Neuroaxonal damage is the pathological substrate of permanent disability in various neurological disorders. Reliable quantification and longitudinal follow-up of such damage are important for assessing disease activity, monitoring treatment responses, facilitating treatment development and determining prognosis. The neurofilament proteins have promise in this context because their levels rise upon neuroaxonal damage not only in the cerebrospinal fluid (CSF) but also in blood, and they indicate neuroaxonal injury independent of causal pathways. First-generation (immunoblot) and second-generation (enzyme-linked immunosorbent assay) neurofilament assays had limited sensitivity. Third-generation (electrochemiluminescence) and particularly fourth-generation (single-molecule array) assays enable the reliable measurement of neurofilaments throughout the range of concentrations found in blood samples. This technological advancement has paved the way to investigate neurofilaments in a range of neurological disorders. Here, we review what is known about the structure and function of neurofilaments, discuss analytical aspects and knowledge of age-dependent normal ranges of neurofilaments and provide a comprehensive overview of studies on neurofilament light chain as a marker of axonal injury in different neurological disorders, including multiple sclerosis, neurodegenerative dementia, stroke, traumatic brain injury, amyotrophic lateral sclerosis and Parkinson disease. We also consider work needed to explore the value of this axonal damage marker in managing neurological diseases in daily practice.

Key points

  • Neuronal damage and loss are the pathological substrates of permanent disability in various acute and chronic neurological disorders.

  • Levels of neurofilament proteins increase in cerebrospinal fluid (CSF) and in the blood upon neuroaxonal damage.

  • First-generation (immunoblot) and second-generation (enzyme-linked immunosorbent assay) neurofilament assays captured only the tip of the iceberg in disease.

  • Third-generation (electrochemiluminescence) and fourth-generation (single-molecule array) assays permit highly sensitive, longitudinal detection of blood neurofilament levels even in mild disease and in healthy controls.

  • Multicentre studies are underway to consolidate neurofilaments as biomarkers that reflect brain tissue damage, enabling longitudinal monitoring of disease activity and drug effects in clinical trials in neurological diseases.

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M.O. is supported by the German Federal Ministry for Education and Research (German FTLD consortium), the Thierry Latran Foundation and the ALS association. H.Z. is supported by grants from the Swedish Research Council, the European Research Council and the Knut and Alice Wallenberg Foundation. K.B. is supported by grants from the Swedish Research Council, the Swedish Alzheimer Association, the Swedish Brain Foundation and the Torsten Söderberg Foundation. J.K. is supported by grants from the Swiss National Science Foundation (320030_160221). F.P. is supported by grants from the Swedish Research Council.

Author information


  1. Department of Neurology, Medical University of Graz, Graz, Austria

    • Michael Khalil
    • , Thomas Gattringer
    •  & Franz Fazekas
  2. Neurochemistry Laboratory and Biobank, Department of Clinical Chemistry, Amsterdam Neuroscience, Amsterdam University Medical Centers, Amsterdam, Netherlands

    • Charlotte E. Teunissen
  3. Department of Neurology, Ulm University Hospital, Ulm, Germany

    • Markus Otto
  4. Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

    • Fredrik Piehl
  5. Department of Health Sciences, University of Genoa, Genoa, Italy

    • Maria Pia Sormani
  6. Ospedale Policlinico San Martino IRCCS, Genoa, Italy

    • Maria Pia Sormani
  7. Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research, and Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland

    • Christian Barro
    • , Ludwig Kappos
    •  & Jens Kuhle
  8. Unit of Clinical Neuroimmunology, Department of Neurology, Hospital Universitari Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain

    • Manuel Comabella
  9. UCL Institute of Neurology, Department of Molecular Neurosciences, Moorfields Eye Hospital and The National Hospital for Neurology and Neurosurgery, London, UK

    • Axel Petzold
  10. Departments of Neurology, Ophthalmology and Expertise Center for Neuro-ophthalmology, Amsterdam UMC, Amsterdam, Netherlands

    • Axel Petzold
  11. Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden

    • Kaj Blennow
    •  & Henrik Zetterberg
  12. Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden

    • Kaj Blennow
    •  & Henrik Zetterberg
  13. Department of Molecular Neuroscience, UCL Institute of Neurology, Queen Square, London, UK

    • Henrik Zetterberg
  14. UK Dementia Research Institute at UCL, London, UK

    • Henrik Zetterberg


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All authors contributed to all aspects of the manuscript.

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The authors declare no competing interests.

Corresponding authors

Correspondence to Michael Khalil or Jens Kuhle.

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