WM1-2 SFX-01 after subarachnoid haemorrhage: protocol of a multi-centre, phase II, double-blinded, randomised controlled trial

Objectives

To assess the safety and efficacy of SFX-01 after subarachnoid haemorrhage.

Design

SFX-01 is a synthetic agent that contains sulforaphane that has been shown to be neuroprotective in animal models of subarachnoid haemorrhage. This is a phase II double-bilinded, placebo-controlled randomised clinical trial.

Subjects

Target of 90 patients with fisher 3 or 4 subarachnoid haemorrhage.

Methods

Patients admitted to the three recruiting centres within 48 hours of ictus will be randomly allocated to placebo or SFX-01. The randomisation is stratified into WFNS 1–3 or 4–5. Participants will receive the trial medication in a capsule format twice-daily for 28 days. Patients will have transcranial dopplers (TCD) on alternate daily basis for at least 7 days. The maximum mean MCA flow velocity as well as safety are the two primary end-points. All patients will have paired blood and CSF taken at day 7 either through an LP or via EVD sampling. Follow-ups are performed at day 28, 3 months and 6 months which include safety bloods, functional questionnaires, mRS, GOSE and MRI.

Results

64 (71% of the target) patients have been enrolled. 35 patients have completed the study. Statistical analysis of the TCD data will be performed at the end of the trial. The mortality is at 9.5% (6). DSMB have met twice since the start of the trial and there have been no safety concerns.

Conclusions

The trial is recruiting on the planned trajectory and at this rate we are projected to complete the trial by the end of the year.

Haemoglobin scavenging after subarachnoid haemorrhage

Rapid and effective clearance of cell-free haemoglobin after subarachnoid haemorrhage (SAH) is important to prevent vasospasm and neurotoxicity and improve long-term outcome. Haemoglobin is avidly bound by haptoglobin, and the complex is cleared by CD163 expressed on the membrane surface of macrophages. We studied the kinetics of haemoglobin and haptoglobin in cerebrospinal fluid after SAH. We show that haemoglobin levels rise gradually after SAH. Haptoglobin levels rise acutely with aneurysmal rupture as a result of injection of blood into the subarachnoid space. Although levels decline as haemoglobin scavenging occurs, complete depletion of haptoglobin does not occur and levels start rising again, indicating saturation of CD163 sites available for haptoglobin-haemoglobin clearance. In a preliminary neuropathological study we demonstrate that meningeal CD163 expression is upregulated after SAH, in keeping with a proinflammatory state. However, loss of CD163 occurs in meningeal areas with overlying blood compared with areas without overlying blood. Becauses ADAM17 is the enzyme responsible for shedding membrane-bound CD163, its inhibition may be a potential therapeutic strategy after SAH.

A web-based tool for personalized prediction of long-term disease course in patients with multiple sclerosis

BACKGROUND AND PURPOSE

The Evidence-Based Decision Support Tool in Multiple Sclerosis (EBDiMS) is the first web-based prognostic calculator in multiple sclerosis (MS) capable of delivering individualized estimates of disease progression. It has recently been extended to provide long-term predictions based on the data from a large natural history cohort.

METHODS

We compared the predictive accuracy and consistency of EBDiMS with that of 17 neurologists highly specialized in MS.

RESULTS

We show that whilst the predictive accuracy was similar, neurologists showed a significant intra-rater and inter-rater variability.

CONCLUSIONS

Because EBDiMS was consistent, it is of superior utility in a specialist setting. Further field testing of EBDiMS in non-specialist settings, and investigation of its usefulness for counselling patients in treatment decisions, is warranted.

Pathophysiology of the lymphatic drainage of the central nervous system: Implications for pathogenesis and therapy of multiple sclerosis

In most organs of the body, immunological reactions involve the drainage of antigens and antigen presenting cells (APCs) along defined lymphatic channels to regional lymph nodes. The CNS is considered to be an immunologically privileged organ with no conventional lymphatics. However, immunological reactions do occur in the CNS in response to infections and in immune-mediated disorders such as multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE). Here, we review evidence that cervical lymph nodes play a role in B and T cell mediated immune reactions in the CNS. Then we define the separate pathways by which interstitial fluid (ISF) and CSF drain to cervical lymph nodes. ISF and solutes drain from the brain along the 100-150nm-wide basement membranes in the walls of capillaries and arteries. In humans, this perivascular pathway is outlined by the deposition of insoluble amyloid (Abeta) in capillary and artery walls in cerebral amyloid angiopathy in Alzheimer's disease. The failure of APCs to migrate to lymph nodes along perivascular lymphatic drainage pathways may be a major factor in immunological privilege of the brain. Lymphatic drainage of CSF is predominantly through the cribriform plate into nasal lymphatics. Lymphatic drainage of ISF and CSF and the specialised cervical lymph nodes to which they drain play significant roles in the induction of immunological tolerance and of adaptive immunological responses in the CNS. Understanding the afferent and efferent arms of the CNS lymphatic system will be valuable for the development of therapeutic strategies for diseases such as MS.

Corticosteroids for the long-term treatment in multiple sclerosis

BACKGROUND

Short term high dose corticosteroid treatment improves symptoms and short term disability after an acute exacerbation of multiple sclerosis (MS) but it is unknown whether its long-term use can reduce the accumulation of disability.

OBJECTIVES

To determine the efficacy and safety of long-term corticosteroid use in MS.

SEARCH STRATEGY

We searched the following bibliographic databases: CENTRAL (Issue 1, 2007), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007). In an effort to identify further published, unpublished and ongoing trials we searched reference lists and contacted trial authors and one pharmaceutical company.

SELECTION CRITERIA

We considered controlled, randomised trials (RCTs), with or without blinding, of long term treatment (i.e. longer than 6 months) of any type of corticosteroid in MS, irrespective of disease course.

DATA COLLECTION AND ANALYSIS

Reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Three trials, all classified at high risk of bias, contributed to this review (Miller 1961; BPSM 1995; Zivadinov 2001) resulting in a total of 183 participants (91 treated). Corticosteroid therapy did not reduce the risk of being worse at the end of follow-up (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.26 to 1.02) but there was a substantial heterogeneity between studies (I(2): 78.4%). I. v. periodic high dose methylprednisolone (MP) was associated with a significant reduction in the risk of disability progression at 5 years in relapsing-remitting (RR) MS (OR 0.26, 95% CI 0.10 to 0.66), while oral continuous low dose prednisolone was not associated with any risk reduction in disability progression at 18 months (OR 1.23, 95% CI 0.43 to 3.56). Risk of experiencing at least one exacerbation at end of follow-up was not significantly reduced with corticosteroid treatment (OR 0.36; 95% CI 0.10 to 1.25). Only one study recorded adverse events: in one patient i. v. MP was discontinued after the fourth pulse when he developed acute glomerulonephritis; a second patient was removed from the study after the fifth i. v. MP pulse because of severe osteoporosis.

AUTHORS' CONCLUSIONS

There is no enough evidence that long-term corticosteroid treatment delays progression of long term disability in patients with MS. Since one study at high risk of bias showed that the administration of pulsed high dose i. v. MP is associated with a significant reduction in the risk of long term disability progression in patients with RR MS, an adequately powered, high quality RCT is needed to investigate this finding.