REVIEW OF LITERATURE

Aishwarya Swaminathan
MPT 1st year
Department of Neuro-Physiotherapy
BIOMARKERS SPECIFIC TO
NEUROLOGICAL DISORDERS

 CONTENTS :-
 Introduction
 Structure
 Function
 Types
 Diagnosis
 Conditions
 Evidences
Biomarker

 Definition :- “A characteristic that is objectively measured and evaluated as an

indicator of normal biological processes, pathogenic processes, or pharmacologic
responses to a therapeutic intervention.” ( National Institutes of Health
Biomarkers).

 Uses :- A) Health risk assessment.

B) For clinical diagnosis.

C) Monitoring purposes
Sites of brain biomarkers
Glial Fibrillary Acidic Protein(GFAP)

 Introduction :-
Glial Fibrillary acidic protein is an intermediate filament III protein which is
found in astrocytes , Schwann cells and enteric glial cells.

 Dr. Lawrence Eng in 1969.

 Structure :-
 Encoded by GFAP Gene (chromosome 17q21.1-q.25)
 Non –soluble ,monomeric protein's of 432 amino acids.
 Molecular mass :- 49.8 kDa-53kDa
 Types of GFAP :-

 GFAP - alpha :- Central nervous system

 GFAP - beta :- Peripheral nervous system.
 GFAP – gamma :- CNS and non- CNS.

 Functions of GFAP :-

 Cytoskeleton of mature astrocytes.

 Co-ordination of cell mobility.
 Transduction of molecular signals
 Contributes to white matter architecture.
 Blood brain barrier integrity.
 GFAP determination/ diagnosis :-

- Glial Fibrillary acidic protein measurement :- Cerebrospinal fluid

Plasma
Serum

- Serum GFAP analysis :- 1) Sandwich ELISA – Enzyme linked immunosorbent assay.

2) DELFIA -Dissociation-enhanced lanthanide

fluorescence immunoassay

- Normal level :- 0.03-0.07 ng/mg

 Conditions :-
1)STROKE
 GFAP is considered as a marker for ischemic stroke(IS) and intracerebral
hemorrhage (ICH).

 GFAP Level :- Intracerebral hemorrhage >> Ischemic stroke.

 Ischemic stroke :- Release occurs > 6-12 hours

 Intracerebral hemorrhage :- 1st few hours (< 2 hours ).

 The release of GFAP depends on the kinetics of cell death.

 The kinetics of cell death in ischemic stroke differs from intra-cerebral hemorrhage.
Mechanism of cell death
ISCHAEMIC STROKE INTRA-CEREBRAL HEMORRHAGE

- Slow release of GFAP. - Rapid release of GFAP.

 Few neurons with necrosis  Shear stress due to hematoma

 Apparent after 6 hrs. expansion.

 Loss of cellular integrity in later stages.

 Immediate glial destruction.
2)TRAUMATIC BRAIN INJURY :-

 Elevated GFAP levels –Diagnostic marker for traumatic

brain injury.

Brain injury

Reactive gliosis

Elevated GFAP levels

GLYMPHATIC PATHWAY

Brain injury

GFAP release

Interstitial
fluid/Extracellular
fluid

Release into
circulating blood
3)ALEXANDER’S DISEASE
- Rare and fatal disease.

- Group of leukodystrophies.

-GFAP levels serve as a biomarker in 2 ways:-

a) GFAP release with injury or damage.

b) Toxic and accumulation of GFAP .

- GFAP aggregates -toxic to astrocytes and contributes to white matter degeneration.

-Presence of Rosenthal fibers.

-Cytoplasmic inclusions in astrocytes.

-Detected by Polymerase chain reaction.

TITLE AIM METHODOLOGY CONCLUSION

Comparing Glial To compare serum and 225 patients were GFAP levels were highly
Fibrillary Acidic Protein plasma GFAP levels included in the study and correlated in serum and
(GFAP) in Serum and following mild TBI they had both serum and plasma, and GFAP had
Plasma Following Mild within the same sample plasma analyzed for similar ability to
Traumatic Brain Injury of subjects using two GFAP. From these 225, discriminate between
in Older Adults. different and widely 121 older adults with a individuals with and
used assays. suspected mTBI, based without intracranial
Nathan A (2020) on a correlation with abnormalities.
Glasgow Coma Scale
(GCS) and blood drawn
within 12 h of injury .
Brain derived neurotropic factor (BDNF)

 Introduction:- Brain derived neurotropic factor is a Neurotrophin which is highly

expressed in brain with potent influence on several aspects of neuronal function.

 Isolated from a pig brain.

 By Yves-Alain Barde and Hans Thoenen.
 Location :- Neocortex, hippocampus, amygdala and cerebellum.

 Structure :-
Encoded by :- BDNF gene.(chromosome 11)
 118 amino acids.
 Molecular mass :- 14 KDa.
FORMS OF
Forms of BDNF :- BDNF

PRO-BDNF BDNF

 Regulated balance between pro- BDNF and m- BDNF.

 Disturbances in transport or signaling by BDNF contributes to the neurodegenerative
disorder
 2 Receptors :n - A) TrkB- Tropomyosin related kinase B
B) p75NTR
Functions :-
 Survival of neurons .
 Synaptic plasticity.
 Morphogenesis.
 Long term potentiation.
 Neurogenesis.
 Neurotransmitter release

 BDNF measurement : - Serum

Plasma
Blood.

 BDNF detection : - ELISA Normal level :- . 15.83–79.77 ng/ml

Conditions
1) Huntington’s disease :-

- Deficits caused by reduced levels of BDNF implicated in selective vulnerability of striatal

neurons in Huntington's disease.

 Impairment of BDNF – TrkB pathway is suspected to underlie the early dysfunction and
degeneration of striatal neurons in these disease.

 BDNF , TrkB and P75NTR are improperly regulated in striata of HD patients and mouse
models of HD.

 Reduction in TrkB mRna expression in caudate but not in the cortex of HD patients
whereas expression of P75NTR was increased.
2) Parkinson’s disease :-

 BDNF is a requirement for establishment of dopaminergic neurons in substantia nigra pars

compacta.

 Protection of dopaminergic neurons against neurotoxin induced neuronal and failure or reduction
in trophic support by BDNF – Etiology for Parkinson’s disease.

 Alpha – synuclein transcriptionally down regulates BDNF expression and alters its axonal
transport.

 Transport disturbances induced by alpha- synuclein is a key pathological factor in progression of

the disease.

 Reduced BDNF expression is co-related with the degree of dopaminergic degeneration .

3) Spinocerebellar ataxia (SCA6) :-

 Polyglutamine (poly Q ) disease.

 Reduced BDNF levels.

 RNA extraction

 BDNF mRna expression level is reduced in SCA6 human cerebellum.

 Reduced BDNF mRNA expression level – reduction in SCA6 cerebellar cortex.

 BDNF is expressed in purkinje cells ,reduced BDNF gene expression in SCA6

cerebella –pathologic mechanism of SCA6.
TITLE AIM METHODOLOGY CONCLUSION

The Effect of Aerobic To determine the effect of Electronic databases were This concludes that
Exercise on Brain- aerobic exercise on brain- systematically reviewed aerobic exercise has a
Derived Neurotrophic derived neurotrophic with the following search positive impact on levels
Factor in People with factor (BDNF) levels in term categories used in of BDNF in neurological
Neurological Disorders: A people with neurological combination: BDNF, populations, as measured
Systematic Review and disorders. exercise and neurological by peripheral blood.
Meta-Analysis. condition/event. Study Including regular aerobic
title and abstract of exercise as a component
Christopher P. retrieved articles were of rehabilitation in a
Mackay(2017) screened by two neurological setting may
independent reviewers. assist to increase BDNF
Full-text articles were levels, potentially leading
reviewed and included for to the enhancement of
analysis based on the neuroplasticity and
following eligibility facilitating improved
criteria. motor performance.
NEUROFILAMENTS
Introduction :-

Neurofilaments are the protein biomarkers which are expressed in the cytoskeleton of
neurons.

 Structure :-

- Encoded by NFL gene (chromosome 8p21)

- 3 amino acids : - lysine - serine- proline .

- Molecular mass :- 53.7 kDA – 111.9 kDA

 Function :-

 Growth of axons during development .

 Maintaining of shape and size of axons.
 Transmission of electrical signals.
 Structural stability to neurons.

 Types/subunits of neurofilaments :-

 Heavy neurofilaments
 Medium neurofilaments
 Light neurofilaments
 Alpha –internexin
Neurofilaments measurement :- Blood Normal level :- 7- 20 pg/mL
CSF

 Detection :- ELISA

Electrochemiluminescence (ECL).

Single Molecule Array (SIMOA).

Normal conditions :- Release of low levels of Nfl from axons

High levels being released at older ages.

 CONDITIONS
1) Amyotrophic lateral sclerosis
 Degenerative disease of motor neurons due to abnormal accumulation of neurofilaments in
perikarya and proximal neurons.

 Two lines of evidence :-

a) Transgenic mice overexpressing neurofilaments proteins develop motor neuron disease.
b) Variant alleles of neurofilaments heavy subunit (NF-H) gene have been found in some
human patients.

- Gradual piling of NF-H – Motor dysfunction

- Degeneration of axons distal to neurofilaments swellings.

 Neurofilament accumulations lead to axonal degeneration .

 Further hinders the transport of components for axonal maintenance.

 Neurofilament byproducts of neuroaxonal breakdown are potential universal

biomarkers of neurodegeneration.

 Codon deletions in the C- terminal region – ALS patients.

 Disease severity – co-related with functional rating scale revised.

2) Charcot- Marie – Tooth – Disease (CMTD)

-Mutations of neurofilaments light subunit form of Charcot Marie Tooth type 2E

(CMT2E).

-Motor neuron degeneration arises from impairment of axonal transport due to NFL
protein aggregation.

-Neurotoxic properties.
 3) Multiple sclerosis :-

 Increase in neurofilaments in CSF – damage to axonal transport.

 Increase neurofilament concentrations are seen in relapsing re-emitting multiple

sclerosis(RRMS).

 Increase in neurofilaments – Related to clinical exacerbations ,exacerbation

frequency and degree of disability.

 Axonal damage occurs during RRMS and that damage contributes to disability and
appearance of clinical exacerbations.
Title Aim Methodology Conclusion

Correlation between To assess the overall This systematic review Moderate correlations
CSF and blood pooled correlation and meta-analysis was are demonstrated
neurofilament light coefficient estimate conducted in accordance between CSF and blood
chain protein: a between cerebrospinal with Preferred Reporting Nfl, especially when
systematic review and fluid (CSF) and blood Items for Systematic blood Nfl was measured
meta-analysis. neurofilament light (Nfl) Reviews and Meta- using Simoa and ECL.
protein. analyses guidelines and
is reported in
Jasmini Alagaratnam compliance with the
(2021) Meta-Analysis of
Observational Studies in
Epidemiology proposal.
A systematic search of
MEDLINE, and Web of
Science electronic
databases for eligible
published articles from
it.
 s100b

 Introduction :- S100b is a calcium binding protein primarily found in astrocytic glial

cells of central nervous system.

- Expressed in astrocytes, certain neurons, schwann cells .

 Structure :-
- Encoded by gene 21q22.3.
 92 amino acid protein.
- Molecular mass :- 21 kDA
 Type :- Subtype of s100 protein biomarker.

 Functions :-

 Promoting neurite outgrowth and astrocytic proliferation which results in increased neuronal
function.

 Prevents mitochondrial failure and cell death by increasing calcium concentration.

 Neurotropic and gliotrophic roles during fetal development.

 Measurement :- Blood, CSF, serum Normal Level :- 0.023–0.059 microgram/L

 Detection :- ELISA
Conditions
1) MIGRAINE :-

 s100b levels increases during ictal and interictal phase.

 Local inflammation Brain damage elevated s100b levels.

 Expression of s100b elevated in cortex by activating astrocytes with advancing age.

 Trigeminal vascular system (TVS)

 Presence of glial cells in TVS system.

 Released in response to inflammatory stimuli.

2) ALZHEIMER DISEASE :-

 Degree of astrocytosis in alzheimers disease correlated with extent of AB deposition.

 Association of s100b astrocytes and AB plaques

 S100b overexpression – pathogenic factor – neurotic plaques in alzheimer’s disease.

 Earliest stage – activated astrocytes present

 Active neuritic injury.

 Later stages :- s100b overexpression (activated astrocytes).

 End stage of plaque progression – “BURNED OUT PLAQUES”.

TITLE AIM METHODOLOGY
S100b in acute To investigate if S100b 122 thrombi from 80 AIS
ischemic stroke clots is levels in AIS clots patients were included.
a biomarker for post- removed by mechanical Within each subgroup, 20
thrombectomy thrombectomy correlated patients had developed
intracranial to increased risk of post- PTIH and 20 patients
hemorrhages. thrombectomy showed no signs of
intracranial hemorrhages. hemorrhage. Gross photos
of each clot were taken and
extracted clot area (ECA)
was measured using
ImageJ.
Immunohistochemistry for
S100b.
Immunofluorescence was
performed for investigation
purposes
CONCLUSION
A higher expression of
S100b in the retrieved
clots is associated with
PTIH regardless of
thrombolytic
administration. Other
factors directly
correlating with PTIH,
such as higher NIHSS
score at admission and
higher number of passes
during mechanical
thrombectomy.
 Ubiquitin carboxy – terminal hydrolase 1(uchl-1)

 Introduction :- UCHL-1 is distributed in the brain and 5 % of total neuronal protein.

 Structure :-
 Encoded by UCHL – 1 gene.
 Composed of 223 amino acids.
 Molecular mass :- 24.8 kDA

 Types :- subtype of UCHL

 Functions :-

 Maintenance of axonal integrity .

Promotes Axonal transport.

 Development of neurons.

 Controls protein synthesis and degradation.

 UCHL-1 Measurement :- Blood
Cerebrospinal fluid.

 Detection :- Enzyme-linked immunosorbent Assay (ELISA)

Conditions
1) Seizures

 Causes molecular and cellular responses

 Results in neuronal damage.

 Elevated level of UCHL-1 present in seizures or status epileptics.

 UCHL-1 enriched in neurons.

 Increase CSF and blood concentration of UCHL-1is associated with the process of
neuron destruction .

 Elevated UCHL-1 –Differences depending on the number of seizures.

 Uchl-1 levels –Recurrent seizures >> few episodes of seizures.

 Excitotoxicity – seizure induced neuronal death.

TITLE AIM METHODOLOGY CONCLUSION

Ubiquitin Carboxy- To investigate A total of 52 patients with Determining levels of

Terminal Hydrolase L1 cerebrospinal fluid single or recurrent tonic– neuronal proteins may
(UCH-L1) is increased (CSF) and plasma clonic or partial provide valuable
in cerebrospinal fluid concentrations of secondarily generalized information on the
and plasma of patients Ubiquitin carboxy- seizures were included.. assessment of brain
after epileptic seizure. terminal hydrolase L1 Written informed consent damage following
(UCH-L1), a sensitive was obtained from all seizure.
Stefania Mondella indicator of acute patients. 48 of the patients
(2012). injury to brain were evaluated in the
neurons, in patients present study and their
with tonic–clonic or biochemical analyses have
partial secondarily been previously reported
generalized seizures elsewhere .CSF and venous
due to various blood samples were taken
etiologies. within 48 h after the
seizure.
 NEURON SPECIFIC ENOLASE(NSE)
 Introduction :- A glycolytic enzyme which is found in the neuronal cytoplasm .
It’s a clinical marker for neuronal and neuroendocrine cells.

 Also known as enolase gamma .

 Isolated from a bovine brain .
 By Moore .

 Structure :-
 Encoded by gene ENO2 (chromosome 12).
 Composed of 434 amino acids.
 Molecular mass :- 78 kDA
 Type :- Sub type of enolase.

 Functions :-

 Maintenance of neuronal integrity.

 Promotes outgrowth of neurons.

 Role in survival of neurons.

 Measurement :- CSF,blood

 Detection:- Enzyme-linked immunosorbent Assay (ELISA)

 Conditions :-

1) Spinal cord injury :-

 Post 30 minutes of injury :- No change in the mild ,moderate and severe SCI .

 2 – 6 hours :- level of NSE was elevated in moderate and severe as compared to mild
SCI.

 Mechanical disruption of spinal cord.

 Co-related with severity of trauma.

Trauma to the spinal cord.

Acute physical injury.

Neuronal necrosis.

Axonal degeneration

Degeneration or death of nerve cells.

Release of proteins and metabolites.

Nervous tissue to CSF

2) Creutzfeldt-Jakob disease

 Elevated levels in CSF .

 Raised NSE levels in the early stages of CJD.

 Persistent increase in the last stage.

 NSE levels = > 35 /ml/mgh

 Values are considered highly suggestive of CJD.

 Rule out other conditions such – e.g. :- stroke, TBI.

 High NSE levels – Maximum- Early stage.

 Presence of acute neuronal loss in Creutzfeldt-Jakob disease.

 Presence of active destructive process.

 Indicator for early diagnosis.

TITLE AIM METHODOLOGY CONCLUSION

Neuronal specific To determine the impact 40 patients with clinical NSE a marker of
enolase as a marker of of seizures on neuronal evidence of acute central neuronal injury was
seizure related neuronal injury in critically ill nervous system disease elevated in patients with
injury . neurology patients by associated with seizures acute central nervous
using neuron specific were included as system diseases. It is
Afshan Jabeen Shaikh enolase as a biomarker. critically ill neurology significantly higher in
( 2019). patients with seizures patients with seizures in
and 43 individuals with comparison to those
central nervous system without seizures.
disorder without
seizures. The serum NSE
assays were performed
using ELISA.
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