Fibrinogenio em Doenças Neurologicas

HHS Public Access
Author manuscript
Nat Rev Neurosci. Author manuscript; available in PMC 2019 September 13.
Author Manuscript
Published in final edited form as:

Nat Rev Neurosci. 2018 May ; 19(5): 283–301. doi:10.1038/nrn.2018.13.
Fibrinogen in neurological diseases: mechanisms, imaging and

therapeutics
Mark A. Petersen1,2, Jae Kyu Ryu1, Katerina Akassoglou1,3,*
1Gladstone Institutes, San Francisco, CA USA.
2Division of Neonatology, Department of Pediatrics, University of California, San Francisco, CA,
USA.
Author Manuscript
3Department of Neurology, University of California, San Francisco, CA, USA.
Abstract
The blood coagulation protein fibrinogen is deposited in the brain in a wide range of neurological
diseases and traumatic injuries with blood–brain barrier (BBB) disruption. Recent research has
uncovered pleiotropic roles for fibrinogen in the activation of CNS inflammation, induction of scar
formation in the brain, promotion of cognitive decline and inhibition of repair. Such diverse roles
are possible in part because of the unique structure of fibrinogen, which contains multiple binding
sites for cellular receptors and proteins expressed in the nervous system. The cellular and
molecular mechanisms underlying the actions of fibrinogen are beginning to be elucidated,
providing insight into its involvement in neurological diseases, such as multiple sclerosis,
Author Manuscript
Alzheimer disease and traumatic CNS injury. Selective drug targeting to suppress the damaging
functions of fibrinogen in the nervous system without affecting its beneficial effects in haemostasis
opens a new fibrinogen therapeutics pipeline for neurological disease.
As we strive to understand the biological complexity of neurological diseases, it becomes

increasingly clear that we cannot study neurons and glia in isolation from their extracellular
environment. Instead, we need to understand how changes in the brain microenvironment
trigger, enable, amplify and contribute to neuronal dysfunction, glial activation and
inflammatory activity in neuronal tissues. Identifying extrinsic molecular determinants of
neurological disease not only deepens our understanding of the mechanisms of
communication between the brain, the immune system and the vasculature but also reveals a
unique niche for novel targets for therapeutic intervention in neurological disease. In the
Author Manuscript
majority of neurological diseases, there is a dramatic transformation of the neurovascular

interface from a safeguarding niche essential for physiological CNS functioning to a pro-
inflammatory niche where an influx of plasma proteins and immune cells contributes to —
*
[email protected].
Author contributions
K.A., M.A.P. and J.K.R. researched data for the article, made substantial contributions to the discussion of content and contributed to
the writing, review and editing of the manuscript before submission.
Competing interests
K.A. is a co-founder of MedaRed. K.A. and J.K.R. are named inventors in patents and patent applications. Their interests are managed
by the Gladstone Institutes in accordance with its conflict of interest policy.
Petersen et al. Page 2
and sometimes drives—the neurodegenerative process. Studying neurological diseases

Author Manuscript
through the multidisciplinary prism of vascular biology, immunology and neuroscience

could be critical for identifying novel mechanisms of disease pathogenesis, developing new
animal models, detecting biomarkers and discovering therapeutic treatments (FIG. 1).
However, the vasculature, immune responses and neurodegeneration have been mostly
studied individually or in pairs in the context of cerebrovascular biology or
neuroimmunology, and mainly in stroke and multiple sclerosis (MS), respectively. As a
result, the sequence of events and causative relationships between alterations in the
vasculature, the immune system and the nervous system that lead to disease remain elusive.
New evidence of immune gene associations and vascular pathology with Alzheimer disease
(AD) pathogenesis has led to a reassessment of the aetiology and mechanisms of
neurodegeneration and has underscored the need for targeting immune and vascular
pathways to develop new therapies for neurodegeneration1–4. Furthermore, common threads
Author Manuscript
among different neurological diseases that share similar vascular and immune abnormalities
have been overlooked.
A fundamental change at the neurovascular interface during disease is the influx of plasma
proteins into the CNS due to increased blood–brain barrier (BBB) permeability that disrupts
the homeostasis between the vasculature and the CNS5. A potential framework for a new
approach to understanding the role of cerebrovascular dysfunction across neurological
diseases could include addressing the following key questions. What are the molecular links
between increased BBB leakage, immune activation and neurodegeneration? Is there
bidirectional crosstalk between the vasculature and the immune system that influences
neuronal functions? Does leakage of plasma proteins in the CNS play a causative role in
neurological disease? Are there cellular targets for plasma proteins in the nervous and the
immune system? Does leakage of plasma proteins into the nervous system contribute to
Author Manuscript
neuronal dysfunction? Do plasma proteins affect nervous system functions directly by acting
on neurons, glia and vascular cells or indirectly by activating the immune response?
A key change in the molecular composition of the extracellular microenvironment in

neurodegeneration, neuroinflammation and traumatic injury is the abundant extravasation of
the plasma protein fibrinogen into the CNS through a leaky BBB6. Fibrinogen is a
pleiotropic protein with essential roles in coagulation, inflammation and tissue repair7.
Although fibrinogen is undetectable in the healthy CNS, it is abundantly deposited in a wide
range of neurological diseases and traumatic injuries associated with BBB disruption. As
such, it has been extensively used as a reliable marker of BBB disruption in human tissue
and relevant animal models. Emerging studies using genetic or pharmacological depletion of
fibrinogen have shown that fibrinogen is not only a marker of BBB disruption but also plays
Author Manuscript
a causative role in a wide range of animal models of neurological diseases, highlighting the
potential role of fibrinogen in MS8,9, AD10,11, brain trauma12 and nerve injury13. The
neuropathological effects of fibrinogen in the nervous system are numerous and include the
following: microglial activation, axonal damage, inhibition of Schwann cell and
oligodendrocyte progenitor cell (OPC) differentiation and remyelination, binding of
amyloid-β (Aβ), opening of the BBB via direct actions on brain endothelial cells, induction
of astrocyte scar formation and inhibition of neurite outgrowth. Fibrinogen is unique among
plasma proteins owing to its molecular structure, which contains binding sites for receptors
expressed by nervous system cells and for proteins that regulate key nervous system
Author Manuscript
functions. The inflammatory functions of fibrinogen mediated primarily via binding to the
CD11b/CD18 integrin receptor (also known as αMβ2 or complement receptor 3) in
microglia and macrophages contribute to neurological deficits in neuroinflammatory disease.
At the same time, fibrinogen binding to proteins such as latent transforming growth factor-β
(TGFβ) or Aβ contributes to brain trauma and AD, respectively. Thus, fibrinogen is at the
nexus of crosstalk between neurons and glia, the vasculature and immune cells and is a key
molecular integrator of neurological, cerebrovascular and immune mechanisms of CNS
injury and disease (FIG. 1).
The goal of this Review is to discuss the pleiotropic functions of fibrinogen in neurological
disease with an emphasis on the cellular targets of fibrinogen in the nervous system and the
fibrinogen-induced signal transduction pathways involved in disease pathogenesis. First, we
highlight the unique evolution and structural characteristics of fibrinogen that enable it to
Author Manuscript
become an active participant in many different biological processes and pathological settings
and include a summary of the many cellular targets and receptors of fibrinogen in the
nervous system. Next, we discuss the mechanisms by which fibrinogen contributes to
inflammation, neurodegeneration and repair in MS, AD and traumatic CNS injury. We then
examine biomarkers present in body fluids and the use of novel imaging probes for the
detection of fibrinogen and increased coagulation activity in neurological diseases. Finally,
we discuss the potential for nervous-system-specific targeting of fibrinogen in neurological
disease without affecting its beneficial effects in haemostasis. Overall, we propose that
fibrinogen leakage upon BBB disruption is a global mediator of neurodegeneration and
activation of innate immunity in the CNS that may be a promising therapeutic target for
neurological diseases with BBB disruption.
Author Manuscript
Fibrinogen enters the diseased CNS

Fibrinogen, a protein synthesized by hepatocytes in the liver and circulating in the
bloodstream, is not present in the healthy brain owing to an intact BBB. The German
physician Paul Ehrlich made the astute observation in the early 1900s that an injected dye
stains all organs except the brain, illuminating the existence of the BBB14. The BBB is a key
component of the neurovascular unit, the dynamic structural and functional unit of the CNS
composed of highly regulated interactions between vascular cells, glial cells and
neurons15,16. With an intact BBB, endothelial cells are connected by tight-junction and
adherens-junction proteins and contain specialized transport systems to regulate paracellular
and transcellular movements of molecules and fluid between the brain and blood17,18.
Pericytes and astrocyte end feet surround the endothelial cells and provide physical contacts,
Author Manuscript
secreted ligands and matrix proteins critical for the development and maintenance of the
BBB19,20. Thus, the BBB provides a dynamic physical and metabolic barrier between the
CNS and systemic circulation, protecting the neural microenvironment from the influx of
potentially harmful substances in the blood, such as plasma proteins and immune cells,
while promoting the efflux of toxins and waste products that may disturb normal neuronal
functions19,20. Therefore, the tightly regulated structure and function of the BBB are
necessary to maintain CNS homeostasis, and, when disturbed, have the potential to promote
neuropathology.
After BBB disruption, fibrinogen enters the nervous system parenchyma and is converted
Author Manuscript
into insoluble fibrin by perivascular tissue factor and procoagulant proteins abundant after
injury21,22. Disruption of the BBB is a common feature of many CNS pathologies, including
traumatic brain and spinal cord injury, stroke, MS, HIV encephalitis, age-related dementia,
Parkinson disease, amyotrophic lateral sclerosis (ALS), cerebral malaria, Huntington
disease, AD and neuropsychiatric disorders such as schizophrenia and bipolar
disease15,19,23–25. Accumulating evidence indicates that BBB disruption and fibrin
deposition precede demyelination and neuronal damage in many of these conditions,
suggesting that neurovascular disruption contributes to disease initiation and/or
progression5,15. Therefore, understanding the mechanisms of action of fibrinogen in the
CNS may potentially open therapeutic avenues targeting the initial pathological changes in
nervous system disease rather than later, downstream effectors.
Author Manuscript
Biology of fibrinogen
What makes fibrinogen stand out among other plasma proteins that leak into the CNS after
BBB disruption? The answer lies in the unique molecular structure of fibrinogen, which
contains multiple binding sites for receptors and proteins, resulting in a pluralistic signalling
network and pleiotropic functions in neurological disease (FIG. 2). Fibrinogen is a 340 kDa
glycoprotein secreted by the liver that circulates in the blood as a soluble homodimer26,27.
Fibrinogen’s two identical disulfide-linked subunits are each composed of three polypeptide
chains, designated Aα, Bβ, and γ28 (FIG. 2). Upon activation of the coagulation cascade,
fibrinogen is converted into insoluble fibrin by thrombin, which enzymatically removes
fibrinopeptide A and fibrinopeptide B from fibrinogen to expose polymerization sites that
facilitate clot formation27,29,30.
Author Manuscript
As the major protein component of blood clots, fibrin binds to activated platelets and acts as
a molecular bridge to enable platelet aggregation and haemostasis31,32. Lysis of the fibrin
clot is mediated by plasmin, which is generated after tissue-type plasminogen activator (tPA)
or urokinase-type plasminogen activator (uPA) activates the zymogen plasminogen33,34.
Plasminogen activator inhibitor 1 (PAI1) and neuroserpin inhibit tPA and uPA, resulting in
decreased fibrinolysis33–35. Increased expression of the low-affinity neurotrophin receptor
p75NTR (NGFR) also suppresses tPA and increases PAI1, resulting in decreased
fibrinolysis36. Disruption of the coagulation–fibrinolysis balance can lead to pathology. For
example, fibrin is an important part of the provisional matrix in cutaneous wounds that
contributes to haemostasis and cellular organization37. However, excessive or prolonged
fibrin deposition in plasminogen-deficient mice inhibits wound repair38–40. Therefore,
proteolysis is a key mechanism for fibrin clearance, and impaired fibrinolysis results in
Author Manuscript
excessive fibrin deposition associated with reduced repair. In addition to proteolytic

degradation, a CC-chemokine receptor 2 (CCR2) macrophage endocytic pathway has been
proposed as a clearance mechanism at sites of inflammation41 (BOX 1).
The polymerization of fibrinogen to fibrin is mediated by highly conserved domains in the

carboxy-terminal globular region of the fibrinogen molecule. These domains, first
recognized in vertebrate fibrinogens, are termed fibrinogen-related domains (FReDs)42. The
carboxy-terminal FReDs on the fibrinogen Bβ and γ-chains form a binding-site ‘hole’ that
interacts with ‘knobs’ protruding from the central amino-terminal region of adjacent
fibrinogen molecules, facilitating the formation of a double-stranded protofibril28,43 (FIG.
Author Manuscript
2). Molecules containing FReDs have been found throughout the animal kingdom; however,
only the FReDs on vertebrate fibrinogen are known to mediate coagulation43. Interestingly,
many FReD-containing molecules in vertebrates, such as fibroleukin, the tenascins and the
ficolins, do not polymerize like fibrinogen but play important roles in innate immunity and
the inflammatory response by directly interacting with surface components of pathogens and
host cells44–46. In invertebrates, the vast majority of FReD-containing proteins are involved
in pathogen pattern recognition and the host defence response47. In addition, some FReD-
containing molecules, such as the scabrous gene product from Drosophila, bind directly to
host cell receptors and mediate signalling events48. Thus, the FReD proteins contribute to a
variety of biological processes that rely on specific interactions with the fibrinogen-related
domains; however, from an evolutionary standpoint, fibrinogen’s role in coagulation is a
Author Manuscript
recent development and unique among FReD proteins. Given that fibrinogen-related proteins
display diverse functions that often include direct cell signalling and host defence, it reasons
that fibrinogen may play a role in the response to injury or disease that goes beyond
coagulation and reflects its ancestral functions. Many pathological conditions involve
vascular disruption and leakage of fibrinogen into the tissue, where it directly interacts with
cells and their receptors. Studies of fibrin deposition in human disease and in mice with
genetic or pharmacological manipulation of the coagulation and fibrinolytic pathways have
revealed a wide range of physiological and pathological conditions that are affected by
fibrin, such as inflammation and tissue repair (FIG. 3; TABLE 1). As a component of the
perivascular extracellular matrix19, fibrinogen directly interacts with all cellular components
of the neurovascular unit, binding receptors on nervous system cells to influence
inflammatory, neurodegenerative and repair processes in the injured CNS6,7. Fibrinogen in
the CNS binds both integrin and non-integrin receptors to directly regulate many basic
Author Manuscript
functions of glia, neurons and endothelial cells (FIG. 2). In addition, fibrinogen acts as a
carrier of diverse proteins that include a number of growth factors as well as components of
the coagulation and fibrinolytic cascade24. Fibrinogen, fibrin and fibrin degradation products
elicit different responses from CNS cells owing to different epitope exposure and different
biochemical properties of soluble molecules and insoluble 3D matrices (detailed description
in FIG. 2). Studies of the cellular and molecular mechanisms of fibrinogen functions in
neurological diseases, as outlined in detail below, have shown that fibrinogen is not merely a
marker of vascular compromise in pathological conditions but rather a critical modulator of
disease that serves as a molecular link between coagulation, inflammation and tissue
regeneration.
MS and neuroinflammation
Author Manuscript
MS is a chronic inflammatory disease of the nervous system characterized by BBB

disruption, perivascular inflammation, demyelination and axonal damage, which can lead to
permanent functional impairments for those individuals affected by this devastating
disease49–51. In 1863, Eduard Rindfleisch, a German pathologist who analysed post-mortem
brain tissue from MS patients, provided the first descriptions suggesting that inflammation
centred around the blood vessels in MS lesions is involved in the underlying aetiology of the
disease52. He wrote: “if one looks carefully at freshly altered parts of the white matter in the
Author Manuscript
brain, one perceives already with the naked eye a red point or line in the middle of each
individual focus, … the lumen of a small vessel engorged with blood. … All this leads us to
search for the primary cause of the disease in an alteration of individual vessels and their
ramifications; an assumption which is completely confirmed by microscopic examination.
All vessels running inside the foci, but also that traverse the immediately surrounding but
still intact parenchyma are in a state characteristic of chronic inflammation.”52 Now, 150
years later, we have begun to delineate how BBB disruption, one of the earliest events in MS
pathology, is linked to the inflammation and white matter injury that define this
neuroinflammatory disease.
BBB disruption and fibrin deposition.

Breakdown of the BBB is a classic hallmark of MS white matter lesions53. MRI has been
Author Manuscript
used clinically for decades as the gold standard for identifying BBB disruption in active MS
lesions by visualizing the leakage of intravenously administered contrast agents such as
gadolinium54,55. MRI studies show that BBB breakdown in MS patients is an early event in
active lesion formation and actually occurs before the onset of clinical symptoms56,57. Serial
MRI scans obtained with dynamic contrast enhancement on high-resolution (3T) and 7T
scanners show that most active enhancing lesions are perivascular and appear to grow
outward from a central vein58,59. Studies that have linked MRI findings to underlying lesion
histopathology reveal extensive leakage of plasma proteins and prominent perivascular
inflammation in these contrast-enhancing lesions60,61. Indeed, fibrin deposition is a
prominent feature of MS pathology and is present throughout the course of the disease
(TABLE 1). Fibrin is found not only in active lesions but also in chronic plaques, where it
persists despite a lack of contrast enhancement on standard MRI62–64. Proteomic analysis of
Author Manuscript
laser-microdissected human MS lesions reveals dysregulation of several proteins of the

coagulation cascade, such as tissue factor and protein C inhibitor, within chronic active MS
lesions65. Fibrin is also deposited in the cortex in patients with progressive MS and
correlates with neuronal loss66. In addition, MS lesions appear to have an impaired capacity
to degrade fibrin owing to an increase in PAI166–68. Interestingly, fibrinogen was detected
not only in the parenchyma but also intracellularly as also documented in prior studies66,69.
The mechanisms of intracellular accumulation of fibrinogen and its potential role in disease
pathogenesis remain unknown. Dysregulation of the coagulation and fibrinolytic pathways
likely contributes to the excessive and prolonged deposition of fibrin observed in MS.
Fibrinogen and the pathways that control fibrin formation and degradation are considered
among the triggers that could contribute to the initiation and course of MS53. Fibrin
deposition in MS lesions correlates with early lesions and areas of demyelination and,
Author Manuscript
importantly, is found in close association with inflammation and damaged axons67,69–71

(TABLE 1). The breakdown of the BBB and activation of the innate immune system appears
to be an early event in MS pathology. In 1952, Adams and Kubik provided the first
pathological description of an early MS lesion in which clusters of microglia, the resident
innate immune cells of the nervous system, were found in areas of morphologically intact
myelin72. This finding is now referred to as a pre-demyelinating or pre-active lesion and is
identified by the characteristic activation of microglia in otherwise normal-appearing white
matter62,69,73. Pre-demyelinating lesions display BBB disruption and fibrin deposition that
colocalize with areas of microglial activation62,63,69. Of note, fibrin deposition and
Author Manuscript
microglial activation in MS lesions precede T cell infiltration, suggesting that fibrin serves
as a critical molecular signal in MS pathology and plays a role in the initiation and/or
progression of inflammation in MS69. This notion is further supported by longitudinal MRI
studies co-registered with histopathology in marmoset experimental autoimmune
encephalomyelitis (EAE), an established autoimmune animal model of MS, which identified
disruption of the BBB 4 weeks before T cell infiltration and demyelination74. Overall, these
studies suggest that BBB leakage and fibrin deposition are early events in the genesis of MS
lesions that precede demyelination and neuronal damage.
Fibrin and neuroinflammation.

Is fibrin merely a marker of BBB disruption or does it have a role in the onset and
Author Manuscript
progression of neuroinflammatory diseases? Fibrin, a potent inducer of microglial activation,

is uniquely positioned to orchestrate immune and oxidative stress responses at sites of BBB
disruption (FIG. 4). Importantly, studies using fibrinogen-mutant mice and anticoagulants
strongly support a causal role for fibrin in neuroinflammation (FIG. 3). Fibrin induces
neuroinflammation by activating microglia and promoting the recruitment and activation of
peripheral inflammatory macrophages into the CNS (FIG. 4)8,9,75. Fibrinogen conversion
into fibrin also exposes a cryptic epitope within the carboxy-terminus of the fibrinogen γ-
chain (amino acid sequence γ377–395), which binds with high affinity to the CD11b-I
domain of CD11b/CD1876,77. Binding of fibrin to the CD11b/CD18 receptor on microglia
and infiltrating macrophages activates multiple signal transduction pathways to promote
inflammatory responses7. Fibrin induces nuclear factor-κB (NF-κB), mitogen-activated
protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K) pathways to mediate
adhesion, migration, chemotaxis and phagocytosis22. Fibrin also activates the serine/
Author Manuscript
threonine-protein kinase AKT and Rho-family GTPases in microglia via CD11b/CD18,

resulting in an increase in cell body size, rearrangements of the actin cytoskeleton and
increased phagocytosis8. In addition to morphological changes and phagocytosis, fibrin
induces a unique transcriptional M1-like activation of microglia and macrophages that is
associated with induction of antigen presentation, release of reactive oxygen species (ROS)
and secretion of the leukocyte-recruiting chemokines monocyte chemoattractant protein 1
(MCP1; also known as CCL2) and CXC-chemokine ligand 10 (CXCL10)9,75. Studies in
macrophages isolated from Toll-like receptor 4 (TLR4)-knockout mice have also indicated
an involvement of TLR4 in fibrinogen-induced activation of NF-κB and cytokine gene
expression78,79. Although there is no evidence to suggest that fibrinogen directly binds
TLR4, TLR4 signalling may be involved in fibrin-induced inflammation. Indeed, crosstalk
between TLR4 and CD11b/CD18 signalling is well established80–83, and fibrin might be a
Author Manuscript
CD11b/CD18 ligand that modulates TLR4-mediated signalling in innate immune cells in the
CNS84. Future studies will be required to determine the relative contribution of known
inflammatory receptors to fibrin and/or fibrinogen signalling and to discover novel cellular
receptors for fibrin and/or fibrinogen in the CNS.
Davalos et al. used two-photon laser scanning microscopy (2pLSM) to study the in vivo
response of microglia to fibrinogen in real time9. Fibrinogen injections into the healthy brain
induced rapid (within ~30 minutes) microglial process extension that was sustained9. These
Author Manuscript
effects were specific for fibrinogen as they were not detected with injections of other blood
proteins or plasma from fibrinogen-knockout mice, which contains all the plasma proteins
except fibrinogen9. Serial in vivo imaging in animals with EAE revealed that fibrinogen-
induced microglial clustering is one of the earliest events in inflammatory demyelination9.
Interestingly, a single stereotactic injection of fibrinogen in the corpus callosum was
sufficient to induce microglial activation and local chemokine secretion, followed by
recruitment and local differentiation of myelin antigen-specific T helper 1 (TH1) cells,
which lead to demyelination75. This fibrin-driven, autoimmune-mediated model of
inflammatory demyelination has been termed fibrin-induced encephalomyelitis (FIE)75 and
has been proposed as a novel experimental setting to study fibrin-induced microglia-driven
demyelination. Induction of FIE in CD11b-knockout mice or after pharmacological
treatment with anti-CD11b neutralizing antibodies ameliorates microglia activation,
chemokine and cytokine release and demyelination75, indicating the requirement of CD11b/
Author Manuscript
CD18 for fibrin-induced immune activation in the CNS in vivo.
Causal role for fibrin in MS pathology.

Genetic depletion of fibrinogen and pharmacological studies targeting the coagulation
cascade and subsequent fibrin deposition have shown a causal role for fibrin in neuro-
inflammatory disease (FIG. 3). The first evidence that fibrin depletion may be beneficial in
inflammatory demyelination came from a study of EAE in rats over 40 years ago85. In this
study, perivascular deposition of fibrin was found in conjunction with paralytic episodes.
EAE animals that had circulating levels of fibrinogen pharmacologically reduced with
ancrod, a thrombin-like serine protease derived from the Malayan pit viper that causes the
abnormal cleavage and degradation of fibrinogen24, demonstrated reduced fibrin deposition
Author Manuscript
and decreased paralysis. Studies in multiple laboratories using EAE, tumour necrosis factor
(TNF)-transgenic and viral models of MS have confirmed the protective and therapeutic
effects of genetic or pharmacological depletion of fibrinogen on inflammatory
demyelination8,86,87. Similar to the fibrinogen-reducing effects of ancrod, blocking the
conversion of fibrinogen into insoluble fibrin with the thrombin inhibitor hirudin was
effective in reducing the severity of EAE9,65. Importantly, therapeutically targeting the
coagulation cascade in EAE not only reduces inflammatory lesions but also protects from
axonal damage9, an increasingly appreciated contributor to MS pathology.
The fibrin γ377–395 epitope binds the CD11b/CD18 integrin receptor on microglia and
macrophages to induce innate inflammatory responses, and, as noted above, fibrin’s effects
in vivo are attenuated in CD11b-knockout mice8,75,76. However, CD11b/CD18 is a
pleiotropic receptor with several endogenous ligands. Therefore, results in CD11b-knockout
Author Manuscript
mice need to be cautiously interpreted and not biasedly associated with a specific ligand,
especially in disease models, such as EAE, in which CD11b/CD18 is exposed to multiple
ligands. To overcome this caveat, the fibrin–CD11b/CD18 interaction can be selectively
disrupted using Fggγ390–396A knock-in mice that express a mutant fibrinogen that cannot
bind CD11b/CD18 (REF. 88) without affecting the binding of other ligands to CD11b/CD18
(FIG. 4). Microglial responses after injection of Fggγ390–396A plasma into the corpus
callosum are significantly lower than the responses to wild-type plasma75. Fggγ390–396A
mice with EAE demonstrate reduced microglial activation, decreased axonal damage, less
demyelination and reduced paralysis8,9. Fggγ390–396A mice are also protected in models of
Author Manuscript
peripheral inflammation, including rheumatoid arthritis, colitis and muscle degeneration7.

The interaction of fibrin with CD11b can also be disrupted pharmacologically using the
fibrin γ377–395 peptide76. Therapeutic administration of the γ377–395 peptide via
intranasal delivery or the vaccination of mice with the γ377–395 peptide also protects from
EAE8. Therefore, fibrinogen entry into the CNS and subsequent CD11b-mediated microglial
activation may be key upstream molecular events that drive inflammatory demyelination75.
Importantly, genetically or pharmacologically inhibiting the fibrin–CD11b/CD18 interaction
does not affect fibrin’s clotting functions8,89; therefore, inhibitory peptides or antibodies that
target the γ377–395 peptide may selectively reduce the pathological effects of fibrin in the
CNS while preserving the benefits of fibrin in blood coagulation. Given the inflammatory
and autoimmune-promoting functions of fibrin in the CNS, fibrin may serve as a therapeutic
Author Manuscript
target that could potentially modify the pathological responses at the onset and progression
of MS.
Alzheimer disease neurodegeneration

AD is a progressive neurodegenerative disorder that results in profound impairments in
learning and memory90. Genetic studies have strongly implicated immune genes, and in
particular pathways regulating microglial functions, in AD1,3,4. Along with microglial
activation and neuronal cell death, the neuropathological hallmarks of AD include the
extracellular deposition of Aβ in senile plaques and blood vessel walls and the intracellular
accumulation of neurofibrillary tangles containing phosphorylated tau34,90. Vascular causes
of dementia have been considered to be critical for AD pathology15,91. However, there is
considerable overlap between these two entities15,91. Cerebrovascular lesions coexist in
Author Manuscript
~50% of patients with clinically diagnosed AD92,93, suggesting that vascular factors play an
important role in AD pathogenesis. In patients with AD, BBB disruption correlates with
disease progression94, and in some AD animal models, BBB permeability actually precedes
other neuropathological alterations in the brain95, suggesting that BBB breakdown has a
causative role in AD initiation and progression. Indeed, microhaemorrhages are frequently
observed in the brains of humans with AD96, and they contribute to the conversion of mild
cognitive impairment into AD97. Microhaemorrhages colocalize with amyloid plaques in the
brains of individuals with AD98, further indicating that BBB disruption or blood itself may
be relevant to plaque deposition.
Accumulating evidence points to the coagulation cascade as a molecular link between

vascular-related and Aβ-related pathology in AD34,99. Fibrin deposition in the CNS is a
Author Manuscript
prominent feature of cerebrovascular pathology in human AD (TABLE 1). Fibrin

accumulations in AD occur within the CNS vessels, especially in conjunction with cerebral
amyloid angiopathy11,100, and in the perivascular brain parenchyma, where it colocalizes
with Aβ plaques, perivascular macrophages, areas of pericyte loss and dystrophic
neurites101–105. CNS fibrin deposits are also increased in patients with AD with two alleles
of apolipoprotein E (Apo-E) ε4 (REF. 100), the strongest genetic risk factor for AD91.
Furthermore, elevated plasma fibrinogen levels are associated with cognitive decline and an
increased risk of AD106,107. Consistent with the human data, CNS fibrin deposition has been
extensively reported in animal models of AD. Transgenic mice with mutations in the human
Author Manuscript
Aβ precursor protein (APP) gene develop AD-like pathology, including accumulations of

Aβ, neurodegeneration and evidence of BBB breakdown108. Perivascular fibrin deposits
have been detected in the brains of AppSw/0 (Tg2576)10,109, Appsw/0 crossed with the
presenilin (Psen)-mutant PsenΔE9 (REF. 110), App V717F (PDAPP)10, AppSwl
(TgCRND8)10 and AppSwFlLo; Psen1M146L/L28 (5×FAD)111 mice. BBB breakdown and
CNS fibrin deposition are also prominent features of the progressive neurodegeneration that
occurs in pericyte-deficient112,113 and APOE-transgenic mice114,115.
Causal role for fibrin in AD pathology.

Given fibrin’s prominence in the brain of people with AD, studies have explored whether
fibrin is causally linked to neurodegeneration in animal models of AD (FIG. 3). In Aβ
injection models, neuroinflammation and AD-like neurodegeneration are exacerbated when
Author Manuscript
fibrinogen is co-injected and significantly reduced when fibrinogen is pharmacologically

depleted with ancrod or upon administration of an anti-CD11b neutralizing antibody116. In
transgenic AD mice, genetic or pharmacological fibrinogen depletion attenuates disease
pathology, reduces microglial activation and improves cognitive function10,11,104. Similarly,
blocking the conversion of fibrinogen into fibrin with anticoagulants is protective in AD
mice117–119. Interestingly, fibrin can physically interact with Aβ to promote Aβ fibril
formation11,120. In turn, Aβ can activate the coagulation factor XII (FXII)-mediated contact
pathway to further drive the conversion of fibrinogen into fibrin121. Fibrin–Aβ interactions
also alter fibrin clot structure and block plasminogen binding to fibrin, which results in
degradation-resistant clots and may further enhance fibrin-induced AD pathology122.
Indeed, Aβ plaque deposition and cognitive impairment are more severe in AD mice lacking
one allele for tPA123, which may be owing to impaired fibrin degradation. Administration of
Author Manuscript
a small molecule that specifically inhibits fibrin–Aβ interaction in AD mice reduces vascular
pathology, blocks neuro-inflammation and protects from cognitive decline111. Similar to
EAE8, therapeutic intranasal administration of the γ377–395 peptide leads to cognitive
improvement and reduction of brain parenchyma Aβ deposition in AβPP/PS1 AD mice124.
Recently, Chen et al. demonstrated that depleting FXII also ameliorates brain pathology and
cognitive impairment in AD mice99,125. These studies suggest that the coagulation system
and its end product fibrin represent a pathogenic constituent of the underlying vascular
damage in AD that promotes inflammatory processes important for disease onset and
progression.
Numerous independent studies by multiple laboratories have consistently demonstrated

increased fibrin deposition and BBB permeability in human patients with AD and in AD
animal models (FIG. 5a; TABLE 1). As recently reviewed108, these studies employ a variety
Author Manuscript
of methods to detect BBB disruption, including fibrin immunodetection and high-resolution

confocal or multiphoton microscopy. A recent study using a single systemic administration
of tracers and antibodies did not detect BBB breakdown in three transgenic AD mouse
models: PS2-APP, TauP301S and APOE126. This study may appear inconsistent with
previous work that showed fibrin deposition in these models10,114. However, it could
potentially be explained by the focal nature and temporal features of BBB disruption.
Fibrinogen immunohistochemistry is an excellent tool to detect the cumulative effect of
BBB disruption over time because fibrinogen clots and accumulates in the brain as fibrin, an
Author Manuscript
insoluble macromolecular deposit that can be removed from the brain only upon proteolytic
degradation34. As such, fibrin can accumulate in the CNS over a long period of time;
therefore, fibrin immunohistochemistry is indicative of long-term leakage. By contrast, a
single injection of exogenous tracers documents BBB disruption only on the specific day of
administration. Although a single administration of tracer can be informative in acute
models with a defined time point of onset (for example, EAE immunization or trauma), it
may be inadequate to determine BBB integrity in a transgenic neurodegeneration model that
develops pathology over several months. High-resolution confocal and multiphoton imaging
of fibrin may also improve the sensitivity of detecting subtle or focal disruptions of the BBB
that may develop over time in AD animal models9,10,112,114. Overall, combining
complementary methods to assess BBB integrity, adapting techniques to account for the
spatiotemporal differences of BBB disruption in acute injury and neuroinflammation models
Author Manuscript
versus chronic models of neurodegeneration and implementing fibrinogen

immunohistochemistry to detect cumulative BBB disruption over time are essential
considerations to rigorously assess BBB integrity in animal models of neurodegeneration.
Other neurodegenerative diseases.

In addition to a potential pathogenic role in AD, fibrinogen may also contribute to the
pathogenesis of other neurodegenerative diseases with vascular dysfunction (TABLE 1).
Indeed, BBB alterations have been reported in patients with frontotemporal dementia127,128,
ALS129,130, Parkinson disease131–133 and Huntington disease25. Similarly, acute traumatic
injuries to the nervous system result in BBB breakdown, inflammation and
neurodegeneration134,135. Of interest, some patients with traumatic brain injury display
continued disruption of the BBB for months or even years after the initial insult136–138.
Author Manuscript
Chronic disruption of the BBB, as seen in transgenic animals with deficient endothelial
transport or aberrant pericyte signalling, is associated with increased perivascular deposition
of fibrin and progressive neurodegeneration109,112. Alterations in the expression of
endothelial tight-junction proteins and/or enhanced bulk-flow transcytosis may both
contribute to the accumulation of CNS fibrin deposits in these animals109,112,139. Fibrin
deposition precedes neuronal degenerative changes and behavioural deficits in pericyte-
mutant mice112, suggesting that fibrin entry into the CNS is a critical factor that initiates or
potentiates neurodegenerative processes after vascular disruption. Unlike animal models of
MS, AD and traumatic injury7, pericyte-deficient mice lack a significant neuroinflammatory
response until late in the disease course after considerable neuronal loss is already
established112. Therefore, fibrin and/or fibrinogen may have direct effects on CNS cells,
such as neurons, oligodendrocytes and pericytes, that promote neurodegenerative and
Author Manuscript
cognitive changes independent from and/or synergistic with the pathology induced by fibrin-
mediated inflammation. Studies with genetic or pharmacological manipulation of fibrinogen
in pericyte-deficient mice and other neurodegenerative disease models are needed to explore
the potential causative role of fibrinogen in these models and to determine the neuronal,
oligodendrocyte and pericyte responses to fibrinogen that may contribute to
neurodegeneration after chronic BBB disruption (see note added in proof).
Note added in proof
Regeneration and repair

Author Manuscript
Disruption of the BBB and fibrinogen deposition in the CNS affects not only underlying
inflammation and neurodegeneration but also the regenerative capacity of the injured tissue.
A growing body of work demonstrates that fibrinogen is a key extrinsic inhibitor of nervous
system repair by regulating growth factor receptor signalling and inflammatory responses
after CNS injury and disease. Fibrinogen activates bone morphogenetic protein (BMP),
TGFβ and epidermal growth factor receptor (EGFR) signalling in OPCs, astrocytes and
neurons, respectively, and influences the polarization of microglia and macrophages to
promote inflammation and inhibit regeneration. As such, fibrinogen plays a critical role in
the inhibition of remyelination, impairment of neuronal regeneration and formation of the
glial scar and serves as a critical environmental signal that transactivates signalling pathways
that limit nervous system repair (FIG. 4).
Author Manuscript
Inhibition of remyelination.
After demyelinating injury in the CNS, myelin sheaths can be regenerated from OPCs,
which are recruited to sites of damage and differentiate into myelin-producing
oligodendrocytes in a process called remyelination140. Remyelination is critical for proper
axonal function and recovery after injury but often fails in a number of neurological
diseases141. Petersen et al. showed that fibrinogen is a key component of the CNS lesion
microenvironment that inhibits remyelination after vascular damage142. Fibrinogen activates
BMP receptor signalling in OPCs142, an important developmental pathway that regulates
oligodendrocyte regeneration after injury143. The BMP–TGFβ superfamily is an
evolutionarily conserved set of ligands, serine/threonine kinase cell surface receptors and
intracellular signalling cascades, including the canonical SMAD pathway, that together
control basic cellular functions, such as proliferation, survival and differentiation144. BMP
Author Manuscript
signalling coordinates processes throughout the body, from developmental patterning and
organ formation to tissue homeostasis and repair, often through the regulation of stem
cells145. Indeed, the BMP–TGFβ superfamily controls the survival and cell fate
determination of many stem cell and progenitor cell populations throughout the body,
including embryonic, mesenchymal, neural and cancer stem cells145,146. In CNS
development, BMP signalling suppresses oligodendrogenesis and promotes astrogliogenesis
from neural stem cells147,148. After demyelinating CNS injury, Petersen et al. found that
fibrinogen is an extrinsic activator of BMP receptor signalling and inhibits OPC
differentiation into myelinating oligodendrocytes while promoting an astrocyte-like cell
fate142. Fibrinogen activates the BMP receptor activin A receptor type I (ACVR1) and
downstream BMP-specific SMAD proteins in OPCs independent of free BMP ligands to
inhibit myelin production142. In addition, fibrin induces M1-like activation of microglia and
Author Manuscript
macrophages9,75, which can be toxic to OPCs and impair remyelination149–151. Indeed,

conditioned medium from fibrin-treated macrophages also inhibits OPC differentiation142,
indicating that fibrin and/or fibrinogen may inhibit remyelination through both immune and
non-immune mechanisms (FIG. 4). In a demyelinating injury model, therapeutic depletion
A recent study published after this review was accepted added pericyte-deficient mice as another animal model with BBB
abnormalities protected from genetic or pharmacologic depletion of fibrinogen and reported effects of fibrinogen on pericytes and
mature oligodendrocytes209.
of fibrinogen decreases BMP pathway activation, increases the number of mature

oligodendrocytes within lesions and enhances remyelination142. Therefore, fibrinogen is a
Author Manuscript
newly recognized blood-derived regulator of BMP receptor signalling and pro-inflammatory

innate immune responses that changes the molecular composition of the stem cell niche after
vascular disruption to direct stem cell fate and function152,153. Fibrinogen-induced signalling
pathways may be important for neurological diseases in which remyelination fails, such as
MS, neonatal brain injury and stroke, and in conditions with aberrant cell fate determination
or disrupted repair, such as brain and spinal cord injury, cancer, cardiovascular disease and
fibrosis.
Fibrinogen’s inhibitory role in remyelination is not limited to the CNS. After peripheral
nerve injury, fibrinogen infiltrates the nerve through a disrupted blood–nerve barrier and is
deposited as fibrin13,154,155. Mice deficient in tPA and/or plasminogen, which have an
impaired ability to degrade fibrin, display increased fibrin deposition and exacerbation of
Author Manuscript
axonal degeneration after experimental sciatic nerve crush injury154. Genetic or

pharmacological depletion of fibrinogen or exogenous administration of tPA attenuates this
injury and promotes regeneration and functional recovery, revealing an important role for
fibrin in peripheral nerve damage and repair13,154,156. Fibrin-activated signalling pathways
in Schwann cells play a central role in inhibiting nerve regeneration by regulating Schwann
cell migration and remyelination13,157. Fibrin induces phosphorylation of extracellular
signal-regulated kinase 1 (ERK1; also known as MAPK3) and ERK2 and production of
NGFR in Schwann cells and maintains them in a proliferating, nonmyelinating state13.
Genetic or pharmacological depletion of fibrinogen after experimental sciatic nerve injury
enhances peripheral nerve remyelination through a faster transition of the Schwann cells to a
myelinating state13. Although through different signalling pathways, fibrinogen impairs the
formation of mature myelinating cells in both the peripheral nervous system and CNS to
Author Manuscript
impair remyelination.
Inhibition of neurite outgrowth.

In addition to its effect on remyelination, fibrinogen also regulates growth factor receptor
signalling in neurons and astrocytes to inhibit neurite outgrowth and induce glial scar
formation, two key features of CNS pathology that limit regeneration12,158. Fibrinogen
inhibits neurite outgrowth by binding the αVβ3 integrin and transactivating the EGFR in
neurons, producing an inhibition of neurite outgrowth as robust as myelin158. In agreement
with these findings, three different in vivo models of spinal cord injury demonstrate
extensive fibrinogen deposition in the CNS that spatially correlates with axonal damage and
phosphorylated EGFR158. Fibrinogen also inhibits axonal regeneration indirectly by
inducing astrocytosis and stimulating the production of inhibitory proteoglycans that form
Author Manuscript
the glial scar. In vitro, fibrinogen-bound latent TGFβ is activated by primary astrocytes and
stimulates the production of neurocan, a potent inhibitor of neurite outgrowth12. In vivo,
fibrinogen-bound latent TGFβ circulating in the blood enters the CNS after BBB disruption
and interacts with perivascular astrocytes to form active TGFβ. Mice with genetic or
pharmacological depletion of fibrinogen display significantly reduced levels of active TGFβ
and dramatic reductions in astrocytosis and glial scar formation after spinal cord injury as
compared with control mice12. These studies again highlight fibrinogen’s role as an
extracellular regulator of growth factor receptor signalling and a critical molecular link
Author Manuscript
between vascular disruption and failure of CNS regeneration. Given its pleiotropic functions,
fibrinogen may be an apical signal that orchestrates the molecular and cellular composition
of the CNS after vascular damage. As such, the persistence of fibrinogen in the CNS may be
an important indicator of a dysfunctional injury response, and therapeutic strategies that
target fibrinogen may tip the balance from a dysregulated environment, which often occurs
in CNS diseases with BBB disruption, to one that promotes regeneration and repair.
Fibrinogen pathway as a biomarker

Immunohistochemical detection of fibrin deposition has been extensively used as a marker
of BBB dysfunction in diverse CNS pathological conditions5,6,34. Fibrin deposition in the
CNS has several advantages as a marker of BBB dysfunction and CNS pathology. First,
fibrin deposition is an early event in CNS disease that often precedes demyelination or
Author Manuscript
neuronal loss. Second, fibrin deposition is sustained in many CNS lesions; therefore, it can
be used to identify sites of BBB dysfunction even after the barrier is restored. Finally, fibrin
deposition is specific among blood proteins as a driver of cellular injury responses;
therefore, it is not only a marker of BBB disruption but also a marker of CNS pathology.
Therefore, detection of fibrin in the CNS provides several advantages over other molecular
tracers or contrast agents that detect only active BBB leakage at the time of administration.
Fibrin detection has the potential to become a valuable diagnostic tool in human CNS
disease but requires advancing from static, immunohistochemical detection of fibrin in post-
mortem tissues to real-time, in vivo monitoring of fibrin formation in animals and humans.
Conjugated molecular probes have been developed to specifically image fibrin and/or
fibrinogen in vivo. Anti-fibrin antibodies or fibrin and/or fibrinogen itself has been
Author Manuscript
fluorescently labelled, injected into mice and imaged in real time using confocal microscopy
or 2pLSM to study the mechanisms and kinetics of fibrin clearance from the vasculature and
tissue41,159,160. Taking advantage of the high subcellular resolution (<1 μm) of 2pLSM,
Davalos et al. used intravenous injections of fluorescently labelled human fibrinogen to
monitor BBB disruption and fibrin deposition in the spinal cord of living mice during the
course of EAE9. The parenchymal fibrin deposition in the CNS correlated with perivascular
microglial clustering, formation of ROS and axonal damage, highlighting the potential use
of fibrin-specific probes to identify areas of pathology9. Tsai et al. developed a novel fibrin-
affinity peptide coupled to a fluorescent near-infrared dye to detect endogenous fibrin
deposition in mice using noninvasive whole-body scans161. To date, fibrin-specific probes
that can be imaged noninvasively with computed tomography (CT)162, MRI163 or positron
emission tomography (PET)164 have been primarily used to monitor intravascular
Author Manuscript
thrombosis in animal models of cardiovascular disease or stroke. Although these fibrin-

specific peptides can identify large clots in the vasculature, it is unknown whether these
probes are sensitive enough to detect perivascular fibrin deposition in the brain parenchyma
after BBB disruption.
An alternative to directly imaging fibrin in the CNS is to utilize probes that can monitor the
activity of upstream components of the coagulation cascade (FIG. 5a). The serine protease
thrombin catalyses the conversion of fibrinogen into insoluble fibrin. Thrombin-specific
activatable cell-penetrating peptides (ACPPs) deliver fluorescent and MRI agents

Author Manuscript
specifically to areas of high thrombin activity, such as acute blood clots, atherosclerotic
plaques and ischaemic areas of the brain165–167. A thrombin-specific ACPP has also been
used to detect coagulation activity in EAE in vivo168. In EAE, thrombin activation is an
early event that precedes demyelination, correlates with disease progression and is strongly
associated with BBB disruption, microglial activation and axonal damage168. The cellular
uptake of the ACPP allows concentration of the probe specifically at sites of increased
protease activity; therefore, ACPP-based probes may improve the sensitivity of CNS lesion
detection compared with passively diffusing contrast agents. In the future, thrombin-
cleavable probes may provide a sensitive and highly specific tool to enable noninvasive
imaging of CNS lesions and perhaps to predict the appearance of newly demyelinating foci
in diseases, such as MS.
In addition to its utility as an imaging biomarker, fibrinogen and components of the

Author Manuscript
coagulation cascade may serve as valuable blood and cerebrospinal fluid (CSF) biomarkers
to diagnose and track neurological disease progression (FIG. 5b). Indeed, an elevated plasma
fibrinogen level is a recognized risk factor for developing AD106,107. Several proteomic
studies in AD identify plasma or CSF fibrinogen as a useful marker of disease severity and
progression169–173 that correlates with neo-cortical amyloid burden174. Proteomics also
revealed elevated fibrin and/or fibrinogen degradation products in the CSF of patients with
traumatic brain injury175. High plasma fibrinogen levels can also be found in MS and the
related inflammatory demyelinating disease neuromyelitis optica and correlate with disease
severity and the presence of active lesions on MRI176. Furthermore, blood levels of the
coagulation factors prothrombin and factor X are significantly higher in relapsing–remitting
and secondary progressive MS patients than in healthy donors177, revealing that additional
upstream components of the coagulation cascade may also serve as valuable biomarkers for
Author Manuscript
MS. Indeed, FXII activity is elevated in the plasma of patients with MS during relapse178.
Elevated plasma FXII is also true for AD, as shown by increased activation of the contact
system, an upstream FXII-mediated cascade that drives fibrin formation through the intrinsic
coagulation pathway179,180. Zamolodchikov et al. demonstrated that markers of contact
system activation, including increased levels of FXIIa, high-molecular-weight kininogen
cleavage and kallikrein activity, are detected in the plasma of patients with AD but not in
plasma from control subjects without dementia179. Increased levels of fibrinogen in the CSF
of patients with major depressive disorder were associated with white matter tract
abnormalities identified by diffusion tensor imaging181. These studies highlight
dysfunctional coagulation as a common thread among diverse CNS diseases with
neurovascular abnormalities. As such, imaging and fluid biomarkers of coagulation may
provide a valuable tool to enhance disease detection and monitoring in a number of CNS
Author Manuscript
pathologies. These studies also need to be interpreted with caution because fibrinogen is an
acute phase reactant.
Testing the ‘fibrin hypothesis’

Studies in neurological diseases and animal models coupled with the pleiotropic functions of
fibrinogen in the CNS have set the stage for a new hypothesis for the genesis and
progression of neurological diseases by proposing fibrinogen as a new molecular player that
can promote and amplify neuroimmune and neurodegenerative processes. Fibrinogen is

Author Manuscript
abundantly detected in the human brain in MS, AD and trauma, and animal studies support
that fibrinogen is necessary and sufficient for the induction of neuroinflammatory processes.
Findings in humans and animal studies coupled with the capacity of fibrinogen and fibrin to
engage multiple receptors and signalling pathways in brain cells have the potential to launch
a field to test the fibrin hypothesis in neurological diseases.
Four key questions would need to be addressed to further elucidate the role of fibrinogen in
the CNS and its potential as a target for therapeutic intervention (FIG. 5b). First, how are the
pleiotropic effects of fibrinogen integrated during the disease course to affect inflammation,
degeneration and repair? To date, fibrinogen mutants have been generated only to inhibit the
interaction of fibrinogen with CD11b/CD18. Expanding the ‘fibrinogen toolbox’ of genetic
models and pharmacological agents and making these widely available to the neuroscience
community would be required to validate the relative contributions of other cellular
Author Manuscript
receptors and the in vivo contribution of its multiple cellular targets. Because cells are
exposed simultaneously to multiple inflammatory and vascular-derived stimulators, studies
using comparative multi-omics approaches would be essential to elucidate how CNS
immune cells integrate signals at sites of BBB disruption to regulate neuroinflammation,
neurodegeneration and repair. Second, what are the cellular targets and underlying molecular
mechanisms of the actions of fibrinogen in the CNS? In 2002, Akassoglou and Strickland
proposed that cells in the nervous tissue are equipped with receptors and intracellular
signalling pathways to mediate fibrin-induced cellular responses22. Indeed, in later years the
identification of microglia, OPCs, neurons, astrocytes, brain endothelial cells and Schwann
cells as cellular targets for fibrinogen changed our understanding of fibrinogen from a
marker of BBB disruption to an active player in nervous system pathogenesis (FIGS. 2–4).
The effects of fibrinogen on other brain cells, such as mature oligodendrocytes, pericytes,
Author Manuscript
different neuronal subtypes and neural progenitor cells, are now starting to be revealed (see
note added in proof). Furthermore, how fibrinogen influences neuron–glia communication
remains poorly understood. Studies to determine the cellular and molecular mechanisms of
fibrinogen and fibrin in the CNS would be critical for the discovery of new mechanisms that
link BBB dysfunction with neurological disease. Third, does fibrinogen contribute to disease
pathogenesis in neurological diseases with BBB disruption other than MS and AD? If so,
what is the magnitude of its pathogenic impact in these conditions or disease subtypes
relative to other pathogenic factors? Does fibrinogen contribute to different conditions
through the same key mechanisms or through a broad range of mechanisms that differ
among diseases? Genetic and pharmacological tools have demonstrated a causal role for
fibrinogen in MS and AD animal models (FIG. 3). These studies could serve as a roadmap
for testing whether fibrinogen plays a role in animal models of trauma, neurodegeneration
Author Manuscript
and even neuropsychiatric disorders. Indeed, emerging evidence suggests increased BBB
leakage in psychiatric disorders such as schizophrenia, bipolar disorder and
psychosis170,182,183. The fibrinogen toolbox (FIG. 1b) could be employed to test the role of
fibrinogen across several animal models of disease with increased BBB permeability,
including brain trauma, spinal cord injury, subarachnoid haemorrhage, cerebral malaria,
epilepsy, pericyte-deficient mice and brain tumours (FIG. 5b; TABLE 1). Such studies have
the potential to identify fibrinogen-induced neuropathology as a common thread among
several neurological diseases and psychiatric conditions and help predict the potential
Author Manuscript
usefulness, impact and market for individual fibrinogen-targeting treatment strategies.

Finally, can we translate fibrin and/or fibrinogen therapeutics to clinical practice for
neurological diseases? Potential pharmacological agents to block fibrinogen’s effects in the
CNS include anticoagulants, drugs that enhance fibrin degradation, agents that protect the
BBB to limit fibrin entrance in the CNS and selective inhibitors of the interactions of
fibrinogen and fibrin with its CNS receptors. The benefits of anticoagulants in multiple
animal models of neurological disease are well established (FIG. 3). Several US Food and
Drug Administration (FDA)-approved drugs, including new oral anticoagulants, can
effectively reduce fibrin formation and, thus, may be of clinical interest in the treatment of
neurological diseases with chronic or repeated opening of the BBB. Similarly, thrombolytic
agents such as tPA that promote fibrin degradation are widely used for the treatment of
stroke. However, the potential haemorrhagic complications of fibrin depletion may limit its
Author Manuscript
widespread clinical use for chronic CNS disease. In addition, these drugs do not deplete
fibrinogen, which also exerts pathogenic effects in the CNS.
Drugs that protect the BBB could potentially limit fibrinogen entrance in the CNS. For
example, activated protein C, which promotes endothelial barrier integrity, prevents
accumulation of blood-derived products in the CNS and attenuates neurodegeneration in
ALS-model mice184. Similarly, blocking the pro-inflammatory cyclophilin A pathway
stabilizes the BBB in APOE transgenic mice and decreases CNS fibrin deposition and
secondary neurodegenerative changes114. In EAE mice, upregulation of tight-junction
molecules in endothelial cells by a protein kinase Cβ inhibitor protects the BBB and
attenuates inflammation, demyelination and axonal damage. Interestingly, many disease-
modifying drugs currently in clinical use for MS have BBB-stabilizing properties185. In
addition to their immunomodulatory effects, interferon-β186, dimethyl fumarate187,
Author Manuscript
fingolimod188 and laquinimod189 all stabilize the BBB, often through actions on endothelial
tight-junction proteins. For example, laquinimod increases expression of tight-junction
proteins p120 and the tight-junction protein zonula occludens 1 in human brain endothelial
cells and suppresses migration of T lymphocytes across the BBB189. Statins, which are
commonly used for the treatment of dyslipidaemias, also reduce BBB permeability190 and
showed promise in the treatment of progressive MS patients191. A caveat of BBB-protective
agents could be that if they are administered therapeutically after the initial opening of the
BBB, they will not target fibrin already deposited in the CNS. Fibrin is an insoluble
substrate that appears to not be easily degraded in the brain. Indeed, there is abundant fibrin
deposition in the cortex in progressive MS66, which is considered to have significantly less
BBB leakage than white matter MS lesions. In this case, further protection of the BBB
would not be efficacious in removing or neutralizing fibrin already deposited in the CNS.
Author Manuscript
Targeting the interactions of fibrin with CD11b has proved a promising strategy in animal
models to selectively inhibit the pathological effects of fibrin in the CNS while preserving its
beneficial effects on blood clotting. The fibrin γ377–395 peptide inhibits the interaction of
fibrin with the CD11b-I domain of CD11b/CD18 and inhibits fibrin-induced microglia
activation in vitro and in vivo8,76. Therapeutic intranasal administration of the fibrin γ377–
395 peptide protects mice from EAE by suppressing paralysis, relapses, demyelination and
neuroinflammation8. Vaccination of EAE mice with the γ377–395 peptide also significantly
protects from neurological disease8. In addition, intranasal administration of the γ377–395

peptide reduces pathology in an AD animal model124. In vivo administration of the γ377–
Author Manuscript
395 peptide does not affect blood coagulation, suggesting that pharmaco-logical tools, such
as monoclonal antibodies against the γ377–395 fibrin epitope, can be developed to
selectively target the pro-inflammatory effects of fibrin without affecting its beneficial role
in haemostasis8. Fibrin–CD11b inhibitors have not yet been evaluated in human clinical
trials.
Targeting the interactions of fibrin with Aβ has shown efficacy in an AD model111.

Fibrinogen and fibrin bind Aβ to form clots that are more resistant to degradation than
normal clots11,120,122. These insoluble fibrin–Aβ complexes are deposited in the blood
vessels and perivascular spaces in AD patients and mice11,120,122 and potentially contribute
to impaired blood flow and chronic fibrin-induced inflammation. In addition, Aβ activates
FXII, an upstream component of the intrinsic coagulation cascade, to further promote fibrin
Author Manuscript
formation192. Activated FXII also increases inflammation through the kallikrein–kininogen–

bradykinin pathway193. Therefore, the fibrin–Aβ interaction may form a feedforward loop
that drives aberrant vascular and inflammatory processes in the CNS that contribute to
neurodegeneration in AD. Indeed, Ahn et al. discovered that a small molecule, RU-505,
which blocks the fibrin–Aβ interaction, significantly reduces vascular pathology, inhibits
neuroinflammation and protects from cognitive decline in AD models111. FXII depletion
also reduces inflammation and neuropathology in AD mice125. Therefore, blocking fibrin’s
interaction with Aβ may break the cycle of fibrin deposition and inflammation that may
potentially contribute to AD progression. Fibrin–Aβ inhibitors have not yet been evaluated
in human clinical trials.
Development of novel fibrin therapeutics would pave the way for targeting blood-induced
Author Manuscript
inflammation and toxicity in the CNS. A fibrin therapeutics pipeline could include selective
targeting of fibrin domains with known deleterious functions in the CNS, structure-guided
drug design and unbiased high-throughput chemical and genomic screens of fibrin-
stimulated nervous system cells. The therapeutic effects in animal models of targeting fibrin
interactions with the CD11b-I domain or with Aβ suggest that it is possible to develop
pharmacological tools to target fibrin–protein interactions selectively in the CNS. An
advantage of this approach is the preservation of the beneficial clotting functions of
fibrinogen. The binding sites of fibrinogen to CNS targets do not overlap with its
coagulation sites, giving the opportunity to develop selective CNS pharmacological
inhibitors for fibrin and fibrinogen. Biochemistry studies to further identify fibrin and/or
fibrinogen receptors and binding proteins in the CNS and map specific binding sites on
fibrinogen would provide the basis for drug discovery. Crystallography studies of the
Author Manuscript
complexes of fibrinogen with its CNS targets could also be instrumental in characterization
of the interactions of fibrin with its receptors and binding proteins to enable structure-guided
drug design. Finally, unbiased small-molecule, RNAi and CRISPR–Cas9 screens can be
developed to identify inhibitors for intracellular pathways induced by fibrin activation of
nervous system cells. Chemical screens in the presence of extrinsic regulators of nervous
system pathology, such as fibrin, could enable the discovery of compounds that can
overcome the toxic lesion environment in vivo. Chemical and genetic screens can also be
performed in human nervous system cells isolated from patients to further enhance the
translational potential of these approaches. Regardless of the therapeutic approach utilized to

Author Manuscript
target fibrinogen and fibrin, patient stratification could facilitate clinical development. Fluid
biomarkers of the coagulation cascade, noninvasive fibrin imaging tools to identify patients
with fibrin deposits in the CNS and metagenome-wide association studies to test whether
there are any potential genetic links with coagulation and/or fibrinolysis genes could be
instrumental for the translation of proof-of-principle fibrin drugs into novel therapies for
neurological diseases.
Acknowledgements
The authors are grateful to L. Mucke and D. Reich for critical reading of the manuscript, T. Roberts and J. Carroll
for graphics and G. Howard for editorial assistance. The authors are supported by the US National Institutes of
Health (NIH), National Institute of Child Health and Human Development (NICHD) K12-HD072222 grant and a
Pediatric Scientist Development Program fellowship (supported by March of Dimes 4-FY10-461 and NIH/NICHD
K12-HD000850) to M.A.P, a Race to Erase MS Young Investigator Award and American Heart Association
Author Manuscript
Scientist Development grant to J.K.R and the National Multiple Sclerosis Society grant RG4985, NIH/NINDS grant
R35 NS097976, the Conrad N. Hilton Foundation grant and US Department of Defense MS160082 grant to K.A.
Literature Cited
1. Zhang B et al. Integrated systems approach identifies genetic nodes and networks in late-onset
Alzheimer’s disease. Cell 153, 707–720 (2013). [PubMed: 23622250]
2. Vemuri P et al. Vascular and amyloid pathologies are independent predictors of cognitive decline in
normal elderly. Brain 138, 761–771 (2015). [PubMed: 25595145]
3. Jonsson T et al. Variant of TREM2 associated with the risk of Alzheimer’s disease. N. Engl. J. Med
368, 107–116 (2013). [PubMed: 23150908]
4. Guerreiro R et al. TREM2 variants in Alzheimer’s disease. N. Engl. J. Med 368, 117–127 (2013).
[PubMed: 23150934]
5. Zlokovic BV The blood-brain barrier in health and chronic neurodegenerative disorders. Neuron 57,
178–201 (2008). [PubMed: 18215617]
Author Manuscript
6. Adams RA, Schachtrup C, Davalos D, Tsigelny I & Akassoglou K Fibrinogen signal transduction as
a mediator and therapeutic target in inflammation: lessons from multiple sclerosis. Curr. Med. Chem
14, 2925–2936 (2007). [PubMed: 18045138]
7. Davalos D & Akassoglou K Fibrinogen as a key regulator of inflammation in disease. Semin.
Immunopathol 34, 43–62 (2012). [PubMed: 22037947]
8. Adams RA et al. The fibrin-derived γ77–395 peptide inhibits microglia activation and suppresses
relapsing paralysis in central nervous system autoimmune disease. J. Exp. Med 204, 571–582
(2007). [PubMed: 17339406]
9. Davalos D et al. Fibrinogen-induced perivascular microglial clustering is required for the
development of axonal damage in neuroinflammation. Nat. Commun 3, 1227 (2012). [PubMed:
23187627]
10. Paul J, Strickland S & Melchor JP Fibrin deposition accelerates neurovascular damage and
neuroinflammation in mouse models of Alzheimer’s disease. J. Exp. Med 204, 1999–2008 (2007).
[PubMed: 17664291]
11. Cortes-Canteli M et al. Fibrinogen and β-amyloid association alters thrombosis and fibrinolysis: a
Author Manuscript
possible contributing factor to Alzheimer’s disease. Neuron 66, 695–709 (2010). [PubMed:
20547128]
12. Schachtrup C et al. Fibrinogen triggers astrocyte scar formation by promoting the availability of
active TGF-β after vascular damage. J. Neurosci 30, 5843–5854 (2010). [PubMed: 20427645]
13. Akassoglou K, Yu WM, Akpinar P & Strickland S Fibrin inhibits peripheral nerve remyelination
by regulating Schwann cell differentiation. Neuron 33, 861–875 (2002). [PubMed: 11906694]
14. Liebner S, Czupalla CJ & Wolburg H Current concepts of blood-brain barrier development. Int. J.
Dev. Biol 55, 467–476 (2011). [PubMed: 21769778]
15. Iadecola C The Neurovascular Unit coming of age: a journey through neurovascular coupling in
health and disease. Neuron 96, 17–42 (2017). [PubMed: 28957666]
Author Manuscript
16. Zlokovic BV Neurovascular pathways to neurodegeneration in Alzheimer’s disease and other

disorders. Nat. Rev. Neurosci 12, 723–738 (2011). [PubMed: 22048062]
17. Tietz S & Engelhardt B Brain barriers: crosstalk between complex tight junctions and adherens
junctions. J. Cell Biol 209, 493–506 (2015). [PubMed: 26008742]
18. Knowland D et al. Stepwise recruitment of transcellular and paracellular pathways underlies
blood–brain barrier breakdown in stroke. Neuron 82, 603–617 (2014). [PubMed: 24746419]
19. Baeten KM & Akassoglou K Extracellular matrix and matrix receptors in blood–brain barrier
formation and stroke. Dev. Neurobiol 71, 1018–1039 (2011). [PubMed: 21780303]
20. Zhao Z, Nelson AR, Betsholtz C & Zlokovic BV Establishment and dysfunction of the blood–brain
barrier. Cell 163, 1064–1078 (2015). [PubMed: 26590417]
21. Thomas WS et al. Tissue factor contributes to microvascular defects after focal cerebral ischemia.
Stroke 24, 847–853 (1993). [PubMed: 8506556]
22. Akassoglou K & Strickland S Nervous system pathology: the fibrin perspective. Biol. Chem 383,
37–45 (2002). [PubMed: 11928820]
Author Manuscript
23. Abbott NJ, Ronnback L & Hansson E Astrocyte-endothelial interactions at the blood–brain barrier.
Nat. Rev. Neurosci 7, 41–53 (2006). [PubMed: 16371949]
24. Adams RA, Passino M, Sachs BD, Nuriel T & Akassoglou K Fibrin mechanisms and functions in
nervous system pathology. Mol. Interv 4, 163–176 (2004). [PubMed: 15210870]
25. Drouin-Ouellet J et al. Cerebrovascular and blood-brain barrier impairments in Huntington’s
disease: potential implications for its pathophysiology. Ann. Neurol 78, 160–177 (2015).
[PubMed: 25866151]
26. Tennent GA et al. Human plasma fibrinogen is synthesized in the liver. Blood 109, 1971–1974
(2007). [PubMed: 17082318]
27. Weisel JW Fibrinogen and fibrin. Adv. Protein Chem 70, 247–299 (2005). [PubMed: 15837518]
28. Lord ST Molecular mechanisms affecting fibrin structure and stability. Arterioscler Thromb. Vasc.
Biol 31, 494–499 (2011). [PubMed: 21325671]
29. Mosesson MW Fibrinogen and fibrin structure and functions. J. Thromb. Haemost 3, 1894–1904
(2005). [PubMed: 16102057]
Author Manuscript
30. Yang Z, Mochalkin I & Doolittle RF A model of fibrin formation based on crystal structures of
fibrinogen and fibrin fragments complexed with synthetic peptides. Proc. Natl Acad. Sci. USA 97,
14156–14161 (2000). [PubMed: 11121023]
31. Holmback K, Danton M, Suh T, Daugherty C & Degen J Impaired platelet aggregation and
sustained bleeding in mice lacking the fibrinogen motif bound by integrin αIIb β3. EMBO J 15,
5760–5771 (1996). [PubMed: 8918453]
32. Rooney MM, Parise LV & Lord ST Dissecting clot retraction and platelet aggregation. Clot
retraction does not require an intact fibrinogen γ chain C terminus. J. Biol. Chem 271, 8553–8555
(1996). [PubMed: 8621481]
33. Castellino FJ & Ploplis VA Structure and function of the plasminogen/plasmin system. Thromb.
Haemost 93, 647–654 (2005). [PubMed: 15841308]
34. Bardehle S, Rafalski VA & Akassoglou K Breaking boundaries-coagulation and fibrinolysis at the
neuro-vascular interface. Front. Cell Neurosci 9, 354 (2015). [PubMed: 26441525]
35. Osterwalder T et al. The axonally secreted serine proteinase inhibitor, neuroserpin, inhibits
Author Manuscript
plasminogen activators and plasmin but not thrombin. J. Biol. Chem 273, 2312–2321 (1998).
[PubMed: 9442076]
36. Sachs BD et al. p75 neurotrophin receptor regulates tissue fibrosis through inhibition of
plasminogen activation via a PDE4/cAMP/PKA pathway. J. Cell Biol 177, 1119–1132 (2007).
[PubMed: 17576803]
37. Laurens N, Koolwijk P & de Maat MP Fibrin structure and wound healing. J. Thromb. Haemost 4,
932–939 (2006). [PubMed: 16689737]
38. Chan JC, Duszczyszyn DA, Castellino FJ & Ploplis VA Accelerated skin wound healing in
plasminogen activator inhibitor-1-deficient mice. Am. J. Pathol 159, 1681–1688 (2001). [PubMed:
Author Manuscript
11696429]
39. Bugge TH et al. Loss of fibrinogen rescues mice from the pleiotropic effects of plasminogen
deficiency. Cell 87, 709–719 (1996). [PubMed: 8929539]
40. Romer J et al. Impaired wound healing in mice with a disrupted plasminogen gene. Nat. Med 2,
287–292 (1996). [PubMed: 8612226]
41. Motley MP et al. A CCR2 macrophage endocytic pathway mediates extravascular fibrin clearance
in vivo. Blood 127, 1085–1096 (2016). [PubMed: 26647393]
42. Doolittle RF A detailed consideration of a principal domain of vertebrate fibrinogen and its
relatives. Protein Sci 1, 1563–1577 (1992). [PubMed: 1304888]
43. Doolittle RF, McNamara K & Lin K Correlating structure and function during the evolution of
fibrinogen-related domains. Protein Sci 21, 1808–1823 (2012). [PubMed: 23076991]
44. Matsushita M et al. A novel human serum lectin with collagen- and fibrinogen-like domains that
functions as an opsonin. J. Biol. Chem 271, 2448–2454 (1996). [PubMed: 8576206]
45. Marazzi S et al. Characterization of human fibroleukin, a fibrinogen-like protein secreted by T
Author Manuscript
lymphocytes. J. Immunol 161, 138–147 (1998). [PubMed: 9647217]

46. Chiquet-Ehrismann R & Tucker RP Tenascins and the importance of adhesion modulation. Cold
Spring Harb. Perspect. Biol 3, a004960 (2011). [PubMed: 21441591]
47. Hanington PC & Zhang SM The primary role of fibrinogen-related proteins in invertebrates is
defense, not coagulation. J. Innate Immun 3, 17–27 (2011). [PubMed: 21063081]
48. Powell PA, Wesley C, Spencer S & Cagan RL Scabrous complexes with Notch to mediate
boundary formation. Nature 409, 626–630 (2001). [PubMed: 11214322]
49. Lassmann H Multiple sclerosis pathology: evolution of pathogenetic concepts. Brain Pathol 15,
217–222 (2005). [PubMed: 16196388]
50. Lassmann H, Bruck W & Lucchinetti C Heterogeneity of multiple sclerosis pathogenesis:
implications for diagnosis and therapy. Trends Mol. Med 7, 115–121 (2001). [PubMed: 11286782]
51. Lucchinetti CF, Brueck W, Rodriguez M & Lassmann H Multiple sclerosis: lessons from
neuropathology. Semin. Neurol 18, 337–349 (1998). [PubMed: 9817538]
52. Rindficisch E Histologisches detail zu der grauen degeneration von gehirn und ruckenmark. Arch.
Author Manuscript
Pathol. Anat. Physiol 26, 474–483 (1863).

53. Reich DS, Lucchinetti CF & Calabresi PA Multiple sclerosis. N. Engl. J. Med 378, 169–180
(2018). [PubMed: 29320652]
54. Grossman RI et al. Multiple sclerosis: serial study of gadolinium-enhanced MR imaging.
Radiology 169, 117–122 (1988). [PubMed: 3420246]
55. Miller DH et al. Serial gadolinium enhanced magnetic resonance imaging in multiple sclerosis.
Brain 111, 927–939 (1988). [PubMed: 3401689]
56. Kermode AG et al. Breakdown of the blood-brain barrier precedes symptoms and other MRI signs
of new lesions in multiple sclerosis. Pathogenetic and clinical implications. Brain 113, 1477–1489
(1990). [PubMed: 2245307]
57. Cotton F, Weiner HL, Jolesz FA & Guttmann CR MRI contrast uptake in new lesions in relapsing-
remitting MS followed at weekly intervals. Neurology 60, 640–646 (2003). [PubMed: 12601106]
58. Gaitan MI, Sati P, Inati SJ & Reich DS Initial investigation of the blood-brain barrier in MS lesions
at 7 tesla. Mult. Scler 19, 1068–1073 (2012). [PubMed: 23246799]
Author Manuscript
59. Gaitan MI et al. Evolution of the blood-brain barrier in newly forming multiple sclerosis lesions.
Ann. Neurol 70, 22–29 (2011). [PubMed: 21710622]
60. Bruck W et al. Inflammatory central nervous system demyelination: correlation of magnetic
resonance imaging findings with lesion pathology. Ann. Neurol 42, 783–793 (1997). [PubMed:
9392578]
61. Katz D et al. Correlation between magnetic resonance imaging findings and lesion development in
chronic, active multiple sclerosis. Ann. Neurol 34, 661–669 (1993). [PubMed: 8239560]
62. Vos CM et al. Blood-brain barrier alterations in both focal and diffuse abnormalities on
postmortem MRI in multiple sclerosis. Neurobiol. Dis 20, 953–960 (2005). [PubMed: 16039866]
63. Kirk J, Plumb J, Mirakhur M & McQuaid S Tight junctional abnormality in multiple sclerosis
white matter affects all calibres of vessel and is associated with blood-brain barrier leakage and
Author Manuscript
active demyelination. J. Pathol 201, 319–327 (2003). [PubMed: 14517850]

64. Kwon EE & Prineas JW Blood-brain barrier abnormalities in longstanding multiple sclerosis
lesions. An immunohistochemical study. J. Neuropathol. Exp. Neurol 53, 625–636 (1994).
[PubMed: 7964903]
65. Han MH et al. Proteomic analysis of active multiple sclerosis lesions reveals therapeutic targets.
Nature 451, 1076–1081 (2008). [PubMed: 18278032]
66. Yates RL et al. Fibrin(ogen) and neurodegeneration in the progressive multiple sclerosis cortex.
Ann. Neurol 82, 259–270 (2017). [PubMed: 28719020]
67. Gveric D et al. Plasminogen activators in multiple sclerosis lesions: implications for the
inflammatory response and axonal damage. Brain 124, 1978–1988 (2001). [PubMed: 11571216]
68. Gveric D, H. B, Petzold A, Lawrence DA & Cuzner ML Impaired fibrinolysis in multiple sclerosis:
a role for tissue plasminogen activator inhibitors. Brain 126, 1–9 (2003).
69. Marik C, Felts PA, Bauer J, Lassmann H & Smith KJ Lesion genesis in a subset of patients with
multiple sclerosis: a role for innate immunity? Brain 130, 2800–2815 (2007). [PubMed:
Author Manuscript
17956913]
70. Gay FW, Drye TJ, Dick GW & Esiri MM The application of multifactorial cluster analysis in the
staging of plaques in early multiple sclerosis. Identification and characterization of the primary
demyelinating lesion. Brain 120, 1461–1483 (1997). [PubMed: 9278635]
71. Wakefield AJ, More LJ, Difford J & McLaughlin JE Immunohistochemical study of vascular injury
in acute multiple sclerosis. J. Clin. Pathol 47, 129–133 (1994). [PubMed: 8132826]
72. Adams RD & Kubik CS The morbid anatomy of the demyelinative disease. Am. J. Med 12, 510–
546 (1952). [PubMed: 14933429]
73. Barnett MH & Prineas JW Relapsing and remitting multiple sclerosis: pathology of the newly
forming lesion. Ann. Neurol 55, 458–468 (2004). [PubMed: 15048884]
74. Maggi P et al. The formation of inflammatory demyelinated lesions in cerebral white matter. Ann.
Neurol 76, 594–608 (2014). [PubMed: 25088017]
75. Ryu JK et al. Blood coagulation protein fibrinogen promotes autoimmunity and demyelination via
chemokine release and antigen presentation. Nat. Commun 6, 8164 (2015). [PubMed: 26353940]
Author Manuscript
76. Ugarova TP et al. Sequence γ377–395(P2), but not γ190–202(P1), is the binding site for the αMI-
domain of integrin αMβ2 in the γC-domain of fibrinogen. Biochemistry 42, 9365–9373 (2003).
[PubMed: 12899623]
77. Lishko VK, Kudryk B, Yakubenko VP, Yee VC & Ugarova TP Regulated unmasking of the cryptic
binding site for integrin αMβ2 in the γC-domain of fibrinogen. Biochemistry 41, 12942–12951
(2002). [PubMed: 12390020]
78. Smiley ST, King JA & Hancock WW Fibrinogen stimulates macrophage chemokine secretion
through toll-like receptor 4. J. Immunol 167, 2887–2894 (2001). [PubMed: 11509636]
79. Millien VO et al. Cleavage of fibrinogen by proteinases elicits allergic responses through Toll-like
receptor 4. Science 341, 792–796 (2013). [PubMed: 23950537]
80. Han C et al. Integrin CD11b negatively regulates TLR-triggered inflammatory responses by
activating Syk and promoting degradation of MyD88 and TRIF via Cbl-b. Nat. Immunol 11, 734–
742 (2010). [PubMed: 20639876]
81. Perera PY et al. CD11b/CD18 acts in concert with CD14 and Toll-like receptor (TLR) 4 to elicit
full lipopolysaccharide and taxol-inducible gene expression. J. Immunol 166, 574–581 (2001).
Author Manuscript
[PubMed: 11123339]
82. Ling GS et al. Integrin CD11b positively regulates TLR4-induced signalling pathways in dendritic
cells but not in macrophages. Nat. Commun 5, 3039 (2014). [PubMed: 24423728]
83. Noubir S, Hmama Z & Reiner NE Dual receptors and distinct pathways mediate interleukin-1
receptor-associated kinase degradation in response to lipopolysaccharide. Involvement of CD14/
TLR4, CR3, and phosphatidylinositol 3-kinase. J. Biol. Chem 279, 25189–25195 (2004).
[PubMed: 15069085]
84. Hanspers K, Akassoglou K & Mendiola AS Fibrin complement receptor 3 signaling pathway
(Homo sapiens) Wikipathways.org/Index.php/Pathway:WP4136 (2017).
85. Paterson PY Experimental allergic encephalomyelitis: role of fibrin deposition in

immunopathogenesis of inflammation in rats. Fed. Proc 35, 2428–2434 (1976). [PubMed: 61895]
Author Manuscript
86. Akassoglou K et al. Fibrin depletion decreases inflammation and delays the onset of demyelination
in a tumor necrosis factor transgenic mouse model for multiple sclerosis. Proc. Natl Acad. Sci.
USA 101, 6698–6703 (2004). [PubMed: 15096619]
87. Yang Y, Tian SJ, Wu L, Huang DH & Wu WP Fibrinogen depleting agent batroxobin has a
beneficial effect on experimental autoimmune encephalomyelitis. Cell. Mol. Neurobiol 31, 437–
448 (2011). [PubMed: 21165693]
88. Flick MJ et al. Leukocyte engagement of fibrin(ogen) via the integrin receptor αMβ2/Mac-1 is
critical for host inflammatory response in vivo. J. Clin. Invest 113, 1596–1606 (2004). [PubMed:
15173886]
89. Flick MJ, Du X & Degen JL Fibrin(ogen)–αMβ2 interactions regulate leukocyte function and
innate immunity in vivo. Exp. Biol. Med 229, 1105–1110 (2004).
90. Huang Y & Mucke L Alzheimer mechanisms and therapeutic strategies. Cell 148, 1204–1222
(2012). [PubMed: 22424230]
91. Iadecola C The pathobiology of vascular dementia. Neuron 80, 844–866 (2013). [PubMed:
Author Manuscript
24267647]
92. Schneider JA, Arvanitakis Z, Bang W & Bennett DA Mixed brain pathologies account for most
dementia cases in community-dwelling older persons. Neurology 69, 2197–2204 (2007).
[PubMed: 17568013]
93. Arvanitakis Z, Capuano AW, Leurgans SE, Bennett DA & Schneider JA Relation of cerebral vessel
disease to Alzheimer’s disease dementia and cognitive function in elderly people: a cross-sectional
study. Lancet Neurol 15, 934–943 (2016). [PubMed: 27312738]
94. Bowman GL et al. Blood-brain barrier impairment in Alzheimer disease: stability and functional
significance. Neurology 68, 1809–1814 (2007). [PubMed: 17515542]
95. Ujiie M, Dickstein DL, Carlow DA & Jefferies WA Blood-brain barrier permeability precedes
senile plaque formation in an Alzheimer disease model. Microcirculation 10, 463–470 (2003).
[PubMed: 14745459]
96. Scheltens P & Goos JD Dementia in 2011: microbleeds in dementia—singing a different ARIA.
Nat. Rev. Neurol 8, 68–70 (2012). [PubMed: 22231195]
Author Manuscript
97. Kirsch W et al. Serial susceptibility weighted MRI measures brain iron and microbleeds in
dementia. J. Alzheimers Dis 17, 599–609 (2009). [PubMed: 19433895]
98. Cullen KM, Kocsi Z & Stone J Microvascular pathology in the aging human brain: evidence that
senile plaques are sites of microhaemorrhages. Neurobiol. Aging 27, 1786–1796 (2006). [PubMed:
17063559]
99. Merlini M & Akassoglou K Alzheimer disease makes new blood contacts. Blood 129, 2462–2463
(2017). [PubMed: 28473412]
100. Hultman K, Strickland S & Norris EH The APOE ε4/ε4 genotype potentiates vascular
fibrin(ogen) deposition in amyloid-laden vessels in the brains of Alzheimer’s disease patients. J.
Cereb. Blood Flow Metab 33, 1251–1258 (2013). [PubMed: 23652625]
101. Ryu JK & McLarnon JG A leaky blood-brain barrier, fibrinogen infiltration and microglial
reactivity in inflamed Alzheimer’s disease brain. J. Cell. Mol. Med 13, 2911–2925 (2008).
[PubMed: 18657226]
102. Fiala M et al. Cyclooxygenase-2-positive macrophages infiltrate the Alzheimer’s disease brain
and damage the blood-brain barrier. Eur. J. Clin. Invest 32, 360–371 (2002). [PubMed:
Author Manuscript
12027877]
103. Miners JS, Schulz I & Love S Differing associations between Aβ accumulation, hypoperfusion,
blood-brain barrier dysfunction and loss of PDGFRB pericyte marker in the precuneus and
parietal white matter in Alzheimer’s disease. J. Cereb. Blood Flow Metab 38, 103–115 (2017).
[PubMed: 28151041]
104. Cortes-Canteli M, Mattei L, Richards AT, Norris EH & Strickland S Fibrin deposited in the
Alzheimer’s disease brain promotes neuronal degeneration. Neurobiol. Aging 36, 608–617
(2015). [PubMed: 25475538]
105. Sengillo JD et al. Deficiency in mural vascular cells coincides with blood-brain barrier disruption
in Alzheimer’s disease. Brain Pathol 23, 303–310 (2013). [PubMed: 23126372]
Author Manuscript
106. Xu G, Zhang H, Zhang S, Fan X & Liu X Plasma fibrinogen is associated with cognitive decline
and risk for dementia in patients with mild cognitive impairment. Int. J. Clin. Pract 62, 1070–
1075 (2008). [PubMed: 17916180]
107. van Oijen M, Witteman JC, Hofman A, Koudstaal PJ & Breteler MM Fibrinogen is associated
with an increased risk of Alzheimer disease and vascular dementia. Stroke 36, 2637–2641
(2005). [PubMed: 16269641]
108. Montagne A, Zhao Z & Zlokovic BV Alzheimer’s disease: a matter of blood-brain barrier
dysfunction? J. Exp. Med 214, 3151–3169 (2017). [PubMed: 29061693]
109. Winkler EA et al. GLUT1 reductions exacerbate Alzheimer’s disease vasculo-neuronal
dysfunction and degeneration. Nat. Neurosci 18, 521–530 (2015). [PubMed: 25730668]
110. McManus RM, Finucane OM, Wilk MM, Mills KHG & Lynch MA FTY720 attenuates infection-
induced enhancement of Aβ accumulation in APP/PS1 mice by modulating astrocytic activation.
J. Neuroimmune Pharmacol 12, 670–681 (2017). [PubMed: 28620801]
111. Ahn HJ et al. A novel Aβ-fibrinogen interaction inhibitor rescues altered thrombosis and
Author Manuscript
cognitive decline in Alzheimer’s disease mice. J. Exp. Med 211, 1049–1062 (2014). [PubMed:
24821909]
112. Bell RD et al. Pericytes control key neurovascular functions and neuronal phenotype in the adult
brain and during brain aging. Neuron 68, 409–427 (2010). [PubMed: 21040844]
113. Nikolakopoulou AM, Zhao Z, Montagne A & Zlokovic BV Regional early and progressive loss of
brain pericytes but not vascular smooth muscle cells in adult mice with disrupted platelet-derived
growth factor receptor-β signaling. PLOS ONE 12, e0176225 (2017). [PubMed: 28441414]
114. Bell RD et al. Apolipoprotein E controls cerebrovascular integrity via cyclophilin A. Nature 485,
512–516 (2012). [PubMed: 22622580]
115. Soto I et al. APOE stabilization by exercise prevents aging neurovascular dysfunction and
complement induction. PLOS Biol 13, e1002279 (2015). [PubMed: 26512759]
116. McLarnon JG & Ryu JK Relevance of Aβ1–42 intrahippocampal injection as an animal model of
inflamed Alzheimer’s disease brain. Curr. Alzheimer Res 5, 475–480 (2008). [PubMed:
18855589]
Author Manuscript
117. Tripathy D et al. Thrombin, a mediator of cerebrovascular inflammation in AD and hypoxia.

Front. Aging Neurosci 5, 19 (2013). [PubMed: 23675346]
118. Timmer NM et al. Enoxaparin treatment administered at both early and late stages of amyloid β
deposition improves cognition of APPswe/PS1dE9 mice with differential effects on brain Aβ
levels. Neurobiol. Dis 40, 340–347 (2010). [PubMed: 20600909]
119. Bergamaschini L et al. Peripheral treatment with enoxaparin, a low molecular weight heparin,
reduces plaques and β-amyloid accumulation in a mouse model of Alzheimer’s disease. J.
Neurosci 24, 4181–4186 (2004). [PubMed: 15115813]
120. Ahn HJ et al. Alzheimer’s disease peptide β-amyloid interacts with fibrinogen and induces its
oligomerization. Proc. Natl Acad. Sci. USA 107, 21812–21817 (2010). [PubMed: 21098282]
121. Zamolodchikov D, Renne T & Strickland S The Alzheimer’s disease peptide β-amyloid promotes
thrombin generation through activation of coagulation factor XII. J. Thromb. Haemost 14, 995–
1007 (2016). [PubMed: 26613657]
122. Zamolodchikov D & Strickland S Aβ delays fibrin clot lysis by altering fibrin structure and
attenuating plasminogen binding to fibrin. Blood 119, 3342–3351 (2012). [PubMed: 22238323]
Author Manuscript
123. Oh SB et al. Tissue plasminogen activator arrests Alzheimer’s disease pathogenesis. Neurobiol.
Aging 35, 511–519 (2014). [PubMed: 24126163]
124. Aso E, Serrano AL, Munoz-Canoves P & Ferrer I Fibrinogen-derived γ377–395 peptide improves
cognitive performance and reduces amyloid-β deposition, without altering inflammation, in
AβPP/PS1 mice. J. Alzheimers Dis 47, 403–412 (2015). [PubMed: 26401562]
125. Chen ZL et al. Depletion of coagulation factor XII ameliorates brain pathology and cognitive
impairment in Alzheimer disease mice. Blood 129, 2547–2556 (2017). [PubMed: 28242605]
126. Bien-Ly N et al. Lack of widespread BBB disruption in Alzheimer’s disease models: focus on
therapeutic antibodies. Neuron 88, 289–297 (2015). [PubMed: 26494278]
127. Sudre CH et al. White matter hyperintensities are seen only in GRN mutation carriers in the
GENFI cohort. Neuroimage Clin 15, 171–180 (2017). [PubMed: 28529873]
Author Manuscript
128. Thal DR et al. Frontotemporal lobar degeneration FTLD-tau: preclinical lesions, vascular, and
Alzheimer-related co-pathologies. J. Neural Transm. (Vienna) 122, 1007–1018 (2015). [PubMed:
25556950]
129. Winkler EA et al. Blood-spinal cord barrier breakdown and pericyte reductions in amyotrophic
lateral sclerosis. Acta Neuropathol 125, 111–120 (2013). [PubMed: 22941226]
130. Evans MC, Couch Y, Sibson N & Turner MR Inflammation and neurovascular changes in
amyotrophic lateral sclerosis. Mol. Cell Neurosci 53, 34–41 (2013). [PubMed: 23110760]
131. Kortekaas R et al. Blood-brain barrier dysfunction in parkinsonian midbrain in vivo. Ann. Neurol
57, 176–179 (2005). [PubMed: 15668963]
132. Pisani V et al. Increased blood-cerebrospinal fluid transfer of albumin in advanced Parkinson’s
disease. J. Neuroinflamm 9, 188 (2012).
133. Gray MT & Woulfe JM Striatal blood–brain barrier permeability in Parkinson’s disease. J. Cereb.
Blood Flow Metab 35, 747–750 (2015). [PubMed: 25757748]
134. Shlosberg D, Benifla M, Kaufer D & Friedman A Blood–brain barrier breakdown as a therapeutic
Author Manuscript
target in traumatic brain injury. Nat. Rev. Neurol 6, 393–403 (2010). [PubMed: 20551947]
135. Chodobski A, Zink BJ & Szmydynger-Chodobska J Blood–brain barrier pathophysiology in
traumatic brain injury. Transl Stroke Res 2, 492–516 (2011). [PubMed: 22299022]
136. Tomkins O et al. Blood–brain barrier disruption in post-traumatic epilepsy. J. Neurol. Neurosurg.
Psychiatry 79, 774–777 (2008). [PubMed: 17991703]
137. Korn A, Golan H, Melamed I, Pascual-Marqui R & Friedman A Focal cortical dysfunction and
blood-brain barrier disruption in patients with Postconcussion syndrome. J. Clin. Neurophysiol
22, 1–9 (2005). [PubMed: 15689708]
138. Hay JR, Johnson VE, Young AM, Smith DH & Stewart W Blood–brain barrier disruption is an
early event that may persist for many years after traumatic brain injury in humans. J.
Neuropathol. Exp. Neurol 74, 1147–1157 (2015). [PubMed: 26574669]
139. Armulik A et al. Pericytes regulate the blood–brain barrier. Nature 468, 557–561 (2010).
[PubMed: 20944627]
140. Franklin RJ & Ffrench-Constant C Remyelination in the CNS: from biology to therapy. Nat. Rev.
Author Manuscript
Neurosci 9, 839–855 (2008). [PubMed: 18931697]

141. Fancy SP, Chan JR, Baranzini SE, Franklin RJ & Rowitch DH Myelin regeneration: a
recapitulation of development? Annu. Rev. Neurosci 34, 21–43 (2011). [PubMed: 21692657]
142. Petersen MA et al. Fibrinogen activates BMP signaling in oligodendrocyte progenitor cells and
inhibits remyelination after vascular damage. Neuron 96, 1003–1012.e7 (2017). [PubMed:
29103804]
143. Gallo V & Deneen B Glial development: the crossroads of regeneration and repair in the CNS.
Neuron 83, 283–308 (2014). [PubMed: 25033178]
144. Salazar VS, Gamer LW & Rosen V BMP signalling in skeletal development, disease and repair.
Nat. Rev. Endocrinol 12, 203–221 (2016). [PubMed: 26893264]
145. Wagner DO et al. BMPs: from bone to body morphogenetic proteins. Sci. Signal 3, mr1 (2010).
[PubMed: 20124549]
146. Pera MF & Tam PP Extrinsic regulation of pluripotent stem cells. Nature 465, 713–720 (2010).
[PubMed: 20535200]
Author Manuscript
147. See J et al. Oligodendrocyte maturation is inhibited by bone morphogenetic protein. Mol. Cell
Neurosci 26, 481–492 (2004). [PubMed: 15276151]
148. Gomes WA, Mehler MF & Kessler JA Transgenic overexpression of BMP4 increases astroglial
and decreases oligodendroglial lineage commitment. Dev. Biol 255, 164–177 (2003). [PubMed:
12618141]
149. Lehnardt S et al. The toll-like receptor TLR4 is necessary for lipopolysaccharide-induced
oligodendrocyte injury in the CNS. J. Neurosci 22, 2478–2486 (2002). [PubMed: 11923412]
150. Back SA, Gan X, Li Y, Rosenberg PA & Volpe JJ Maturation-dependent vulnerability of

oligodendrocytes to oxidative stress-induced death caused by glutathione depletion. J. Neurosci
Author Manuscript
18, 6241–6253 (1998). [PubMed: 9698317]

151. Oka A, Belliveau MJ, Rosenberg PA & Volpe JJ Vulnerability of oligodendroglia to glutamate:
pharmacology, mechanisms, and prevention. J. Neurosci 13, 1441–1453 (1993). [PubMed:
8096541]
152. Norris EH & Strickland S Fibrinogen in the nervous system: glia beware. Neuron 96, 951–953
(2017). [PubMed: 29216454]
153. Nave KA & Ehrenreich H A bloody brake on myelin repair. Nature 553, 31–32 (2018). [PubMed:
29300019]
154. Akassoglou K, Kombrinck KW, Degen JL & Strickland S Tissue plasminogen activator-mediated
fibrinolysis protects against axonal degeneration and demyelination after sciatic nerve injury. J.
Cell Biol 149, 1157–1166 (2000). [PubMed: 10831618]
155. Previtali SC et al. The extracellular matrix affects axonal regeneration in peripheral neuropathies.
Neurology 71, 322–331 (2008). [PubMed: 18663178]
156. Zou T et al. Exogenous tissue plasminogen activator enhances peripheral nerve regeneration and
Author Manuscript
functional recovery after injury in mice. J. Neuropathol. Exp. Neurol 65, 78–86 (2006).
[PubMed: 16410751]
157. Akassoglou K, Akpinar P, Murray S & Strickland S Fibrin is a regulator of Schwann cell
migration after sciatic nerve injury in mice. Neurosci. Lett 338, 185–188 (2003). [PubMed:
12581827]
158. Schachtrup C et al. Fibrinogen inhibits neurite outgrowth via β3 integrin-mediated
phosphorylation of the EGF receptor. Proc. Natl Acad. Sci. USA 104, 11814–11819 (2007).
[PubMed: 17606926]
159. Lam CK, Yoo T, Hiner B, Liu Z & Grutzendler J Embolus extravasation is an alternative
mechanism for cerebral microvascular recanalization. Nature 465, 478–482 (2010). [PubMed:
20505729]
160. Falati S, Gross P, Merrill-Skoloff G, Furie BC & Furie B Real-time in vivo imaging of platelets,
tissue factor and fibrin during arterial thrombus formation in the mouse. Nat. Med 8, 1175–1181
(2002). [PubMed: 12244306]
Author Manuscript
161. Tsai YT et al. Optical imaging of fibrin deposition to elucidate participation of mast cells in
foreign body responses. Biomaterials 35, 2089–2096 (2013). [PubMed: 24342726]
162. Kim JY et al. Direct imaging of cerebral thromboemboli using computed tomography and fibrin-
targeted gold nanoparticles. Theranostics 5, 1098–1114 (2015). [PubMed: 26199648]
163. Overoye-Chan K et al. EP-2104R: a fibrin-specific gadolinium-based MRI contrast agent for
detection of thrombus. J. Am. Chem. Soc 130, 6025–6039 (2008). [PubMed: 18393503]
164. Blasi F et al. Multisite thrombus imaging and fibrin content estimation with a single whole-body
PET scan in rats. Arterioscler Thromb. Vasc. Biol 35, 2114–2121 (2015). [PubMed: 26272938]
165. Olson ES et al. In vivo fluorescence imaging of atherosclerotic plaques with activatable cell-
penetrating peptides targeting thrombin activity. Integr. Biol 4, 595–605 (2012).
166. Chen B et al. Thrombin activity associated with neuronal damage during acute focal ischemia. J.
Neurosci 32, 7622–7631 (2012). [PubMed: 22649241]
167. Whitney M et al. Ratiometric activatable cell-penetrating peptides provide rapid in vivo readout of
thrombin activation. Angew. Chem. Int. Ed Engl 52, 325–330 (2013). [PubMed: 23080482]
168. Davalos D et al. Early detection of thrombin activity in neuroinflammatory disease. Ann. Neurol
Author Manuscript
75, 303–308 (2014). [PubMed: 24740641]

169. Lee JW et al. Fibrinogen γ-A chain precursor in CSF: a candidate biomarker for Alzheimer’s
disease. BMC Neurol 7, 14 (2007). [PubMed: 17565664]
170. Craig-Schapiro R et al. Multiplexed immunoassay panel identifies novel CSF biomarkers for
Alzheimer’s disease diagnosis and prognosis. PLOS ONE 6, e18850 (2011). [PubMed:
21526197]
171. Vafadar-Isfahani B et al. Identification of SPARC-like 1 protein as part of a biomarker panel for
Alzheimer’s disease in cerebrospinal fluid. J. Alzheimers Dis 28, 625–636 (2012). [PubMed:
22045497]
172. Thambisetty M et al. Plasma biomarkers of brain atrophy in Alzheimer’s disease. PLOS ONE 6,
e28527 (2011). [PubMed: 22205954]
Author Manuscript
173. Yang HQ et al. Prognostic polypeptide blood plasma biomarkers of alzheimer’s disease
progression. J. Alzheimers Dis 40, 659–666 (2014). [PubMed: 24503613]
174. Ashton NJ et al. Blood protein predictors of brain amyloid for enrichment in clinical trials?
Alzheimers Dement 1, 48–60 (2015).
175. Conti A et al. Proteome study of human cerebrospinal fluid following traumatic brain injury
indicates fibrin(ogen) degradation products as trauma-associated markers. J. Neurotrauma 21,
854–863 (2004). [PubMed: 15307898]
176. Zhang Y et al. Elevated fibrinogen levels in neuromyelitis optica is associated with severity of
disease. Neurol. Sci 37, 1823–1829 (2016). [PubMed: 27450097]
177. Gobel K et al. Prothrombin and factor X are elevated in multiple sclerosis patients. Ann. Neurol
80, 946–951 (2016). [PubMed: 27774643]
178. Gobel K et al. Blood coagulation factor XII drives adaptive immunity during neuroinflammation
via CD87-mediated modulation of dendritic cells. Nat. Commun 7, 11626 (2016). [PubMed:
27188843]
Author Manuscript
179. Zamolodchikov D, Chen ZL, Conti BA, Renne T & Strickland S Activation of the factor XII-
driven contact system in Alzheimer’s disease patient and mouse model plasma. Proc. Natl Acad.
Sci. USA 112, 4068–4073 (2015). [PubMed: 25775543]
180. Bergamaschini L et al. Activation of the contact system in cerebrospinal fluid of patients with
Alzheimer disease. Alzheimer Dis. Assoc. Disord 12, 102–108 (1998). [PubMed: 9651139]
181. Hattori K et al. Increased cerebrospinal fluid fibrinogen in major depressive disorder. Sci. Rep 5,
11412 (2015). [PubMed: 26081315]
182. Pollak TA et al. The blood-brain barrier in psychosis. Lancet Psychiatry 5, 79–92 (2018).
[PubMed: 28781208]
183. Patel JP & Frey BN Disruption in the blood–brain barrier: the missing link between brain and
body inflammation in bipolar disorder? Neural Plast 2015, 708306 (2015). [PubMed: 26075104]
184. Winkler EA et al. Blood–spinal cord barrier disruption contributes to early motor-neuron
degeneration in ALS-model mice. Proc. Natl Acad. Sci. USA 111, E1035–E1042 (2014).
[PubMed: 24591593]
Author Manuscript
185. Spencer JI, Bell JS & DeLuca GC Vascular pathology in multiple sclerosis: reframing
pathogenesis around the blood–brain barrier. J. Neurol. Neurosurg. Psychiatry 89, 42–52 (2017).
[PubMed: 28860328]
186. Kraus J & Oschmann P The impact of interferon-β treatment on the blood–brain barrier. Drug
Discov. Today 11, 755–762 (2006). [PubMed: 16846804]
187. Kunze R et al. Dimethyl fumarate attenuates cerebral edema formation by protecting the blood–
brain barrier integrity. Exp. Neurol 266, 99–111 (2015). [PubMed: 25725349]
188. Nishihara H et al. Fingolimod prevents blood–brain barrier disruption induced by the sera from
patients with multiple sclerosis. PLOS ONE 10, e0121488 (2015). [PubMed: 25774903]
189. Luhder F et al. Laquinimod enhances central nervous system barrier functions. Neurobiol. Dis
102, 60–69 (2017). [PubMed: 28235673]
190. Ifergan I et al. Statins reduce human blood–brain barrier permeability and restrict leukocyte
migration: relevance to multiple sclerosis. Ann. Neurol 60, 45–55 (2006). [PubMed: 16729291]
191. Chataway J et al. Effect of high-dose simvastatin on brain atrophy and disability in secondary
Author Manuscript
progressive multiple sclerosis (MS-STAT): a randomised, placebo-controlled, phase 2 trial.

Lancet 383, 2213–2221 (2014). [PubMed: 24655729]
192. Zamolodchikov D & Strickland S The Alzheimer’s disease peptide β-amyloid promotes thrombin
generation through activation of coagulation factor XII: reply. J. Thromb. Haemost 14, 1489
(2016). [PubMed: 27173418]
193. Zamolodchikov D & Strickland S A possible new role for Aβ in vascular and inflammatory
dysfunction in Alzheimer’s disease. Thromb. Res 141, S59–S61 (2016). [PubMed: 27207427]
194. Claudio L, Raine CS & Brosnan CF Evidence of persistent blood–brain barrier abnormalities in
chronic-progressive multiple sclerosis. Acta Neuropathol 90, 228–238 (1995). [PubMed:
Author Manuscript
8525795]
195. Inoue A, Koh CS, Shimada K, Yanagisawa N & Yoshimura K Suppression of cell-transferred
experimental autoimmune encephalomyelitis in defibrinated Lewis rats. J. Neuroimmunol 71,
131–137 (1996). [PubMed: 8982112]
196. Inoue A et al. Fibrin deposition in the central nervous system correlates with the degree of
Theiler’s murine encephalomyelitis virus-induced demyelinating disease. J. Neuroimmunol 77,
185–194 (1997). [PubMed: 9258249]
197. Medved L, Tsurupa G & Yakovlev S Conformational changes upon conversion of fibrinogen into
fibrin. The mechanisms of exposure of cryptic sites. Ann. NY Acad. Sci 936, 185–204 (2001).
[PubMed: 11460474]
198. Engvall E, Ruoslahti E & Miller EJ Affinity of fibronectin to collagens of different genetic types
and to fibrinogen. J. Exp. Med 147, 1584–1595 (1978). [PubMed: 567240]
199. Suehiro K et al. Fibrinogen binds to integrin α5β1via the carboxyl-terminal RGD site of the Aα-
chain. J. Biochem 128, 705–710 (2000). [PubMed: 11011154]
Author Manuscript
200. Smith JW, Ruggeri ZM, Kunicki TJ & Cheresh DA Interaction of integrins αvβ3 and
glycoprotein IIb-IIIa with fibrinogen: differential peptide recognition accounts for distinct
binding sites. J. Biol. Chem 265, 12267–12271 (1990). [PubMed: 2373693]
201. Chernousov MA & Carey DJ αVβ8 integrin is a Schwann cell receptor for fibrin. Exp. Cell Res
291, 514–524 (2003). [PubMed: 14644171]
202. Gorlatov S & Medved L Interaction of fibrin(ogen) with the endothelial cell receptor VE-
cadherin: mapping of the receptor-binding site in the NH2-terminal portions of the fibrin β
chains. Biochemistry 41, 4107–4116 (2002). [PubMed: 11900554]
203. Yakovlev S et al. Identification of VLDLR as a novel endothelial cell receptor for fibrin that
modulates fibrin-dependent transendothelial migration of leukocytes. Blood 119, 637–644
(2012). [PubMed: 22096238]
204. Altieri DC, Duperray A, Plescia J, Thornton GB & Languino LR Structural recognition of a novel
fibrinogen γ chain sequence (117–133) by intercellular adhesion molecule-1 mediates leukocyte-
endothelium interaction. J. Biol. Chem 270, 696–699 (1995). [PubMed: 7822297]
Author Manuscript
205. Fan H et al. Protective effects of Batroxobin on spinal cord injury in rats. Neurosci. Bull 29, 501–
508 (2013). [PubMed: 23852558]
206. Lu W, Bhasin M & Tsirka SE Involvement of tissue plasminogen activator in onset and effector
phases of experimental allergic encephalomyelitis. J. Neurosci 22, 10781–10789 (2002).
[PubMed: 12486171]
207. Leech S, Kirk J, Plumb J & McQuaid S Persistent endothelial abnormalities and blood-brain
barrier leak in primary and secondary progressive multiple sclerosis. Neuropathol. Appl.
Neurobiol 33, 86–98 (2007). [PubMed: 17239011]
208. Hochmeister S et al. Dysferlin is a new marker for leaky brain blood vessels in multiple sclerosis.
J. Neuropathol. Exp. Neurol 65, 855–865 (2006). [PubMed: 16957579]
209. Montagne A et al. Pericyte degeneration causes white matter dysfunction in the mouse central
nervous system. Nat. Med 10.1038/nm.4482 (2018).
210. Gay D & Esiri M Blood-brain barrier damage in acute multiple sclerosis plaques. An
immunocytological study. Brain 114, 557–572 (1991). [PubMed: 2004256]
211. Lipinski B & Sajdel-Sulkowska EM New insight into Alzheimer disease: demonstration of
Author Manuscript
fibrin(ogen)-serum albumin insoluble deposits in brain tissue. Alzheimer Dis. Assoc. Disord 20,
323–326 (2006). [PubMed: 17132984]
212. Brown H et al. Evidence of blood-brain barrier dysfunction in human cerebral malaria.
Neuropathol. Appl. Neurobiol 25, 331–340 (1999). [PubMed: 10476050]
213. Bardos H, Molnar P, Csecsei G & Adany R Fibrin deposition in primary and metastatic human
brain tumours. Blood Coagul. Fibrinolysis 7, 536–548 (1996). [PubMed: 8874864]
Box 1 |
Author Manuscript
Fibrinogen frequently asked questions

Is it fibrinogen or fibrin?
Converting fibrinogen into fibrin exposes cryptic epitopes that promote inflammation.
Fibrinogen converted into fibrin by thrombin or immobilized on a substrate binds to
CD11b/CD18 and activates microglia and macrophages. Fibrinogen, fibrin and their
degradation products contribute to neurological disease via multiple mechanisms.
Do fibrin and complement bind the same receptor?

Yes, both bind the CD11b‑I domain of complement receptor 3 (CR3) and induce
pro‑inflammatory signal transduction. Studies in Itgam−/− mice in disease models with
blood–brain barrier (BBB) leakage must be cautiously interpreted to attribute CD11b/
Author Manuscript
CD18 binding to either ligand.
Will blocking fibrin in the CNS inhibit repair?

Inhibiting fibrin promotes repair in the nervous system. Excessive fibrin deposition in Plg
−/− mice, which cannot degrade fibrin, delays wound healing and remyelination, an effect
rescued in Plg−/−Fga−/− mice. Fibrinogen depletion enhances repair in mice after sciatic
nerve crush injury and chemical demyelination.
How is fibrin removed from the brain?

Proteolysis via tissue‑type plasminogen activator (tPA) and plasmin is the main
mechanism. Plasminogen‑deficient humans have fibrin deposition in tissues similar to
Plg−/− mice, which are rescued by fibrinogen deficiency. Fibrin is internalized in cells,
Author Manuscript
possibly by phagocytosis. The balance between coagulation and degradation could

determine fibrin’s contribution to disease.
Is fibrin expressed in brain and is it genetically linked with neurological diseases?

Fibrinogen is not expressed in brain and must cross a disrupted BBB from the circulation
to be found in the nervous system. Fibrinogen is highly polymorphic with over 300
single-nucleotide polymorphisms. Metagenome-wide association studies are needed to
test for a genetic link with disease.
What is the evolutionary benefit of fibrin?

Fibrinogen is essential for clotting and reproduction. Pro‑inflammatory functions of
clotting could be beneficial if fibrin is cleared. In neurological diseases, there is impaired
fibrin clearance by plasminogen activator inhibitor 1 (PAI1) upregulation or binding of
Author Manuscript
fibrin to amyloid‑β. Chronic fibrin deposition contributes to chronic inflammation and

neurodegeneration.
Author Manuscript
Author Manuscript
Author Manuscript
Figure 1 |. Fibrinogen at the nexus of the brain–vascular–immune axis.

a | Fibrinogen is a molecular mediator entering the CNS after blood–brain barrier (BBB)
disruption that is causally linked with neuroinflammation, neuronal damage and immune
cell recruitment in the nervous system. As a key component of the pathological lesion
environment, fibrinogen is uniquely positioned to serve as an imaging and fluid biomarker as
well as a therapeutic target for neurological diseases. b | A ‘fibrinogen toolbox’ of
Author Manuscript
experimental models, pharmacological and genetic tools, molecular imaging probes and
novel therapeutics has been developed to study fibrinogen’s contribution to neurovascular
pathology in CNS disease. To study cellular responses and dissect molecular signalling
mechanisms in vitro, fibrinogen and fibrin can be added to culture media, coated onto plates
or formed into 3D gels8,12,13,36,75,142,158. Fibrin and/or fibrinogen can be detected in the
diseased or injured nervous system with specific antibodies and through electron
microscopy9,194 (TABLE 1). A number of pharmacological agents and genetic tools have
been used to test the causal role of fibrinogen in neurological disease, including fibrinogen-
depleting drugs8,13,75,86,142,195,196, inhibitors of fibrin formation9,65, inhibitors of fibrin
Author Manuscript
interactions with integrin receptors and other proteins8,111,124 and fibrinogen-knockout and
knock-in mice8,9–13,86. Stereotactic fibrinogen injections and infusions into the CNS provide
experimental models to test fibrinogen-induced cellular responses and signalling pathways
in vivo9,12,75,116,142. Novel imaging tools also allow for real-time analysis of fibrinogen and
coagulation dynamics at the neurovascular unit in health and disease9,166,168. Altogether, the
fibrinogen toolbox can be employed to determine the role of fibrinogen in any neurological
disease with BBB disruption and a dysfunctional brain–vascular–immune axis.
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
Figure 2 |. Fibrinogen structure, cellular targets and signalling networks in the nervous system.
Fibrin and fibrinogen interact with receptors on nervous system cells to activate downstream
signalling, regulate basic cellular functions and influence inflammatory, neurodegenerative
and repair processes in disease6,7,24,34. Fibrinogen is composed of three distinct
polypeptides, designated Aα, Bβ and γ28, which contain multiple binding sites for cellular
receptors and proteins. Grey-shaded areas designate the location of binding sites, with
Author Manuscript
fibrinogen amino acid sequence numbers and the corresponding receptor or bound protein
listed above the site. Fibrinogen chain Aα (blue) binds plasminogen/tissue-type
plasminogen activator (tPA)197, fibronectin198 and latent transforming growth factor-β
(TGFβ)12 and interacts with the integrin receptors α5β1 (REF. 199), αvβ3 (REF. 200) and
αvβ8 (REF. 201) through its Arg–Gly–Asp (RGD) motif. Fibrinogen chain Bβ (green)
binds vascular endothelial cadherin (VE-cadherin; also known as CDH5)202, very low-
density lipoprotein receptor (VLDLR)203 and amyloid-β120. Fibrinogen chain γ (red) binds
tPA197, the integrin receptors CD11b/CD1876,77 and αIIbβ3 (REF. 27); it also binds
intercellular adhesion molecule 1 (not shown on figure)204. Upon activation of the
Author Manuscript
coagulation, fibrinogen is converted into insoluble fibrin by thrombin, which cleaves

fibrinopeptide A and B from fibrinogen (red triangles) to expose polymerization sites that
facilitate clot formation29. Fibrinogen, fibrin and fibrin degradation products produce
different responses from CNS cells. Soluble fibrinogen can induce growth factor receptor
pathway activation in astrocytes, oligodendrocyte progenitor cells (OPCs) and neurons to
regulate scar formation, cell differentiation and inhibition of neurite outgrowth,
respectively12,142,158. Fibrinogen and fibrin also exert biological effects on mature
oligodendrocytes and pericytes (see note added in proof). Conversion of fibrinogen into
fibrin or immobilization of fibrinogen to a substrate exposes cryptic epitopes, such as the
γ377–395 epitope, which is the binding site for the CD11b/CD18 integrin receptor76,77.
Indeed, immobilized fibrinogen or fibrin activates microglia and macrophages8,9,75. Similar
to soluble fibrinogen, immobilized fibrinogen inhibits OPC maturation142. 3D fibrin gels
Author Manuscript
have also been utilized for testing Schwann cell differentiation and migration13,157. 3D fibrin
gels are ideally suited for the study of mechanisms of fibrin degradation and the discovery of
novel mechanisms in the CNS that regulate fibrinolysis. Indeed, the discovery of the low-
affinity neurotrophin receptor p75NTR (NGFR) as a regulator of PLAT and plasminogen
activator inhibitor 1 (PAI1) transcriptional regulation was facilitated by the culture of
Schwann cells on 3D fibrin gels13,36. Studies to methodically compare the responses of CNS
cells to all the potential forms of fibrinogen, fibrin and fibrin degradation products are
required to associate fibrinogen structure and function with an observed biological outcome.
These studies can be influenced by the experimental setting, the purity of fibrinogen
preparations, the methods of primary cell isolation and the stage of cell differentiation at the
time of fibrinogen or fibrin treatment. ACVR1, activin A receptor type 1; P-AKT,
phosphorylated serine/threonine-protein kinase; P-EGFR, phosphorylated epidermal growth
Author Manuscript
factor receptor; P-SMAD2/3, phosphorylated MAD homologue 2/3; RHOA, transforming

protein RhoA; ROS, reactive oxygen species; TGFR1, TGFβ receptor type 1.
Author Manuscript
Author Manuscript
Author Manuscript
Figure 3 |. Timeline of in vivo genetic and pharmacological evidence showing a causal role for
fibrin and/or fibrinogen in the development of neurological disease.
Pharmacological depletion of fibrinogen with the defibrinogenating agents ancrod or
batroxobin protected Lewis rats in multiple sclerosis (MS) models85,195,196; this finding was
later confirmed in mouse MS models8,75,86. Akassoglou et al. provided the first genetic
proof for a causal role for fibrin in a nervous system experimental model of nerve
regeneration13. Later studies demonstrated fibrin to be a critical determinant of
neuroinflammation as fibrinogen-knockout mice showed reduced microglial activation and
Author Manuscript
improved neurological function in animal models of MS8,86 and protection from

neuropathology and cognitive deficits in Alzheimer disease (AD)10,11. In addition, blocking
the conversion of fibrinogen to fibrin with the thrombin inhibitor hirudin protected from
experimental autoimmune encephalitis (EAE)9,65. To selectively inhibit the inflammatory
actions of fibrin in the CNS while preserving coagulation, Adams et al. blocked fibrin’s
interaction with its high-affinity receptor CD11b/CD18 genetically by using Fggγ390−396A
mice, in which fibrinogen has been mutated to lack the CD11b/CD18-binding motif88, and
pharmacologically by administering the γ377–395 peptide8. Genetic and pharmacological
inhibition of fibrin–CD11b/CD18 reduced paralysis, inflammation, microglia activation,
axonal damage and demyelination in EAE8,9. In AD mice, administration of a compound
that specifically inhibits fibrin–amyloid-β (Aβ) interaction reduced vascular pathology,
blocked neuroinflammation and protected from cognitive decline111. Altogether, the genetic
Author Manuscript
and pharmacological evidence point to a causal role for fibrin and/or fibrinogen in the CNS
and may represent a novel target for therapeutic intervention in neurological disease. GFAP,
glial fibrillary acidic protein; MOG, myelin-oligodendrocyte glycoprotein; PLP, myelin
proteolipid protein; TNF, tumour necrosis factor.
Author Manuscript
Author Manuscript
Author Manuscript
Figure 4 |. Fibrinogen at the helm of CNS innate immune activation and neurodegeneration.
Fibrin is a key contributor to inflammatory demyelination, neurodegeneration and inhibition
of CNS repair. a | In multiple sclerosis animal models, blood–brain barrier (BBB) disruption
leads to increased coagulation activity and fibrin deposition in the brain, which binds to the
CD11b/CD18 integrin receptor, thus driving early microglial activation, recruitment of
peripheral macrophages and T cells and leading to demyelination and axonal damage8, 9,75.
Fibrin-induced activation induces a gene transcription signature characterized by increased
secretion of chemokines (such as CXC-chemokine ligand 10 (CXCL10) and monocyte
Author Manuscript
chemoattractant protein 1 (MCP1)) to promote recruitment of T cells, increased antigen

presentation and release of instructive signals (such as interleukin 12 (IL-12)) for inducing T
helper 1 (TH1) cell differentiation to promote autoimmunity and demyelination75. In
parallel, perivascular microglia cluster at sites of fibrin deposition, which correlate with
areas of reactive oxygen species (ROS) generation and axonal damage in vivo9. Mechanisms
and consequences of fibrin-induced ROS release in the CNS are not known (dotted lines).
Fibrinogen also blocks oligodendrocyte progenitor cell (OPC) differentiation to myelinating
cells by direct and immune-mediated mechanisms142. b | In animal models of Alzheimer

Author Manuscript
disease (AD), fibrin binds to amyloid-β (Aβ), which results in degradation-resistant

clots11,120,122. Aβ further drives fibrin formation and the release of pro-inflammatory
molecules121,193. The mechanisms by which fibrin–Aβ interaction contributes to neuronal
loss in AD models are not known (question marks and dotted lines). In addition, whether
fibrin-induced microglia activation contributes to amyloid-driven neurodegeneration is
unknown (question marks and dotted lines).
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
Figure 5 |. The coagulation cascade and its final product fibrin as clinically relevant biomarkers
and potential therapeutic targets for neurological disease.
a | Fibrinogen and components of the coagulation cascade could serve as clinically relevant
plasma and cerebrospinal fluid (CSF) biomarkers to diagnose and track disease progression
in neurological disease. Upstream components of the coagulation cascade, including the
contact system, coagulation factor X and prothrombin, are elevated in multiple sclerosis
Author Manuscript
(MS)177,178 and/or Alzheimer disease (AD)179. Fibrinogen itself is elevated in the plasma or
CSF from patients with MS176 and AD106,107,169–173 and often correlates with disease
severity. Fibrin degradation products are also found in the CSF of traumatic brain injury
(TBI) patients175. Studies of animal models of AD and MS highlight the therapeutic
potential of targeting coagulation for CNS disease. Coagulation factor XII depletion protects
mice in the experimental autoimmune encephalitis (EAE) MS model178 and in AD
models125. The thrombin inhibitor hirudin blocks the conversion of fibrinogen into fibrin
and is protective in EAE9,65. Genetic and/or pharmacological depletion of fibrinogen is
protective in animal models of MS8,75,85–87,195,196, AD10,101 and nervous system

injury13,205. By contrast, tissue-type plasminogen activator (tPA)-knockout (KO) mice,
Author Manuscript
which have impaired fibrin degradation, show increased severity of EAE and delayed
recovery206. Together, human biomarker and animal studies highlight the potential utility of
monitoring and perhaps targeting the coagulation cascade in neurological disease. b | In the
future, expanding the ‘fibrinogen toolbox’ will enable translation of novel therapeutics,
biomarkers and imaging probes to human clinical trials to test the ‘fibrin hypothesis’ of
neurological disease. ALS, amyotrophic lateral sclerosis; Apo-E, apolipoprotein E; ASO,
antisense oligonucleotide; BBB, blood–brain barrier; CTE, chronic traumatic
encephalopathy; GFAP, glial fibrillary acidic protein; GWAS, genome-wide association
studies; HD, Huntington disease; PD, Parkinson disease; SAH, subarachnoid haemorrhage;
TMEV, Theiler murine encephalomyelitis virus; TNF, tumour necrosis factor; 5×FAD and
TgCRND8 are both transgenic mouse models of AD that develop severe amyloid pathology.
Author Manuscript
Author Manuscript
Author Manuscript
Table 1 |
Fibrin(ogen) deposition in neurological diseases

Author Manuscript
Multiple sclerosis Comment Refs

Progressive (primary and/or secondary)
NAWM Occasional fibrillary pattern of fibrin centred around vessels in areas of intact myelin 62,63,207
Pre-active NAWM Fibrin centred around vessels with clusters of microglia with enhanced MHCII+ CD45+ 62
cells and CD68+ cells in areas of intact myelin
Active Fibrin throughout the demyelinated lesion parenchyma but centred around vessels along 62–64,68,
with MHCII+ Oil Red O-stained macrophages 207,208
Chronic active Fibrin throughout the demyelinated lesion, colocalized with astrocytic and axonal processes; 62
lesion borders with MHCII+ macrophages
Chronic inactive Fibrin throughout the demyelinated lesion, colocalized with astrocytic and axonal processes; 62–64, 142,207
hypocellular lesions with widespread astrogliosis
EM detection of parenchymal fibrin deposition in the perivascular space associated with 194
gliosis
Author Manuscript
Fibrin deposition in the MS motor cortex correlated with decreased neuronal density 66
Acute
Active Fibrin deposition present in all active lesions correlating with microglia and/or macrophages 69,142,
and perivenous demyelination 208,210
Pre-active NAWM Fibrin deposition in areas of intact myelin with microglial activation, iNOS+ cells and APP 69
+ neurons, but no parenchymal T cell infiltration
Other neurological diseases

Alzheimer disease Perivascular fibrin correlating with monocyte and/or macrophages, COX2+ cells and 102
interruptions of ZO1
ELISA detection of insoluble fibrinogen–albumin complexes 211
Fibrin in the perivascular area with amyloid plaques, microglial activation, astrogliosis and 101
HLA-DR+ cells
Fibrin deposition in the vessels with cerebral amyloid angiopathy 11

Author Manuscript
Fibrin deposition in the vessels associated with cerebral amyloid angiopathy and increased 100
perivascular macrophages
Perivascular fibrin deposits correlated with loss of pericyte coverage of brain vessels 105
Fibrin detection in areas with amyloid plaques and dystrophic neurites 104
Fibrin accumulation in the parietal cortex correlated with PDGFRβ loss and fibrillary Aβ 103
accumulation
Amyotrophic lateral Fibrin accumulations found in motor-neuron-dense regions in the cervical spinal cord 129
sclerosis anterior horn grey matter
PD Extravascular fibrin increased 9.4-fold in the striatum of PD patients compared with 133
controls; all 12 PD patients showed fibrin extravasation
HD Extravascular fibrin increased 2.5-fold in the putamen of HD patients compared with 25

controls
Traumatic brain injury Widespread perivascular fibrin deposition in both acute and chronic phases after traumatic 138
brain injury
Author Manuscript
Cerebral malaria Widespread fibrin deposition associated with perivascular cell processes 212
Brain tumour Fibrinogen and/or fibrin found in primary (glioblastoma) and metastatic human brain 213
tumours in close association with macrophages
Aβ, amyloid-β; APP, Aβ precursor protein; COX2, cyclooxygenase 2 (also known as PTGS2); EM, electron microscope; ELISA, enzyme-linked
immunosorbent assay; HD, Huntington disease; HLA-DR, human leukocyte antigen-DR; iNOS, inducible NO synthase (also known as NOS2);
MHCII, major histocompatibility complex class II; MS, multiple sclerosis; NAWM, normal-appearing white matter; PD, Parkinson disease;
PDGFRβ, platelet-derived growth factor receptor-β; ZO1, zonula occludens protein 1.
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript

Fibrinogenio em Doenças Neurologicas

Uploaded by

Copyright:

Available Formats

Fibrinogenio em Doenças Neurologicas

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fibrinogenio em Doenças Neurologicas

Uploaded by

Copyright:

Available Formats

HHS Public Access

Published in final edited form as:

Fibrinogen in neurological diseases: mechanisms, imaging and

3Department of Neurology, University of California, San Francisco, CA, USA.

As we strive to understand the biological complexity of neurological diseases, it becomes

majority of neurological diseases, there is a dramatic transformation of the neurovascular

and sometimes drives—the neurodegenerative process. Studying neurological diseases

through the multidisciplinary prism of vascular biology, immunology and neuroscience

A key change in the molecular composition of the extracellular microenvironment in

Fibrinogen enters the diseased CNS

excessive fibrin deposition associated with reduced repair. In addition to proteolytic

The polymerization of fibrinogen to fibrin is mediated by highly conserved domains in the

MS is a chronic inflammatory disease of the nervous system characterized by BBB

BBB disruption and fibrin deposition.

laser-microdissected human MS lesions reveals dysregulation of several proteins of the

importantly, is found in close association with inflammation and damaged axons67,69–71

Fibrin and neuroinflammation.

progression of neuroinflammatory diseases? Fibrin, a potent inducer of microglial activation,

threonine-protein kinase AKT and Rho-family GTPases in microglia via CD11b/CD18,

CD18 for fibrin-induced immune activation in the CNS in vivo.

Causal role for fibrin in MS pathology.

peripheral inflammation, including rheumatoid arthritis, colitis and muscle degeneration7.

Alzheimer disease neurodegeneration

Accumulating evidence points to the coagulation cascade as a molecular link between

prominent feature of cerebrovascular pathology in human AD (TABLE 1). Fibrin

Aβ precursor protein (APP) gene develop AD-like pathology, including accumulations of

Causal role for fibrin in AD pathology.

fibrinogen is co-injected and significantly reduced when fibrinogen is pharmacologically

Numerous independent studies by multiple laboratories have consistently demonstrated

of methods to detect BBB disruption, including fibrin immunodetection and high-resolution

versus chronic models of neurodegeneration and implementing fibrinogen

Other neurodegenerative diseases.

Note added in proof

Regeneration and repair

macrophages9,75, which can be toxic to OPCs and impair remyelination149–151. Indeed,

of fibrinogen decreases BMP pathway activation, increases the number of mature

newly recognized blood-derived regulator of BMP receptor signalling and pro-inflammatory

axonal degeneration after experimental sciatic nerve crush injury154. Genetic or

Inhibition of neurite outgrowth.

Fibrinogen pathway as a biomarker

thrombosis in animal models of cardiovascular disease or stroke. Although these fibrin-

activatable cell-penetrating peptides (ACPPs) deliver fluorescent and MRI agents

In addition to its utility as an imaging biomarker, fibrinogen and components of the

Testing the ‘fibrin hypothesis’

can promote and amplify neuroimmune and neurodegenerative processes. Fibrinogen is

usefulness, impact and market for individual fibrinogen-targeting treatment strategies.

protects from neurological disease8. In addition, intranasal administration of the γ377–395

Targeting the interactions of fibrin with Aβ has shown efficacy in an AD model111.

formation192. Activated FXII also increases inflammation through the kallikrein–kininogen–

translational potential of these approaches. Regardless of the therapeutic approach utilized to

16. Zlokovic BV Neurovascular pathways to neurodegeneration in Alzheimer’s disease and other

lymphocytes. J. Immunol 161, 138–147 (1998). [PubMed: 9647217]

Pathol. Anat. Physiol 26, 474–483 (1863).

active demyelination. J. Pathol 201, 319–327 (2003). [PubMed: 14517850]

85. Paterson PY Experimental allergic encephalomyelitis: role of fibrin deposition in

117. Tripathy D et al. Thrombin, a mediator of cerebrovascular inflammation in AD and hypoxia.

Neurosci 9, 839–855 (2008). [PubMed: 18931697]

150. Back SA, Gan X, Li Y, Rosenberg PA & Volpe JJ Maturation-dependent vulnerability of