Multiple sclerosis (MS) currently affects ~2.5 million people worldwide. MS is typically
diagnosed in young adults and is usually not fatal, meaning people live long lives
with MS. Affected individuals usually suffer from progressive physical and/or cognitive
disability, often including fatigue (89.6%), depression (53.9%), memory loss (49.0%),
motor or sensory dysfunction (76.4%, 70.4%) and urinary incontinence (50.8%). This
disability weighs on patients, loved ones and caretakers, and costs the economy billions
of dollars each year.
MS is a chronic, progressive, demyelinating neurodegenerative disease driven by an
aberrant immune system that affects the brain and spinal cord. Neuronal loss and brain
atrophy, apparent even during early disease, is thought to be the major mechanism
of irreversible physical and cognitive disability in MS. There remains a lack of effective
treatments targeting these processes, largely due to an absence of understanding what
drives neurodegeneration. What causes neurodegeneration in MS? The process of widespread
progressive neurodegeneration requires more than the formation of acute demyelinating
lesions driven by an autoimmune attack. Others have proposed that age, iron accumulation,
chronic microglial activation, mitochondrial dysfunction and glutamate excitotoxicity
(all well-characterized mechanisms that lead to neuronal damage) could be contributing
factors leading to neuronal cell death in MS. Recently, it has also been suggested
that there could be a direct autoimmune attack against neurons.
But let us take a step back for a moment, and understand the topographic distribution
of pathology in MS. Focal lesions of active demyelination can be visualized on MRI
during an MS relapse and appear throughout the spinal cord and/or brain as localized
enhancing lesions that are usually associated with blood vessels. Interestingly, one
other common zone of demyelination is near the periventricular region located in deep
grey and white matter (Haider et al., 2014). These lesions usually directly abut the
ventricles and typically follow their perimeter adjacent to the cerebrospinal fluid
(CSF). In the most advanced stages of MS, striking patterns of superficial cortical
lesions become widespread, where the perimeter of cortical grey matter lining the
CSF-rich subarachnoid space is affected (Haider et al., 2014).
Regions of lesion formation do not have a bias for white matter or grey matter, rather
their biases lie in their proximity to the blood-brain barrier (BBB) or blood-cerebral
spinal fluid barrier (BCSFB), and over time, adjacent to the CSF-rich subarachnoid
space. Given that the mode of immune cell entry into the central nervous system (CNS)
is via the BBB and BCSFB, these regions of lesion formation come as no surprise. It
is thought that initiating mechanisms involves the infiltration of myelin-reactive
T lymphocytes. At these regions of inflammation, glial cell and neurons are affected.
Nearby oligodendrocytes and neurons become damaged and die. Microglia and astrocytes
also become reactive contributing to disease processes. Microglia contribute to oxidative
stress via oxidative burst, which is considered a major mode of pathology in MS. Astrocytes,
meanwhile, assume distinctive hypertrophic morphologies, and span from active sites
of demyelination to normal appearing brain matter, and likely play an early and active
role in MS. Other cells, such as oligodendrocyte progenitor cells and neural stem
cells, are queued to contribute to regenerative events. Oligodendrocyte progenitor
cells are recruited to sites of demyelination, where they differentiate into remyelinating
oligodendrocytes via a number of mechanisms. Neural stem cells possess a remarkable
ability to specialize into neurons or glial cells, and have been considered targets
for MS therapy. Brain endothelial cells lose efficacy as tight junction barrier cells,
creating an avenue for entry of unwanted and neurotoxic substances into the CNS. Pericytes
have also been implicated in MS pathology, with phenotypic changes corresponding to
disease severity.
Ependymal cells in MS: Ependymal cells are a type of glial cell that reside within
the CNS whose role in MS is critically understudied. They are simple ciliated epithelial
cells with radial glial origin, that line the entire ventricular surface of the CNS
and the central canal of the spinal cord (Del Bigio, 2010). As such, ependymal cells
are the most predominant cell type associated with CSF. Importantly, they are the
only cell type that lie between the CSF and deep white and grey matter periventricular
lesions in MS. Ependymal cells provide both an immunological barrier and a partial
barrier that regulates the bidirectional transport of molecules between the ventricular
CSF and interstitial fluid. Ependymal cells appear to play an integral role in clearance
of toxic metabolites, nutrient sensing, and metabolic regulation within the brain.
They contain a primary cilium that senses circulating molecules within the CSF and
tufts of motile cilia that maintain laminar flow of CSF at the ventricle surface.
Ependymal cells are also equipped with gap junctions, adherens junctions, and specialized
transporters that enable selective transport of molecules (Del Bigio, 2010).
Researchers have provided evidence that suggests that ependymal cells are sensitive
to inflammation and become pathological in MS (Nathoo et al., 2016; Lisanti et al.,
2005; Schubert et al., 2019). Using MRI technology, Lisanti et al. (2005) discovered
a unique pattern associated with the ependyma of MS patients, which they termed “the
ependymal ‘Dot-Dash’ sign”. On fluid-attenuated inversion recovery images, they described
a “Dot” as a round hyperintense irregularity of the ependymal undersurface with a
diameter larger than the thickness of a “Dash” adjacent to it. The ‘Dot-Dash’ sign
is specific and sensitive to the detection of MS, especially in younger patients (Age
< 50; specificity 71.9%, sensitivity 95.7%) (Lisanti et al., 2005). Our own work has
suggested that these cells are particularly vulnerable to cell death; adult ependymal
cells are not capable of surviving beyond several hours in vitro, even under supportive
conditions (Shah et al., 2018). In cases of neurodegenerative diseases, including
Alzheimer’s disease and MS, our preliminary work suggests that these cells are vulnerable
to abnormal morphology in pathological brains. We found that large portions of the
ependymal layer were lost (beyond normal aging); and many of the ependymal cells that
remained no longer projected processes into the parenchyma (unpublished observations).
As mentioned, ependymal cells are involved in CSF circulation and these cells appear
to become pathological in MS (Lisanti et al., 2005). Schubert et al. (2019) tracked
CSF flow in individuals with MS, and found that the rate of CSF circulation in patients
with MS was significantly decreased in comparison to healthy individuals. CSF is a
major avenue for moving parenchymal byproducts, including cellular wastes that gather
in the interstitial fluid, in preparation for excretion. CSF flows from the ventricular
cavities, along the subarachnoid space and out of the brain and into draining lymph
nodes. This flow occurs at high rates with the average person circulating CSF 2–3
times per 24 hours. Similar to MS, aging results in changes to the ependyma (Todd
et al., 2018). But, unlike MS, ependymal cell dysfunction has been relatively well
studied in aging. In aging, the ependymal layer thins significantly as astrocytes
simultaneously form junctions with resident ependymal cells. Moreover, there are pronounced
reductions in the density of motile cilia on the apical surface of ependymal cells
and an accumulation of lipid. As a consequence, metabolic waste derived from the brain
likely accumulates in the aged brain. Most importantly, ependymal cell damage and
periventricular anomalies have been correlated with neurocognitive decline (Todd et
al., 2018). Whether ependymal cell dysfunction causes cognitive decline that is observed
in MS patients is yet to be studied (Chiaravalloti and DeLuca, 2008). In ependymal
cell-associated gene knock-out studies, experimental animals often present with brain
atrophy, neuroinflammation, periventricular demyelination and ventricular enlargement,
which are features of MS pathology (Liu et al., 2014; Juurlink, 2015). Whether ependymal
cell dysfunction contributes to any of these pathological features observed in MS
patients has not been studied.
In MS, the early dominance of periventricular lesions, which abut the CSF, coupled
with the eventual accumulation of lesions adjacent to the CSF in the subarachnoid
space, makes it highly likely that the presence and progressive accumulation of CSF-associated
factors contributes to disease. Given ependymal cells are the major cell type that
interact with CSF, and are the major barrier cell type that lies between the CSF and
periventricular MS lesions, it is highly probable that this cell is affected by CSF-associated
factors in MS. There are several inflammatory cytokines and cells, as well as debris,
that circulate in the CSF of MS patients; including proinflammatory factors such as,
interferon-gamma (INFγ), Cxcl12, tumor necrosis factor, interleukin-2, and interleukin-22
(Magliozzi et al., 2018). Whether the accumulation of CSF-associated factors in MS
is driven by ependymal cell dysfunction is unknown, and whether ependymal cell dysfunction
directly contributes to MS brain pathogenesis and MS symptoms, or is a secondary consequence,
remains unclear.
There are likely many mechanisms that drive ependymal cell dysfunction and death in
pathological states (
Figure 1
). In particular, ependymal cells are sensitive to certain cytokines, including Cxcl12
and INFγ (Shah et al., 2018). Interestingly, INFγ has already been shown to be associated
with aging and cognitive decline, associated with MS progression. Myelin fragments
that enter the CSF of MS patients, likely also cause damage to ependymal cells (Laabich
et al., 1991). Additionally, T-helper cells in MS likely interact directly with ependymal
cells via Fas-FasL binding, and may also contribute to ependymal cell dysfunction
or death (Shah et al., 2018).
Figure 1
Proposed mechanisms of molecular interactions between CSF-associated factors and ependymal
cells in MS.
Cytokines, such as INFγ and Cxcl12, as well as myelin debris circulate in the CSF
of MS patients. Ependymal cells are equipped with receptors that have binding affinity
for INFγ and Cxcl12, and have also been shown to be sensitive to myelin-induced damage.
In addition, T-helper cells in MS likely interact directly with ependymal cells via
Fas-FasL binding, and may contribute to ependymal cell dysfunction or death. Created
with BioRender.com. CSF: Cerebrospinal fluid; INF: interferon; MS: multiple sclerosis.
Conclusion: If damage to ependymal cells, either directly or indirectly, cause dysfunction
at any point within the intricate circulatory system of the brain, it is possible
that the removal of cellular waste is inadequate and may cause an accumulation of
toxic, damaging factors. Even though there is evidence that ependymal cells are vulnerable
to dysfunction in disease, the study of ependymal cell biology in the context of MS
and inflammation is critically understudied. Deciphering the precise role(s) of ependymal
cells in MS will hopefully reveal new therapeutic targets to effectively treat individuals
with this disease.
Additional file:
Open peer review report 1.
OPEN PEER REVIEW REPORT 1