
biogenesis
process of exosomes. The cell membrane undergoes inward invagination, forming early sorting
process of exosomes. The cell membrane undergoes inward invagination, forming early sorting
endosomes, which then mature into late endosomes. With the assistance of ESCRT, “cargo” is
endosomes, which then mature into late endosomes. With the assistance of ESCRT, “cargo” is loaded
loaded into MVBs, leading to the formation of late MVBs. Some exosomes may undergo degrada-
into
tionMVBs,
throughleading to the formation
lysosomes, of late
while late MVBs.
MVBs canSome exosomes
release may undergo
exosomes into thedegradation through
extracellular space
lysosomes, while late MVBs can release exosomes into the extracellular space through
through membrane fusion. The left panel depicts the basic structure of exosomes and their com- membrane
fusion. The
ponents. Theleft panelsection
middle depictshighlights
the basic structure of exosomes
the potential functions and
that their components.
exosomes may exert.The middle
section highlights the potential functions that exosomes may exert.
2.2. Exosomes Uptaken by Target Cells
2.2. Exosomes Uptaken by Target Cells
Exosomes play an essential role in intercellular information exchanges by deliver-
Exosomes play an essential role in intercellular information exchanges by delivering
ing bioactive molecules to the receptor cells, which in turn affects the physiological pro-
bioactive molecules to the receptor cells, which in turn affects the physiological processes
cesses and disease development of the organism. Exosomes are uptaken by adjacent re-
and disease development of the organism. Exosomes are uptaken by adjacent recipient
cipient cells after being released into the extracellular space by the donor cells [20,21].
cells after being released into the extracellular space by the donor cells [20,21]. The modes
The modes of exosomes uptaken by receptor cells are classified into three pathways: (1)
of exosomes uptaken by receptor cells are classified into three pathways: (1) Endocytosis:
Endocytosis: Endocytosis is one of the dominant manners by which exosomes enter re-
Endocytosis is one of the dominant manners by which exosomes enter recipient cells,
cipient cells, which could be mediated by clathrin-dependent or clathrin-independent
which could be mediated by clathrin-dependent or clathrin-independent pathways, lipid
pathways, lipid rafts-mediate internalization, micropinocytosis, and phagocytosis [41].
rafts-mediate internalization, micropinocytosis, and phagocytosis [41]. (2) Direct fusion:
(2) Directmembrane
Exosome fusion: Exosome membrane
fuses with fuses with
the plasma the plasma
membrane of themembrane
recipient of theand
cell, recipient
then
cell, and then “cargo” such as exosomal miRNAs are released into the cytoplasm
“cargo” such as exosomal miRNAs are released into the cytoplasm of the recipient cell [14]. of the
recipient
(3) Bindingcell [14]. (3)surface
exosomal Binding exosomal
proteins: surface proteins:
Exosomes bond to theExosomes
receptorsbond to the recep-
on recipient cell
tors on recipient cell membranes such as the integrin-quadruple transmembrane
membranes such as the integrin-quadruple transmembrane protein complex and then protein
are
complex and
transferred then
into are
cells transferred into cells [42].
[42].

2.3.Functions
2.3. FunctionsofofExosomes
Exosomes
Exosomeswere
Exosomes wereinitially
initiallythought
thoughttoto
bebe one
one way
way forfor cells
cells to eliminate
to eliminate waste
waste prod-
products,
ucts, and to remove excess or unnecessary substances from cells so as to maintain
and to remove excess or unnecessary substances from cells so as to maintain the homeostasis the
of the intracellular environment [24]. Later on, it was found that exosomes could exchange
materials and information between cells, and impact the physiopathological activities of
target cells [34]. Exosomes can not only act on targeted cells by paracrine secretion, but also
impact the peripheral or distal targets by circulation [15]. In recent years, exosomes derived
from MSC exhibited satisfactory outcomes in the treatment of diseases. Xin et al. reported
that MSCs-derived exosomes promoted neurites outgrowth and the functional recovery
of a rat stroke model [43]. Exosomes exhibited comparable effects to those of MSCs, but
Int. J. Mol. Sci. 2023, 24, 11054 5 of 19

it steered clear of the limitation of stem cell transplantation such as immune responses,
tumorigenesis, and inadequate differentiation [44]. Based on the biological properties
of exosomes, such as their small size, good biocompatibility, prolonged circulation time
in fluids, and ability to penetrate deep tissues, they have been developed as carriers for
drug delivery [45]. Moreover, the “cargo” of exosomes is also closely correlated with
the occurrence and progress of diseases, so the components of exosomes could serve as
biomarkers for the diagnosis of diseases [23,46]. A notable observation is that exosomes
are heterogenous. Exosomes secreted by different cells display distinct functions, and
exosomes secreted by the same kind of cells also show diversity depending on the status of
the cells. With the deepening of their study, more functions of exosomes will be revealed.

3. Exosomes and AD
AD is the most common neurodegenerative disease. It is estimated that by 2050,
the number of AD patients will reach 131.5 million, which poses a heavy global social
and economic burden [47]. AD remains incurable, and AD patients inevitably suffer
irreversible brain damage. Diagnostic and therapeutic methods face great challenges, and
novel strategies are in high demand. Exosomes have opened up an alternative window for
understanding pathogenesis and its theranostic [48].

3.1. Exosomes and AD Pathogenesis

AD occurs mainly due to the aggregation of misfolded proteins, resulting in neuronal
degeneration in multiple regions of the brain, particularly the hippocampus [2]. AD
is characterized by the presence of abnormally aggregated proteins. The aggregated
proteins are mainly composed of amyloid-beta (Aβ), neurofibrillary tangles (NFTs), and the
hyperphosphorylated Tau protein [2,10]. The underlying mechanisms of AD pathogenesis
remain to be further elucidated. In recent years, the role of exosomes in AD pathogenesis
has been receiving increasing attention.
Zheng et al. by tracking exosomes injected into AD mice found that plasma-derived
exosomes accumulated in Aβ plaques, suggesting that exosomes participated in plaques
formation [49]. Exosomes have been shown to transport Aβ and Tau proteins from damaged
neurons to healthy ones, contributing to the formation of Aβ plaques and neurofibrillary
tangles (NFTs) [50]. Exosomes released by microglial cells also contribute to the progression
of AD. It is widely accepted that the activation of the PINK1/Parkin enhances mitophagy.
When exosomes derived from M2 microglia are administrated into a cellular AD model
(HT-22), mitochondria clearance is strengthened, and intracellular reactive oxygen species
are decreased [51]. It is notable how the effects of exosomes can vary depending on the
cell type from which they originate. Research has shown that exosomes derived from M1
microglial cells can activate quiescent microglial cells towards M1 polarization, leading
to the release of pro-inflammatory factors and exacerbating pathological processes [52].
In AD mice, it has been revealed that Aβ is firstly translocated to MVBs and then to
exosomes before being secreted out of neurons and transmitted [53]. Exosomes were also
involved in tau protein transport in an AD mice model, and inhibiting exosomes synthesis
could prevent tau protein dissemination in the brain [54]. Alongside proteins, miRNAs
in exosomes derived from both CSF and blood of AD patients were found to impact Aβ
genesis and accumulation [55]. Ding et al. reported that in the physiological state, miR-
185-5p could target the 30 -UTR of an amyloid precursor protein (APP) transcript in N2a
cells and transport it to receptor cells through exosomes, preventing the transcription
of APP. In APP-overexpressing N2a, exosomes loaded miR-185-5p was reduced, thereby
aggravating the pathological progress of AD [56]. Collectively, exosomes get involved in
AD pathogenesis by transmitting materials or information between neurons as well as
neuron-glia, which further leads to abnormal protein accumulation (e.g., Aβ, tau) and
ultimate AD pathogenesis.
Collectively, AD is characterized by the aggregation of misfolded proteins, including
Aβ and hyperphosphorylated Tau, leading to neuronal degeneration, especially in the
Int. J. Mol. Sci. 2023, 24, 11054 6 of 19

hippocampus. Exosomes play a significant role in AD pathogenesis by participating

in plaque formation, transporting Aβ and Tau proteins, and impacting Aβ genesis and
accumulation through miRNAs. These findings highlight the involvement of exosomes in
facilitating material and information transfer between neurons and neuron-glia interactions,
ultimately contributing to abnormal protein accumulation and the progression of AD.

3.2. Exosome-Based AD Diagnosis

Currently, diagnosis of AD is mainly based on positron emission tomography (PET)/CT,
cognitive behavioral syndrome (CBS), and biomarkers of AD pathology (Aβ1-42/1-40,
T-Tau, p-Tau) [9,57]. However, bioimaging (PET/CT) and CBS-based diagnosis are often
delayed due to the latent onset of AD. Biomarkers for checkup especially with CSF were
invasive which brought injury to patients [58]. There is still a lack of methods to accu-
rately predict or diagnose AD. In the clinic, the diagnosis of AD is multimode, including
bioimaging, biochemical analysis, and questionnaires. Bioimaging such as PET or CT is
costly, and the results could be interfered with by other kinds of dementia diseases [9].
Questionnaires are subjective and easily affected by the surveyor. Exosomes derived from
neurons have characteristic receptors associated with nervous tissues, which may include
neuron adhesion molecules and neurotransmitter receptors. Those receptors play a vital
role in mediating the interactions between exosomes and target cells [59]. They facilitate the
selective binding and uptake of exosomes, enabling the delivery of their “cargo” to specific
cellular recipients. The presence of those receptors on exosomes facilitates their diagnos-
tic application in NDDS [59,60]. Exosomes from patients with AD can be isolated from
various biological fluids, including blood, urine, and saliva [60]. Hence, the non-invasive
and convenient collection of exosomes, along with their stability after sample acquisition,
further supports their utility in the field of diagnostics for AD and related disorders.
Ruihua Sun et al. using transmission electron microscopy (TEM) and nanoparticle
tracking analysis (NTA) demonstrated that exosomes derived from the blood of AD patients
were smaller in size and quantity compared to those from healthy controls [61]. Consistent
with that finding, Antonio Longobardi et al. found that the number of exosomes in the blood
of AD patients was 40% less than that of healthy controls. However, another group reported
that exosomes from AD patients were larger than those of healthy controls [62]. Currently,
there is a lack of consistentaffectede supporting the exact differences in exosome size
between AD patients and healthy controls. The variation in exosomes size could be affected
by various factors, including sample sources, collection techniques, and analysis methods.
Further studies are needed to validate these differences and gain a deeper understanding of
their role in the pathogenesis of AD and their potential diagnostic value [63]. Morphology
of exosomes could be used as one parameter for diagnosis of AD, but the procedure for
collecting and analyzing exosomes needs to be standardized.
Proteins are important components of exosomes. In the exosomes derived from AD
patients, β-site APP cleaving enzyme 1 (BACE-1), soluble peptide APP beta (sAPPβ),
soluble peptide APP alpha (sAPPα), γ-secretase, and Aβ1-42 were found, which closely
correlates with the pathogenesis and progression of AD [64]. Lipids of exosomes could
also be used as promising biomarkers for AD diagnosis. With the help of semi-quantitative
mass-spectrometry, Su et al. found that plasmalogen glycerophosphoethanolamine (PE)
molecules (p-36:2, p-38:4) and lipids on the membranes of AD patients’ brain-derived
exosomes were significantly upregulated compared with those of control groups [65].
MiRNAs, which are another kind of “cargo” from exosomes, have gained increased
attention due to their role in the control of gene expression. It was proved that miRNAs
in exosomes derived from AD patients showed significant alterations compared to those
from healthy controls [66,67]. Liu et al. reported that nineteen miRNAs (e.g., miR-15a-5p)
were upregulated, while five other miRNAs (e.g., miR-15b-3p) were downregulated in the
exosomes from AD patients’ serum [68]. Gamez-Valero et al. checked the expression levels
of miRNA in CSF of AD patients by microarray analysis, and found increased levels of
miR-132-5p, miR-485-5p, and miR-125b-5p, as well as decreased levels of miR-16-2, miR-29c,
Int. J. Mol. Sci. 2023, 24, 11054 7 of 19

and miR-331-5p [67]. MiRNAs in exosomes extracted from different body fluids, such as
serum, plasma, and CSF, showed a distinguished profile, which should be considered when
analyzing miRNA in AD and control groups.
The alteration in the “cargo” and levels of exosomes-derived biomarkers indicate their
high potential value for AD diagnosis. Exosomes derived from a variety of body fluids
ensures their availability and accessibility in diagnosis and exosomes derived from blood
and neurons show even better creditability than CSF biomarkers or PET/CT.

3.3. Exosomes-Based AD Therapeutic

In the clinic, AD patients are usually treated with cholinesterase inhibitors, such as
donepezil, galantamine, and rivastigmine, which are the first-line drugs [10]. However,
these drugs can only relieve the clinical symptoms, rather than prevent neuronal death [11].
So far, AD is still incurable. In recent years, exosomes, as one novel intervention for AD,
are attracting more attention due to their capacity to transfer bioactive substances and
pass across the BBB [69,70]. It is predicted that exosomes could potentially represent an
alternative strategy for “decellularization” AD therapy.
Hirohide Asai et al. found that exosomes secreted by microglia could disseminate
tau, and the inhibition of exosome secretion reduces tau levels in mouse brains [71,72].
Exosomes biogenesis inhibition via the blocking of neutral sphingomyelinase 2 (nSmase2)
activity, a critical enzyme regulating ceramide biogenesis, significantly decreased Aβ
plaques as well as tau propagation in an AD mice model [73]. Those studies suggest
that interfering with the formation of disease-associated exosomes could mitigate the
progression of AD. There were also studies showing that exosomes exert neuroprotective
effects in AD. Exosomes derived from curcumin-treated cells inhibited the phosphorylation
of Tau protein by activating the AKT/GSK-3β pathway, thereby preventing neuronal death
both in vitro and in vivo and alleviating the symptoms of AD [74]. It has been reported that
miRNA-193b present in exosomes derived from the serum, plasma, or CSF of healthy donors
could bind to the 30 -UTR region of APP and suppress the expression of APP [60]. Vella et al.
reported that enzymes in exosomes such as neprilysin and insulin-degrading enzymes
present in exosomes could degrade Aβ peptides and reduce extracellular and intracellular
Aβ levels [75]. In addition, exosomes derived from human CSF or N2a cells improved
the synaptic-plasticity-disrupting activity of both synthetic and AD cerebral-derived Aβ
in vivo [76]. Those reports suggested that exogenous exosomes from healthy donors and
cell lines ameliorated Aβ accumulation and delayed the progress of AD.
In recent years, exosomes derived from stem cells showed promising therapeutic
effects in AD. Allaura S. Cone et al. demonstrated that exosomes derived from human
umbilical cord-derived mesenchymal stem cells (hucMSCs) inhibited neuroinflammation
and promoted the degradation of Aβ, thereby reducing Aβ aggregation in the brain of
AD mice [77]. Xinyi Ma et al. demonstrated that exosomes secreted by adipose-derived
mesenchymal stem cells (ADSCs) rapidly and efficiently entered the brains and accumu-
lated mainly in the neurons of AD mice after intranasal administration Administering
exosomes reduced Aβ deposition and decreased microglia activation, demonstrating that
ADSCs-derived exosomes might serve as a feasible way for AD treatment [78]. Although
stem cell-derived exosomes play an important role in AD therapy, there are difficulties in
applying exosomes to clinical applications due to their limitations such as short half-life
and poor targeting [79].
Given its ability to cross the BBB and carry “cargo”, exosomes have been engi-
neered into the carrier to deliver therapeutic agents for AD treatment. Exosomes carrying
beta-secretase (BACE1) siRNAs, intravenously injected into AD mice, alleviated disease-
associated phenotypes by reducing Aβ levels [80]. Exosomes containing medicinal RNA,
peptides, and synthetic drugs were applied in AD treatment and displayed optimistic
results. Exosomes-mediated delivery of plant-derived bioactive components also showed a
rescue effect in an AD model [81,82]. It is notable how exosomes tended to be trapped in
peripheral tissues (especially liver and lung), leading to insufficient delivery to the brain.
 ease-associated phenotypes by reducing Aβ levels [80]. Exosomes containing m
RNA, peptides, and synthetic drugs were applied in AD treatment and display
mistic results. Exosomes-mediated delivery of plant-derived bioactive compone
showed a rescue effect in an AD model [81,82]. It is notable how exosomes tend
Int. J. Mol. Sci. 2023, 24, 11054 trapped in peripheral tissues (especially liver and lung), leading to insufficient 8 of 19

to the brain. Appropriate modifications of exosomes could improve its delivery

cy, targeting ability, and therapeutic efficacy [83]. Alvarez-Erviti et al. modif
Appropriate modifications of exosomes could improve its delivery efficiency, targeting
somes with rabies virus glycoprotein (RVG) and realized specific targeting of t
ability, and therapeutic efficacy [83]. Alvarez-Erviti et al. modified exosomes with rabies
[80].glycoprotein
virus Kim et al. (RVG)
modified exosomes
and realized with
specific one peptide
targeting that[80].
of the brain enabled
Kim etits
al. binding
mod- to n
andexosomes
ified nasal delivery
with oneof modified
peptide exosomes
that enabled reduced
its binding the tumor
to neurons, necrosis
and nasal deliveryfactor- ce
of modified exosomes reduced the tumor necrosis factor- cell-alpha (TNF-α)
(TNF-α) level and cell apoptosis [84]. Engineered exosomes emerge as a new the level and
cell apoptosis [84]. Engineered exosomes emerge as a new therapeutic strategy and are
strategy and are expected to be an alternative option for exosomes-based therapy
expected to be an alternative option for exosomes-based therapy [85]. In conclusion, there
isconclusion, there isinsignificant
significant potential potential
the utilization in the
of exosomes asutilization of exosomes
a drug delivery system for as thea drug
system for
treatment the(Figure
of AD treatment
2). of AD (Figure 2).

Figure2. 2.The
Figure Therolerole of exosomes
of exosomes in ADinand
ADexosome-based
and exosome-based
therapies. therapies. Thedepicts
The left panel left panel
the depic
tential “harmful”
potential “harmful” or or “beneficial”
“beneficial” effectseffects of exosomes
of exosomes on AD.
on AD. Harmful Harmful
effects include effects
inducinginclude
neuronal
neuronal dysfunction,
dysfunction,cell death,
cell contributing to the spreadtoofthe
death, contributing Aβ/Tau,
spreadandof
triggering
Aβ/Tau, inflammation.
and triggering in
Conversely, exosomes exosomes
tion. Conversely, also have beneficial effects
also have on AD sucheffects
beneficial as participating
on AD in Aβ clearance,
such anti-
as participating in
inflammation, or serving as diagnostic biomarkers. The right panel demonstrates
ance, anti-inflammation, or serving as diagnostic biomarkers. The right panel demonst the potential thera-
peutic applications of exosomes in AD, such as by directly exerting neuroprotective effects through
potential therapeutic applications of exosomes in AD, such as by directly exerting neurop
exosomes derived from stem cells or healthy donors, or by serving as carriers for drug delivery.
effects through exosomes derived from stem cells or healthy donors, or by serving as ca
4.drug delivery.
Exosomes and PD
PD is the second most prevalent NDDS, significantly threatening the well-being
of individuals, and of elderly people in particular [2]. The pathological feature of PD
is the presence of intracellular aggregates that consist of α-syn [86]. The etiology of
PD is thought to include age, genetic background, and environmental factors, which
lead to the death of dopaminergic neurons of the substantia nigra of the midbrain by
inducing mitochondria dysfunction, oxidative stress, and protein aggregation [87,88].
Earlier diagnosis and effective treatment of PD remain unmet. Therefore, defining novel
biomarkers for preclinical diagnosis and exploring better strategies for the treatment of PD
is a highly demanding pursuit.
Int. J. Mol. Sci. 2023, 24, 11054 9 of 19

4.1. Exosomes and Pathogenesis of PD

It is generally agreed that exosomes play a crucial role in the pathogenesis of PD,
and the accumulation of α-syn is a feature of PD. Shi et al. injected 125 I-labeled α-syn
intracerebroventricularly (ICV) into the brains of mice and found that 125 I-labeled α-syn
was presented in blood exosomes, demonstrating that exosomes may serve as a α-syn dis-
seminator to aggravate PD pathogenesis [89]. In addition, Emmanouilidou et al. found that
α-syn was encapsulated in exosomes in SH-SY5Y and exported by a calcium-dependent
endosomal mechanism, which illustrated the relationship between α-syn and exosomes
from another perspective [90]. Gustafsson et al. reported that exosomes encapsulation
could affect the uptake efficiency of α-syn in SH-SY5Y, but the mechanism had not been
clearly elucidated [91]. In addition to delivering α-syn as “cargo”, exosomes could also
serve as an incubator for α-syn aggregation formation [92]. Exosomes derived from PD
patients were found to enhance α-syn accumulation and induce neuronal degeneration
in PD mice in a dosage dependent manner. Glial cell-derived exosomes (GDEs) play a
crucial role in facilitating communication between neurons and glia. Alpha-synuclein
could be transferred from glial cells to neurons via GDEs [93]. Chemokines of GDEs could
bind the toll-like receptor 2 (TLR2) and the toll-like receptor 4 (TLR4) of neurons and
trigger neuroinflammation and even dopaminergic neuron apoptosis [94]. GDE could also
transport aberrantly expressed miRNAs which could trigger or propagate neuroinflam-
mation in neurons [95,96]. In the PD patients’ plasma-derived exosomes, miR-44438 was
significantly upregulated, and inhibited the α-syn efflux from neurons which aggravated
α-syn accumulation and aggregation [97]. A few groups have demonstrated that disease-
associated miRNAs, such as miR-19b, miR-24, miR-195, and miR-331-5p, are remarkably
altered in PD patients’ plasma-derived exosomes, and those miRNAs mediated proce-
dures of PD pathogenesis, including inflammation, protein aggregation, and inhibition of
autophagy [98–100].
In summary, exosomes play a crucial role in PD pathogenesis by disseminating α-
syn and promoting its aggregation. Moreover, GDEs transfer α-syn or inflammatory
factors to neurons, exacerbating the progress of PD. Overall, exosomes are involved in PD
pathogenesis in multiple aspects.

4.2. Exosomes-Based Diagnosis of PD

Currently, PD is diagnosed mainly based on the presence of obvious clinical motor
symptoms such as resting tremor, muscle rigidity, bradykinesia, stooped posture, and the
results of bioimaging [93]. The clinical symptoms-based diagnosis was somehow subjective
and retarded, and bioimaging was tedious and costly. An alternative diagnostic way was
desired, and exosomes emerged as one of the promising candidates.
Researchers reported that α-syn in exosomes derived from PD patients’ body fluids
was upregulated compared with that of a healthy control [89]. This group also found that
the level of tau, one hyperphosphorylated and aggregated protein in tauopathies, was
significantly elevated in exosomes from PD patients’ plasma. The authors speculated that
exosomes might serve as the carrier to transport tau from brain to blood and this made it
more feasible to detect the level of PD associated tau [101]. Phosphorylated leucine-rich
repeat kinase 2 (LRRK2), another PD associated protein, was found up-regulated in the
exosomes of PD patients’ urine, and the level of Phospho-LRRK2 was correlated with
the impairment of PD patients [102]. Moreover, Wang et al. reported that synaptosome
associated protein 23 (SNAP23) and calbindin in exosomes from PD patients’ urine was
higher than those of the control [103]. Rennika Kluge et al. reported that a pathological
form of α-syn in neuron-derived exosomes of PD patients’ plasma was obviously increased
compared with that of healthy controls. The extracted α-syn showed more β-sheet-rich
structures and fibrillary appearance which could result in the accumulation of amyloid
proteins after amplification [104]. More concretely, Leng et al. analyzed the protein ex-
pression profile in neuron-derived exosomes from PD patients with and without rapid eye
movement sleep behavior disorder (RBD). They found that exosomes from PD patients
 exosomes from PD patients with RBD had lower levels of excitatory amino acid trans
porters-2 (EAAT-2) and vesicular glutamate transporter type 1 (VGLUT-1), suggesting
that they could be used as predictors to differentiate subtypes of PD patients [105].
MiRNAs are another kind of biomolecule usually present in exosomes. Pallab
Int. J. Mol. Sci. 2023, 24, 11054 Bhattacharyya et al. reported that miR-128 was down-regulated in plasma-derived 10 of 19 exo
somes from PD patients [106]. Yao et al. reported that the level of miR-331-5p from PD
patients’ plasma exosomes was increased, while that of miR-505 was decreased [107]
with
Cao RBD
et al.had lower
found levels
that theoflevel
excitatory aminoand
of miR-24 acidmiR-195
transporters-2
in PD(EAAT-2)
patients’and vesicularwere ele
exosomes
glutamate transporter type 1 (VGLUT-1), suggesting that they could
vated, while that of miR-19b was reduced [108]. Cheng et al. analyzed the circRNAs obe used as predictors
to differentiate subtypes of PD patients [105].
exosomes from a 1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) induced mice
MiRNAs are another kind of biomolecule usually present in exosomes. Pallabi Bhat-
PD modeletand
tacharyya found that
al. reported that circSV2b
miR-128 was wasdown-regulated
downregulated, indicating thatexosomes
in plasma-derived circSV2b had the
potential
from to serve
PD patients as aYao
[106]. new et biomarker
al. reported in the
that thediagnosis of PD [109].
level of miR-331-5p fromMost of the diagnos
PD patients’
tic biomarkers mentioned in Figure 3 have only been validated
plasma exosomes was increased, while that of miR-505 was decreased [107]. Cao in animal models
et al. of PD
Among
found thatthem, α-syn
the level has been
of miR-24 andutilized
miR-195 as a clinical
in PD patients’biomarker
exosomes forwerePD diagnosis
elevated, while[110]. It i
that of miR-19b
notable how was reduced
a recent [108]. Cheng
clinical et al. analyzed thehas
trial (NCT01860118) circRNAs of exosomes
validated from a derived
that LRRK2
1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine
from exosome could serve as biomarkers (MPTP) for PD. induced mice PD model and found
that circSV2b was downregulated, indicating
Collectively, proteins, miRNAs, circRNAs, that circSV2b
and had
other themolecules
potential toderived
serve asfrom
a exo
new biomarker in the diagnosis of PD [109]. Most of the diagnostic biomarkers mentioned
somes could serve as biomarkers for PD diagnosis. It is notable how exosomes could be
in Figure 3 have only been validated in animal models of PD. Among them, α-syn has
obtained
been utilized fromas avarious body fluids
clinical biomarker for including
PD diagnosis CSF, plasma,
[110]. serum,
It is notable howsaliva, and urine
a recent
which trial
clinical ensure the accessibility
(NCT01860118) and availability
has validated that LRRK2 of derived
those biomarkers.
from exosome Therefore,
could serve exosome
could serve as
as biomarkers for PD. valuable resources for PD diagnosis.

Figure3.3.Exosomes-based
Figure Exosomes-based diagnostics
diagnostics and and therapeutics
therapeutics for
for PD. PD. Cargos
Cargos of exosomes
of exosomes derived from
derived from
variousbodily
various bodilyfluids
fluids such
such as CSF,
as CSF, serum,
serum, plasma,
plasma, saliva,saliva, andcould
and urine urineserve
couldasserve as PD biomarkers
PD biomarkers,
including α-syn, miRNA, and proteins. The right panel showcases exosome-based therapeutics
approaches, such as intranasal delivery of exosomes derived from SHEDs and tail vein injection of
engineered DA-loaded exosomes.

Collectively, proteins, miRNAs, circRNAs, and other molecules derived from exosomes
could serve as biomarkers for PD diagnosis. It is notable how exosomes could be obtained
from various body fluids including CSF, plasma, serum, saliva, and urine, which ensure
the accessibility and availability of those biomarkers. Therefore, exosomes could serve as
valuable resources for PD diagnosis.

4.3. Exosomes-Based PD Therapy

In the clinic, PD patients are treated by administering levodopa, surgery, and deep
brain stimulation. Yet the effect of those treatments is unsatisfactory and the side effect is
unneglectable. New interventive methods need to be explored (Figure 3). Exosomes attract
Int. J. Mol. Sci. 2023, 24, 11054 11 of 19

attention due to their features including good biocompatibility, higher capacity for drug
delivery, and penetrating the BBB [111].
Jarmalavičiūtė et al. reported that exosomes from stem cells derived from the dental
pulp of human exfoliated deciduous teeth (SHEDs) displayed a neuroprotective effect
on 6-hydroxy dopamine (6-OHDA) triggered dopaminergic neuron [112]. Narbute et al.
proved that intranasal administration of exosomes from SHEDS ameliorated dyskine-
sia and dopaminergic neuron loss in PD rats [113]. Shakespear et al. reported that an
astrocytes-derived exosomes-rescued neurotoxin, N-Methyl-4-phenylpyridinium Iodide
(MPP+ ), induced dopaminergic neuron death [114]. Another group reported that exosomes
derived from astrocytes stimulated by chemokine CCL3 exhibited remarkable protective
ability on H2 O2 -induced apoptosis of differentiated SH-SY5Y. Furthermore, exosomes
derived from the ventral intraventricular region enhance ATP production and survival in
SH-SY5Y subjected to MPP+ [115].
Recently, exosomes have been engineered to serve as a platform for PD therapy.
Exosomes loaded with peroxidase effectively deliver peroxidase into neurons, and microglia
exert a neuroprotective effect in substantia nigra pars compacta (SNpc) neurons in PD
mice [116]. Qu et al. demonstrated that exosomes loaded with dopamine after tail vein
injection could be delivered into the brains of PD mice, and this approach showed alleviated
symptoms. Dopamine-loaded exosomes increased the brain dopamine concentration of a
mice PD model by more than 15-fold [117].
In addition, Yang et al. demonstrated that exosomes-mediated delivery of ASO4, one
antisense oligonucleotides targeting human α-syn sequence, significantly reduces α-syn
expression and aggregation, and ameliorates dopaminergic neuron degeneration in PD
mice [118]. All those studies showed that original or engineered exosomes could hold great
potential for PD treatment. The level of NDDS related “cargo” in exosomes is summarized
and listed in Table 2 [65–67,89,102–104,107–109,119–126].

Table 2. The alterations in the “cargo” of exosomes in AD and PD.

Disease Exosome Exosomal

Level Ref.
Types Sources Biomarker
miR-135a
miR-384
miR-193b
miR-126-3p
AD Serum miR-138-5p up-regulated
miR-659-5p
miR-5001-3p [66,119–124]
miR-361-5p
miR-30e-5p
miR-23b-3p
miR-24-3p
AD Serum down-regulated
miR-29b-3p
miR-125b-5p
miR-132-5p
AD CSF miR-125b-5p up-regulated
miR-485-5p
[67]
miR-16-2
AD CSF miR-29c down-regulated
miR-331-5p
blood neuron miR-212
AD down-regulated [125]
derived exosome miR-132
(PE) molecules
AD brain tissue up-regulated [65]
(p-36:2, p-38:4)
Int. J. Mol. Sci. 2023, 24, 11054 12 of 19

Table 2. Cont.

Disease Exosome Exosomal

Level Ref.
Types Sources Biomarker
α-syn
PD Serum up-regulated
miR-331-5p
[89,107,109]
miR-505
PD Serum down-regulated
circSV2b
α-syn
PD plasma miR-24 up-regulated
[104,108]
miR-195
PD plasma miR-19b down-regulated
α-syn
PD saliva up-regulated [126]
L1CAM
calbindin
PD urine SNAP23 up-regulated [102,103]
LRRK2

5. Engineered Exosomes and Drug Delivery

Exosomes have exhibited potential for serving as biomarkers, drug delivery agents,
and therapeutic tools. Yet there are still certain limitations of native exosomes which
might hinder the application of exosomes. For example, the “cargo” of exosomes is limited
by its origin. Exosomes from different resources have distinct functions and could not
be regarded as possessing uniformity. Native exosomes also lack targeting capabilities,
and it is necessary to develop methods for targeted delivery. One more aspect about
exosomes to be noted is their short half-life and how they are rapidly cleared by immune
cells [127,128]. Hence, there is an urgent need to modify or engineer exosomes so as to
endow them with better practicability. One approach is to engineer exosomes to load
specific therapeutic “cargo”, such as drugs, RNA molecules, or proteins [129]. It has been
reported that exosomes loaded with levodopa improved the motor impairments of PD
mice after being administered via tail vein injection. Another strategy is to modify the
surfaces of exosomes to improve their stability, targeting capabilities, or immune system
evasion, which can be achieved by modifying membrane proteins or introducing specific
ligands on the outside edges. Researchers have modified exosomes with RVG peptide and
it renders exosomes specifically delivering the “cargo” to neurons in the brain [80]. Through
modification or engineering, exosomes can be optimized to enhance their functionality,
paving the way for innovative diagnostic approaches and therapeutic interventions in these
neurodegenerative disorders.
In the context of AD/PD therapeutics, different delivery methods for exosomes have
been proposed. Intranasal delivery offers a non-invasive and convenient approach, allow-
ing direct access to the brain through the olfactory pathway [130]. Intravenous injection
provides systemic delivery, although it faces challenges in crossing the BBB. Intracere-
broventricular injection or direct brain injection enables specific brain regions delivery,
but which is one invasive procedure. Focused ultrasound can temporarily disrupt the
BBB so as to facilitate exosome brain delivery [131]. Additionally, exosomes coated with
nanoparticles show enhanced BBB penetration and increased payload capacity [132]. It
should be noted that the choice of delivery method depends on multiple factors, including
the exact therapeutic goals, the nature of the exosomes, the desired target brain region, and
safety considerations [133,134]. Each method has its own limitations, and optimizations
surrounding these methods are ongoing for more efficient delivery into the brain (Table 3).
Another significant aspect to consider is the uptake capacity of target cells. Increasing the
cellular uptake of exosomes by target cells may potentially enhance therapeutic efficacy.
Int. J. Mol. Sci. 2023, 24, 11054 13 of 19

Table 3. Different methods for exosomes delivery.

Delivery
Advantages Disadvantages
Methods
1 Complex engineering process that may affect
1 Precise targeting to receptors on the BBB, natural characteristics of exosomes;
1 Engineered
increasing the chances of crossing; 2 Flexibility 2 Challenges in achieving optimal targeting
Exosomes
to customize exosomes for specific applications efficiency and maintaining engineered
exosome stability
1 Low efficiency in crossing the
2Intravenous Systemic delivery, allowing exosomes blood-brain barrier;
Injection to reach various organs including the brain. 2 Exosomes may undergo clearance by the liver
and other organs before reaching the brain.
1 Allows direct and localized delivery Invasive procedure requiring
3Intracerebroventricular
of exosomes to specific brain regions; surgical intervention;
Injection
2 Bypasses the blood-brain barrier Limited to targeted brain regions
Invasive procedure requiring
4Direct Injection Precise delivery to specific brain regions;
surgical intervention;
into Brain Tissue Allows for localized effects
Limited to targeted brain regions
1 Allows temporary and localized opening of 1 Precise targeting and control of BBB opening
5Focused the BBB, enabling exosomes to pass through; required to avoid potential side effects;
Ultrasound 2 Non-invasive method with potential for 2 Safety and long-term effects of the method
delivering various therapeutic agents require further investigation
1 Non-invasive and relatively simple method for
1 Amount of exosomes reaching the brain may
delivering exosomes to the brain;
6Intranasal be limited;
2 Bypasses the BBB through the olfactory and
Delivery 2 Distribution of exosomes throughout the brain
trigeminal pathways, providing direct transport
may not be uniform
to the brain

6. Summary and Perspectives

Collectively, given their convenient availability, good biocompatibility, and flexibility
for engineering, exosomes attract ascending attention for potential biological application in
basic research as well as in clinic especially for AD and PD. “Cargo” of exosomes could
serve as diagnostic biomarkers. Original or engineered exosomes could be adopted for
the clinical treatment of AD and PD. Notably, for the better application of exosomes, some
aspects deserve to be considered. Firstly, biomarker detection based only on exosomes is not
deterministic for AD and PD diagnosis, and supportive information from manifestations or
bioimaging of patients is still needed. Secondly, exosomes from different cells or resources
might have distinguished “cargo” functions, and exosomes should not be assumed to be
uniformly applicable. Thirdly, exosomes applied in vivo could be transported to the liver
and spleen for degradation before they reach the brain to exert their roles, and the ultimate
therapeutic effect is debatable. Last but not least, more efforts are still needed to enhance
the applicability of exosomes by improving neuron targeting ability, drug-loading capacity,
and responsiveness to pathological environments. Exosomes hold great potential in clinical
application, which could be strengthened by modification or engineering.

Author Contributions: C.Z. and L.L. were responsible for the selection, organization, and writing the
summary and outlook of the published literature in this review. K.L. was responsible for organizing
and compiling the scientific publications cited in this review. A.H. compiled and summarized the
section on exosomes in the diagnosis and treatment of AD in this review, while M.W. compiled the
section on exosomes in the diagnosis and treatment of PD in this review. X.L. and H.C. created
the illustrations for this review. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Int. J. Mol. Sci. 2023, 24, 11054 14 of 19

Informed Consent Statement: Not applicable.

Data Availability Statement: Data sharing is not applicable as no new data were created or analyzed
in this study.
Conflicts of Interest: The authors declare no conflict of interest.

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