Mathematical Modeling of Glioblastoma Multiforme Treatments

Jnane Abdelhamid, The City College of New York

BME 14200 Organ Transport and Pharmacokinetics
Department of Biomedical Engineering

The human brain consists of vast networks containing neurons, glial cells and structural support

systems. Unlike neural cells, glial cells provide structural support and nutrition to the brain.

Furthermore, glia aid in neural signal transmission throughout the nervous system, insulate

individual neurons and hold them in place, and destroy and remove foreign bodies and dead

neurons. Damaged or injured glial cells will result in neurological issues in the patient, varying

from lack of nervous system communication and impaired neural function to tumors developing

in the glial areas of the brain [1].

One of the most common forms of brain tumor in the glial region of the brain is known as

Glioblastoma Multiforme, or GBM. A patient presenting with symptoms including memory loss

and neurological deficit (inability to maintain their typical personality traits, nausea, seizure and

prolonged headache or migraine will be examined for a brain tumor of any sort [2]. Given that

approximately 80% of malignant brain tumors are known as gliomas and more than 50% of all

primary brain tumor cases are Glioblastoma multiforme tumors, the first course of action by

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physicians is to conduct a cranial MRI to note the presence of a glioblastoma tumor [3]. Because

of the prevalence with which GBM presents itself in patients throughout the US, doctors along

with the World Health Organization have developed a class system based on the size and

progression of the glioblastoma tumor to determine typical survival rate percentages and

durations. Without treatment, survival rate ranges merely between 4 months to approximately 24

months, in the most historical of cases [4].

Given the high mortality rate in patients diagnosed with GBM, it is extremely important that

treatment methods be implemented to extend the life expectancy and enhance the quality of life

of the patients. Currently, the state-of-the-art treatments vary, along with their respective success

rates. Prior to more advanced treatment methods, the typical means of healing GBM was through

bulk glioma removal. With this, tremendous risk brain damage, loss of neurological function,

and death are highly probable and has typically been avoided in recent years.

Another means of treatment that has been implemented readily consists of radiation therapies.

These therapies focally deliver radiation to the region of the glial tumor, and thereby spare the

surrounding healthy tissue and brain matter, thereby lowering the likelihood of permanent brain

damage or loss of neurological function. And although the use of radiation is quite advantageous

in its limiting damage to the surrounding tissue, overexposure to radiation therapies may cause

the cancerous tumor to develop resistance to the radiation and necrosis, or cell damage, to the

surrounding tissue. Glioblastoma multiformes also have the tendency of being quite aggressive

and spreading rapidly to the surrounding tissue, rendering the radiation nearly useless.

Chemotherapy wafers have grown in popularity recently as a means of treatment of GBMs.

These wafers, also known as chemotherapy wafers, are Gliadel-biodegradable wafers soaked in a

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chemotherapy drug BCNU. Once treatment begins, high doses of BCNU are released over a 10-

20 day period [5]. This methodology does not necessarily kill the glioblastoma cancer, however,

it does prolong the projected lifespan of the patient based on their World Health Organization

GBM Grade [4]. Although there are a variety of methods that can be implemented on patients

based on their specific needs and the progression of their cancer.

Due to the specificity required in each case, generalizations cannot be made as to the sole

treatments to be used for GBM. Mathematical modeling has therefore been implemented in a

number of studies over the past decade in which the growth and invasion of glioma and

Glioblastoma multiform have been predicted and potential treatment methods examined.

Comprehension of migration and proliferation of the cancerous cells throughout the tumor and

the surrounding tissue will aid greatly in potentially targeting GBM and determining the ideal

treatment method for each individual patient.

Simulations of virtual gliomas will also allow physicians to determine lifespan based on the

expansion of the tumor with a variety of treatments. The following summarizes the advances

made in GBM proliferation modeling, survival time approximation, and chemotherapy and

radiation drug delivery modeling. Modeling allows physicians and clinicians to predetermine

their patients’ outlook and give the most realistic and accurate determination of their chance of

survival prior to treatment.

The mathematical modeling is powerful tool for analyzing different biological problems that

allows for development and testing of hypothesis for a better understanding of biological

processes. Each variable in the mathematical formulation can be considered individually or

together to assess significance to the biological problem and to suggest conclusions and

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inferences that can be tested biologically. Equation 1 represents the conservation equation of

migration interaction and net proliferation of gliomas and Gliobastoma Multiforme [6]. In this

equation, the rate of change of tumor population equals the diffusion (motility) of tumor cells

plus the net proliferation of tumor cells.

Eq. 1

From this, it is important to note that c denotes the tumor density, and is thereby a function of

distance x at time, t, while ρ denotes the net proliferation rate.

Assuming Fick’s Law of Diffusion to hold true (J = D C), the model can be written as:

Eq. 2

In Equation 2, D defines the diffusion coefficient of active motility of tumor cells. This

mathematical model hold true only when two boundary conditions are assumed: No migration of

cells beyond the brains boundary and c(x,0) = f(x), where f(x) is the initial spatial distribution of

malignant tumor cells [7].

Mathematical formulations from Equation 2 can be modified by incorporating cell loss/death on

account of chemotherapy treatments in a temporal profile (G(t)), as shown in Equation 3.

Eq. 3

Glioblastoma Multiforme (GBM) is one of the most common primary malignant brain tumors

and is difficult to treat effectively. The most common issue to be dealt with when considering

treatment options for GMB and glioma is drug transport across the blood brain barrier (BBB) to

the tumor, as modeled in Swanson et al (2003). As previously stated, there are a number of

treatment options currently available, depending on each individual patient’s requirements.

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Biological barriers, mechanisms that control the entry of compounds into certain organ systems,

regulate brain homeostasis, thereby protecting the central nervous system. In the brain, the

blood–brain barrier (BBB), acts as this protection mechanism. Formed by the endothelial cells of

the brain capillaries, the BBB restricts access of blood-borne compounds to brain cells and

facilitates nutrients essential for normal metabolism. While the function of the BBB is generally

beneficial to a normal, healthy person, it poses as an obstacle in the treatment of glioma and

Glioblastoma multiforme (GBM). Therefore, various strategies are being developed to enhance

the amount and concentration of therapeutic compounds in the brain, such as chemotherapy

treatments taken orally or intravenously, thereby allow for an increased likelihood of BBB

penetration.

Chemotherapy would seem to be the best way to reach all tumor cells, both the local bulk and the

diffusely invading cells. However, the drugs must be able to penetrate the normal blood-brain

barrier. Still, the heterogeneity of the vascular density within the grey and white matter can affect

the results. Swanson et al showed that, although the total number of tumor cells within the brain

may be decreasing with chemotherapy, the extent of invasion of the tumor remains practically

unaffected due to the continuing motility of the tumor cells within the white matter [8].

Even though the tumor appears to be regressing on MRI, extensively invaded tumor cells remain

below the detection abilities of the MRI, primarily throughout the white matter. This suggests a

potential difficulty with the design of clinical trials relying solely on MRI data as a measure of

success of treatment [9].

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It should be noted that capillary permeability has considerable effects on drug delivery. To

understand these effects, some general concepts should be introduced. Once injected

intravascularly, a drug mixes with the total body volume of blood, or in the case of water-soluble

compounds that are not protein bound, with total body plasma. Because a 70-kg human contains

3 liters of plasma, to achieve a starting plasma concentration of 1 unit of “ideal” drug per ml,

3000 units of drug must be given. As will be shown, this will affect all attempts to increase drug

delivery associated with intravascular administration. The human body acts as an enormous sink

in which the majority of intravascularly administered drug will be distributed, not to the brain

tumor, but to other body tissues [10]. Once mixed with total body plasma, the drug distributes

throughout body tissues and is then eliminated. The time course of the mixing, distribution, and

elimination of the drug in plasma is generally described by several different half-times, which

represent the process of fitting the plasma concentration-time data to a multiexponential

expression of the form:

Eq. 4

where A, B, and C represent the y-intercepts and a, b, and gamma represent the time constants,

with units of min–1[11]. The time constants are related to the half-times by the expression:

Eq. 5

where the half-time has units of minutes. The integrated value of plasma concentration over

time, usually referred to as the area under the curve (AUCPL), represents the amount of drug

passing through the brain or tumor vessels, that is, the amount of drug to which the brain or

tumor vessels are exposed. The time course of drug concentration over time in brain or brain

tumor tissue is more complex. As previously studied [9], the concentration of ideal drug in tissue

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(Ci) (assuming passive transport across the capillary, no plasma or tissue binding, and first order

metabolism and inactivation kinetics) is given by:

Eq. 6

where K1 is the blood-to-tissue transfer constant (with units of ml g–1 min–1), k2 is the tissue

efflux constant (with units of reciprocal time, min-1), and k3 is a metabolism or inactivation

constant, also with units of reciprocal time. Equation 4 can be used to calculate the tissue drug

concentration over time, and can be used to explore the impact of different values of k 1, k2, and

k3 on tissue drug concentrations. Assuming that the drug is passively distributed across the BBB

and not removed by other means, then K1 and k2 are related by the expression gamma = K1/k2,

where gamma is the equilibrium distribution volume of the drug in the tissue. It is very useful to

have some expression of the efficiency of the drug delivery process, at least to compare one

experimental methodology for increasing drug delivery with another. The next equation is called

the pharmacokinetic rule. It expresses the efficiency of drug entry, as shown in Equation 7 [12].

Eq.7

In this equation, ID represents the percent of injected dose of drug delivered per gram of tissue,

PS is the permeability surface area product (which for most water-soluble compounds is equal to

K1, with units of ml g–1 min–1), and AUC is the plasma area under the curve (for which the units

are %ID/min/μl). However, this expression does not consider drug efflux from tissue and/or

metabolism. In this review, two expressions were used to indicate the fractional efficiency of the

drug delivery process. Both expressions contain a term in the numerator that refers to the

concentration-time product of drug in brain or tumor tissue (AUC B). The first expression, called

the local exposure fraction, represents the fraction of drug removed from the blood to which the

brain or tumor is exposed, that is, the blood circulating locally within the tissue:

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 Eq. 8

This equation expresses the fraction of drug removed from the plasma to which the tissue was

exposed and is, therefore, an expression of local delivery efficiency. However, this is still a

small fraction of the drug in the entire body. The second expression, called the total exposure

fraction, incorporates the total body plasma volume:

Eq. 9

The AUCPL can be obtained from Equation & and AUCB can be obtained from integrating

Equation 6. Equation 7 is a reminder that the fraction of drug entering a gram of brain or tumor

is a small fraction of the drug circulating in the entire body. This route of delivery is inherently

inefficient. Equations 6 and 7 can be used to illustrate drug delivery to normal brain and brain

tumor in what may be viewed as “best case” and “worst case” scenarios. The worst case scenario

will almost always be represented by water-soluble drugs and the normal BBB, that is, the most

restrictive situation. It is therefore obvious that lipid-soluble drugs and highly permeable tumors

will allow for the best-case scenario.

Another means of treatment aside from chemotherapy for the focal treatments of Glioblastoma

Multiforme includes Gliadel-biodegradable soaked chemotherapy wafers. And despite of the

difficulty, the local drug delivery of chemotherapeutic drugs to glioma and GBM, the use of

chemotherapy wafers has provided a way to circumvent the blood brain barrier and allows the

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drugs to diffuse directly to the malignant brain cells [13]. The local chemotherapeutic drug

delivery to the brain includes the polymeric controlled release, via BCNU/Carmustine

chemotherapy wafers. The tumor is surgically removed to create a cavity where up to eight

wafers are implanted. The dime sized wafers (14 mm in diameter and 1 mm thick loaded with

7.7 mg of Carmustine) have been tested various times by studying in rodent and non-human

primate brains but due to localized nature of the drug in brain tissue, no pharmacokinetic

measurement have been made in humans after implantation. The studies suggest that these

Gliadel wafers show capability of producing high dose-delivery within the area of the brain

where the polymer has been implanted.

Studies have been done to investigate human pharmacokinetic properties by modeling the drug

delivery from a Gliadel wafer into human brain using COSMOL-multiphysics modeling and

simulation software. The effect of diffusion, convection and elimination of the drug Carmustine

is investigated [14].

Figure 1: The 3D geometry of the model. The wafer is placed is placed at the top of tumor tissue. The
wafer releases the drugs which diffuse through the tumor tissue and finally reach the healthy tissue [14].

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The surgeons cannot remove the entire GBM tumor without damaging the healthy tissue and as

a result, a minimal layer of tumor tissue remains in the cavity. The flux at the top of the wafer is

assumed to be zero. The diffusion of the drug from the sides of the wafer is zero as the drug is

assumed to diffuse in vertical direction only. Finally, the flux at the bottom of the tissue layer is

zero [2]. The mathematical modeling that has been introduced to this system for the analysis is as

shown in Equation 4, where u is velocity, Da is the diffusivity in the tumor tissue or normal

tissue and Ka is the first order reaction rate in the tissue:

Eq. 4

The initial and boundary conditions of this model are:

1) No drug will transport from the sides of the tissue as the drug is assumed to diffuse in
vertical direction only.
2) There is an insulated boundary condition at the bottom of the tissue so concentration of
the drug does not reach there.
3) The flux at the top of the wafer is assumed to be zero and
4) The flux between the wafer and tumor tissue is F = F0e-t/ where F0 and  are constant.

Table 1: Input parameters of diffusivity, reaction rates, and velocities were obtained from
research involving carmustine drug delivery in human and monkey tissues [14].
The results indicate that the carmustine was delivered at high concentration within the residual

tumor tissue but the drug was delivered in fewer amounts to the healthy tissue. The model also

describes the sensitivity of four parameters and they are convection velocity, rate of elimination,

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diffusivity and initial concentration. Convection velocity shows significant effect at interstitial

bulk fluid. Changing the rate of elimination just by one order of magnitude shows the extreme

effect on concentration-time profile. Diffusivity has a significant effect where as initial

concentration shows insignificant effect on concentration-time profile [14].

Despite the large amount of research that has been carried to investigate Glioblastoma (GBM),

the median survival is still 1 year or less for this deadly tumor. GBM tumors have the ability to

infiltrate local structures and migrate long distances, even to the contralateral hemisphere,

leading to disease recurrence despite aggressive resection. Even after curative resection of the

tumor, there are often microsatellites of tumor cells scattered throughout normal brain tissue that

have the potential to continue proliferating and cause tumor recurrence in other areas of the

brain. Radiotherapy and chemotherapy have had limited success in treating glioblastoma. Both

are limited by their toxicity to normal brain tissue that could lead to further brain damage and

decreased quality of life for patients [15, 16, 17]. However, Stem cells represent a powerful new

way to treat glioblastoma. Numerous studies have documented the tropism of stem cells for

tumor cells and their ability to migrate to areas of pathology. This behavior of stem cells is

exciting in that it provides a new way to provide therapy and elicit an immune response to all

glioblastoma cells, even those that have invaded deep into normal brain tissue [18].

The brain requires essential substances for metabolism and survival, such as glucose, insulin,

growth hormone, low-density lipoprotein (LDL), and others. These substances are recognized by

specific receptors or transport mechanisms, resulting in specific transport into the brain. Since

almost every neuron in the brain is perfused by its own capillary as a result of the small distance

separating capillaries (40 μm), the most effective way of delivering neuroactive drugs is via

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transporters or internalizing receptors on these capillaries. The techniques to deliver small and

large molecule to brain used to this day involve direct injection or infusion of therapeutic

compounds into the brain, but all these approaches are severely limited by poor distribution into

brain parenchyma. Only the use of technologies able to transport molecules through the

endothelial cells of the BBB will allow a homogenous distribution of therapeutics in the brain

and thus provide a uniform and rapid exposure to brain cells [19, 20]. The most promising new

technology uses a physiological approach to take advantage of endogenous receptors highly

expressed at the BBB. Unlike invasive or pharmacological approaches to deliver drugs to the

brain, the Angiopep technology takes advantage of using the receptors on the surface of the

blood-brain barrier that are responsible for actively transporting necessary molecules across the

barrier to the brain. These receptors provide brain cells with nutrients, and belong to the LDL

receptor family, transferrin and insulin receptors among others. Monoclonal antibodies and

ligands of these receptors can be used as Trojan horses for transcytosis of therapeutic compounds

to the brain. A new technology using the peptide Angiopep as the ligand for the LRP-1 receptor

demonstrates a high transport rate across the BBB and the ability to transport both small and

large drugs to the brain parenchyma. This technology is the most advanced of the technologies

targeting receptor-mediated endocytosis, and it is currently in Phase I for the treatment of

recurrent glioblastoma [21].

Gabathuler and his colleague used a CyDye fluorophore, cy5.5 labeled Angiopep-2 and

demonstrated that the labeled construct is very rapidly transported into the brain parenchyma, as

measured by in-vivo imaging followed by fluorescence analysis of brain slices. In Figure 2,

Angiopep-2-cy5.5 (red) is clearly localized in the brain parenchyma 1h post injection, and in

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close proximity to brain cell nuclei [22]. The insert on the right confirms that Angiopep-7-cy5.5,

a peptide with Lys residues, replaced by Arg residues.

Figure 2. Fluorescence microscopy 1 h post injection — distribution of Angiopep-2 and Angiopep-7-

brain capillaries are labeled green, brain cell nuclei are labeled blue.

Future stem cell therapies will probably be even more effective at tracking down tumor cells,

controlling tumor growth, amplifying the anti-tumor immune response and limiting invasion of

glioma cells into normal tissue. Before stem cell therapy can be applied for the treatment of

human brain tumors, much more research must be conducted to investigate the biology of stem

cells and brain tumors. Thus, in coming years, it is believed that significant advances will be

made in the understanding of how tumors, stem cells and the immune system interact with one

another, and how these interactions can be utilized from a therapeutic standpoint. Further

research needs to be carried out in finding new and more powerful genetic modifications to stem

cells so that their anti-tumor effects are maximized. As these stem cell therapies advance and

become more sophisticated, stem cells will probably be engineered to have multiple genetic

modifications and thus be equipped to apply several different therapeutic strategies towards

treating the cancer cells. More studies must also be carried out to demonstrate the signaling

pathways involved in the behavior of stem cells. Understanding the signals involved in the

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tropism of stem cells for gliomas will enable better engineering of therapeutic stem cells so that

they are more sensitive to signals secreted from the tumor environment and thus better able to

track tumor cells. Moreover, there are still many potential applications that have not been

explored. Although there is still much work to be done, the progress in stem cell therapies has

provided us with new hope that, in the future, we will be able to better treat aggressive brain

tumors such as GBM [23, 24].

In the other hand, new finding suggest that Cytomegalovirus (CMV) may serve as target for

vaccine in fight against Glioblastoma Multiforme (GBM). The human cytomegalovirus (CMV)

is found in up to 80 percent of Americans, though the virus normally produces very few clinical

symptoms, is inactive, and usually undetectable in most people [24]. However, more than 80

percent of patients newly diagnosed with the brain cancer glioblastoma multiform (GBM) exhibit

detectable CMV in their blood as well as in their tumors. Therefore, investigators thought this

might provide an opportunity to target brain tumors by going after the virus. Duane Mitchell and

his colleagues, at Duke University Medical Center, tested a vaccine in small group of patients

that seems to show some efficacy in stopping the reappearance of these tumors after removal.

Their aim was to take advantage of the connection between this virus and the brain tumor cancer

to treat one by treating the other. They found that the vaccine appears to have delayed the re-

growth of tumors from six to seven months after surgery to more than 12 months [25]. Their

results also show a lengthened overall survival among GBM patients, from about 14 months with

standard treatment to greater than 20 months. However, this still doesn't address the question,

why GBM is the only sort of cancer with which CMV seems to be associated, an area in which

greater strides need to be made to expand the lifespan and quality of life of those diagnosed with

GBM [25].

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