Astrocyte-Schwann cell interactions in culture

Schwann cells: Rescuers of central demyelination

The presence of peripheral myelinating cells in the central nervous system (CNS) has gained the neurobiologist attention over the years. Despite the confirmed presence of Schwann cells in the CNS in pathological conditions, and the long list of their beneficial effects on central remyelination, the cues that impede or allow Schwann cells to successfully conquer and remyelinate central axons remain partially undiscovered. A better knowledge of these factors stands out as crucial to foresee a rational therapeutic approach for the use of Schwann cells in CNS repair. Here, we review the diverse origins of Schwann cells into the CNS, both peripheral and central, as well as the CNS components that inhibit Schwann survival and migration into the central parenchyma. Namely, we analyze the astrocyte- and the myelin-derived components that restrict Schwann cells into the CNS. Finally, we highlight the unveiled mode of invasion of these peripheral cells through the central environment, using blood vessels as scaffolds to pave their ways toward demyelinated lesions. In short, this review presents the so far uncovered knowledge of this complex CNS-peripheral nervous system (PNS) relationship.

Novel insights into the glia limitans of the olfactory nervous system

Olfactory ensheathing cells (OECs) are often described as being present in both the peripheral and the central nervous systems (PNS and CNS). Furthermore, the olfactory nervous system glia limitans (the glial layer defining the PNS-CNS border) is considered unique as it consists of intermingling OECs and astrocytes. In contrast, the glia limitans of the rest of the nervous system consists solely of astrocytes which create a distinct barrier to Schwann cells (peripheral glia). The ability of OECs to interact with astrocytes is one reason why OECs are believed to be superior to Schwann cells for transplantation therapies to treat CNS injuries. We have used transgenic reporter mice in which glial cells express DsRed fluorescent protein to study the cellular constituents of the glia limitans. We found that the glia limitans layer of the olfactory nervous system is morphologically similar to elsewhere in the nervous system, with a similar low degree of intermingling between peripheral glia and astrocytes. We found that the astrocytic layer of the olfactory bulb is a distinct barrier to bacterial infection, suggesting that this layer constitutes the PNS-CNS immunological barrier. We also found that OECs interact with astrocytes in a similar fashion as Schwann cells in vitro. When cultured in three dimensions, however, there were subtle differences between OECs and Schwann cells in their interactions with astrocytes. We therefore suggest that glial fibrillary acidic protein-reactive astrocyte layer of the olfactory bulb constitutes the glia limitans of the olfactory nervous system and that OECs are primarily "PNS glia."

Dystrophin 71 and α1syntrophin in morpho-functional plasticity of rat supraoptic nuclei: Effect of saline surcharge and reversibly normal hydration

Dystrophin (Dp) is a multidomain protein that links the actin cytoskeleton to the extracellular matrix through the dystrophin associated proteins complex (DAPC). Dp of 71 kDa (Dp71), corresponding to the COOH-terminal domain of dystrophin, and α1-syntrophin (α1Syn) as the principal component of the DAPC, are strongly expressed in the brain. To clarify their involvement in the central control of osmotic homeostasis, we investigated the effect of 14 days of salt loading (with drinking water containing 2% NaCl) and then reversibly to 30 days of normal hydration (with drinking water without salt), first on the expression by western-blotting and the distribution by immunochemistry of Dp71 and α1Syn in the SON of the rat and, second, on the level of some physiological parameters, as the plasma osmolality, natremia and hematocrit. Dp71 is the most abundant form of dystrophin revealed in the supraoptic nucleu (SON) of control rat. Dp71 was localized in magnocellular neurons (MCNs) and astrocytes, when α1Syn was observed essentially in astrocytes end feet. After 14 days of salt-loading, Dp71 and α1Syn signals decreased and a dual signal for these two proteins was revealed in the astrocytes processes SON surrounding blood capillaries. In addition, salt loading leads to an increase in plasma osmolality, natremia and hematocrit. Reversibly, after 30 days of normal hydration, the intensity of the signal for the two proteins, Dp71 and α1Syn, increased and approached that of control. Furtheremore, the levels of the physiological parameters decreased and approximated those of control. This suggests that Dp71 and α1Syn may be involved in the functional activity of the SON. Their localization in astrocyte end feet emphasizes their importance in neuronal-vascular-astrocyte interactions for the central detection of osmolality. In the SON, Dp71 and α1Syn may be involved in osmosensitivity.

Biomaterial-Supported Cell Transplantation Treatments for Spinal Cord Injury: Challenges and Perspectives

Spinal cord injury (SCI), resulting in para- and tetraplegia caused by the partial or complete disruption of descending motor and ascending sensory neurons, represents a complex neurological condition that remains incurable. Following SCI, numerous obstacles comprising of the loss of neural tissue (neurons, astrocytes, and oligodendrocytes), formation of a cavity, inflammation, loss of neuronal circuitry and function must be overcome. Given the multifaceted primary and secondary injury events that occur with SCI treatment options are likely to require combinatorial therapies. While several methods have been explored, only the intersection of two, cell transplantation and biomaterial implantation, will be addressed in detail here. Owing to the constant advance of cell culture technologies, cell-based transplantation has come to the forefront of SCI treatment in order to replace/protect damaged tissue and provide physical as well as trophic support for axonal regrowth. Biomaterial scaffolds provide cells with a protected environment from the surrounding lesion, in addition to bridging extensive damage and providing physical and directional support for axonal regrowth. Moreover, in this combinatorial approach cell transplantation improves scaffold integration and therefore regenerative growth potential. Here, we review the advances in combinatorial therapies of Schwann cells (SCs), astrocytes, olfactory ensheathing cells (OECs), mesenchymal stem cells, as well as neural stem and progenitor cells (NSPCs) with various biomaterial scaffolds.

Sulfatase-mediated manipulation of the astrocyte-Schwann cell interface

Schwann cell (SC) transplantation following spinal cord injury (SCI) may have therapeutic potential. Functional recovery is limited however, due to poor SC interactions with host astrocytes and the induction of astrogliosis. Olfactory ensheathing cells (OECs) are closely related to SCs, but intermix more readily with astrocytes in culture and induce less astrogliosis. We previously demonstrated that OECs express higher levels of sulfatases, enzymes that remove 6-O-sulfate groups from heparan sulphate proteoglycans, than SCs and that RNAi knockdown of sulfatase prevented OEC-astrocyte mixing in vitro. As human OECs are difficult to culture in large numbers we have genetically engineered SCs using lentiviral vectors to express sulfatase 1 and 2 (SC-S1S2) and assessed their ability to interact with astrocytes. We demonstrate that SC-S1S2s have increased integrin-dependent motility in the presence of astrocytes via modulation of NRG and FGF receptor-linked PI3K/AKT intracellular signaling and do not form boundaries with astrocytes in culture. SC-astrocyte mixing is dependent on local NRG concentration and we propose that sulfatase enzymes influence the bioavailability of NRG ligand and thus influence SC behavior. We further demonstrate that injection of sulfatase expressing SCs into spinal cord white matter results in less glial reactivity than control SC injections comparable to that of OEC injections. Our data indicate that sulfatase-mediated modification of the extracellular matrix can influence glial interactions with astrocytes, and that SCs engineered to express sulfatase may be more OEC-like in character. This approach may be beneficial for cell transplant-mediated spinal cord repair. GLIA 2016 GLIA 2017;65:19-33.

Astrocyte-Schwann-cell coculture systems

Schwann cells are one of the cellular candidates used in repair strategies following trauma and demyelination of the spinal cord. One of the major obstacles in the use of Schwann cells is their limited migratory ability within the astrocytic environment of the CNS and boundary formation between the Schwann cells of the graft and the host astrocytes. This boundary creates an abrupt obstacle for regenerating axons attempting to exit the Schwann cell graft back to the CNS. To facilitate the study of mechanisms underlying these interactions, in vitro coculture assays of Schwann-Astrocytes have been developed. In this chapter, we have described the methodology for two commonly used coculture systems known as the Schwann-Astrocyte boundary assay and the inverted coverslip migration assay.

Analysis of Schwann-astrocyte interactions using in vitro assays

Schwann cells are one of the commonly used cells in repair strategies following spinal cord injuries. Schwann cells are capable of supporting axonal regeneration and sprouting by secreting growth factors (1,2) and providing growth promoting adhesion molecules (3) and extracellular matrix molecules (4). In addition they myelinate the demyelinated axons at the site of injury (5). However following transplantation, Schwann cells do not migrate from the site of implant and do not intermingle with the host astrocytes (6,7). This results in formation of a sharp boundary between the Schwann cells and astrocytes, creating an obstacle for growing axons trying to exit the graft back into the host tissue proximally and distally. Astrocytes in contact with Schwann cells also undergo hypertrophy and up-regulate the inhibitory molecules (8-13). In vitro assays have been used to model Schwann cell-astrocyte interactions and have been important in understanding the mechanism underlying the cellular behaviour. These in vitro assays include boundary assay, where a co-culture is made using two different cells with each cell type occupying different territories with only a small gap separating the two cell fronts. As the cells divide and migrate, the two cellular fronts get closer to each other and finally collide. This allows the behaviour of the two cellular populations to be analyzed at the boundary. Another variation of the same technique is to mix the two cellular populations in culture and over time the two cell types segregate with Schwann cells clumped together as islands in between astrocytes together creating multiple Schwann-astrocyte boundaries. The second assay used in studying the interaction of two cell types is the migration assay where cellular movement can be tracked on the surface of the other cell type monolayer (14,15). This assay is commonly known as inverted coverslip assay. Schwann cells are cultured on small glass fragments and they are inverted face down onto the surface of astrocyte monolayers and migration is assessed from the edge of coverslip. Both assays have been instrumental in studying the underlying mechanisms involved in the cellular exclusion and boundary formation. Some of the molecules identified using these techniques include N-Cadherins 15, Chondroitin Sulphate proteoglycans(CSPGs) (16,17), FGF/Heparin (18), Eph/Ephrins(19). This article intends to describe boundary assay and migration assay in stepwise fashion and elucidate the possible technical problems that might occur.

Soluble forms of the cell adhesion molecule L1 produced by insect and baculovirus-transduced mammalian cells enhance Schwann cell motility

For biotechnological applications, insect cell lines are primarily known as hosts for the baculovirus expression system that is capable to direct synthesis of high levels of recombinant proteins through use of powerful viral promoters. Here, we demonstrate the implementation of two alternative approaches based on the baculovirus system for production of a mammalian recombinant glycoprotein, comprising the extracellular part of the cell adhesion molecule L1, with potential important therapeutic applications in nervous system repair. In the first approach, the extracellular part of L1 bearing a myc tag is produced in permanently transformed insect cell lines and purified by affinity chromatography. In the second approach, recombinant baculoviruses that express L1-Fc chimeric protein, derived from fusion of the extracellular part of L1 with the Fc part of human IgG1, under the control of a mammalian promoter are used to infect mammalian HEK293 and primary Schwann cells. Both the extracellular part of L1 bearing a myc tag accumulating in the supernatants of insect cultures as well as L1-Fc secreted by transduced HEK293 or Schwann cells are capable of increasing the motility of Schwann cells with similar efficiency in a gap bridging bioassay. In addition, baculovirus-transduced Schwann cells show enhanced motility when grafted on organotypic cultures of neonatal brain slices while they retain their ability to myelinate CNS axons. This proof-of-concept that the migratory properties of myelin-forming cells can be modulated by recombinant protein produced in insect culture as well as by means of baculovirus-mediated adhesion molecule expression in mammalian cells may have beneficial applications in the field of CNS therapies.

Schwann cell migration is integrin-dependent and inhibited by astrocyte-produced aggrecan

Schwann cells transplantation has considerable promise in spinal cord trauma to bridge the site of injury and for remyelination in demyelinating conditions. They support axonal regeneration and sprouting by secreting growth factors and providing a permissive surface and matrix molecules while shielding axons from the inhibitory environment of the central nervous system. However, following transplantation Schwann cells show limited migratory ability and they are unable to intermingle with the host astrocytes. This in turn leads to formation of a sharp boundary and an abrupt transition between the Schwann cell graft and the host tissue astrocytes, therefore preventing regenerating axons from exiting the graft. The objective of this study was to identify inhibitory elements on astrocytes involved in restricting Schwann cell migration. Using in vitro assays of cell migration, we show that aggrecan produced by astrocytes is involved in the inhibition of Schwann cell motility on astrocytic monolayers. Knockdown of this proteoglycan in astrocytes using RNAi or digestion of glycosaminglycan chains on aggrecan improves Schwann cell migration. We further show aggrecan mediates its effect by disruption of integrin function in Schwann cells, and that the inhibitory effects of aggrecan can overcome by activation of Schwann cell integrins.

Towards personalized cell-replacement therapies for brain repair

The inability of the CNS to efficiently repair damage caused by trauma and neurodegenerative or demyelinating diseases has underlined the necessity for developing novel therapeutic strategies. Cell transplantation to replace lost neurons and the grafting of myelinating cells to repair demyelinating lesions are promising approaches for treating CNS injuries and demyelination. In this review, we will address the prospects of using stem cells or myelinating glial cells of the PNS, as well as olfactory ensheathing cells, in cell-replacement therapies. The recent generation of induced pluripotent stem cells from adult somatic cells by introduction of three or four genes controlling ‘stemness’ and their subsequent differentiation to desired phenotypes, constitutes a significant advancement towards personalized cell-replacement therapies.

Evaluation of olfactory ensheathing and schwann cells after implantation into a dorsal injury of adult rat spinal cord

Olfactory ensheathing cells (OECs) and Schwann cells (SCs) obtained from adult transgenic rats expressing alkaline phosphatase (AP) were studied following implantation into intact spinal cord and after dorsal column crush (DCC) injury, either within the lesion or near the lesion borders. We observed no evidence of migration of AP OECs or AP SCs after lesion site injections, with most cells remaining in or nearby the injection/lesion site. Acute injection of either cell type outside of the lesion site resulted in the presence of cells in the lesion even two hours after injection. However, after a 2-week delay between DCC injury and cell injection, only OECs injected 2.5-mm outside of a DCC lesion entered the lesion, while SCs did not pass a region of increased astroglial immunoreactivity. GFAP-immunoreactivity also revealed differences in the astroglial scar at the lesion border with openings apparent in this region only in the OEC group. SCs induced greater ingrowth of CGRP-positive axons within the lesion, two weeks post-injury. Equivalent numbers of GAP-43-positive axons grew within the lesion after SC or OEC implantation. These findings show that, although there is no active migration for either cell type, both OECs and SCs are able to support axonal regrowth and/or sprouting into the lesion. The openings in the astroglial boundary at the lesion site may give OECs a potential advantage over SCs in promoting axonal growth through the astroglial scar.

FGF/heparin differentially regulates Schwann cell and olfactory ensheathing cell interactions with astrocytes: a role in astrocytosis

After injury, the CNS undergoes an astrocyte stress response characterized by reactive astrocytosis/proliferation, boundary formation, and increased glial fibrillary acidic protein (GFAP) and chondroitin sulfate proteoglycan (CSPG) expression. Previously, we showed that in vitro astrocytes exhibit this stress response when in contact with Schwann cells but not olfactory ensheathing cells (OECs). In this study, we confirm this finding in vivo by demonstrating that astrocytes mingle with OECs but not Schwann cells after injection into normal spinal cord. We show that Schwann cell-conditioned media (SCM) induces proliferation in monocultures of astrocytes and increases CSPG expression in a fibroblast growth factor receptor 1 (FGFR1)-independent manner. However, SCM added to OEC/astrocyte cocultures induces reactive astrocytosis and boundary formation, which, although sensitive to FGFR1 inhibition, was not induced by FGF2 alone. Addition of heparin to OEC/astrocyte cultures induces boundary formation, whereas heparinase or chlorate treatment of Schwann cell/astrocyte cultures reduces it, suggesting that heparan sulfate proteoglycans (HSPGs) are modulating this activity. In vivo, FGF2 and FGFR1 immunoreactivity was increased over grafted OECs and Schwann cells compared with the surrounding tissue, and HSPG immunoreactivity is increased over reactive astrocytes bordering the Schwann cell graft. These data suggest that components of the astrocyte stress response, including boundary formation, astrocyte hypertrophy, and GFAP expression, are mediated by an FGF family member, whereas proliferation and CSPG expression are not. Furthermore, after cell transplantation, HSPGs may be important for mediating the stress response in astrocytes via FGF2. Identification of factors secreted by Schwann cells that induce this negative response in astrocytes would further our ability to manipulate the inhibitory environment induced after injury to promote regeneration.

Failure of Schwann cells as supporting cells for adult neural progenitor cell grafts in the acutely injured spinal cord

Adult neural progenitor cells (NPC) co-grafted with fibroblasts replace cystic lesion defects and promote cell-contact-mediated axonal regeneration in the acutely injured spinal cord. Fibroblasts are required as a platform to maintain NPC within the lesion; however, they are suspected to create an inhospitable milieu for regenerating central nervous system (CNS) axons. Therefore, we thought to replace fibroblasts by primary Schwann cells, which might serve as a superior scaffold to maintain NPC within the lesion and might further enhance axon regrowth and remyelination following spinal cord injury. Adult rats underwent a cervical dorsal column transection immediately followed by transplantation of either NPC/Schwann cell or NPC/Schwann cell/fibroblast co-grafts. Animals receiving Schwann cell or fibroblast grafts alone, or Schwann cell/fibroblast co-grafts served as controls. At 3 weeks after injury/transplantation, histological analysis revealed that only fibroblast-containing grafts were able to replace the cystic lesion defect. In both co-cultures and co-grafts, Schwann cells and NPC were segregated. Almost all NPC migrated out of the graft into the adjacent host spinal cord. As a consequence, only peripheral-type myelin, but no CNS-type myelin, was detected within co-grafts containing NPC/Schwann cells. Corticospinal axon regeneration into Schwann-cell-containing co-grafts was reduced. Taken together, Schwann cells within NPC grafts contribute to remyelination. However, Schwann cells fail as a supporting platform to maintain NPC within the graft and impair CNS axon regeneration; this makes them an unfavorable candidate to support/augment NPC grafts following spinal cord injury.

Schwann cells genetically engineered to express PSA show enhanced migratory potential without impairment of their myelinating ability in vitro

Schwann cells, the myelin-forming cells of the PNS, are attractive candidates for remyelination therapy as they can remyelinate CNS axons. Yet their integration in CNS tissue appears hampered, at least in part, by their limited motility in the CNS environment. As the polysialylated (PSA) form of NCAM regulates migration of neural precursors in the CNS and is not expressed by developing Schwann cells, we investigated whether conferring sustained expression of PSA to Schwann cells derived from postnatal rats enhances their motility. Cells were transduced with a retrovirus encoding polysialyl-transferase STX, an enzyme that synthesizes PSA on NCAM. Migration of wild type and transduced cells expressing STX or the marker gene alkaline phosphatase was examined using a gap bridging assay in dissociated cells and by grafting cells in slice cultures of postnatal brain. Migration of PSA expressing cells was significantly increased in both models, as compared to control cells, and this effect was abolished by endoneuraminidase-N stripping of PSA. PSA-positive Schwann cells retained the ability to differentiate in vitro and expressed the Krox20 and P zero myelination markers. When grafted in neonatal cerebellar slices, STX-transduced cells started to myelinate Purkinje cell axons like control cells and make myelin internodes after 2 to 3 weeks. PSA was redistributed on the cell membrane and downregulated during differentiation in pure Schwann cell cultures and slice co-cultures. Thus, migratory properties of PNS myelin-forming cells within the CNS can be enhanced without altering their differentiation program. This finding may be beneficial for the development of remyelination therapies.

Survival, integration, and axon growth support of glia transplanted into the chronically contused spinal cord

Due to an ever-growing population of individuals with chronic spinal cord injury, there is a need for experimental models to translate efficacious regenerative and reparative acute therapies to chronic injury application. The present study assessed the ability of fluid grafts of either Schwann cells (SCs) or olfactory ensheathing glia (OEG) to facilitate the growth of supraspinal and afferent axons and promote restitution of hind limb function after transplantation into a 2-month-old, moderate, thoracic (T8) contusion in the rat. The use of cultured glial cells, transduced with lentiviral vectors encoding enhanced green fluorescent protein (EGFP), permitted long-term tracking of the cells following spinal cord transplantation to examine their survival, migration, and axonal association. At 3 months following grafting of 2 million SCs or OEG in 6 microl of DMEM/F12 medium into the injury site, stereological quantification of the three-dimensional reconstructed spinal cords revealed that an average of 17.1 +/- 6.8% of the SCs and 2.3 +/- 1.4% of the OEG survived from the number transplanted. In the OEG grafted spinal cord, a limited number of glia were unable to prevent central cavitation and were found in patches around the cavity rim. The transplanted SCs, however, formed a substantive graft within the injury site capable of supporting the ingrowth of numerous, densely packed neurofilament-positive axons. The SC grafts were able to support growth of both ascending calcitonin gene-related peptide (CGRP)-positive and supraspinal serotonergic axons and, although no biotinylated dextran amine (BDA)-traced corticospinal axons were present within the center of the grafts, the SC transplants significantly increased corticospinal axon numbers immediately rostral to the injury-graft site compared with injury-only controls. Moreover, SC grafted animals demonstrated modest, though significant, improvements in open field locomotion and exhibited less foot position errors (base of support and foot rotation). Whereas these results demonstrate that SC grafts survive, support axon growth, and can improve functional outcome after chronic contusive spinal cord injury, further development of OEG grafting procedures in this model and putative combination strategies with SC grafts need to be further explored to produce substantial improvements in axon growth and function.

N-cadherin differentially determines Schwann cell and olfactory ensheathing cell adhesion and migration responses upon contact with astrocytes

Olfactory ensheathing cells (OECs) and Schwann cells provide a cellular environment that promotes axonal outgrowth in several models of CNS injury. However, they exhibit different properties when in contact with astrocytes. Schwann cells, but not OECs, induce characteristics that typify hypertrophy in astrocytes and exhibit a poor capacity to migrate within astrocyte-rich areas, making them less favourable for transplant-mediated repair. N-cadherin has been implicated in the adhesion of Schwann cells to astrocytes. Despite indistinguishable expression of N-cadherin, Schwann cells adhered more strongly to an astrocyte monolayer and migrated more slowly on astrocytes when compared to OECs. We have examined the role of N-cadherin in mediating these cellular interactions using RNA interference and found differing effects. In Schwann cells, suppression of N-cadherin reduced heterotypic and homotypic adhesion and they gained adhesion properties more akin to OECs. In contrast, suppression of N-cadherin in OECs had no effect. These findings imply that N-cadherin is differentially regulated in OECs and Schwann cells.

Olfactory ensheathing cells: unique glial cell types?

Olfactory ensheathing cells (OECs) have recently been shown to have a remarkable ability to repair spinal cord injury. These cells were originally selected for transplant-mediated repair as their inherent behavior in the olfactory system is to support continual regeneration of olfactory receptor neurons throughout life. What is unique about this system is that olfactory receptor neurons, from the PNS are able to extend primary axons from the olfactory mucosa into the central nervous system (CNS) tissue of the olfactory bulb and synapse with second order neurons. This is one of the rare instances of axons crossing from the peripheral neurons system (PNS) into the CNS in the adult animal. In this paper the basic biology of these cells is described, making comparison with another promising candidate for transplant-mediated repair, the Schwann cell. The growth factor requirement for OECs is summarized detailing the influence of these factors on their antigenic and morphological characteristics. Evidence that OECs have distinct glial cell properties is provided with emphasis on their unique ability to interact with astrocytes. A brief background is given of the data obtained using OECs in transplantation studies and the resulting pros and cons discussed with emphasis on limitations of functional recovery.

Olfactory ensheathing cells induce less host astrocyte response and chondroitin sulphate proteoglycan expression than Schwann cells following transplantation into adult CNS white matter

Both Schwann cells and olfactory ensheathing cells (OECs) create an environment favorable to axon regeneration when transplanted into the damaged CNS. However, transplanted cells can also exert an effect on the host tissue that will influence the extent to which regenerating axons can grow beyond the transplanted area and reenter the host environment. In this study equivalent numbers of Lac-Z-labeled Schwann cells and OECs have been separately transplanted into normal white matter of adult rat spinal cord and the host astrocyte response to each compared. Schwann cell transplantation resulted in a greater area of increased glial fibrillary acidic protein (GFAP) expression compared to that associated with OEC transplantation. This was accompanied by a greater increase in the expression of axon growth inhibitory chrondroitin sulfate proteoglycans (CSPGs) following Schwann cell transplantation compared to OEC transplantation. However, no differences were detected in the increased expression of the specific CSPG neurocan following transplantation of the two cell types. These results mirror differences in the interactions between astrocytes and either Schwann cells or OECs observed in tissue culture models and reveal one aspect of the complex biology of creating regeneration-promoting environments by cell transplantation where transplanted OECs have favorable properties compared to transplanted Schwann cells.

Olfactory ensheathing cells (OECs) and the treatment of CNS injury: advantages and possible caveats

One of the main research strategies to improve treatment for spinal cord injury involves the use of cell transplantation. This review looks at the advantages and possible caveats of using glial cells from the olfactory system in transplant-mediated repair. These glial cells, termed olfactory ensheathing cells (OECs), ensheath the axons of the olfactory receptor neurons. The primary olfactory system is an unusual tissue in that it can support neurogenesis throughout life. In addition, newly generated olfactory receptor neurons are able to grow into the CNS environment of the olfactory bulb tissue and reform synapses. It is thought that this unique regenerative property depends in part on the presence of OECs. OECs share some of the properties of both astrocytes and Schwann cells but appear to have advantages over these and other glial cells for CNS repair. In particular, OECs are less likely to induce hypertrophy of CNS astrocytes. As well as remyelinating demyelinated axons, OEC grafts appear to promote the restoration of functions lost following a spinal cord lesion. However, much of the evidence for this is based on behavioural tests, and the mechanisms that underlie their potential benefits in transplant-mediated repair remain to be clarified.

Remyelination by transplanted olfactory ensheathing cells

The olfactory ensheathing cells (OECs) of the peripheral olfactory system associate with the axons of the first cranial nerve. These axons are not myelinated by OECs because of their very small diameter. However, when OECs are transplanted into areas where they encounter larger-diameter axons, such as in a model of primary demyelination, these cells assume a myelinating phenotype. Myelinating OECs very closely resemble myelinating Schwann cells by all criteria currently examined, including morphology, ultrastructure, biochemistry, and transcriptional regulation. Indeed, it is currently impossible to reliably distinguish myelinating OECs and myelinating Schwann cells that have been transplanted into experimental models of CNS demyelination. This article describes recent studies on the myelinating properties of transplanted OECs, focusing on their intrinsic myelinating potential and how this can be augmented by the presence of meningeal cells. The relative merits of OECs compared with Schwann cells when transplanted into astrocyte-containing lesions in the CNS are discussed together with their potential role in transplanted-mediated repair of demyelinating disease such as multiple sclerosis.

Remyelination of the demyelinated CNS: the case for and against transplantation of central, peripheral and olfactory glia

Although originally developed as a research tool for studying glial-glial and glial-axonal interactions, the technique of transplanting glial cell into the central nervous system has more recently been employed as a potential means for repairing persistent demyelination in clinical disease. It has now been clearly established using various experimental models that oligodendrocyte lineage cells, Schwann cells and olfactory ensheathing cells can all produce new myelin sheaths around demyelinated or amyelinated axons following transplantation. However, this property alone does not necessarily mean that transplantation of these cells into demyelinated lesions in clinical disease will be successful. This article considers some of the properties that would be required of a transplanted myelinogenic cell and assesses the advantages and disadvantages of the currently available cell types.

A quantitative morphometric analysis of rat spinal cord remyelination following transplantation of allogenic Schwann cells

Quantitative morphometric techniques were used to assess the extent and pattern of remyelination produced by transplanting allogenic Schwann cells into demyelinated lesions in adult rat spinal cords. The effects of donor age, prior culturing of donor cells, prior lesioning of donor nerves, and host immunosuppression were evaluated by transplanting suspensions of 30,000 acutely dissociated or cultured Schwann cells from neonatal, young adult, or aged adult rat sciatic nerves into X-irradiation and ethidium bromide-induced demyelinated dorsal column lesions, with or without co-transplantation of neonatal optic nerve astrocytes. Three weeks after transplantation, spinal cords were processed for histological analysis. Under all Schwann cell transplant protocols, large areas containing many Schwann cell-like myelinated axon profiles could be readily observed throughout most of the lesion length. Within these "myelin-rich" regions, the vast majority of detectable axons showed a peripheral-like pattern of myelination. However, interaxonal spacing also increased, resulting in densities of myelinated axons that were more similar to peripheral nerve than intact dorsal columns. Freshly isolated Schwann cells remyelinated more axonal length than cultured Schwann cells, and cells from younger donors remyelinated slightly more axon length than cells from older donors, but all Schwann cell transplant protocols remyelinated tens of thousands of millimeters of axon length and remyelinated axons at similar densities. These results indicate that Schwann cells prepared under a variety of conditions are capable of eliciting remyelination, but that the density of remyelinated axons is much lower than the myelinated axon density in intact spinal cords.

Olfactory ensheathing cells and Schwann cells differ in their in vitro interactions with astrocytes

Transplanted olfactory ensheathing cells (OECs) are able to remyelinate demyelinated axons and support regrowth of transected axons after transplantation into the adult CNS. Transplanted Schwann cells (SCs) share these repair properties but have limitations imposed on their behavior by the presence of astrocytes (ACs). Because OECs exist alongside astrocytes in the olfactory bulb, we have hypothesized that they have advantages over SCs in transplant-mediated CNS repair due to an increased ability to integrate and migrate within an astrocytic environment. In this study, we have tested this hypothesis by comparing the interactions between astrocytes and either SCs or OECs, using a range of in vitro assays. We have shown that (1) astrocytes and SCs segregate into defined non-overlapping domains in co-culture, whereas astrocytes and OECs freely intermingle; (2) both SCs and OECs will migrate across astrocyte monolayers, but only OECs will migrate into an area containing astrocytes; (3) SCs spend less time in contact with astrocytes than do OECs; and (4) astrocytes undergo hypertrophy when in contact with SCs, but not with OECs. Expression of N-cadherin has been implicated as a key mediator of the failure of SCs to integrate with astrocytes. However, we found no differences in the intensity of N-cadherin immunoreactivity between SCs and OECs, suggesting that it is not the adhesion molecule that accounts for the observed differences. In addition, the number of astrocytes expressing chondroitin sulfate proteoglycans (CSPG) is increased when astrocytes are co-cultured with Schwann cells compared with the number when astrocytes are grown alone or with OECs. Taken together, these data support the hypothesis that OECs will integrate more extensively than Schwann cells in astrocytic environments and are therefore better candidates for transplant-mediated repair of the damaged CNS.

Schwann cell-induced loss of synapses in the central nervous system

Synaptophysin immunostaining of areas of spinal gray matter occupied by radiation-induced intraspinal Schwann cells revealed a loss of immunoreactivity from the neuropil. In contrast, synaptophysin immunoreactivity was preserved on the somata and proximal dendrites of motor neurons. The present study extended these observations to the ultrastructural level and confirmed the absence not only of synapses but also of astrocytes and small- and medium-sized dendrites. These neural elements were abundant and appropriately organized in contiguous areas of irradiated neuropil not occupied by Schwann cells.

A new type of biocompatible bridging structure supports axon regrowth after implantation into the lesioned rat optic tract

We have developed a new type of polymer/cell/matrix implant and tested whether it can promote the regrowth of retinal ganglion cell (RGC) and other axons across surgically induced tissue defects in the CNS. The constructs, which consisted of 2-2.5-mm-long polycarbonate tubes filled with lens capsule-derived extracellular matrix coated with cultured neonatal Schwann cells, were implanted into lesion cavities made in the left optic tract (OT) of 18-21-day-old rats. In one group, to promote Schwann cell proliferation and perhaps also to stimulate axon regrowth, basic fibroblast growth factor (bFGF) was added to the lens capsule matrix prior to implantation. In another group, to determine whether application of growth factors to the somata of cells enhances the regrowth of distally injured axons, the neurotrophin NT-4/5 was injected into the eye contralateral to the OT lesion. NT-4/5 and bFGF treatments were combined in some rats. After medium-term (4-10 weeks) or long-term (15-20 weeks) survivals, axon growth into implants was assessed immunohistochemically using a neurofilament (RT97) antibody. RGC axons were visualized after injection of WGA/HRP into the right eye. Viable Schwann cells were present in implants at all times after transplantation. Large numbers of RT97+ axons were consistently found within the bridging implants, often associated with the peripheral glia. Axons were traced up to 1.7 mm from the nearest CNS neuropil and there was immunohistochemical evidence of myelination by Schwann cells and by host oligodendrocytes. There were fewer RGC axons in the implants, fibers growing up to 1.6 mm from the thalamus. Neither NT-4/5 nor bFGF, alone or in combination, significantly increased the extent of RGC axon growth within the implants. A group of OT-lesioned rats was implanted with polymer tubes filled with 2-2.5-mm-long pieces of predegenerate peripheral nerve. Surprisingly, polymer/cell/matrix constructs contained comparatively greater numbers of RGC and other axons and supported more extensive axon elongation. Thus, implants of this type may potentially be useful in bridging large tissue defects in the CNS.

Schwann cells transplanted into normal and X-irradiated adult white matter do not migrate extensively and show poor long-term survival

Although Schwann cells are able to enter the central nervous system (CNS) when the integrity of the glia limitans is disrupted, their ability to migrate through intact CNS remains unclear. We have addressed this issue by transplanting lacZ-labeled Schwann cells into normal adult spinal cord white matter, and into X-irradiated spinal cord (an environment that, unlike normal spinal cord, permits the migration of transplanted oligodendrocyte progenitors). Schwann cell cultures, obtained from neonatal rat sciatic nerve and expanded using bovine pituitary extract and forskolin, were transfected by repeated exposure to retroviral vectors encoding the Escherichia coli lacZ gene. The normal behavior of the transduced cells was confirmed by transplantation into a nonrepairing area of demyelination in the spinal cord, where they formed myelin sheaths around demyelinated axons. A single microliter containing 4 x 10(4) cells was then transplanted into unlesioned normal and X-irradiated white matter of the spinal cord of adult syngeneic rats. One hour after injection, blue cells were observed as a discrete mass within the dorsal funiculus with a longitudinal distribution of 2-3 mm, indicating the extent of passive spread of the injected cells. At subsequent survival times (1, 2, and 4 weeks posttransplantation) blue cells had a distribution that was no more extensive than that seen 1 h after transplantation. However, the number of Schwann cells declined with time following transplantation such that at 4 weeks there were few surviving Schwann cells in both X-irradiated and nonirradiated spinal cord. These results indicate that transplanted Schwann cells do not migrate extensively and show poor long-term survival when introduced into a normal CNS environment.

Schwann cell remyelination is restricted to astrocyte-deficient areas after transplantation into demyelinated adult rat brain

The ability to generate large numbers of Schwann cells from a peripheral nerve biopsy makes them potential candidates for the clinical application of cell transplantation to enhance remyelination in human demyelinating disease. Transplant-derived Schwann cell remyelination has previously been demonstrated in the spinal cord but not for demyelinated axons in the brain, a more likely site for initial clinical intervention. We have transplanted Schwann cells from male neonatal rat sciatic nerves into ethidium bromide-induced areas of demyelination in the deep cerebellar white matter of adult female rats. The extent of Schwann cell remyelination 28 days after transplantation was significantly increased in lesions that received direct injections of Schwann cells compared with non-transplanted lesions. Using in situ hybridisation to identify the rat Y chromosome, transplanted male cells were found to co-localise with the P0 immunoreactive area of Schwann cell remyelination. Combined immunohistochemistry and in situ hybridisation confirmed that many remyelinating Schwann cells were transplant-derived. P0 immunoreactivity and transplanted male cells were found in GFAP-negative, astrocyte-free areas. Transplanted Schwann cells were not identified outside of transplanted lesions, nor did they did not contribute to remyelination of a lesion at a distance from the site of transplantation. Our findings indicate that demyelinated axons in the adult brain can be remyelinated by transplanted Schwann cells but that migration and remyelination are restricted to areas from which astrocytes are absent.

Growth promoting and inhibitory effects of glial cells in the mammalian nervous system

In the central nervous system (CNS) of mammals axonal regeneration is limited by two main factors: first, the low intrinsic regenerative potential of adult CNS neurons and second, inhibitory influences of the glial and extracellular environment. Myelin-associated inhibitors of neurite growth as well as some properties of so called "reactive astrocytes" contribute to the non-permissive of CNS tissue for axonal growth. In contrast, the peripheral nervous system (PNS) environment is supportive of regeneration because Schwann cells provide suitable substrates for regrowing axons. Purified PNS myelin, however, inhibits growth of PNS and CNS axons to a similar extent as does CNS myelin. The molecular basis of glial substrate properties has been studied intensively in the recent years and a large number of molecules have been recognized which might play a role in the regulation of axonal growth. Although the exact mechanisms are still not fully understood, accumulating data shed light on the complex interactions between neurons and glia that are required to establish, maintain, and regenerate axonal connections in the nervous system. In the following chapter we review the role of glial cells in the CNS and PNS during processes of de- and regeneration with respect to our own work.

N-Cadherin inhibits Schwann cell migration on astrocytes

Astrocytes exclude Schwann cells (SCs) from the central nervous system (CNS) at peripheral nerve entry zones and restrict their migration after transplantation into the CNS. We have modeled the interactions between SCs, astrocytes, and fibroblasts in vitro. Astrocytes and SCs in vitro form separate territories, with sharp boundaries between them. SCs migrate poorly when placed on astrocyte monolayers, but migrate well on various other surfaces such as laminin (LN) and skin fibroblasts. Interactions between individual SCs and astrocytes result in long-lasting adhesive contacts during which the SC is unable to migrate away from the astrocyte. In contrast, SC interactions with fibroblasts are much shorter with less arrest of migration. SCs adhere strongly to astrocytes and other SCs, but less well to substrates that promote migration, such as LN and fibroblasts. SC-astrocyte and SC-SC adhesion is mediated by the calcium-dependent cell adhesion molecule N-cadherin. Inhibition of N-cadherin function by calcium withdrawal, peptides containing the classical cadherin cell adhesion recognition sequence His-Ala-Val, or antibodies directed against this sequence inhibit SC adhesion and increase SC migration on astrocytes. We suggest that N-cadherin-mediated adhesion to astrocytes inhibits the widespread migration of SCs in CNS tissue.

Demyelination and remyelination of the caudal cerebellar peduncle of adult rats following stereotaxic injections of lysolecithin, ethidium bromide, and complement/anti-galactocerebroside: a comparative study

Experimentally induced demyelination due to the direct injection of gliotoxic agents has provided powerful models for studying the biology of remyelination. For the most part, these models have involved injection into white matter tracts of the spinal cord. However, the spinal cord has a number of limitations, such as the size of lesions that it is possible to make and its unsuitability for long-term direct cannulation for the delivery of putative remyelination-enhancing agents. In this study, we describe the natural history of three new models of demyelination/remyelination based on the stereotaxic injection of three gliotoxins: lysolecithin, ethidium bromide, and a combination of anti-galactocerebroside antibody and complement (GalC-ab/comp) into the caudal cerebellar peduncle of adult rats. All three agents produced large areas of demyelination with minimal axonal damage, which undergo extensive remyelination. Ethidium bromide- and GalC-ab/comp-induced lesions remyelinated more slowly than those induced by lysolecithin. The contribution to the remyelination of the lesion by Schwann cells reflects the degree of astrocyte damage incurred within the demyelinated area and is greatest for ethidium bromide-induced demyelination. These new models not only provide further insights into the mechanisms of CNS remyelination but also provide a valuable new resource for addressing a series of key issues relevant to current efforts to promote CNS remyelination either by the enhancement of intrinsic processes or by the transplantation of myelinogenic cells.

Do olfactory glia have advantages over Schwann cells for CNS repair?

To a large extent the success of axon regeneration and sustained remyelination which distinguishes the PNS from the CNS is attributable to differences in their respective glial environments. For this reason, many have been attracted to the idea that repair of the CNS might be achieved by transplanting Schwann cells into areas of CNS pathology. Schwann cells will not only promote regeneration but will also myelinate axons thereby making them an appropriate cell type to mediate repair of lesions characterised by demyelination as well as axotomy. The recent discovery that olfactory glia are capable of forming myelin sheaths, together with their well-documented ability to support axon regeneration, means that these cells have a range of repair properties similar to that of Schwann cells. It is not clear at present which of these two alternatives, the Schwann cells or the olfactory glial cell, would be of greater benefit for achieving regeneration of axons or remyelination of persistent demyelination following transplantation into the CNS. In this article we review the repair properties of olfactory glia and identify the areas in which their use for repairing the CNS may have advantages over Schwann cells.

Blood-brain barrier permeability in astrocyte-free regions of the central nervous system remyelinated by Schwann cells

The patency of the blood-brain barrier was examined during the development and repair of focal demyelinating lesions induced in the dorsal columns of rats by the intraspinal injection of ethidium bromide, with or without concomitant irradiation. Blood-brain barrier integrity was determined by the intravenous injection of horseradish peroxidase or by the immunofluorescent localization of endogenous albumin. Following repair, the central area of the lesions was remyelinated by Schwann cells and lacked astrocytes. In unirradiated lesions, demyelination was established at one week and the lesion was largely repaired by remyelination by 12 weeks. Horseradish peroxidase extravasation was absent at one day after injection, but was present at three days and throughout the period of repair. With one exception, all animals which exhibited regions of demyelination also exhibited horseradish peroxidase extravasation. No horseradish peroxidase was seen in lesions where all the demyelinated axons had been repaired by remyelination, and strong albumin immunofluorescence was also absent from such lesions. Albumin immunoreactivity was also absent from normal spinal cords, although it was prominent in normal sciatic nerves and dorsal roots. Irradiation of lesions resulted in a delay in the repair by remyelination, and repair of the blood-brain barrier was similarly delayed. Promotion of Schwann cell remyelination has been suggested as a potential therapy for central demyelinating disorders such as multiple sclerosis; however, central regions remyelinated by Schwann cells lack astrocytes, cells which have been implicated in the induction and maintenance of the blood-brain barrier. Since blood-brain barrier opening may be an early step in the production of new lesions, a defective barrier could allow such remyelinated regions to act as foci for further lesion development. We conclude, however, that the remyelination of central demyelinating lesions by Schwann cells is accompanied by recovery of properties of an intact blood-brain barrier, despite the lack of astrocytes. The present findings support the idea that promotion of remyelination by Schwann cells may form an effective therapy for central demyelinating diseases.

Astrocytoma and Schwann cells in coculture

Glial fibrillary acidic protein (GFAP) is the principal intermediate filament protein found in mature astrocytes. Although the exact function of GFAP is poorly understood, it is presumed to stabilize the astrocyte's cytoskeleton and help in maintaining cell shape. Previous studies from our laboratory have shown that when astrocytes were cocultured with primary Schwann cells (pSCs), astrocytes became hypertrophied and fibrous with intensely positive GFAP staining and segregated Schwann cells (SCs) into pockets. In order to understand the functional role of GFAP in this already established astrocyte-SC coculture model, we generated GFAP-negative cell lines from a GFAP-positive astrocytoma cell line and cocultured both the cell lines with pSCs. Our studies demonstrate that the GFAP-positive cell line put out processes toward the SCs, whereas the GFAP-negative cells did not form processes and the majority of the cells remained round. The most significant and interesting finding of this study, however, is the formation of elaborate processes by SCs when grown in coculture with the astrocytoma cells, unlike SCs cultured alone, which showed their typical bipolar spindle-shaped morphology. The extent of processes did not seem to be dependent of GFAP, since SCs cultured with both the cell lines formed similar processes. This coculture model may be useful in elucidating the factor(s) responsible for the formation of processes by SCs and can be further help in our understanding of the mechanism of morphological transformation of SCs.

Astrocyte-astrocytoma cell line interactions in culture

Astrocytomas are the most common brain tumors arising in the CNS and account for 65% of all primary brain tumors. Astrocytes have been shown to have the highest predisposition to malignant transformation compared to any other CNS cell type. The majority of astrocytomas are histologically malignant neoplasm. Previous studies have shown that resident astrocytes are the first cell type to react to tumors and surround them. However, the role of these astrocytes in tumor formation and progression has not been determined. In the present study, we have co-cultured astrocytes with a permanent cell line S635c15 (derived from anaplastic astrocytoma) in order to understand the cellular interactions between astrocytes and astrocytoma cells. Our studies demonstrate that astrocytes in contact with the tumor cells become reactive and fibrous with an increase in glial fibrillary acidic protein (GFAP) immunoreactivity as early as 4 days in culture. By 8 days, astrocytes formed glial boundaries around the tumor cells which grew as round colonies. The astrocytic processes surrounding the tumor cells were also intensely GFAP positive. Since the behavior of these cells observed in culture is very similar to their interaction seen in vivo, this co-culture system may serve as an in vitro model for astrocyte and astrocytoma cell line interaction and aid in our understanding of the molecular and cellular mechanisms during early stages of tumor formation and cell interactions.

Cell-cell interactions during the migration of myelin-forming cells transplanted in the demyelinated spinal cord

In the present paper, Dil-labeled myelin-forming cells were traced after their transplantation at a distance from a lysolecithin induced lesion in the adult wild-type and shiverer mouse spinal cord. Optical and ultrastructural observations indicate that after their transplantation, Dil-labeled Schwann cells and oligodendrocyte progenitors were found at the level of the graft as well as at the level of the lesion thus confirming that myelin-forming cells were able to migrate in the adult lesioned CNS (Gout et al., Neurosci Lett 87:195-199, 1988). Between the graft and the lesion, labeled Schwann cells and oligodendrocyte progenitors were absent in the gray matter, but were found as previously described, in specific locations (Baron-Van Evercooren et al., J Neurosci Res 35:428-438, 1993; Vignais et al., J Dev Neurosci 11:603-612, 1993). Both cell types were found along blood vessel walls and more precisely in the Virchow-Robin perivascular spaces. They were identified in the meninges among meningeal cells, collagen fibers, or occasionally in direct contact with the basement membrane forming the glia limitans. In addition to these findings, three major observations were made. In the ependymal region, myelin-forming cells were localized between or at the basal pole of ependymocytes. While Dil-labeled oligodendrocyte progenitors were noted to migrate along the outer surface of myelin sheats in CNS wild-type and shiverer white matter, Schwann cells were excluded from this structure in the wild-type mouse spinal cord. Moreover, in the shiverer mouse, migrating Schwann cells did not seem to interact directly with myelin sheats nor with mature oligodendrocytes. Finally, both cell types were seen to invade extensively the spinal peripheral roots. Our ultrastructural observations clearly suggest that multiple cell-cell and cell-substrate interactions rule the migration of myelin-forming cells in the adult CNS infering that multiple mechanisms are involved in this process.

The use of transplanted glial cells to reconstruct glial environments in the CNS

Transplantation studies have demonstrated that glia-depleted areas of the CNS can be reconstituted by the introduction of cultured cells. Thus, the influx of Schwann cells into glia-free areas of demyelination in the spinal cord can be prevented by the combined introduction of astrocytes and cells of the O-2A lineage. Although Schwann cell invasion of areas of demyelination is associated with destruction of astrocytes, the transplantation of rat tissue culture astrocytes ("type-1") alone cannot suppress this invasion, indicating a role for cells of the O-2A lineage in reconstruction of glial environments. By transplanting different glial cell preparations and manipulating lesions so as to prevent meningeal cell and Schwann cell proliferation it is possible to demonstrate that the behaviour of tissue culture astrocytes ("type-1") and astrocytes derived from O-2A progenitor cells ("type-2") is different. In the presence of meningeal cells, tissue culture astrocytes clump together to form cords of cells. In contrast, type-2 astrocytes spread throughout glia-free areas in a manner unaffected by the presence of meningeal cells or Schwann cells. Thus, progenitor-derived astrocytes show a greater ability to fill glia-free areas than tissue culture astrocytes. Similarly, when introduced into infarcted white matter in the spinal cord, progenitor-derived astrocytes fill the malacic area more effectively than tissue culture astrocytes, although axons do not regenerate into the reconstituted area.

Chondroitin sulfate proteoglycan staining in astrocyte-Schwann cell co-cultures

Transplantation of Schwann cells (SCs) in the central nervous system (CNS) for remyelination in pathological situations has been considered a promising approach. However, numerous studies have indicated that astrocytes have a restrictive effect on SC migration within the CNS. We have previously established an in vitro model which demonstrates the restrictive effect of astrocytes on SCs (Ghirnikar and Eng, Glia 4:367-377, 1994). Using this culture model, in the present study, we have characterized the molecular basis underlying astrocyte-SC interaction and demonstrated chondroitin sulfate proteoglycan (CSP) staining in the co-cultures. Following 1-2 weeks of incubation, CSP staining was specifically associated with SCs co-cultured with astrocytes. Staining with antibodies specific for the different chondroitin sulfate isomers revealed the presence of both, chondroitin-4- and 6-sulfates in SCs. In contrast, SCs when cultured alone, or in the presence of astrocytes conditioned medium did not show CSP staining. These data suggest that CSP staining is associated with SCs following co-culture with astrocytes and mediated by cell to cell contact. We hypothesize that the CSP, alone or in combination with other molecules expressed by astrocytes and/or SCs, may be involved in the restrictive effects of astrocytes on SCs. Identification of molecules involved in the unfavorable interaction between astrocytes and SCs will have an important bearing on efforts to remyelinate demyelinated axons by SC transplantation within the damaged CNS.