Myelination is critical for the normal functioning of the vertebrate nervous system. In the CNS, myelin is produced by oligodendrocytes, and the loss of oligodendrocytes and myelin results in severe functional impairment. Although spontaneous remyelination occurs in chronic demyelinating diseases such as multiple sclerosis, the repair process eventually fails, often resulting in long-term disability. Two distinct general approaches can be considered to promote myelin repair. In one the target is stimulation of the endogenous myelin repair process through delivery of growth factors, and in the second the target is augmentation of the repair process through the delivery of exogenous cells with myelination potential. In both cases, effective treatment of diseases such as multiple sclerosis requires modulation of the immune system, since demyelination is associated with specific immunological activation. Recent studies have shown that some populations of stem cells, including mesenchymal stem cells, have the capacity of promoting endogenous myelin repair and modulating the immune response, prompting an assessment of their use as therapy in demyelinating diseases such as MS. Other types of demyelinating disorders, such as the leukodystrophies, may require multiple repair strategies including both replacement of dysfunctional cells and delivery or supplementation of growth factors, immune modulators or metabolic enzymes. Here we discuss the use of stem cells for the treatment of demyelinating diseases. While the current number of stem cell-based clinical trials for demyelinating diseases is limited, this is likely to increase significantly in the next few years, and a clear understanding of the applicability, limitations and underlying mechanisms mediating stem cell repair is critical.Demyelination, a characteristic of multiple sclerosis (MS), is also an important component of the pathology of a variety of other insults and injuries to the CNS. For example, extensive demyelination accompanies trauma to the brain or spinal cord, as well as stroke. More recently, demyelination has been linked to functional CNS deterioration associated with Alzheimer's disease [1], normal aging [2] and psychiatric disorders such as schizophrenia [3], suggesting that the development of therapeutic approaches to enhance remyelination may have widespread applications in the nervous system.The demyelination that develops in MS is probably a consequence of inflammation and an autoimmune attack on the cells of the CNS that involves three distinct mechanisms:• Direct immunological insults;• Excitotoxic insults and compromise of CNS cell metabolism Immunological insults may be a direct attack on neurons and axons by T cells and antibodies, or an indirect damaging of neurons and axons by inflammatory mediators from the innate immune system, cytokine-mediated neurotoxicity and inflammation-related toxic factors such as nitric oxide. Excitotoxic demyelination may result from release of neurotransmitters such as glutamate, inducing an influx of calc...