The Bloo d^Brain Barrier in Psychoneuroimmunolo gy

William A. Banks, MDa,b,*

KEYWORDS  Blood-brain barrier  Cerebrovascular  Cytokine  Central nervous system  Brain  Neurovascular unit  Hormone

Classically, two great communication systems have been described: the nervous system and the endocrine system. Not surprisingly, a role for the nervous system, especially the vagus and sympathetic outflow, was found early in the history of psychoneuroimmunology. Similarly, blood-borne signals were known to be critical for immune cell communication. Increasing evidence also showed that circulating immune signals, including immune cells themselves, somehow exerted an effect on the central nervous system (CNS). It was known that this endocrine-like interaction between the circulating factors of the immune system and the elements of the CNS was complicated by the existence of the bloodbrain barrier (BBB). Early work clearly showed that the BBB prevents as free an exchange of the circulating immune elements with the CNS as with the peripheral tissues. The existence of barrier function preventing the unrestricted exchange of immune substances between the blood and CNS raised another, more exciting possibility: that the BBB might preside over a regulated interaction between the immune system and the peripheral tissues. Work in the last 15 years has shown that the BBB is in fact a regulatory interface between the CNS and peripheral tissues. This interface does not exit in isolation but is modified and affected by circulating substances and, even more, by cells, substances, and events on the CNS side. These intimate interactions of the BBB with events on its luminal (blood) and abluminal (brain) sides have led to the concept of the neurovascular unit (NVU). The concept of the NVU emphasizes that the BBB is in a pivotal position to control the humoral exchanges between the peripheral tissues and the CNS and that such control is modified by CNS and circulatory factors. The
This issue is a repurpose of August 2006 issue of the Neurologic Clinics (NCL Volume 24, Issue 3). a Geriatrics Research Education and Clinical Center, Veterans Affairs Medical Center-St. Louis, 915 North Grand Boulevard, St. Louis, MO 63106, USA b Division of Geriatrics, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA * Correspondence. Geriatrics Research Education and Clinical Center, Veterans Affairs Medical Center-St. Louis, 915 North Grand Boulevard, St. Louis, MO 63106. E-mail address: bankswa@slu.edu Immunol Allergy Clin N Am 29 (2009) 223228 doi:10.1016/j.iac.2009.02.001 immunology.theclinics.com 0889-8561/09/$ see front matter 2009 Elsevier Inc. All rights reserved.

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roles of the BBB and the NVU in psychoneuroimmunology still are being described, but current thinking can categorize them broadly. This article considers the four functions that are most fundamental to psychoneuroimmunology: (1) barrier functions; (2) permeability functions, further considered here as permeability to cytokines and to immune cells; (3) clearance functions; and (4) secretory functions.
BARRIER FUNCTIONS

The defining characteristic of the BBB is its barrier function (Fig. 1). Experiments by Paul Erlich and others at the end of the nineteenth century found that some dyes could not stain the brain after intravenous injection. Eventually, this lack of staining was found to occur because these dyes bound to circulating albumin and, unlike in peripheral organs and tissues, albumin was unable to leak out of the blood vessels of the CNS. In the late 1960s, electron microscopy studies revealed the anatomic basis for the BBB.1 Tight junctions cement together the endothelial cells that form capillaries in the brain and spinal cord and that line their arterioles and venules. Other modifications include a lack of intracellular fenestrations and a decreased rate of pinocytosis. Besides the endothelial barrier of the vasculature, there are parallel barriers comprised of epithelial cells at the choroid plexus and tanycytes at the circumventricular organs. Taken together, these modifications prevent the production of a plasma ultrafiltrate and, hence, leakage of serum proteins into the CNS. The barrier formed is the most impressive in biology, with serum/cerebrospinal fluid (CSF) to ratios for restricted proteins of about 200:1.2 This lack of leakage no doubt has great benefits to the CNS. Preventing the unrestricted entry of circulating substances into the CNS is one of several ways that the BBB helps provide an ideal environment for the functioning of the CNS. This ultrafiltrate, however, provides much of the nourishment to peripheral tissues. Without it, the CNS must obtain its nutrients by some other means. The BBB serves this need of the CNS as well. The BBB possesses selective saturable transporters for nearly every substance needed for the homeostatic and nutritional maintenance of the CNS. There are, for example, transporters for glucose, amino acids, free fatty acids, vitamins, minerals, and electrolytes. These transporters often have been shown to be modifiable so that they adapt to the needs of the CNS. This dualism of the

Fig. 1. Multiple roles are played by the cells that comprise the bloodbrain barrier. CNS, central nervous system.

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BBBthe power to restrict leakage so severely and to transport substances on a selective basismakes it a vital player in the interactions between the CNS and the periphery. Adrenergic compounds are perhaps the most significant class of neuroimmune substances excluded by the BBB. Epinephrine and norepinephrine secreted from the adrenal medulla and adrenergic nerves have been shown to affect immune cell functions.3 Adrenergic compounds are excluded by the physical presence of the BBB and also by enzymatic degradation by the brain capillaries.4 Disruption of the BBB is a highly pathologic event and is associated with many neuroimmune phenomena. The first such phenomenon described was the ability of lipopolysaccharide (LPS) to disrupt the BBB. It is assumed that the release of cytokines such as tumor necrosis factor-a (TNF-a) is the mechanism for such disruption, which also is known to be prostaglandin dependent and independent of nitric oxide. Most events and substances that disrupt the BBB do so not by dissolving the tight junctions of the brain endothelial cells (ie, the paracelluar pathway) but by enhancing pinocytosis and other vesicular-dependent mechanisms (the transcytotic pathway). Recent work, however, has emphasized the role of the paracellular pathway in disease states because of recent advances in understanding how tight junctions work. It is becoming increasingly clear that there are many subtypes of vesicles at the BBB, including those related to transport of viruses across the BBB.
PERMEABILITY FUNCTIONS

If substances could not cross the vascular BBB, the CNS would not survive. As noted previously, numerous classes of substances cross the BBB by way of saturable transporters. Some of these substances act as hormones toward the brain; that is, they are secreted into the blood by peripheral tissues and travel through the bloodstream to affect CNS function.5 To affect the CNS, these substances must negotiate the BBB. Although there are several indirect ways by which blood-borne substances can influence the CNS, the most direct way is by crossing the BBB. It has long been known that steroid hormones cross the BBB and influence brain function. The idea that peptides and regulatory proteins could cross the BBB was highly controversial when first proposed. It now is clear that many peptides and regulatory proteins can do so. Indeed, consistent with the concept of an NVU, the BBB can be viewed as the crucial intersection in a humoral-based communication between the CNS and peripheral tissues. Many of the substances that cross the BBB influence the neuroimmune system. The substances that most clearly fit into this category are the cytokines. Currently, more than two dozen cytokines have been examined for their abilities to cross the BBB.6 Among those found to be transported by a saturable system from blood to brain are interleukin (IL)-1, IL-6, TNF-a, nerve growth factor, neurotensin-3, brain-derived neurotrophic factor, fibroblast growth factor, epidermal growth factor, leukemia inhibitory factor, ciliary neurotrophic factor, gamma interferon, and granulocyte macrophage colony-stimulating factor. It is increasingly clear that the cytokine transporters are involved in pathologic as well as physiologic states. For example, numerous publications from the laboratory of Pan have shown that the transporters are altered with injuries to the CNS.7 Those and other studies also show that cytokines with neurotrophic potential can cross the BBB in normal animals as well as in those with injuries to the CNS. At the current time, little or no work is being done to use these transporters to deliver neurotrophic agents to injured brain tissue.

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The ability of immune cells to cross the BBB also is of profound importance to neuroimmunology. Trafficking between the CNS and blood occurs under normal circumstances and can be greatly increased in disease conditions.8 Penetration of the BBB by immune cells does not occur because of a disrupted BBB. Instead, an intimate and orchestrated interaction occurs between the immune cell and the brain endothelial cell. Expression of complementary adhesion molecules by both cells is vital to binding and subsequent interactions. Expression of intercellular adhesion molecule-1 by brain endothelial cells has been identified as a key step in immune cell trafficking in the CNS. The expression of these adhesion molecules is influenced by proinflammatory cytokines. A prominent route by which immune cells cross the BBB is the process of diapedesis in which the immune cell tunnels through the brain endothelial cell, not between the tight junctions between cells. Thus cells programmed or activated by events outside the CNS can enter the brain or spinal cord to secrete substances or otherwise interact with cells within the CNS.
CLEARANCE FUNCTIONS

The role of the movement of substances from the CNS into the blood is an important, but seldom considered, topic for psychoneuroimmunology. Substances enter the blood from the CNS by two broad mechanisms: the efflux of substances from brain interstitial fluid into the blood and the reabsorption of CSF.9 Efflux from brain interstitial fluid into blood occurs across the capillary wall and can be mediated by saturable efflux systems or by nonsaturable diffusion across the cell membranes comprising the brain endothelial cell. Reabsorption of CSF can occur at the arachnoid villi, in which case the CSF enters the venous drainage of the brain, or at the olfactory bulbs, in which case the CSF enters the lymphatic drainage for the head. Brief examples can show why movement from the CNS to blood is so important in psychoneuroimmunology. The CNS can be a tremendous source of cytokine production, particularly in states such as meningitis. These cytokines can enter the blood with the reabsorption of the CNS at the arachnoid villi. Only one cytokine has been found to have a saturable transporter directed from the brain to the blood: IL-2. This efflux of cytokine from brain to blood can elevate brain levels, and it is possible that much of the cytokine found in the blood is derived from the CNS.10 It seems that much of the methionine enkephalin found in blood is derived from the CNS. Methionine enkephalin is a small opiate peptide produced by both peripheral tissues and the CNS that has neuroimmune functions. It is transported from the CNS to the blood by the saturable peptide transport system-1. It has been estimated that about 30% to 40% of the circulating methionine enkephalin is derived from the CNS.11 Substances injected into the CSF can have profound effects on peripheral immune function. This area is understudied, and the mechanisms of action are not clear. The major hypothesis is that the substances are reabsorbed with the CSF and travel to the cervical lymphatics, where they affect immune cell function.12 In a somewhat similar manner, corticotropin-releasing hormone is transported from brain to blood, where it circulates to the spleen. Once there, it affects splenic production of the opiate neuroimmune modulator b-endorphin.13
SECRETORY FUNCTIONS

The BBB can be the conduit by which circulating cytokines affect the CNS through mechanisms other than direct passage. The cytokines, for example, can alter the

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permeability of the BBB to a variety of substances and through numerous mechanisms. Cytokines also can alter receptor levels on brain endothelial cells. Another mechanism that has received much less attention is the ability of the cells that comprise the BBB to secrete cytokines. In 1993 Fabry and colleagues14 showed that brain endothelial cells can secrete IL-1 and IL-6. In 1999, Hoffman and colleagues15 showed that exposure to the HIV-1 protein Tat induced release of IL-8, and Reyes and colleagues16 showed release of IL-6 on exposure to LPS. Since then, it has been shown that numerous other cytokines are released from brain endothelial cells and the choroid plexus either spontaneously or upon stimulation. Other substances important to the neuroimmune system, including prostaglandins and nitric oxide, also are released from the BBB. The importance of the BBB release of cytokines in psychoneuroimmunology can be illustrated by the versatility of pathways. First, the brain endothelial cell could receive input from its brain side and secrete substances back into the CNS. As such, it could be the fourth member of the currently popular triad involving cross-talk among neurons, astrocytes, and microglia. Likewise, the BBB could receive neuroimmune stimulation from the blood and respond by secreting substances back into the blood. The most exciting aspect of the BBB secretion of cytokines is that the BBB could receive stimulation from one side and secrete cytokines into the other. For example, a brain endothelial cell might receive an immune signal at its blood side and respond by secreting a cytokine from its brain side. No other part of the immune system, with the exception of immune cells that cross the BBB, can be activated in one compartment of the CNS-immune axis and respond by releasing substances into the other compartment. Recently, it has been shown that brain endothelial cells indeed can receive input from one side and secrete cytokines into the other.17
SUMMARY

The very term psychoneuroimmunology connotes separate compartments that interact. The BBB is the physical and physiologic dividing line between the immune system and the CNS and is the locale for interaction. Interactions between the immune system and the CNS are mediated at the BBB through a variety of mechanisms. The BBB restricts unregulated mixing of the immune substances in the blood with those in the CNS, directly transports neuroimmune active substances between the blood and the CNS, and secretes neuroimmune substances. All these normal functions of the BBB can be altered in an adaptive or pathologic manner by neuroimmune events. As such, the BBB is an important conduit in the communication of the immune and the central nervous systems.
REFERENCES

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