Neurological diseases and disorders (NDDs) present a significant societal
burden and currently available drug- and biological-based therapeutic strategies
have proven inadequate to alleviate it. Gene therapy is a suitable alternative
to treat NDDs compared to conventional systems since it can be tailored to
specifically alter select gene expression, reverse disease phenotype and restore
normal function. The scope of gene therapy has broadened over the years with the
advent of RNA interference and genome editing technologies. Consequently,
encouraging results from central nervous system (CNS)-targeted gene delivery
studies have led to their transition from preclinical to clinical trials. As we
shift to an exciting gene therapy era, a retrospective of available literature
on CNS-associated gene delivery is in order. This review is timely in this
regard, since it analyzes key challenges and major findings from the last two
decades and evaluates future prospects of brain gene delivery. We emphasize
major areas consisting of physiological and pharmacological challenges in gene
therapy, function-based selection of an ideal cellular target, available therapy
modalities, and diversity of viral vectors and nanoparticles as vehicle systems.
Further, we present plausible answers to key questions such as strategies to
circumvent low blood-brain barrier permeability, most suitable CNS cell types
for targeting. We compare and contrast pros and cons of the tested viral vectors
in context of delivery systems used in past and current clinical trials. Gene
vector design challenges are also evaluated in the context of cell-specific
promoters. Key challenges and findings reported for recent gene therapy clinical
trials, assessing viral vectors and nanoparticles, are discussed in the context
of bench to bedside gene therapy translation. We conclude this review by tying
together gene delivery challenges, available vehicle systems and comprehensive
analysis of neuropathogenesis to outline future prospects of CNS-targeted gene
therapies.