Protocol Intra-arterial bone marrow mononuclear cells (BM-MNCs) transplantation in acute ischemic stroke (IBIS trial): protocol of a phase II, randomized, dose-finding, controlled multicenter trial Francisco Moniche1*, Irene Escudero1, Elena Zapata-Arriaza1, María Usero-Ruiz1, María Prieto-León1, Javier de la Torre1, Miguel-Angel Gamero2, Jose Antonio Tamayo3, Juan-José Ochoa-Sepúlveda4, José Maestre5, Magdalena Carmona6, Pilar Piñero7, Cristina Calderón-Cabrera6, Maria-Dolores Jimenez1, Alejandro Gonzalez7, and Joan Montaner1,8 Rationale No neuroprotective or neurorestorative therapies have been approved for ischemic stroke. Bone marrow mononuclear cell intra-arterial transplantation improves recovery in experimental models of ischemic stroke. Aims This trial aims to test safety and efficacy of intra-arterial injection of autologous bone marrow mononuclear cell in ischemic stroke patients. Design Multicenter, prospective, phase II, randomized, controlled (non-treated group as control), assessor-blinded clinical trial. Seventy-six stroke patients will be enrolled. Patients fulfilling clinical and radiological criteria (e.g. age between 18 and 80 years, middle cerebral artery ischemic stroke with a National Institutes of Health Stroke Scale score of 6–20 within one- to seven-days from stroke onset and no lacunar stroke) will be randomized to intervention or control group (1 : 1). Bone marrow harvest and intra-arterial injection of autologous bone marrow mononuclear cell will be done in the intervention group with two different doses (2 × 106/kg or 5 × 106/kg in 1 : 1 proportion). Patients will be stratified at randomization by National Institutes of Health Stroke Scale score. Patients will be followed up for two-years. Study outcomes The primary outcome is the proportion of patients with modified Rankin Scale scores of 0–2 at 180 days. Secondary outcomes include National Institutes of Health Stroke Scale and Barthel scores at six-months, infarct volume, mortality, and seizures. Discussion This is the first trial to explore efficacy of different doses of intra-arterial bone marrow mononuclear cell in Correspondence: Francisco Moniche*, Neurology Department, Hospital Universitario Virgen del Rocío, Avda.Manuel Siurot s/n.Seville, 41013, Spain. E-mail:[email protected] 1 Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain 2 Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain 3 Department of Neurology, Hospital Regional de Malaga, Malaga, Spain 4 Department of Neurology, Hospital Reina Sofia, Cordoba, Spain 5 Department of Neurology, Hospital Virgen de las Nieves, Granada, Spain 6 Department of Hematology, Hospital Universitario Virgen del Rocío, Seville, Spain 7 Department of Radiology, Hospital Universitario Virgen del Rocío, Seville, Spain 8 Instituto de Biomedicina de Sevilla-IBiS, Hospital Universitario Virgen del Rocío, Seville, Spain Received: 2 February 2015; Accepted: 8 April 2015; Published online 4 June 2015 Conflict of interest: The authors declare no conflicts of interest. DOI: 10.1111/ijs.12520 © 2015 World Stroke Organization
moderate-to-severe acute ischemic stroke patients. The trial is registered as NCT02178657. Key words: bone marrow, cell transplantation, clinical trial, ischemic stroke, mononuclear cell, stem cell
Introduction and rationale Stroke is the leading cause of long-term disability in adults. However, there are no neuroprotective or neurorestorative therapies approved for ischemic stroke (1). Despite acute stroke treatments, such as tissue plasminogen activator, more than one-third of survivors are disabled after stroke. Based on animal stroke models, cell therapy is a potential new treatment for regaining neurological function after stroke (2). One of the most studied cell types for ischemic stroke is bone marrow mononuclear cells (BM-MNCs). Main mechanisms of those cells claimed to improve stroke outcomes work by modulating microglia, increasing neoangiogenesis, and promoting neurogenesis (2,3). Although BM-MNC transplantation seems to be safe (4–6), the efficacy of this therapy in stroke patients is not yet demonstrated and neither clear the optimal dose of cells to be used in humans. The aim of this study is to test whether autologous BM-MNC intra-arterial transplantation in stroke patients improves neurological outcomes and if higher doses of cells lead to better recovery after stroke.
Methods Design The design is a multicenter, prospective, phase II, randomized, controlled (non-treated group as control), assessor-blinded, academic clinical trial of intra-arterial transplantation of autologous BM-MNC in acute ischemic stroke patients. The study flow chart is shown in Fig. 1. The protocol is registered in http:// clinicaltrials.gov (NCT 02178657) and approved by the Spanish Agency of Medicines and Medical Devices (AEMPS) (EudraCT:2013-002135-15). Patient population – inclusion and exclusion criteria The patients included will be ischemic strokes involving the middle cerebral artery (MCA) within the first and seventh days Vol 10, October 2015, 1149–1152
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Fig. 1 IBIS trial flow chart. AE, adverse event; BM-MNC, bone marrow mononuclear cell; CPG, clinical practice guidelines; ECG, electrocardiography; IBIS, Intra-arterial BM-MNC transplantation in acute Ischemic Stroke; MRI/MRA, magnetic resonance imaging/angiography; mRS modified Rankin Scale; NIHSS, National Institute of Health Stroke Scale. Table 1 The IBIS trial inclusion and exclusion criteria Inclusion criteria • Patients with middle cerebral artery (MCA) acute ischemic stroke • Time of stroke onset is known and treatment can be started between day 1 and 7 of onset • DWI-MRI has reliably shown acute MCA ischemic lesions • Magnetic resonance angiography must confirm ipsilateral MCA permeability • NIHSS score of 6–20 at inclusion • Age 18–80 years • Written informed consent Exclusion criteria • Haemorrhagic stroke or symptomatic haemorrhagic transformation • Lacunar infarction • Pre-occlusive stenosis or total occlusion of ipsilateral carotid artery • Worsening of ≥4 points in NIHSS in the 24 hours previous to inclusion, attributable to edema or haemorrhagic transformation or suspicious of malignant edema • Decrease of consciousness with a Glasgow Coma Scale of 2 mg/dl) • Coagulopathy • Severe comorbidity • Pregnancy, childbearing potential (unless it is certain that pregnancy is not possible), or breast feeding • Modified Rankin Score before stroke of ≥2 • Participation in any clinical trial in the last three-months DWI, diffusion-weighted imaging; IBIS, Intra-arterial BM-MNC transplantation in acute Ischemic Stroke; MRI, magnetic resonance imaging; NIHSS, National Institute of Health Stroke Scale.
from stroke onset and with a moderate-to-severe deficit [National Institutes of Health Stroke Scale (NIHSS) score of 6–20 at inclusion]. The detailed inclusion and exclusion criteria are shown in Table 1.
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Randomization After written inform consent is provided, patients will be randomized 1 : 1 to control group (standard stroke treatment) or interventional group (BM-MNC transplantation) based on a central computer-generated code list. Patients will be stratified at randomization by severity of neurological deficit measure by NIHSS (NIHSS score of 6–13 and 14–20). In the interventional group, patients will be also randomized in a 1 : 1 ratio to receive a lower or higher BM-MNC dose (2 × 106/kg or 5 × 106/kg). Treatment Every patient included will receive best medical treatment based on current clinical practice guidelines and rehabilitation will be assessed by a questionnaire. In the interventional group, bone marrow harvest will be performed obtaining 100 ml or 150 ml in the low-dose and high-dose group, respectively. Approximately each 5 ml of bone marrow aspirated will be deposited into a transfer bag with 10 ml of acid citrate dextrose solution and 1 ml of preservative-free heparin. After bone marrow harvest, it will be centrifuged on a Ficoll density gradient to isolate the mononuclear cells and obtain the low and high doses (2 × 106/kg or 5 × 106/kg), which will be washed and resuspended in 20 ml of 0·9% sodium chloride [phosphatebuffered saline (PBS)] supplemented with 0·1% heparin for infusion to the patient. Aliquots of the final BM-MNC product will be separated for cell counting, flow cytometry, and bacterial culture. On the same day, and three- to four-hours after bone marrow harvest, a cerebral angiography (3000 U heparin) will be done and BM-MNCs will be infused through microcatheter in the M1 segment of the infarct-related MCA at a rate of 0·5–1 ml/min. The final suspension of BM-MNC will be shaken until moment of infusion to avoid precipitating or clumping. After injection, a control angiography will be done to ensure MCA patency. Patients will be followed up for two-years. In case of neurological worsening after inclusion of the patient in the trial, a new brain © 2015 World Stroke Organization
Protocol
F. Moniche et al. imaging [magnetic resonance imaging (MRI) is recommended to investigators] must be performed to clarify the adverse event. Primary outcomes The primary outcome is the proportion of patients with modified Rankin Scale (mRS) scores of 0–2 at 180 days. Neurologist assessing the outcomes will be blinded to the group assigned to each patient. Secondary outcomes • Categorical shift in mRS ordinal (0–6) scale. • mRS scores of 0–3 at six-months. • National Institute of Health Stroke Scale (NIHSS) and Barthel scores at one-, three-, and six-months. • Infarct volume change between baseline [diffusion-weighted imaging (DWI)] and six-months [fluid-attenuated inversion recovery (FLAIR)]. • Mortality at 180 days. • Presence of seizures during follow-up. • Serious adverse events. Data monitoring body Study monitoring to assure quality and conduct according to good clinical practice will be performed by an external contract research organization, with phone contacts and in-person monitoring visits. No formal interim analyses for efficacy or futility are planned. Prior to site activation, study personnel at each enrolling center are trained on the transplantation protocol, International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) Good Clinical Practices, and investigator responsibilities. All investigators will be certified for mRS and NIHSS. Sample size Sample size was calculated based on a previous trial (4). The total sample size of 76 patients, with 38 patients in each arm, provides an 80% power to detect a difference of 18% in dependency in mRS. We estimate recruiting five participants/year/center, that is, ∼25 participants/year overall. Statistical analyses The primary efficacy analysis will be on an intention-to-treat basis. For the primary outcome, the proportion of patients with mRS scores of 0–2 at 180 days will be compared between control and treatment arms. A secondary analysis of the categorical shift in mRS will be undertaken on the full range (0–6) of the mRS using Cochran– Mantel–Haenszel shift test and proportional odds logistic regression subject to the validity of shift analysis model assumptions. The two different doses of BM-MNC in the treatment arm will be compared in order to detect differences in safety or efficacy. Other secondary outcome analyses will be carried out according to standard statistical principles for comparison of parametric or nonparametric distributions as appropriate. Study organization and funding The Andalusian Initiative for Advanced Therapies is the study sponsor. The study is funded by a grant from the Junta de Andalucía (PI-0228–2012). © 2015 World Stroke Organization
Discussion We chose to transplant autologous BM-MNCs as it is feasible to obtain high number of cells without the need of cell culture and inject them within hours from bone marrow harvest, making possible to treat acute stroke patients and avoiding the possibility of rejection in comparison with other cells (i.e. allogenic cells). Also, as recommended in the STem cells as an Emerging Paradigm in Stroke (STEPS) guidelines (7), BM-MNCs have demonstrated consistently beneficial effects in stroke animal models and have proven a good safety profile in preliminary clinical trials in humans (3–6). To date, there is no description either in animals or in humans of tumour formation. However, in this trial as required by the regulatory agency, every patient will be followed up to two-years to evaluate the long-term safety. Preclinical evidence favors administering cell therapy within the first days after stroke, when active process of inflammation and neuroplasticity occurs (2). The goal of restorative therapies should be to activate and amplify this endogenous restorative brain plasticity process to potentiate functional recovery. Within the first days after stroke, BM-MNCs seem to induce changes in serum cytokines and growth factors, which could enhance neurological recovery (8). Also, the intra-arterial route seems to be superior to intravenous route (9,10). In fact, a recently published trial failed to demonstrate efficacy of BM-MNCs when administered intravenously at a median of 18 days after stroke (6). Another issue of cell therapy trials is the dose of cells administered. The optimal dose in humans is not clear and to date, different doses have not yet been evaluated in a clinical trial. There is strong evidence in animal models of stroke that a higher dose of cells leads to a better neurological outcome (9) and our group also found a trend toward better neurological recovery with higher cells injected (4). Therefore, to evaluate this dose–response relationship, we will randomize patients into two different BM-MNC doses. In previous clinical trials, cell dose was not pre-specified in protocol, leading to a wide variability in the final number of injected cells (4,6). In our previous trial, mean dose of BM-MNC was 2·17 × 106/kg (range 0·33–4·96 × 106/kg) (8). In a previous trial with a fixed dose of 10 × 106/kg, in 2 of 10 patients, the target dose was not reached (5), therefore we decided to test the mean BM-MNC dose of our previous trial (i.e. 2 × 106/kg) as ‘low dose’ and 5 × 106/kg as ‘high dose’. This ‘high dose’ is feasible to be obtained in every patient with a bone marrow harvest of 150 ml and its efficacy has already been demonstrated in preclinical studies (11).
Summary and conclusions This is the first trial to explore efficacy of different doses of intraarterial BM-MNC in moderate-to-severe acute ischemic stroke patients. As stroke is the leading cause of disability, there is an urgent need of treatments for regaining neurological function. If positive, this therapeutic approach will significantly increase the options for stroke recovery. Vol 10, October 2015, 1149–1152
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Protocol References 1 Jauch EC, Saver JL, Adams HP Jr et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870–947. 2 Zhang ZG, Chopp M. Neurorestorative therapies for stroke: underlying mechanisms and translation to the clinic. Lancet Neurol 2009; 8:491–500. 3 Fujita Y, Ihara M, Ushiki T et al. Early protective effect of bone marrow mononuclear cells against ischemic white matter damage through augmentation of cerebral blood flow. Stroke 2010; 41:2938–43. 4 Moniche F, Gonzalez A, Gonzalez-Marcos JR et al. Intra-arterial bone marrow mononuclear cells in ischemic stroke: a pilot clinical trial. Stroke 2012; 43:2242–4. 5 Savitz SI, Misra V, Kasam M et al. Intravenous autologous bone marrow mononuclear cells for ischemic stroke. Ann Neurol 2011; 70:59–69. 6 Prasad K, Sharma A, Garg A et al. Intravenous autologous bone marrow mononuclear stem cell therapy for ischemic stroke: a multicentric, randomized trial. Stroke 2014; 45:3618–24.
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F. Moniche et al. 7 Savitz SI, Cramer SC, Wechsler L. STEPS 3 Consortium. Stem cells as an emerging paradigm in stroke 3: enhancing the development of clinical trials. Stroke 2014; 45:634–9. 8 Moniche F, Montaner J, Gonzalez-Marcos JR et al. Intra-arterial bone marrow mononuclear cell (BM-MNC) transplantation correlates with GM-CSF, PDGF-BB and MMP-2 serum levels in stroke patients: results from a clinical trial. Cell Transplant 2014; 23(Suppl. 1):57– 64. 9 Vu Q, Xie K, Eckert M, Zhao W, Cramer SC. Meta-analysis of preclinical studies of mesenchymal stromal cells for ischemic stroke. Neurology 2014; 82:1277–86. 10 Kamiya N, Ueda M, Igarashi H et al. Intraarterial transplantation of bone marrow mononuclear cells immediately after reperfusion decreases brain injury after focal ischemia in rats. Life Sci 2008; 83:433–7. 11 Brenneman M, Sharma S, Harting M et al. Autologous bone marrow mononuclear cells enhance recovery after acute ischemic stroke in young and middle-aged rats. J Cereb Blood Flow Metab 2010; 30: 140–9.
© 2015 World Stroke Organization
moderate-to-severe acute ischemic stroke patients. The trial is registered as NCT02178657. Key words: bone marrow, cell transplantation, clinical trial, ischemic stroke, mononuclear cell, stem cell
Introduction and rationale Stroke is the leading cause of long-term disability in adults. However, there are no neuroprotective or neurorestorative therapies approved for ischemic stroke (1). Despite acute stroke treatments, such as tissue plasminogen activator, more than one-third of survivors are disabled after stroke. Based on animal stroke models, cell therapy is a potential new treatment for regaining neurological function after stroke (2). One of the most studied cell types for ischemic stroke is bone marrow mononuclear cells (BM-MNCs). Main mechanisms of those cells claimed to improve stroke outcomes work by modulating microglia, increasing neoangiogenesis, and promoting neurogenesis (2,3). Although BM-MNC transplantation seems to be safe (4–6), the efficacy of this therapy in stroke patients is not yet demonstrated and neither clear the optimal dose of cells to be used in humans. The aim of this study is to test whether autologous BM-MNC intra-arterial transplantation in stroke patients improves neurological outcomes and if higher doses of cells lead to better recovery after stroke.
Methods Design The design is a multicenter, prospective, phase II, randomized, controlled (non-treated group as control), assessor-blinded, academic clinical trial of intra-arterial transplantation of autologous BM-MNC in acute ischemic stroke patients. The study flow chart is shown in Fig. 1. The protocol is registered in http:// clinicaltrials.gov (NCT 02178657) and approved by the Spanish Agency of Medicines and Medical Devices (AEMPS) (EudraCT:2013-002135-15). Patient population – inclusion and exclusion criteria The patients included will be ischemic strokes involving the middle cerebral artery (MCA) within the first and seventh days Vol 10, October 2015, 1149–1152
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Fig. 1 IBIS trial flow chart. AE, adverse event; BM-MNC, bone marrow mononuclear cell; CPG, clinical practice guidelines; ECG, electrocardiography; IBIS, Intra-arterial BM-MNC transplantation in acute Ischemic Stroke; MRI/MRA, magnetic resonance imaging/angiography; mRS modified Rankin Scale; NIHSS, National Institute of Health Stroke Scale. Table 1 The IBIS trial inclusion and exclusion criteria Inclusion criteria • Patients with middle cerebral artery (MCA) acute ischemic stroke • Time of stroke onset is known and treatment can be started between day 1 and 7 of onset • DWI-MRI has reliably shown acute MCA ischemic lesions • Magnetic resonance angiography must confirm ipsilateral MCA permeability • NIHSS score of 6–20 at inclusion • Age 18–80 years • Written informed consent Exclusion criteria • Haemorrhagic stroke or symptomatic haemorrhagic transformation • Lacunar infarction • Pre-occlusive stenosis or total occlusion of ipsilateral carotid artery • Worsening of ≥4 points in NIHSS in the 24 hours previous to inclusion, attributable to edema or haemorrhagic transformation or suspicious of malignant edema • Decrease of consciousness with a Glasgow Coma Scale of 2 mg/dl) • Coagulopathy • Severe comorbidity • Pregnancy, childbearing potential (unless it is certain that pregnancy is not possible), or breast feeding • Modified Rankin Score before stroke of ≥2 • Participation in any clinical trial in the last three-months DWI, diffusion-weighted imaging; IBIS, Intra-arterial BM-MNC transplantation in acute Ischemic Stroke; MRI, magnetic resonance imaging; NIHSS, National Institute of Health Stroke Scale.
from stroke onset and with a moderate-to-severe deficit [National Institutes of Health Stroke Scale (NIHSS) score of 6–20 at inclusion]. The detailed inclusion and exclusion criteria are shown in Table 1.
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Randomization After written inform consent is provided, patients will be randomized 1 : 1 to control group (standard stroke treatment) or interventional group (BM-MNC transplantation) based on a central computer-generated code list. Patients will be stratified at randomization by severity of neurological deficit measure by NIHSS (NIHSS score of 6–13 and 14–20). In the interventional group, patients will be also randomized in a 1 : 1 ratio to receive a lower or higher BM-MNC dose (2 × 106/kg or 5 × 106/kg). Treatment Every patient included will receive best medical treatment based on current clinical practice guidelines and rehabilitation will be assessed by a questionnaire. In the interventional group, bone marrow harvest will be performed obtaining 100 ml or 150 ml in the low-dose and high-dose group, respectively. Approximately each 5 ml of bone marrow aspirated will be deposited into a transfer bag with 10 ml of acid citrate dextrose solution and 1 ml of preservative-free heparin. After bone marrow harvest, it will be centrifuged on a Ficoll density gradient to isolate the mononuclear cells and obtain the low and high doses (2 × 106/kg or 5 × 106/kg), which will be washed and resuspended in 20 ml of 0·9% sodium chloride [phosphatebuffered saline (PBS)] supplemented with 0·1% heparin for infusion to the patient. Aliquots of the final BM-MNC product will be separated for cell counting, flow cytometry, and bacterial culture. On the same day, and three- to four-hours after bone marrow harvest, a cerebral angiography (3000 U heparin) will be done and BM-MNCs will be infused through microcatheter in the M1 segment of the infarct-related MCA at a rate of 0·5–1 ml/min. The final suspension of BM-MNC will be shaken until moment of infusion to avoid precipitating or clumping. After injection, a control angiography will be done to ensure MCA patency. Patients will be followed up for two-years. In case of neurological worsening after inclusion of the patient in the trial, a new brain © 2015 World Stroke Organization
Protocol
F. Moniche et al. imaging [magnetic resonance imaging (MRI) is recommended to investigators] must be performed to clarify the adverse event. Primary outcomes The primary outcome is the proportion of patients with modified Rankin Scale (mRS) scores of 0–2 at 180 days. Neurologist assessing the outcomes will be blinded to the group assigned to each patient. Secondary outcomes • Categorical shift in mRS ordinal (0–6) scale. • mRS scores of 0–3 at six-months. • National Institute of Health Stroke Scale (NIHSS) and Barthel scores at one-, three-, and six-months. • Infarct volume change between baseline [diffusion-weighted imaging (DWI)] and six-months [fluid-attenuated inversion recovery (FLAIR)]. • Mortality at 180 days. • Presence of seizures during follow-up. • Serious adverse events. Data monitoring body Study monitoring to assure quality and conduct according to good clinical practice will be performed by an external contract research organization, with phone contacts and in-person monitoring visits. No formal interim analyses for efficacy or futility are planned. Prior to site activation, study personnel at each enrolling center are trained on the transplantation protocol, International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) Good Clinical Practices, and investigator responsibilities. All investigators will be certified for mRS and NIHSS. Sample size Sample size was calculated based on a previous trial (4). The total sample size of 76 patients, with 38 patients in each arm, provides an 80% power to detect a difference of 18% in dependency in mRS. We estimate recruiting five participants/year/center, that is, ∼25 participants/year overall. Statistical analyses The primary efficacy analysis will be on an intention-to-treat basis. For the primary outcome, the proportion of patients with mRS scores of 0–2 at 180 days will be compared between control and treatment arms. A secondary analysis of the categorical shift in mRS will be undertaken on the full range (0–6) of the mRS using Cochran– Mantel–Haenszel shift test and proportional odds logistic regression subject to the validity of shift analysis model assumptions. The two different doses of BM-MNC in the treatment arm will be compared in order to detect differences in safety or efficacy. Other secondary outcome analyses will be carried out according to standard statistical principles for comparison of parametric or nonparametric distributions as appropriate. Study organization and funding The Andalusian Initiative for Advanced Therapies is the study sponsor. The study is funded by a grant from the Junta de Andalucía (PI-0228–2012). © 2015 World Stroke Organization
Discussion We chose to transplant autologous BM-MNCs as it is feasible to obtain high number of cells without the need of cell culture and inject them within hours from bone marrow harvest, making possible to treat acute stroke patients and avoiding the possibility of rejection in comparison with other cells (i.e. allogenic cells). Also, as recommended in the STem cells as an Emerging Paradigm in Stroke (STEPS) guidelines (7), BM-MNCs have demonstrated consistently beneficial effects in stroke animal models and have proven a good safety profile in preliminary clinical trials in humans (3–6). To date, there is no description either in animals or in humans of tumour formation. However, in this trial as required by the regulatory agency, every patient will be followed up to two-years to evaluate the long-term safety. Preclinical evidence favors administering cell therapy within the first days after stroke, when active process of inflammation and neuroplasticity occurs (2). The goal of restorative therapies should be to activate and amplify this endogenous restorative brain plasticity process to potentiate functional recovery. Within the first days after stroke, BM-MNCs seem to induce changes in serum cytokines and growth factors, which could enhance neurological recovery (8). Also, the intra-arterial route seems to be superior to intravenous route (9,10). In fact, a recently published trial failed to demonstrate efficacy of BM-MNCs when administered intravenously at a median of 18 days after stroke (6). Another issue of cell therapy trials is the dose of cells administered. The optimal dose in humans is not clear and to date, different doses have not yet been evaluated in a clinical trial. There is strong evidence in animal models of stroke that a higher dose of cells leads to a better neurological outcome (9) and our group also found a trend toward better neurological recovery with higher cells injected (4). Therefore, to evaluate this dose–response relationship, we will randomize patients into two different BM-MNC doses. In previous clinical trials, cell dose was not pre-specified in protocol, leading to a wide variability in the final number of injected cells (4,6). In our previous trial, mean dose of BM-MNC was 2·17 × 106/kg (range 0·33–4·96 × 106/kg) (8). In a previous trial with a fixed dose of 10 × 106/kg, in 2 of 10 patients, the target dose was not reached (5), therefore we decided to test the mean BM-MNC dose of our previous trial (i.e. 2 × 106/kg) as ‘low dose’ and 5 × 106/kg as ‘high dose’. This ‘high dose’ is feasible to be obtained in every patient with a bone marrow harvest of 150 ml and its efficacy has already been demonstrated in preclinical studies (11).
Summary and conclusions This is the first trial to explore efficacy of different doses of intraarterial BM-MNC in moderate-to-severe acute ischemic stroke patients. As stroke is the leading cause of disability, there is an urgent need of treatments for regaining neurological function. If positive, this therapeutic approach will significantly increase the options for stroke recovery. Vol 10, October 2015, 1149–1152
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Protocol References 1 Jauch EC, Saver JL, Adams HP Jr et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870–947. 2 Zhang ZG, Chopp M. Neurorestorative therapies for stroke: underlying mechanisms and translation to the clinic. Lancet Neurol 2009; 8:491–500. 3 Fujita Y, Ihara M, Ushiki T et al. Early protective effect of bone marrow mononuclear cells against ischemic white matter damage through augmentation of cerebral blood flow. Stroke 2010; 41:2938–43. 4 Moniche F, Gonzalez A, Gonzalez-Marcos JR et al. Intra-arterial bone marrow mononuclear cells in ischemic stroke: a pilot clinical trial. Stroke 2012; 43:2242–4. 5 Savitz SI, Misra V, Kasam M et al. Intravenous autologous bone marrow mononuclear cells for ischemic stroke. Ann Neurol 2011; 70:59–69. 6 Prasad K, Sharma A, Garg A et al. Intravenous autologous bone marrow mononuclear stem cell therapy for ischemic stroke: a multicentric, randomized trial. Stroke 2014; 45:3618–24.
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F. Moniche et al. 7 Savitz SI, Cramer SC, Wechsler L. STEPS 3 Consortium. Stem cells as an emerging paradigm in stroke 3: enhancing the development of clinical trials. Stroke 2014; 45:634–9. 8 Moniche F, Montaner J, Gonzalez-Marcos JR et al. Intra-arterial bone marrow mononuclear cell (BM-MNC) transplantation correlates with GM-CSF, PDGF-BB and MMP-2 serum levels in stroke patients: results from a clinical trial. Cell Transplant 2014; 23(Suppl. 1):57– 64. 9 Vu Q, Xie K, Eckert M, Zhao W, Cramer SC. Meta-analysis of preclinical studies of mesenchymal stromal cells for ischemic stroke. Neurology 2014; 82:1277–86. 10 Kamiya N, Ueda M, Igarashi H et al. Intraarterial transplantation of bone marrow mononuclear cells immediately after reperfusion decreases brain injury after focal ischemia in rats. Life Sci 2008; 83:433–7. 11 Brenneman M, Sharma S, Harting M et al. Autologous bone marrow mononuclear cells enhance recovery after acute ischemic stroke in young and middle-aged rats. J Cereb Blood Flow Metab 2010; 30: 140–9.
© 2015 World Stroke Organization
