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Asoğlu S, Kılınçer A, Özer H, Topaloğlu ÖF, Cebeci H. Evaluation of signal intensity changes in dentate nucleus and globus pallidus on magnetic resonance imaging after intrathecal gadolinium-based contrast agent administration. Clin Imaging 2024; 109:110140. [PMID: 38574605 DOI: 10.1016/j.clinimag.2024.110140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/14/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Gadolinium deposition has been reported in several normal anatomical structures in the brain after repeated administration of intravenous gadolinium-based contrast agents (GBCAs) used in magnetic resonance imaging (MRI). This study presents preliminary results to see if there is any gadolinium deposition in the dentate nucleus and globus pallidus after using intrathecal GBCAs. METHODS Between November 2018 and November 2020, 29 patients who underwent intrathecal contrast-enhanced MR cisternography with the suspicion of rhinorrhea were included in this prospective study. In contrast-enhanced MR cisternography, gadoterate meglumine was administered by intrathecal injection at a dose of 1 ml. One month later, patients had a control MRI with 3D T1 SPACE fat-saturated (FS) and susceptibility weighted images (SWI) sequences. The ratio of dentate nucleus signal intensity to middle cerebellar peduncle signal intensity (DN/MCP ratio) and the ratio of globus pallidus signal intensity to thalamus signal intensity (GP/T ratio) were calculated using region of interest (ROI) on pre-contrast and control MRI sequences. RESULTS There was no significant difference for DN/MCP ratio and GP/T ratio on 3D T1 SPACE FS and SWI sequences after intrathecal GBCAs administration compared to baseline MRI. CONCLUSION Administration of intrathecal GBCAs did not cause a measurable change in the signal intensity of the dentate nucleus and globus pallidus after a single injection.
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Affiliation(s)
- Semih Asoğlu
- Department of Radiology, School of Medicine, Selçuk University, Konya, Turkey
| | - Abidin Kılınçer
- Department of Radiology, School of Medicine, Selçuk University, Konya, Turkey
| | - Halil Özer
- Department of Radiology, School of Medicine, Selçuk University, Konya, Turkey
| | | | - Hakan Cebeci
- Department of Radiology, School of Medicine, Selçuk University, Konya, Turkey
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Yee KS, Alexanderian D, Martin S, Olayinka-Amao B, Whiteman DAH. Clinical investigator perspectives on patient outcomes in children with neuronopathic mucopolysaccharidosis II during intrathecal idursulfase-IT treatment. Orphanet J Rare Dis 2024; 19:158. [PMID: 38610004 PMCID: PMC11015594 DOI: 10.1186/s13023-024-03147-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 03/24/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Mucopolysaccharidosis II (MPS II) is a rare lysosomal storage disease characterized by iduronate-2-sulfatase gene (IDS) deficiency and downstream glycosaminoglycan accumulation. Two-thirds of patients present with neuronopathic disease and evaluating cognitive function in these patients is challenging owing to limitations of currently available tests. During the clinical development of intrathecal idursulfase (idursulfase-IT), regulatory authorities requested qualitative data to further understand the neurocognitive changes observed by the investigators through the clinical trials. RESULTS This qualitative study consisted of semi-structured interviews with all nine of the principal investigators who participated in the idursulfase-IT phase 2/3 (NCT02055118) and extension (NCT02412787) trials. These investigators enrolled the 56 patients with neuronopathic MPS II who qualified for the extension phase of the trial. The investigators were asked to rate the disease status of their patients. Of the 56 patients, 49 (88%) were rated as having disease that was improved/improving, stabilized or slowing progression compared with the expected outcomes with no treatment. Three patients were rated as worsening, while the remaining four patients were considered to have slowing progression or worsening disease. Similar results were demonstrated for patients aged from 3 to under 6 years at baseline, with 33 of 39 patients (85%) rated as having disease that was improved/improving, stabilized or slowing progression. Of the seven patients rated with slowing progression/worsening or worsening disease, five of them had an IDS variant other than missense, while two had a missense class variant. All the assigned improved/improving ratings were in patients receiving idursulfase-IT from the start of the phase 2/3 trial. Moreover, patients under 3 years of age at baseline were all rated as either improved/improving or stabilized disease. In a blinded review of patient profiles, investigators were requested to assign a disease status rating to 18 patients with large IDS deletions; 67% of these patients were rated as improved/improving or stabilized disease. CONCLUSIONS This qualitative analysis provides a snapshot of clinicians' considerations when evaluating treatment in patients with neuronopathic MPS II, compared with the expected decline in cognitive function in the absence of treatment. The results highlight the importance of robust assessment tools in treatment evaluation.
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Affiliation(s)
- Karen S Yee
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
- Present affiliation: Alexion Pharmaceuticals, Inc., AstraZeneca Rare Disease, Boston, MA, USA
| | - David Alexanderian
- Takeda Development Center Americas, Inc., Lexington, MA, USA
- Present affiliation: Merck, Boston, MA, USA
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Moustafa MMI, Ali MS, McCaul C, Abbas MS. Comparison of sequential and mixture injections of opioids and hyperbaric bupivacaine for subarachnoid block for lower segment caesarean section: a randomised controlled study. Ir J Med Sci 2024:10.1007/s11845-024-03682-w. [PMID: 38602618 DOI: 10.1007/s11845-024-03682-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION Opioids are commonly added to local anaesthetic for subarachnoid block for caesarean section due to their synergistic effects. The physiochemical characteristics of opioids suggest premixing with hyperbaric bupivacaine may limit their distribution within the CSF. We studied the effect of a separate injection with a combination of bupivacaine, morphine and fentanyl on block characteristics, haemodynamic changes, postoperative pain and patient satisfaction. METHOD Following ethical approval and informed consent, a prospective double-blinded randomised controlled trial was performed in a university hospital. A total of 126 patients undergoing caesarean section were randomised to two groups. In group M, the premixed group, patients received 12 mg of hyperbaric bupivacaine, 20 mcg of fentanyl and 100 mcg of morphine injected as a single mixture. In group S, the separate injection group, patients received the same drugs in separate injections. Measurements included haemodynamics, block distribution, intra- and postoperative pain, as well as patient satisfaction. RESULTS Patients in both groups had similar block height, time to maximum sensory block, time to block regression and motor block. However, haemodynamics were different between the groups. The proportion of systolic hypotension episodes was greater in group S [159/1320 (12.05%)] than group M [113/1452 (7.78%)], with P = 0.0002. Moreover, a greater amount of ephedrine was administered in group S than group M, with values 12.09 (8.1) and 9.09 (8.5) mg respectively (P = 0.001). Additionally, postoperative pain, as measured by the Visual Analogue Scale (VAS), was greater in group M, with a VAS of 4.6 (1.7), vs. group S, which recorded a VAS of 3.8 (2.0) (P = 0.017). CONCLUSION Sequential injection of intrathecal opioids and hyperbaric bupivacaine resulted in greater early haemodynamic instability and slightly better postoperative analgesia without any difference in block height or patient satisfaction. CLINICAL TRIAL REGISTRATION NCT04403724.
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Affiliation(s)
- Moustafa M I Moustafa
- Mater Misericordiae University Hospital, Tandy's Lane, eircode K78V1W3, Dublin, Ireland.
| | - Mohamed S Ali
- Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Conan McCaul
- Rotunda Hospital, Dublin, Ireland
- University College Dublin, Dublin, Ireland
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Kakde A, Chia P, Tan HS, Sultana R, Tan CW, Sng BL. Factors associated with an inadvertent dural puncture or post-dural puncture headache following labour epidural analgesia: A retrospective cohort study. Heliyon 2024; 10:e27511. [PMID: 38501002 PMCID: PMC10945181 DOI: 10.1016/j.heliyon.2024.e27511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/16/2024] [Accepted: 02/29/2024] [Indexed: 03/20/2024] Open
Abstract
Inadvertent dural puncture and post-dural puncture headache are complications of labour epidural analgesia and may result in acute and chronic morbidity. Identification of risk factors may enable pre-emptive management and reduce associated morbidity. In this retrospective cohort study, we aimed to identify factors associated with an inadvertent dural puncture or post-dural puncture headache by identifying parturients who received labour epidural analgesia from January 2017 to December 2021. The primary outcome was any witnessed inadvertent dural puncture, inadvertent placement of an intrathecal catheter, clinical diagnosis of post-dural puncture headache, or headache that was assessed to have characteristic post-dural puncture headache features. A wide range of demographic, obstetric, and anaesthetic factors were analysed using univariate and multivariable analyses to identify independent associations with the primary outcome. Data from 26,395 parturients were analysed, of whom 94 (0.36%) had the primary outcome. Within these 94 parturients, 26 (27.7%) had inadvertent dural puncture, 30 (31.9%) had inadvertent intrathecal catheter, and 38 (40.4%) had post-dural puncture headache without documented inadvertent dural puncture or intrathecal catheter insertion. Increased number of procedure attempts (adjusted odds ratio 1.39, 95% confidence interval 1.19 to 1.63), longer procedure duration adjusted odds ratio 1.03, 95% confidence interval 1.01 to 1.05), increased depth of epidural space (adjusted odds ratio 1.10, 95% confidence interval 1.04 to 1.18), greater post-procedure Bromage score (adjusted odds ratio 7.70, 95% confidence interval 4.22 to 14.05), and breakthrough pain (adjusted odds ratio 3.97, 95% confidence interval 2.59 to 6.08) were independently associated with increased odds of the primary outcome, while the use of standard patient-controlled epidural analgesia (PCEA) regimen (adjusted odds ratio 0.50, 95%confidence interval 0.31 to 0.81), increased concentration of ropivacaine (adjusted odds ratio 0.08 per 0.1%, 95% confidence interval 0.02 to 0.46), and greater satisfaction score (adjusted odds ratio 0.96, 95% confidence interval 0.95 to 0.97) were associated with reduced odds. The area under curve of this multivariable model was 0.83. We identified independent association factors suggesting that greater epidural depth and procedure difficulty may increase the odds of inadvertent dural puncture or post-dural puncture headache.
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Affiliation(s)
- Avinash Kakde
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Pamela Chia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine Duke-NUS Medical School, Singapore
| | - Chin Wen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
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Yee KS, Lewis S, Evans E, Romano C, Alexanderian D. Caregiver experiences and observations of intrathecal idursulfase-IT treatment in a phase 2/3 trial in pediatric patients with neuronopathic mucopolysaccharidosis II. Orphanet J Rare Dis 2024; 19:110. [PMID: 38462612 PMCID: PMC10926613 DOI: 10.1186/s13023-024-03034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 01/19/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Approximately two-thirds of patients with mucopolysaccharidosis II (MPS II) have a severe, neuronopathic phenotype, characterized by somatic, cognitive, and behavioral issues. Current standard of care for the treatment of MPS II is enzyme replacement therapy with intravenous recombinant human iduronate-2-sulfatase (idursulfase). To target cognitive manifestations of MPS II, idursulfase has been formulated for intrathecal administration into the cerebrospinal fluid (idursulfase-IT). In accordance with recommendations for patient-focused drug development, semi-structured interviews were conducted to assess caregiver experiences and observations in a 52-week phase 2/3 trial of idursulfase-IT, in addition to intravenous idursulfase in pediatric patients with neuronopathic MPS II, or a substudy which enrolled patients younger than 3 years old, all of whom received idursulfase-IT. RESULTS Overall, 46 caregivers providing care for 50 children (mean [range] age 7.9 [3-17] years at interview) took part in a single 60-min exit interview; six of these children had participated in the substudy. Qualitative and quantitative data were obtained demonstrating the burden of MPS II experienced by caregivers and their families. Following participation in the trials, 39 (78%) of the children were reported by their caregivers to have experienced improvements in the symptoms and impact of disease. Of those with improvements, 37 (95%) experienced cognitive improvements and 26 (67%) experienced emotional/behavioral improvements. Overall, 43 children (86%) were rated by caregivers as having moderate or severe symptoms before the trials; after the trials, 28 children (56%) were considered to have mild or no symptoms. For the six children who participated in the substudy, these proportions were 83% and 100%, respectively. Caregivers' qualitative descriptions of trial experiences suggested improvements in children's verbal and non-verbal functioning and spatial and motor skills, as well as a positive impact on family life. CONCLUSIONS This study revealed caregiver-reported improvements in children's MPS II symptoms and the impact of the disease on patients and their families. There was a trend for cognitive improvement and a reduction in severity of MPS II symptoms. After many years of extensive review and regulatory discussions of idursulfase-IT, the clinical trial data were found to be insufficient to meet the evidentiary standard to support regulatory filings.
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Affiliation(s)
- Karen S Yee
- Takeda Development Center Americas, Inc., Cambridge, MA, USA.
| | - Sandy Lewis
- RTI Health Solutions, Research Triangle Park, Raleigh, NC, USA
| | - Emily Evans
- RTI Health Solutions, Research Triangle Park, Raleigh, NC, USA
| | - Carla Romano
- RTI Health Solutions, Research Triangle Park, Raleigh, NC, USA
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Li MT, Wu QQ, Li JB, Chen JS. Intrathecal or intraventricular antimicrobial therapy for post-neurosurgical Gram-negative bacillary meningitis or ventriculitis: a systematic review and meta-analysis. Int J Antimicrob Agents 2024; 63:107033. [PMID: 37967659 DOI: 10.1016/j.ijantimicag.2023.107033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE Extensively-drug-resistant Gram-negative bacteria (XDR GNB)-related post-neurosurgical infection is closely related to mortality, which represents a major challenge for neurosurgeons. There is an urgent need to review and evaluate methods to reduce mortality. METHODS Both international and Chinese databases were searched independently from their inception to 15 June 2023. A meta-analysis was conducted using RevMan 5.4 to compare the efficacy and safety of intravenous (IV) treatment in combination with intrathecal or intraventricular (ITH/IVT) treatment with IV treatment alone for post-neurosurgical meningitis or ventriculitis due to GNB. Mortality, microbiological clearance and adverse events were considered as primary outcomes. RESULTS In total, 18 eligible studies involving 602 patients were included in the meta-analysis. The IV + ITH/IVT group was associated with significantly lower mortality (especially in the XDR GNB subgroup) and acceptable safety. In terms of microbiological clearance, a significant decrease was shown in the XDR GNB subgroup. Significant benefits were shown in laboratory parameters and clinical symptoms after patients were treated with ITH/IVT. CONCLUSION Additional ITH/IVT treatment may promote XDR GNB clearance and reduce mortality. In addition, ITH/IVT administration can improve clinical symptoms and cerebrospinal fluid indicators of patients with post-neurosurgical infections. Significantly, ITH/IVT treatment does not increase the incidence of adverse events at the recommended dose.
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Affiliation(s)
- Meng-Ting Li
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, Guangdong Province, China
| | - Qi-Quan Wu
- Department of Pharmacy, Ganzhou People's Hospital, Jiangxi Ganzhou, China
| | - Jia-Bao Li
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, Guangdong Province, China
| | - Ji-Sheng Chen
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou City, Guangdong Province, China.
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Uribe Cardenas R, Laramee M, Ray I, Dahmane N, Souweidane M, Martin B. Influence of focused ultrasound on locoregional drug delivery to the brain: Potential implications for brain tumor therapy. J Control Release 2023; 362:755-763. [PMID: 37659767 DOI: 10.1016/j.jconrel.2023.08.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/04/2023]
Abstract
INTRODUCTION Efficient delivery of therapeutics across the blood-brain barrier (BBB) for the treatment of central nervous system (CNS) tumors is a major challenge to the development of safe and efficacious therapies. Locoregional drug delivery platforms offer an improved therapeutic index by achieving high drug concentrations in the target tissue with negligible systemic exposure. Intrathecal (intraventricular) [IT] and convection-enhanced delivery [CED] are two clinically relevant methods being employed for various CNS malignancies. Both of these standalone platforms suffer from passive post-administration distribution forces, sometimes limiting the desired distribution for tumor therapy. Focused ultrasound and microbubble-mediated blood-brain barrier opening (FUS-BBBO) is a recent modality used for enhanced drug delivery. It is postulated that coupling of FUS with these alternative delivery routes may provide benefits. Multimodality FUS may provide the desired ability to increase the depth of parenchymal delivery following IT administration and provide a means for contour directionality with CED. Further, the transient enhanced permeability achieved with FUS-BBBO is well established, but drug residence and transit times, important to clinical dose scheduling, have not yet been defined. The present investigation comprises two discrete studies: 1. Conduct a comprehensive quantitative evaluation to elucidate the effect of FUS-BBBO as it relates to varying routes of administration (IT and IV) in its capacity to facilitate drug penetration within the striatal-thalamic region. 2. Investigate the impact of combining FUS-BBBO with CED on drug distribution, with a specific focus on the temporal dynamics of drug retention within the target region. METHODS Firstly, we quantitatively assessed how FUS-BBBO coupled with IT and IV altered fluorescent dye (Dextran 2000 kDa and 70 kDa) distribution and concentration in a predetermined striatal-thalamic region in naïve mice. Secondly, we analyzed the pharmacokinetic effects of using FUS mediated BBB disruption coupled with CED by measuring the volume of distribution and time-dependent concentration of the dye. RESULTS Our results indicate that IV administration coupled with FUS-BBBO successfully enhances delivery of dye into the pre-defined sonication targets. Conversely, measurable dye in the sonication target was consistently less after IT administration. FUS enhances the distribution volume of dye after CED. Furthermore, a shorter time of residence was observed when CED was coupled with FUS-BBBO application when compared to CED alone. CONCLUSION 1. Based on our findings, IV delivery coupled with FUS-BBBO is a more efficient means for delivery to deep targets (i.e. striatal-thalamic region) within a predefined spatial conformation compared to IT administration. 2. FUS-BBBO increases the volume of distribution (Vd) of dye after CED administration, but results in a shorter time of residence. Whether this finding is reproducible with other classes of agents (e.g., cytotoxic agents, antibodies, viral particles, cellular therapies) needs to be studied.
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Affiliation(s)
| | - Madeline Laramee
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Ishani Ray
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Nadia Dahmane
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Mark Souweidane
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Brice Martin
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA.
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Ringstad G, Valnes LM, Vatnehol SAS, Pripp AH, Eide PK. Prospective T1 mapping to assess gadolinium retention in brain after intrathecal gadobutrol. Neuroradiology 2023; 65:1321-1331. [PMID: 37479768 PMCID: PMC10425514 DOI: 10.1007/s00234-023-03198-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE A possible pathway behind gadolinium retention in brain is leakage of contrast agents from blood to cerebrospinal fluid and entry into brain along perivascular (glymphatic) pathways. The object of this study was to assess for signs of gadolinium retention in brain 4 weeks after intrathecal contrast enhanced MRI. METHODS We prospectively applied standardized T1 mapping of the brain before and 4 weeks after intrathecal administration of 0.5 mmol gadobutrol in patients under work-up of cerebrospinal fluid circulation disorders. Due to methodological limitations, a safety margin for percentage change in T1 time was set to 3%. Region-wise differences were assessed by pairwise comparison using t-tests and forest plots, and statistical significance was accepted at .05 level (two-tailed). RESULTS In a cohort of 76 participants (mean age 47.2 years ± 17.9 [standard deviation], 47 women), T1 relaxation times remained unchanged in cerebral cortex and basal ganglia 4 weeks after intrathecal gadobutrol. T1 was reduced from 1082 ± 46.7 ms to 1070.6 ± 36.5 ms (0.98 ±2.9%) (mean [standard deviation]) (p=0.001) in white matter, thus within the pre-defined 3% safety margin. The brain stem and cerebellum could not be assessed due to poor alignment of posterior fossa structures at scans from different time points. CONCLUSION Gadolinium retention was not detected in the cerebral hemispheres 4 weeks after an intrathecal dose of 0.5 mmol gadobutrol, implying that presence of contrast agents in cerebrospinal fluid is of minor importance for gadolinium retention in brain.
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Affiliation(s)
- Geir Ringstad
- Department of Radiology, Oslo University Hospital- Rikshospitalet, Oslo, Norway
- Department of Geriatrics and Internal Medicine, Sorlandet Hospital, Arendal, Norway
| | - Lars Magnus Valnes
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway
| | - Svein Are Sirirud Vatnehol
- The Interventional Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Institute of Optometry Radiography and Lighting Design, Faculty of Health and Social Sciences, University of South Eastern Norway, Drammen, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Postboks 4950 Nydalen, 0424, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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Holdaway M, Ablyazova F, Huda S, D'Amico RS, Wong T, Shani D, Ben-Shalom N, Boockvar JA. First in-human intrathecal delivery of bevacizumab for leptomeningeal spread from recurrent glioblastoma: rationale for a dose escalation trial. J Neurooncol 2023; 164:231-237. [PMID: 37548850 DOI: 10.1007/s11060-023-04412-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/28/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE To outline the dose rationale for the first in-human intrathecal delivery of bevacizumab for LMS of GBM. METHODS A 19-year-old female patient presented to Lenox Hill Hospital following thalamic GBM recurrence. She subsequently underwent two infusions of intra-arterial BEV (NCT01269853) and experienced a period of relative disease stability until progression in 2022. One month later, MRI disclosed diffuse enhancement representative of LMS of GBM. The patient subsequently underwent five cycles of IT BEV in mid-2022 (IND 162119). Doses of 25 mg, 37.5 mg, 50 mg, 50 mg, and 37.8 mg were delivered at two-week intervals between doses 1-4. The final 37.8 mg dose was given one day following her fourth dose, given that the patient was to be discharged, traveled several hours to our center, and was tolerating therapy well. Dosage was decreased due to the short interval between the final two treatments. Shortly after IT BEV completion, she received a third dose of IA BEV. RESULTS Our patient did not show any signs of serious adverse effects or dose limiting toxicities following any of the treatments. It is difficult to determine PFS due to the rapid progression associated with LMS of GBM and rapid timeframe of treatment. CONCLUSION LMS continues to be a devastating progression in many types of cancer, including GBM, and novel ways to deliver therapeutics may offer patients symptomatic and therapeutic benefits.
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Affiliation(s)
- Matthew Holdaway
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA.
- Albany Medical College, Albany, NY, USA.
| | - Faina Ablyazova
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
| | - Shayan Huda
- CUNY School of Medicine, New York City, NY, USA
| | - Randy S D'Amico
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
| | - Tamika Wong
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
| | - Dana Shani
- Department of Hematology, Medical Oncology, Internal Medicine, Lenox Hill Hospital, New York City, NY, USA
- Northwell Health Cancer Institute, New Hyde Park, New York, NY, USA
| | - Netanel Ben-Shalom
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
| | - John A Boockvar
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Lenox Hill Hospital, 130 East 77th Street, New York, NY, 10065, USA
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Martin S, Harris N, Romanus D. Evaluating meaningful changes in physical functioning and cognitive declines in metachromatic leukodystrophy: a caregiver interview study. J Patient Rep Outcomes 2023; 7:70. [PMID: 37458805 DOI: 10.1186/s41687-023-00595-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/23/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Metachromatic leukodystrophy (MLD) is a rare lysosomal storage disease caused by deficient activity of arylsulfatase A (ASA). Treatment options for patients are limited; gene therapy based on haematopoietic stem cell transplantation is the only approved treatment for some subtypes of MLD. Any therapeutic benefit of treatments must be meaningful for patients and their families. We evaluated the clinical meaningfulness of slowing the decline in gross motor function as measured by the Gross Motor Function Classification in MLD (GMFC-MLD) from the caregiver perspective via semi-structured telephone interviews with caregivers of children with late-infantile MLD. We also evaluated the perceived significance of declines in communication abilities measured by the Expressive Language Function Classification in MLD (ELFC-MLD). This work could help to inform the endpoints of a phase 2 clinical trial (NCT03771898) assessing the efficacy of intrathecal recombinant human ASA in MLD. RESULTS Twelve caregivers were recruited, reporting on 12 children with MLD. Children had a mean age of 6.1 years; mean age at symptom onset was 17.6 months. Most children (10/12) progressed from walking without support (categories 0-1) to a loss of locomotion (categories 5-6) in ≤ 2 years. Caregivers felt that GMFC-MLD and ELFC-MLD accurately described motor and language declines in their children, respectively. Most caregivers (10/12) reported that the idea of delaying disease progression would be meaningful. Further, a slowing of motor function decline in GMFC-MLD, from category 1 to category 3 or from category 2 to category 4 over 2 years, was seen as meaningful by all caregivers asked; however, only 3/12 caregivers reported that delayed decline would be meaningful if baseline category was ≥ 3. Caregivers also reported that delaying expressive language decline at any level that did not indicate a complete loss of expressive language (indicated by categories 1-3) would be meaningful. CONCLUSIONS Caregivers of children with MLD felt that a delayed decline in gross motor function, as assessed by the GMFC-MLD, would be meaningful, supporting the selection of primary and secondary endpoints for the phase 2 clinical trial. Communication abilities were another area of significance for consideration in future clinical trial design.
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Affiliation(s)
| | | | - Dorothy Romanus
- Takeda Development Center Americas, Inc., Lexington, MA, USA
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Lazaratos AM, Maritan SM, Quaiattini A, Darlix A, Ratosa I, Ferraro E, Griguolo G, Guarneri V, Pellerino A, Hofer S, Jacot W, Stemmler HJ, van den Broek MPH, Dobnikar N, Panet F, Lahijanian Z, Morikawa A, Seidman AD, Soffietti R, Panasci L, Petrecca K, Rose AAN, Bouganim N, Dankner M. Intrathecal trastuzumab versus alternate routes of delivery for HER2-targeted therapies in patients with HER2+ breast cancer leptomeningeal metastases. Breast 2023; 69:451-468. [PMID: 37156650 PMCID: PMC10300571 DOI: 10.1016/j.breast.2023.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/07/2023] [Accepted: 04/30/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Patients with HER2+ breast cancer (BC) frequently develop leptomeningeal metastases (LM). While HER2-targeted therapies have demonstrated efficacy in the neoadjuvant, adjuvant, and metastatic settings, including for parenchymal brain metastases, their efficacy for patients with LM has not been studied in a randomized controlled trial. However, several single-armed prospective studies, case series and case reports have studied oral, intravenous, or intrathecally administered HER2-targeted therapy regimens for patients with HER2+ BC LM. METHODS We conducted a systematic review and meta-analysis of individual patient data to evaluate the efficacy of HER2-targeted therapies in HER2+ BC LM in accordance with PRISMA guidelines. Targeted therapies evaluated were trastuzumab (intrathecal or intravenous), pertuzumab, lapatinib, neratinib, tucatinib, trastuzumab-emtansine and trastuzumab-deruxtecan. The primary endpoint was overall survival (OS), with CNS-specific progression-free survival (PFS) as a secondary endpoint. RESULTS 7780 abstracts were screened, identifying 45 publications with 208 patients, corresponding to 275 lines of HER2-targeted therapy for BC LM which met inclusion criteria. In univariable and multivariable analyses, we observed no significant difference in OS and CNS-specific PFS between intrathecal trastuzumab compared to oral or intravenous administration of HER2-targeted therapy. Anti-HER2 monoclonal antibody-based regimens did not demonstrate superiority over HER2 tyrosine kinase inhibitors. In a cohort of 15 patients, treatment with trastuzumab-deruxtecan was associated with prolonged OS compared to other HER2-targeted therapies and compared to trastuzumab-emtansine. CONCLUSIONS The results of this meta-analysis, comprising the limited data available, suggest that intrathecal administration of HER2-targeted therapy for patients with HER2+ BC LM confers no additional benefit over oral and/or IV treatment regimens. Although the number of patients receiving trastuzumab deruxtecan in this cohort is small, this novel agent offers promise for this patient population and requires further investigation in prospective studies.
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Affiliation(s)
- Anna-Maria Lazaratos
- Rosalind and Morris Goodman Cancer Institute, Montreal, Quebec, Canada; Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Sarah M Maritan
- Rosalind and Morris Goodman Cancer Institute, Montreal, Quebec, Canada; Faculty of Medicine, Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Andrea Quaiattini
- Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal, Quebec, Canada
| | - Amelie Darlix
- Department of Medical Oncology, Institut régional du Cancer de Montpellier, University of Montpellier, Montpellier, France; Institut de Génomique Fonctionnelle, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Ivica Ratosa
- Division of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Emanuela Ferraro
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, NewYork, USA
| | - Gaia Griguolo
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Valentina Guarneri
- Division of Oncology 2, Istituto Oncologico Veneto IRCCS, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science Hospital, Turin, Italy
| | - Silvia Hofer
- Department of Neurology, University Hospital Zurich, Switzerland
| | - William Jacot
- Department of Medical Oncology, Institut régional du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | | | | | - Nika Dobnikar
- Division of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Francois Panet
- Gerald Bronfman Department of Oncology, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Zubin Lahijanian
- Department of Diagnostic Radiology, McGill University, Montreal, Quebec, Canada
| | - Aki Morikawa
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, NewYork, USA
| | - Andrew D Seidman
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, NewYork, USA
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science Hospital, Turin, Italy
| | - Lawrence Panasci
- Gerald Bronfman Department of Oncology, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Kevin Petrecca
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - April A N Rose
- Gerald Bronfman Department of Oncology, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Lady Davis Institute, Segal Cancer Centre, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Nathaniel Bouganim
- Gerald Bronfman Department of Oncology, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Matthew Dankner
- Rosalind and Morris Goodman Cancer Institute, Montreal, Quebec, Canada; Faculty of Medicine, Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada.
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Fischer T, Zing NP, Fortier SC, Schmidt J, Silveira TB, Chiattone CS. Application of the Central Nervous System International Prognostic Index (CNS-IPI) score in daily practice: a retrospective analysis apart from the clinical trial at two centers in Brazil. Hematol Transfus Cell Ther 2023:S2531-1379(23)00044-5. [PMID: 37085346 DOI: 10.1016/j.htct.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/12/2023] [Accepted: 02/09/2023] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION The diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL) and, despite all the progress in this field, central nervous system infiltration (CNSi) still occurs at an incidence of 2-10%. The objective of the present study was to evaluate the Central Nervous System International Prognostic Index (CNS-IPI) score in daily practice regarding the reproducibility in a heterogeneous cohort apart from a clinical trial. METHODS Primary DLBCL patients were eligible for this study, between January 2007 and January 2017. All patients were treated with rituximab-based chemotherapy, mostly R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). The CNSi was diagnosed by liquor (positive cytology and/or immunophenotype), computerized tomography, magnetic resonance image and/or fluorodeoxy-glucose-positron emission tomography, requested only in symptomatic patients when the CNSi was clinically suspected. The CNS-IPI was assessed by graphical comparison and calibration. RESULTS After applying the inclusion/exclusion criteria, 322 patients were available for the analysis. The median follow-up was 60 months and the median age was 58 years. Seven patients experienced CNSi, characterizing an incidence of 2.17% (7/322). Comparing groups of patients with and without CNSi, we observed that the lactate dehydrogenase (LDH), number of extranodal sites, IPI, kidney/adrenal and absence of complete response were statistically different. The CNS-IPI model stratified patients in a three-risk group model as low-, intermediate- and high-risk. In our cohort, using the same stratification, we obtained an equivalent the 2-year rate of CNS relapse of 0.0%, 0.8% and 13.8%, respectively. CONCLUSION Our study reinforces the reproducibility of the CNS-IPI, specifically apart from clinical trials, and suggests the CNS-IPI score as a tool to guide therapy.
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Affiliation(s)
- Thais Fischer
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil; Ac Camargo Cancer Center, São Paulo, SP, Brazil.
| | - Natalia Pc Zing
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil
| | - Sergio C Fortier
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil
| | | | - Talita B Silveira
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil; Ac Camargo Cancer Center, São Paulo, SP, Brazil
| | - Carlos S Chiattone
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil
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Muresan P, Woodhams S, Smith F, Taresco V, Shah J, Wong M, Chapman V, Smith S, Hathway G, Rahman R, Gershkovich P, Marlow M. Evaluation of cannabidiol nanoparticles and nanoemulsion biodistribution in the central nervous system after intrathecal administration for the treatment of pain. Nanomedicine 2023; 49:102664. [PMID: 36813014 DOI: 10.1016/j.nano.2023.102664] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023]
Abstract
We investigated how the biodistribution of cannabidiol (CBD) within the central nervous system (CNS) is influenced by two different formulations, an oil-in-water (O/W) nanoemulsion and polymer-coated nanoparticles (PCNPs). We observed that both CBD formulations administered were preferentially retained in the spinal cord, with high concentrations reaching the brain within 10 min of administration. The CBD nanoemulsion reached Cmax in the brain at 210 ng/g within 120 min (Tmax), whereas the CBD PCNPs had a Cmax of 94 ng/g at 30 min (Tmax), indicating that rapid brain delivery can be achieved through the use of PCNPs. Moreover, the AUC0-4h of CBD in the brain was increased 3.7-fold through the delivery of the nanoemulsion as opposed to the PCNPs, indicating higher retention of CBD at this site. Both formulations exhibited immediate anti-nociceptive effects in comparison to the respective blank formulations.
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Affiliation(s)
- Paula Muresan
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Stephen Woodhams
- Pain Centre Versus Arthritis, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2RD, UK
| | - Fiona Smith
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Vincenzo Taresco
- School of Chemistry, University of Nottingham, Nottingham NG7 2RD, UK
| | - Jaymin Shah
- Research and Development, Pfizer, Groton, CT 06340, USA
| | - Mei Wong
- Drug Product Design, Discovery Park, Pfizer, Sandwich CT13 9ND, UK
| | - Victoria Chapman
- Pain Centre Versus Arthritis, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2RD, UK
| | - Stuart Smith
- School of Medicine, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2RD, UK
| | - Gareth Hathway
- Pain Centre Versus Arthritis, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2RD, UK
| | - Ruman Rahman
- School of Medicine, Biodiscovery Institute, University of Nottingham, Nottingham NG7 2RD, UK
| | - Pavel Gershkovich
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Maria Marlow
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK.
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Harby SA, Kohaf NA. Accidental intrathecal injection of tranexamic acid: a case report. J Med Case Rep 2023; 17:55. [PMID: 36793087 DOI: 10.1186/s13256-023-03768-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 01/06/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Tranexamic acid is a well-known antifibrinolytic medication frequently prescribed to individuals with bleeding disorders. Following accidental intrathecal injection of tranexamic acid, major morbidities and fatalities have been documented. The aim of this case report is to present a novel method for management of intrathecal injection of tranexamic acid. CASE PRESENTATION In this case report, a 400 mg intrathecal injection of tranexamic acid resulted in significant back and gluteal pain, myoclonus of the lower limbs, agitation, and widespread convulsions in a 31-year-old Egyptian male with history of left arm and right leg fracture. Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 μg) was delivered with no response in seizure termination. A 1000 mg phenytoin intravenous infusion and subsequently, induction of general anesthesia was performed by thiopental sodium (250 mg) and atracurium (50 mg) infusion, and the trachea of the patient was intubated. Maintenance of anesthesia was achieved by isoflurane 1.2 minimum alveolar concentration and atracurium 10 mg every 20 minutes, and subsequent doses of thiopental sodium (100 mg) to control seizures. The patient developed focal seizures in the hand and leg, so cerebrospinal fluid lavage was done by inserting two spinal 22-gauge Quincke tip needles, one on level L2-L3 (drainage) and the other on L4-L5. Intrathecal normal saline infusion (150 ml) was done over an hour by passive flow. After cerebrospinal fluid lavage and the patient's stabilization was obtained, he was transferred to the intensive care unit. CONCLUSIONS Early and continuous intrathecal lavage with normal saline, with the airway, breathing, and circulation protocol is highly recommended to decrease morbidity and mortality. The selection of the inhalational drug as a sedative and for brain protection in the intensive care unit provided possible benefits in management of this event with medication errors.
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Choi SE, Rahman A, Ayoub T, Botelho O, Lee G, Gazdzinski LM, Wheeler AL, Weksberg R, Guger SL, Schachar RJ, Ito S, Hitzler J, Nieman BJ. High-frequency ultrasound-guided intrathecal injections in a young mouse model: Targeting the central nervous system in drug delivery. J Neurosci Methods 2023; 386:109778. [PMID: 36572156 DOI: 10.1016/j.jneumeth.2022.109778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/12/2022] [Accepted: 12/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intrathecal injections provide important access to the central nervous system for delivery of anesthetic, analgesic or chemotherapeutic drugs that do not otherwise cross the blood-brain barrier. The administration of drugs via this route in animal models is challenging due to an inability to visualize the small target space during injection. Successful drug delivery therefore requires expertise in indirectly assessing vertebral and spinal cord anatomy and gaining advanced procedural skills. These factors are especially compounded in small animals such as mice (the most common mammalian model) and in investigations modeling pediatric drug delivery, where the animal is even smaller. NEW METHOD To address these issues, we have developed a method in which high-frequency ultrasound imaging is used to visualize and target the lumbar intrathecal space for injections. The technique is demonstrated in mice as young as postnatal day 16. To evaluate the method, a gadolinium-based magnetic resonance imaging (MRI) contrast agent was injected intrathecally, and subsequent brain delivery was verified post-injection by MRI. RESULTS Successful intrathecal injections of the MRI contrast agent showed distribution to the brain. In this study, we achieved a targeting success rate of 80% in 20 animals. COMPARISON WITH EXISTING METHODS AND CONCLUSION We expect that the new method will be convenient for drug delivery to the central nervous system in rodent research and provide higher reliability than unguided approaches, an essential contribution that will enable intrathecal delivery in pediatric mouse models.
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Affiliation(s)
- Sun Eui Choi
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
| | - Anum Rahman
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Tiffany Ayoub
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Owen Botelho
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Gail Lee
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Lisa M Gazdzinski
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Neuroscience and Mental Health, Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Anne L Wheeler
- Neuroscience and Mental Health, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Rosanna Weksberg
- Developmental and Stem Cell Biology, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Institutes of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Sharon L Guger
- Department of Psychology, Hospital for Sick Children, Toronto, ON, Canada
| | - Russell J Schachar
- Institutes of Medical Science, University of Toronto, Toronto, ON, Canada; Psychiatry Research, Hospital for Sick Children, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, ON, Canada
| | - Shinya Ito
- Translational Medicine, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Johann Hitzler
- Developmental and Stem Cell Biology, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Brian J Nieman
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada; Ontario Institute for Cancer Research, ON, Canada
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Shafeinia A, Rahimi M, Nikoubakht N, Ghaed MA. The Effect of Painless Delivery with Intrathecal Sufentanil on Labor Progress and Neonatal Outcomes: A Single Center Study on Pregnant Women. Anesth Pain Med 2022; 12:e121297. [PMID: 36938112 PMCID: PMC10016133 DOI: 10.5812/aapm-121297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 05/21/2022] [Accepted: 10/26/2022] [Indexed: 11/30/2022] Open
Abstract
Background Delivery pain is the most unbearable pain and can be relieved with intrathecal opioids. This study aimed to investigate the effect of intrathecal sufentanil for painless delivery on labor progress and neonatal outcomes in pregnant women. Methods This was a single-arm observational cohort study on 1055 pregnant women candidates for vaginal delivery with spinal analgesia referred to the Akbarabadi Hospital. First, 0.1 µg/kg of intrathecal sufentanil was used, and maternal blood pressure and maternal and fetal heart rates were recorded after analgesia. During delivery, the mothers were monitored for nausea, pruritus, motor block, apnea, urinary retention, or the possibility of an emergency cesarean section. The duration of the analgesia, the duration of the second stages of labor, and the mother's pain scores were recorded based on the Visual Analogue Scale (VAS). 1- and 5-minute Apgar scores and arterial blood gas (ABG) of the umbilical cord were also recorded. Results The most common station was -3 for 723 women, followed by -2 for 229 women. Fifty-two women underwent cesarean section, and fetal distress was the most common reason for cesarean section (57.7%). The mean time for initiating analgesia was 5.93 ± 2.87 minutes, and the mean visual analog scale was 1.08 ± 0.16. The mean Apgar was 9.0 ± 0.47; the mean weight at birth was 2917.39 ± 449.90 gr; PH was 7.31 ± 2.03; HCO3 was 22.67 ± 3.08mEq/liter, and PaCo2 was 43.36 ± 7.06 mmHg. Regarding complications, the patients just developed itching (n = 78), and hypotension, bradycardia, apnea, and decreased consciousness were overlooked. Conclusions Intrathecal sufentanil is safe and efficient in painless delivery, resulting in normal Apgar and normal PH with no specific side-effect.
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Affiliation(s)
- Amineh Shafeinia
- Department of Anesthesiology, School of Medicine, Shahid Akbar-Abadi Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Rahimi
- Department of Obstetrics and Gynecology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nasim Nikoubakht
- Department of Anesthesiology, School of Medicine, Rasool Akram Medical Complex, Iran University of Medical Sciences, Tehran, Iran
- Department of Anesthesiology and Pain Medicine, Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Ghaed
- Endourology Fellowship, Labbafi Nejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Urology, Rasool Akram Medical Complex, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Endourology Fellowship, Labbafi Nejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Muenzer J, Burton BK, Harmatz P, Gutiérrez-Solana LG, Ruiz-Garcia M, Jones SA, Guffon N, Inbar-Feigenberg M, Bratkovic D, Hale M, Wu Y, Yee KS, Whiteman DAH, Alexanderian D. Intrathecal idursulfase-IT in patients with neuronopathic mucopolysaccharidosis II: Results from a phase 2/3 randomized study. Mol Genet Metab 2022; 137:127-139. [PMID: 36027721 PMCID: PMC10826424 DOI: 10.1016/j.ymgme.2022.07.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022]
Abstract
Two-thirds of patients with mucopolysaccharidosis II (MPS II; Hunter syndrome) have cognitive impairment. This phase 2/3, randomized, controlled, open-label, multicenter study (NCT02055118) investigated the effects of intrathecally administered idursulfase-IT on cognitive function in patients with MPS II. Children older than 3 years with MPS II and mild-to-moderate cognitive impairment (assessed by Differential Ability Scales-II [DAS-II], General Conceptual Ability [GCA] score) who had tolerated intravenous idursulfase for at least 4 months were randomly assigned (2:1) to monthly idursulfase-IT 10 mg (n = 34) via an intrathecal drug delivery device (IDDD; or by lumbar puncture) or no idursulfase-IT treatment (n = 15) for 52 weeks. All patients continued to receive weekly intravenous idursulfase 0.5 mg/kg as standard of care. Of 49 randomized patients, 47 completed the study (two patients receiving idursulfase-IT discontinued). The primary endpoint (change from baseline in DAS-II GCA score at week 52 in a linear mixed-effects model for repeated measures analysis) was not met: although there was a smaller decrease in DAS-II GCA scores with idursulfase-IT than with no idursulfase-IT at week 52, this was not significant (least-squares mean treatment difference [95% confidence interval], 3.0 [-7.3, 13.3]; p = 0.5669). Changes from baseline in Vineland Adaptive Behavioral Scales-II Adaptive Behavior Composite scores at week 52 (key secondary endpoint) were similar in the idursulfase-IT (n = 31) and no idursulfase-IT (n = 14) groups. There were trends towards a potential positive effect of idursulfase-IT across DAS-II composite, cluster, and subtest scores, notably in patients younger than 6 years at baseline. In a post hoc analysis, there was a significant (p = 0.0174), clinically meaningful difference in change from baseline in DAS-II GCA scores at week 52 with idursulfase-IT (n = 13) versus no idursulfase-IT (n = 6) among those younger than 6 years with missense iduronate-2-sulfatase gene variants. Overall, idursulfase-IT reduced cerebrospinal glycosaminoglycan levels from baseline by 72.0% at week 52. Idursulfase-IT was generally well tolerated. These data suggest potential benefits of idursulfase-IT in the treatment of cognitive impairment in some patients with neuronopathic MPS II. After many years of extensive review and regulatory discussions, the data were found to be insufficient to meet the evidentiary standard to support regulatory filings.
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Affiliation(s)
- Joseph Muenzer
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Barbara K Burton
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Paul Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | | | - Simon A Jones
- St Mary's Hospital, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Nathalie Guffon
- Reference Center for Inherited Metabolic Diseases, Hospices Civils de Lyon, Lyon, France
| | - Michal Inbar-Feigenberg
- University of Toronto, Toronto, ON, Canada; The Hospital for Sick Children, Toronto, ON, Canada
| | - Drago Bratkovic
- Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Michael Hale
- Takeda Development Center Americas, Inc., Cambridge, MA, USA; Hale Scientific Statistics, LLC, Beaverton, OR, USA
| | - Yuna Wu
- Takeda Development Center Americas, Inc., Lexington, MA, USA
| | - Karen S Yee
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | | | - David Alexanderian
- Takeda Development Center Americas, Inc., Lexington, MA, USA; Affinia Therapeutics, Inc., Waltham, MA, USA
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Muenzer J, Burton BK, Harmatz P, Gutiérrez-Solana LG, Ruiz-Garcia M, Jones SA, Guffon N, Inbar-Feigenberg M, Bratkovic D, Hale M, Wu Y, Yee KS, Whiteman DAH, Alexanderian D. Long-term open-label extension study of the safety and efficacy of intrathecal idursulfase-IT in patients with neuronopathic mucopolysaccharidosis II. Mol Genet Metab 2022; 137:92-103. [PMID: 35961250 PMCID: PMC10826456 DOI: 10.1016/j.ymgme.2022.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022]
Abstract
Enzyme replacement therapy with weekly infused intravenous (IV) idursulfase is effective in treating somatic symptoms of mucopolysaccharidosis II (MPS II; Hunter syndrome). A formulation of idursulfase for intrathecal administration (idursulfase-IT) is under investigation for the treatment of neuronopathic MPS II. Here, we report 36-month data from the open-label extension (NCT02412787) of a phase 2/3, randomized, controlled study (HGT-HIT-094; NCT02055118) that assessed the safety and efficacy of monthly idursulfase-IT 10 mg in addition to weekly IV idursulfase on cognitive function in children older than 3 years with MPS II and mild-to-moderate cognitive impairment. Participants were also enrolled in this extension from a linked non-randomized sub-study of children younger than 3 years at the start of idursulfase-IT therapy. The extension safety population comprised 56 patients who received idursulfase-IT 10 mg once a month (or age-adjusted dose for sub-study patients) plus IV idursulfase (0.5 mg/kg) once a week. Idursulfase-IT was generally well tolerated over the cumulative treatment period of up to 36 months. Overall, 25.0% of patients had at least one adverse event (AE) related to idursulfase-IT; most treatment-emergent AEs were mild in severity. Of serious AEs (reported by 76.8% patients), none were considered related to idursulfase-IT treatment. There were no deaths or discontinuations owing to AEs. Secondary efficacy analyses (in patients younger than 6 years at phase 2/3 study baseline; n = 40) indicated a trend for improved Differential Ability Scale-II (DAS-II) General Conceptual Ability (GCA) scores in the early idursulfase-IT versus delayed idursulfase-IT group (treatment difference over 36 months from phase 2/3 study baseline: least-squares mean, 6.8 [90% confidence interval: -2.1, 15.8; p = 0.2064]). Post hoc analyses of DAS-II GCA scores by genotype revealed a clinically meaningful treatment effect in patients younger than 6 years with missense variants of the iduronate-2-sulfatase gene (IDS) (least-squares mean [standard error] treatment difference over 36 months, 12.3 [7.24]). These long-term data further suggest the benefits of idursulfase-IT in the treatment of neurocognitive dysfunction in some patients with MPS II. After many years of extensive review and regulatory discussions, the data were found to be insufficient to meet the evidentiary standard to support regulatory filings.
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Affiliation(s)
- Joseph Muenzer
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Barbara K Burton
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Paul Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | | | - Simon A Jones
- St Mary's Hospital, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Nathalie Guffon
- Reference Center for Inherited Metabolic Diseases, Hospices Civils de Lyon, Lyon, France
| | - Michal Inbar-Feigenberg
- University of Toronto, Toronto, ON, Canada; The Hospital for Sick Children, Toronto, ON, Canada
| | - Drago Bratkovic
- Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Michael Hale
- Takeda Development Center Americas, Inc., Cambridge, MA, USA; Hale Scientific Statistics, LLC, Beaverton, OR, USA
| | - Yuna Wu
- Takeda Development Center Americas, Inc., Lexington, MA, USA
| | - Karen S Yee
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | | | - David Alexanderian
- Takeda Development Center Americas, Inc., Lexington, MA, USA; Affinia Therapeutics, Inc., Waltham, MA, USA
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19
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Khang M, Bindra RS, Mark Saltzman W. Intrathecal delivery and its applications in leptomeningeal disease. Adv Drug Deliv Rev 2022; 186:114338. [PMID: 35561835 DOI: 10.1016/j.addr.2022.114338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 04/26/2022] [Accepted: 05/06/2022] [Indexed: 12/22/2022]
Abstract
Intrathecal delivery (IT) of opiates into the cerebrospinal fluid (CSF) for anesthesia and pain relief has been used clinically for decades, but this relatively straightforward approach of bypassing the blood-brain barrier has been underutilized for other indications because of its lack of utility in delivering small lipid-soluble drugs. However, emerging evidence suggests that IT drug delivery be an efficacious strategy for the treatment of cancers in which there is leptomeningeal spread of disease. In this review, we discuss CSF flow dynamics and CSF clearance pathways in the context of intrathecal delivery. We discuss human and animal studies of several new classes of therapeutic agents-cellular, protein, nucleic acid, and nanoparticle-based small molecules-that may benefit from IT delivery. The complexity of the CSF compartment presents several key challenges in predicting biodistribution of IT-delivered drugs. New approaches and strategies are needed that can overcome the high rates of turnover in the CSF to reach specific tissues or cellular targets.
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Bany Hamdan A, Ballourah W, Elghazaly A, Javison S, Alshammary S, Erlandez R, Garatli A, Mohammed H, Alharbi M. The Effect of Video-Assisted Education Prior Intrathecal Chemotherapy on Anxiety and Knowledge Enhancement. J Cancer Educ 2022; 37:65-70. [PMID: 32519327 DOI: 10.1007/s13187-020-01787-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Intrathecal chemotherapy procedures are stressful to patients and caregivers, especially the first time. Providing the patient and caregiver with sufficient information to address their concerns before the scheduled procedure is necessary. This study aims to determine whether the use of video instructions could enhance learning outcomes and decrease anxiety levels in patients' caregivers. A prospective trial was conducted in pediatric hematology for 1 year. Thirty-seven respondents were randomly assigned to two groups wherein one group was given conventional educational leaflets and verbal instructions, while the other group received the same information through an educational video presentation before the intrathecal chemotherapy procedure. Knowledge enhancement in the two groups was evaluated using the summative assessment method and measured by a 10-point Likert scale. The validated Arabic version of the Beck Anxiety Inventory (BAI) scale was used to assess anxiety levels. The anxiety level (12.31 ± 8.84) in the video presentation group was significantly higher than that in the conventional group (6.16 ± 5.91). Similarly, the overall Beck scale score revealed that palpitation, frightening, lightheadedness, and hot/cold sweat levels were decreased in the video presentation group. Additionally, a significant difference in knowledge enhancement was noted between the two groups, as knowledge enhancement in the video presentation group (7.61 ± 1.88) was better than that in the conventional group (6.00 ± 1.00). This produced a domino effect on the anxiety level scores of both groups. An educational video presentation before the intrathecal chemotherapy procedure is effective since both visual and auditory senses are involved. This could be considered a good source of an interventional approach before a therapeutic procedure.
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Affiliation(s)
| | - Walid Ballourah
- Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Assem Elghazaly
- Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sherwynn Javison
- Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sami Alshammary
- Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Richard Erlandez
- Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ali Garatli
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Husain Mohammed
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Musa Alharbi
- Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
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Abstract
Anesthetic management of chelonians represents a unique challenge; the order Chelonia includes numerous species that display diverse anatomic features, habitats, body sizes, temperaments, and metabolic rates. Owing to their peculiar characteristics, safe and effective sedation and anesthesia may be more complicated than in other animals. For example, gas inductions are not indicated, and intravenous catheterization requires practice. The pharmacology of anesthetic drugs is severely impacted by body/environmental temperature, site of administration, and organ function. This review will summarize the current knowledge in terms of anatomy, physiology, and drug metabolism in chelonians, before discussing practical aspects of anesthesia.
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Affiliation(s)
- Stefania Scarabelli
- Clinica Veterinaria Malpensa-Anicura, Via G. Marconi 27, Samarate, VA 21017, Italy
| | - Nicola Di Girolamo
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, 2065 West Farm Road, Stillwater, OK 74078, USA.
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22
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Demir A, Çamlar M, Kuşçu GC, Gürel Ç, Oltulu F, Oren M, Karabey Yavaşoğlu NÜ, Sandal E, Ozer F. How safe is the use of intrathecal vancomycin? World Neurosurg 2021; 160:e55-e60. [PMID: 34971834 DOI: 10.1016/j.wneu.2021.12.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022]
Abstract
AIM Central Nervous System (CNS) infection after neurosurgical procedures is a severe complication with high morbidity rates and sometimes mortality. The present experimental study aims to investigate the biochemical and histopathological effects of vancomycin on neural tissues when applied to the cisterna magna. MATERIAL AND METHOD Wistar albino rats were randomly divided into four groups: Control (Group 1) and different vancomycin dose groups (groups 2, 3 and 4). In Group 1, 0.1 mL Cerebrospinal Fluid (CSF) was drained from the cisterna magna, and 0.1 mL 0.9% NaCI (normal saline) was administered into the subarachnoid space. In the study groups, 0.1 mL CSF was drained from the cisterna magna, 0.1 mg/day (Group 2), 0.2 mg/day (Group 3) and 0.4 mg/day (Group 4) vancomycin were administered into the subarachnoid space for seven days, and all rats were sacrificed on 8th day. Serum Superoxide dismutase (SOD) and Catalase (CAT) levels were measured. Histopathologic and immunohistochemical analyses were conducted. RESULT The findings showed that the administration of 0.2 and 0.4 mg/kg doses had significant differences in SOD and CAT activity compared to the controls (p<0.05). These vancomycin doses also induced the apoptotic process, and the enzyme activity results correlated with immunohistochemical results. CONCLUSION Dose-related neurotoxicity of intrathecal vancomycin was shown at the cellular level. The importance of dose regulation of intrathecal vancomycin has come into view. To our knowledge, this is the first study in the literature that has investigated the neurotoxic effects of vancomycin.
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Affiliation(s)
- Abdulkadir Demir
- Department of Neurosurgery, Adıyaman Universtiy Training ad Research Hospital, Adıyaman, 02100, Turkey
| | - Mahmut Çamlar
- Department of Neurosurgery, Tepecik Research and Training Hospital, University of Health Sciences, Izmir, 35100, Turkey.
| | - Gökçe Ceren Kuşçu
- Department of Histology and Embryology, Ege University, Faculty of Medicine, İzmir, 35100, Turkey
| | - Çevik Gürel
- Department of Histology and Embryology, Ege University, Faculty of Medicine, İzmir, 35100, Turkey; Department of Histology and Embryology, Harran University, Faculty of Medicine, Şanlıurfa, 63100, Turkey
| | - Fatih Oltulu
- Department of Histology and Embryology, Ege University, Faculty of Medicine, İzmir, 35100, Turkey
| | - Merve Oren
- Erzurum Provincial Health Directorate, Public Health Services Presidency, Erzurum, 25100, Turkey
| | | | - Evren Sandal
- Department of Neurosurgery, Medicana İnternational Hospital, Izmir, 35100, Turkey
| | - Fusun Ozer
- Department of Neurosurgery, Tepecik Research and Training Hospital, University of Health Sciences, Izmir, 35100, Turkey
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23
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Marathe A, Allahabadi S, Abd-Elsayed A, Saulino M, Hagedorn JM, Orhurhu V, Karri J. Intrathecal Baclofen Monotherapy and Polyanalgesia for Treating Chronic Pain in Patients with Severe Spasticity. Curr Pain Headache Rep 2021; 25:79. [PMID: 34894303 DOI: 10.1007/s11916-021-00994-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW Intrathecal drug delivery is a well evidenced strategy for the treatment of many chronic pain syndromes. While opioids, anesthetics, and ziconotide are the most commonly used agents, intrathecal baclofen (ITB), which is indicated to treat spasticity, is also thought to have some analgesic properties that are poorly understood. These analgesic benefits have been reported with ITB use in treating patients with central neurological disorders who suffer from severe spasticity and chronic pain. Our review aims to characterize ITB's effects on pain, function, and quality of life in patients with severe spasticity. We performed a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The primary outcome parameters were analgesic relief and functional improvements. Secondarily, quality of life and adverse effects were also recorded. RECENT FINDINGS After an initial survey identified 393 studies, 20 studies met final inclusion criteria. Of these, 16 utilized ITB monotherapy and 4 utilized ITB polyanalgesia. Overall, there was a paucity of high-powered studies. Mean titrated ITB doses ranged from 140 to 627.9 μg daily. Nineteen studies reported improved pain and spasticity. Seven studies reported improved functional outcomes and quality of life. Our results show that ITB may be an effective agent in treatingfor the treatment of chronic pain in patients with severe spasticity independent of its spasmolytic effects. Although this evidence was largely derived from studies lacking clearly defined outcomes of pain relief, ITB is reasonable to consider for concurrent spasticity and pain management. Well-designed studies are still needed to characterize ITB's analgesic efficacy when used in patients with severe spasticity.
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24
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Shashi KK, Stone SSD, Berde CB, Padua HM. Intrathecal catheter and port placement for nusinersen infusion in children with spinal muscular atrophy and spinal fusion. Pediatr Radiol 2021; 51:2588-2595. [PMID: 34254153 DOI: 10.1007/s00247-021-05126-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/18/2021] [Accepted: 06/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spinal administration of medications is challenging in patients with complete posterior spinal fusion. We describe percutaneous image-guided intrathecal port placement for administration of the antisense oligonucleotide nusinersen for children and young adults with spinal muscular atrophy. OBJECTIVE To describe and present our initial experience with a new technique for administering nusinersen in patients with spinal muscular atrophy and posterior spinal fusion. MATERIALS AND METHODS We reviewed medical records of 13 patients who received intrathecal ports using DynaCT, biplane fluoroscopy and iGuide from April 2018 through June 2019, and we describe the clinical course over 1 year. RESULTS Image-guided catheter and port implantation was successful in all cases. Two ports were subsequently removed, one for persistent cerebrospinal fluid leak and one for superficial infection. The other 11 have functioned successfully for a minimum of 23 months. CONCLUSION We report our experience with image-guided intrathecal port placement in children with complete posterior spine fusion. The implanted port permits dosing in an outpatient setting and avoids the need for multiple future radiologic procedures, and it reduces discomfort, procedural costs and potential risks and sequelae of multiple anesthetics and radiation exposures. Further studies are needed to define the relative risks and benefits of intrathecal ports compared to other approaches such as repeated transforaminal lumbar punctures.
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Affiliation(s)
- Kumar K Shashi
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Scellig S D Stone
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
| | - Charles B Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Horacio M Padua
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.
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25
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Karri J, Singh M, Modi DJ, Orhurhu V, Seale C, Saulino M, Marathe A, Vydra D, Hagedorn JM, Bruel B, Abd-Elsayed A. Combination Intrathecal Drug Therapy Strategies for Pain Management. Pain Physician 2021; 24:549-569. [PMID: 34793643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Numerous combination intrathecal drug therapy (CIDT) strategies exist and are utilized for varying pain syndromes, typically when monotherapy dose escalation or medication alternation is deemed untenable or unfeasible. Unfortunately, the supportive evidence basis for the use of these strategies and specific drug combinations is generally lacking and unclear, with many medications being used for off-label indications. OBJECTIVE In this manuscript, we provide a robust exploration and analysis of the literature to provide an evidence-based narrative for the use of CIDT strategies in regard to clinical indications, pharmacologic parameters, specific drug combinations, safety profiles, and future directions. STUDY DESIGN Narrative review. METHODS This was an evidence based narrative performed after extensive review of the literature. RESULTS Variances in intrathecal pharmacokinetics and pharmacodynamics are utilized advantageously with CIDT strategies to achieve improved analgesic benefit; however, appropriate use may be limited by increased or compounded risk of adverse effects. The supportive evidence for CIDT use for chronic pain conditions is largely lacking and limited to small, uncontrolled, observational studies, with many having various confounding factors, including a lack of standardized dosing. The most evidenced CIDT strategies include polyanalgesia with morphine-ziconotide, opioid-clonidine, and morphine-bupivacaine. Notably, in addition to pain relief, morphine-bupivacaine has been shown to decrease early opioid escalation requirements. LIMITATIONS The supportive evidence for CIDT use for chronic pain conditions is largely lacking and limited to small, uncontrolled, observational studies, with many having various confounding factors including a lack of standardized dosing. CONCLUSIONS CIDT strategies and polyanalgesia combinations can be effective for treating various patient populations with chronic pain. The appropriate use of these strategies may be limited by increased or compounded risk of adverse effects, both of which are highly patient and scenario dependent. Therefore, practitioners should maintain a particularly low threshold of suspicion for adverse effects in patients with CIDT such that safety profiles associated with this therapy can be favorably maintained.
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Affiliation(s)
- Jay Karri
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX
| | - Mani Singh
- Department of Rehabilitation and Regenerative Medicine, NewYork-Presbyterian Hospital at Columbia and Cornell, New York, NY
| | - Devas J Modi
- Department of Rehabilitation and Regenerative Medicine, NewYork-Presbyterian Hospital at Columbia and Cornell, New York, NY
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Pain, University of Pittsburgh Medical Center, Williamsport, PA
| | - Caleb Seale
- Department of Physical Medicine and Rehabilitation, University of Texas Health Sciences Center at San Antonio, San Antonio, TX
| | - Michael Saulino
- Department of Rehabilitation Medicine, Moss Rehab and Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Anuj Marathe
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX
| | - Darrell Vydra
- Department of Physical Medicine and Rehabilitation, University of Texas Health Sciences Center at San Antonio, San Antonio, TX
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN
| | - Brian Bruel
- Department of Physical Medicine and Rehabilitation, McGovern Medical School and Cy Pain and Spine PLLC, Houston, TX
| | - Alaa Abd-Elsayed
- Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI
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Fahmi A, Aji YK, Aprianto DR, Wido A, Asadullah A, Roufi N, Indiastuti DN, Subianto H, Turchan A. The Effect of Intrathecal Injection of Dextromethorphan on the Experimental Neuropathic Pain Model. Anesth Pain Med 2021; 11:e114318. [PMID: 34540637 PMCID: PMC8438745 DOI: 10.5812/aapm.114318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 12/22/2022] Open
Abstract
Background Peripheral glucocorticoid receptors (GRs) are altered by peripheral nerve injury and may modulate the development of neuropathic pain. Two central pathogenic mechanisms underlying neuropathic pain are neuroinflammation and N-methyl-D-aspartate receptor (NMDAR)-dependent neural plasticity in the spinal cord. Objectives This study examined the effect of the non-competitive NMDAR antagonist dextromethorphan on partial sciatic nerve ligation (PSL)-induced neuropathic pain and the spinal expression of the glucocorticoid receptor (GR). Methods Male mice were randomly assigned into a sham group and two groups receiving PSL followed by intrathecal saline vehicle or dextromethorphan (iDMP). Vehicle or iDMP was administered 8 - 14 days after PSL. The hotplate paw-withdrawal latency was considered to measure thermal pain sensitivity. The spinal cord was then sectioned and immunostained for GR. Results Thermal hyperalgesia developed similarly in the vehicle and iDMP groups prior to the injections (P = 0.828 and 0.643); however, it was completely mitigated during the iDMP treatment (P < 0.001). GR expression was significantly higher in the vehicle group (55.64 ± 4.50) than in the other groups (P < 0.001). The iDMP group (9.99 ± 0.66) showed significantly higher GR expression than the sham group (6.30 ± 1.96) (P = 0.043). Conclusions The suppression of PLS-induced thermal hyperalgesia by iDMP is associated with the downregulation of GR in the spinal cord, suggesting that this analgesic effect is mediated by inhibiting GR-regulated neuroinflammation.
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Affiliation(s)
- Achmad Fahmi
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
- Corresponding Author: Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia.
| | - Yunus Kuntawi Aji
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Dirga Rachmad Aprianto
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Akbar Wido
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Asadullah Asadullah
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | | | - Danti Nur Indiastuti
- Department of Pharmacology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Heri Subianto
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Agus Turchan
- Neurosurgery Department, Faculty of Medicine, Dr. Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, Indonesia
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Santiago JA, Babico M, Stitt G, Thomas CA, Desai S, Willard S, Swing T, Kruer MC. Low-dose intrathecal rituximab is a safe and potentially effective treatment for pediatric neuroimmunologic disorders. J Neuroimmunol 2021; 359:577687. [PMID: 34364103 DOI: 10.1016/j.jneuroim.2021.577687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 11/25/2022]
Abstract
Historically, treatment options for refractory neuroimmunologic disorders have been limited. Use of intrathecal rituximab has been described in a few case reports but experience in pediatric patients is limited. Here, we report our experience with intrathecal rituximab in 5 pediatric patients with refractory neuroimmunologic conditions. Patients were identified based on treatment-refractory symptoms despite first and second-line therapies and treated according to a standardized protocol. Although individual outcomes varied, intrathecal rituximab showed a favorable safety profile and was well-tolerated. Three out of five patients showed evidence of a positive clinical response assessed by modified Rankin score or Mitchell-Pike Opsoclonus-Myoclonus score. Findings from this retrospective observational study suggest that intrathecal rituximab is a safe and potentially effective therapy in carefully selected patients with refractory neuroimmunologic disorders despite appropriate first and second-line therapies.
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Affiliation(s)
- Jason A Santiago
- Pediatric Neuroimmunology Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, USA.
| | - Mary Babico
- Department of Pharmacy, Phoenix Children's Hospital, Phoenix, AZ, USA.
| | - Gideon Stitt
- Department of Pharmacy, Phoenix Children's Hospital, Phoenix, AZ, USA.
| | | | - Sudhen Desai
- Department of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA.
| | - Scott Willard
- Department of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA.
| | - Ted Swing
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA.
| | - Michael C Kruer
- Pediatric Neuroimmunology Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, USA.
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28
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Bidikian AH, Bazarbachi A, Hourani R, El-Cheikh J, Abou Dalle I. Intrathecal methotrexate induced myelopathy, rare yet serious complication: A case report and review of the literature. Curr Res Transl Med 2021; 69:103296. [PMID: 34139603 DOI: 10.1016/j.retram.2021.103296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/21/2021] [Accepted: 05/11/2021] [Indexed: 11/15/2022]
Abstract
The regular administration of intrathecal chemotherapy has significantly reduced the risk of central nervous system leukemia in patients with acute lymphoblastic leukemia. We report the case of 28-year-old man who developed intrathecal methotrexate induced myelopathy; a rare but serious side effect of intrathecal chemotherapy. In the light of absent effective treatment strategies, description of the case, along with reviewing similar cases published in the literature will help shed a light on the possible pathophysiologic mechanisms behind this injury. To this date, there are no specific clinical, biochemical and imaging signs that would allow timely detection of intrathecal methotrexate induced myelopathy. This in turn is causing delayed treatment of this injury, resulting in significant morbidity and mortality.
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Affiliation(s)
- Aram H Bidikian
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Roula Hourani
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El-Cheikh
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Iman Abou Dalle
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Naseri Kouzehgarani G, Feldsien T, Engelhard HH, Mirakhur KK, Phipps C, Nimmrich V, Clausznitzer D, Lefebvre DR. Harnessing cerebrospinal fluid circulation for drug delivery to brain tissues. Adv Drug Deliv Rev 2021; 173:20-59. [PMID: 33705875 DOI: 10.1016/j.addr.2021.03.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/10/2021] [Accepted: 03/01/2021] [Indexed: 12/31/2022]
Abstract
Initially thought to be useful only to reach tissues in the immediate vicinity of the CSF circulatory system, CSF circulation is now increasingly viewed as a viable pathway to deliver certain therapeutics deeper into brain tissues. There is emerging evidence that this goal is achievable in the case of large therapeutic proteins, provided conditions are met that are described herein. We show how fluid dynamic modeling helps predict infusion rate and duration to overcome high CSF turnover. We posit that despite model limitations and controversies, fluid dynamic models, pharmacokinetic models, preclinical testing, and a qualitative understanding of the glymphatic system circulation can be used to estimate drug penetration in brain tissues. Lastly, in addition to highlighting landmark scientific and medical literature, we provide practical advice on formulation development, device selection, and pharmacokinetic modeling. Our review of clinical studies suggests a growing interest for intra-CSF delivery, particularly for targeted proteins.
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Mohseni R, Hamidieh AA, Shoae-Hassani A, Ghahvechi-Akbari M, Majma A, Mohammadi M, Nikougoftar M, Shervin-Badv R, Ai J, Montazerlotfelahi H, Ashrafi MR. An open-label phase 1 clinical trial of the allogeneic side population adipose-derived mesenchymal stem cells in SMA type 1 patients. Neurol Sci 2021. [PMID: 34032944 DOI: 10.1007/s10072-021-05291-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Spinal muscular atrophy (SMA), an autosomal recessive neurodegenerative disorder of alpha motor neurons of spinal cord associated with progressive muscle weakness and hypotonia, is the most common genetic cause of infant mortality. Although there is few promising treatment for SMA, but the field of translational research is active in it, and stem cell-based therapy clinical trials or case studies are ongoing. Combination of different therapeutic approaches for noncurative treatments may increase their effectiveness and compliance of patients. We present a phase 1 clinical trial in patients with SMA1 who received side population adipose-derived mesenchymal stem cells (SPADMSCs). METHODS The intervention group received three intrathecal administrations of escalating doses of SPADMSCs and followed until 24 months or the survival time. The safety analysis was assessed by controlling the side effects and efficacy evaluations performed by the Hammersmith Infant Neurological Examination (HINE), Ballard score, and electrodiagnostic (EDX) evaluation. These evaluations were performed before intervention and at the end of the follow-up. RESULTS The treatment was safe and well tolerated, without any adverse event related to the stem cell administration. One of the patients in the intervention group was alive after 24 months of study follow-up. He is a non-sitter 62-month-old boy with appropriate weight gain and need for noninvasive ventilation (NIV) for about 8 h per day. Clinical scores, need for supportive ventilation, and number of hospitalizations were not meaningful parameters in the response of patients in the intervention and control groups. All five patients in the intervention group showed significant improvement in the motor amplitude response of the tibial nerve (0.56mV; p: 0.029). CONCLUSION This study showed that SPADMSCs therapy is tolerable and safe with promising efficacy in SMA I. Probably same as other treatment strategies, early intervention will increase its efficacy and prepare time for more injections. We suggest EDX evaluation for the follow-up of treatment efficacy.
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Young J, Macpherson A, Thakerar A, Alexander M. Intrathecal Morphine in Postoperative Analgesia for Colorectal Cancer Surgery: A Retrospective Study. Pain Med 2021; 22:402-406. [PMID: 33164104 DOI: 10.1093/pm/pnaa319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Colorectal cancer surgery is commonly performed with adequate analgesia essential for patient recovery. This study assessed the effectiveness of intrathecal morphine and patient-controlled analgesia (ITM + PCA) vs patient-controlled analgesia alone (PCA) for postoperative pain management in colorectal cancer surgery. METHODS This retrospective study extracted and analyzed data covering a 4-year period (2014-2018) from a clinical database with 24- and 48-hour postsurgery follow-up. Primary outcomes included pain scores, median opioid consumption (oral morphine equivalence dose), sedation, nausea and vomiting, and length of admission. Outcomes were analyzed for ITM + PCA vs PCA alone, overall and stratified by laparotomy or laparoscopy procedures. RESULTS In total, 283 patients were included: ITM + PCA (163) and PCA alone (120). Median opioid consumption in the first 24 hours for ITM + PCA vs PCA alone was lower for laparotomy (-32.7 mg, P<0.001) and laparoscopy (-14.3 mg, P<0.001). Median pain score (worst pain) within the first 24 hours for ITM + PCA vs PCA alone was similar for laparotomy (P>0.05) and lower for laparoscopy (-1 unit, P=0.031). Sedation occurred less frequently for ITM + PCA vs PCA at 24 hours (3.5% vs 11.4%, P=0.031), with nonsignificant reduction at 48 hours (4.8% vs 18.8%, P=0.090) for laparotomy, but with no difference for laparoscopy (P>0.05). Incidence of nausea and vomiting and length of admission were similar for ITM + PCA vs PCA alone for laparotomy or laparoscopy (P>0.05). CONCLUSION This retrospective study demonstrated that ITM + PCA can achieve similar analgesic effects after laparotomy and laparoscopy colorectal cancer surgery compared with PCA alone while resulting in a reduction of oral opioid consumption and lower incidence of sedation.
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Affiliation(s)
- Jamie Young
- Department of Anaesthesia and Pain, Peter MacCallum Cancer Centre, Melbourne, Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | | | - Arti Thakerar
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Marliese Alexander
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Oncology, University of Melbourne, Parkville, Australia
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Wojcikiewicz T, Nkhoma J, James E, Johannsson H, Cousins J, Kynoch M. A Prospective Observational Study of High-Dose Intrathecal Diamorphine in Laparoscopic Bariatric Surgery: a Single-Centre Experience. Obes Surg 2021; 30:1814-1819. [PMID: 32006237 DOI: 10.1007/s11695-020-04384-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-operative pain management following laparoscopic bariatric surgery can be challenging. There are concerns regarding the use of opioids. The rate of cardiorespiratory problems following neuraxial opioids is unclear. There is little published data on their use in bariatric surgery. This study aimed to assess technique feasibility, pain outcomes, patient acceptability, and the side effects and complications of a 'high-dose' (1.0 mg) intrathecal diamorphine technique for patients undergoing primary laparoscopic bariatric surgery. MATERIALS AND METHODS Fifty patients were included. Eleven patients (22%) had a diagnosis of OSA. All patients had a spinal anaesthetic with 2.0 mL of 0.25% isobaric bupivacaine containing 1.0 mg diamorphine. General anaesthesia followed together with multi-modal analgesia and anti-emesis. Post-operative pain scores, complications, and side effects in the first 24 h post-operative period were documented. Patients were followed up 6 to 8 weeks after discharge. RESULTS All patients had a working spinal anaesthetic with thirty-nine insertions (78%) on the first attempt. Pain scores were similar to previously published data where they were found to be superior to a non-spinal analgesic regime. The median 24 h post-operative oral morphine equivalent consumption was 5 mg. Eight patients (16%) required urinary catheterisation. Four patients (8%) complained of pruritus. Eighteen patients (36%) had post-operative nausea or vomiting. Thirty-three patients (66%) responded to the follow-up request. Thirty of the thirty-three patients (91%) stated they would have the spinal anaesthetic again. CONCLUSION We have demonstrated that neuraxial blockade is a simple, practical, and feasible technique to adopt. Our case series demonstrated a high level of patient acceptability.
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Affiliation(s)
- T Wojcikiewicz
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - J Nkhoma
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - E James
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - H Johannsson
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - J Cousins
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - M Kynoch
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Vahabi Z, Etesam F, Zandifar A, Badrfam R. Psychosocial stress, blood brain barrier and the development of anti N-methyl-D-aspartate receptor (NMDAR) encephalitis. Mult Scler Relat Disord 2021; 50:102876. [PMID: 33690087 DOI: 10.1016/j.msard.2021.102876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/21/2021] [Accepted: 02/28/2021] [Indexed: 10/22/2022]
Abstract
Throughout life, mechanisms such as damage and inflammation can alter the permeability of the blood-brain barrier(BBB). According to some studies, increasing the permeability of the blood-brain barrier can occur in a time-dependent manner following restraint stress. On the other hand, there have been reports of increased N-Methyl-D-Aspartate Receptor (NMDAR) -Ab seroprevalence in chronic stress conditions. The presence of antibody-secreting cells / memory B cells in the intrathecal area of the brain and their redistribution under various environmental stresses, which can be independent of the BBB status, are other points in this area that can emphasize the role of environmental stress in Anti NMDAR encephalitis.
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Affiliation(s)
- Zahra Vahabi
- Geriatric Department, Ziaeean Hospital, Tehran University of Medical Sciences, Tehran, Iran; Memory and Behavioral Neurology Division, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farnaz Etesam
- Psychosomatic Medicine Research Center, Department of Psychiatry, School of Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Zandifar
- Cardiovascular Research Center, Shahid Rajaei Educational & Medical Center, Alborz University of Medical Sciences, Karaj, Iran; Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Rahim Badrfam
- Psychosomatic Medicine Research Center, Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran; Department of Psychiatry, Roozbeh Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Shim JW, Cho YJ, Moon HW, Park J, Lee HM, Kim YS, Moon YE, Hong SH, Chae MS. Analgesic efficacy of intrathecal morphine and bupivacaine during the early postoperative period in patients who underwent robotic-assisted laparoscopic prostatectomy: a prospective randomized controlled study. BMC Urol 2021; 21:30. [PMID: 33637066 PMCID: PMC7908773 DOI: 10.1186/s12894-021-00798-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background The present study was performed to investigate the analgesic efficacy of intrathecal morphine and bupivacaine (ITMB) in terms of treating early postoperative pain in adult patients who underwent robotic-assisted laparoscopic prostatectomy (RALP). Methods Fifty patients were prospectively enrolled and randomly classified into the non-ITMB (n = 25) and ITMB (n = 25) groups. The ITMB therapeutic regimen consisted of 0.2 mg morphine and 7.5 mg bupivacaine (total 1.7 mL). All patients were routinely administered the intravenous patient-controlled analgesia and appropriately treated with rescue intravenous (IV) opioid drugs, based on the discretion of the attending physicians who were blinded to the group assignments. Cumulative IV opioid consumption and the numeric rating scale (NRS) score were assessed at 1, 6, and 24 h postoperatively, and opioid-related complications were measured during the day after surgery. Results Demographic findings were comparable between patients who did and did not receive ITMB. The intraoperative dose of remifentanil was lower in the ITMB group than in the non-ITMB group. Pain scores (i.e., NRS) at rest and during coughing as well as cumulative IV opioid consumption were significantly lower in patients who received ITMB than in those who did not in the post-anesthesia care unit (PACU; i.e., at 1 h after surgery) and the ward (i.e., at 6 and 24 h after surgery). ITMB was significantly associated with postoperative NRS scores of ≤ 3 at rest and during coughing in the PACU (i.e., at 1 h after surgery) before and after adjusting for cumulative IV opioid consumption. In the ward (i.e., at 6 and 24 h after surgery), ITMB was associated with postoperative NRS scores of ≤ 3 at rest and during coughing before adjusting for cumulative IV opioid consumption but not after. No significant differences in complications were observed, such as post-dural puncture headache, respiratory depression, nausea, vomiting, pruritus, or neurologic sequelae, during or after surgery. Conclusion A single spinal injection of morphine and bupivacaine provided proper early postoperative analgesia and decreased additional requirements for IV opioids in patients who underwent RALP. Trial registration: Clinical Research Information Service, Republic of Korea; approval number: KCT0004350 on October 17, 2019. https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=15637
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Affiliation(s)
- Jung-Woo Shim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Yun Jeong Cho
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Hyong Woo Moon
- Department of Urology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Hyung Mook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Yong-Suk Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Young Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Paquet J, Cordier F, Vandersteene J. Spinal Syrinx Due to Lipiodol-Induced Arachnoiditis. World Neurosurg 2021; 149:64-6. [PMID: 33601077 DOI: 10.1016/j.wneu.2021.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/04/2021] [Indexed: 11/20/2022]
Abstract
We present a case of a progressive symptomatic intramedullary cyst, diagnosed decades after Lipiodol injection. Lipiodol was originally administered intrathecally for the radiologic diagnosis of spinal masses. A link between the lesion and the history of Lipiodol injection was never suspected. Surgical exploration revealed a membrane above the lesion, separating the intradural space in a cranial and caudal compartment. On the level of the cyst, we identified glassy pearls containing a fatty liquid, compatible with Lipiodol deposits. We hypothesize that the syrinx is secondary to the impact of cerebrospinal fluid pulsations on the reactive membrane and that this membrane originated from an arachnoiditis caused by Lipiodol deposits. Lipiodol was indeed abandoned after it was found to cause arachnoiditis and neurologic sequelae. Despite the cessation of its usage, the causal role of Lipiodol in arachnoiditis and spinal cyst formation should still be considered, as symptoms may arise many years after Lipiodol administration.
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Shukla AB, Vu TN, Vorobeychik Y. Permanent Paraplegia as a Complication of Injection of Contrast Media at L2-L3 Vertebral Level. Pain Med 2021; 21:261-265. [PMID: 31578563 DOI: 10.1093/pm/pnz198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The lumbar intrathecal (subarachnoid) space is accessed for both therapeutic and diagnostic purposes. Occasionally, the needle may unintentionally enter the intrathecal space during lumbar interlaminar epidural steroid injections (LESIs)-one of the most commonly performed medical procedures in the United States. Ordinarily, this merely constitutes a minor complication or even a desired placement (in the case of some diagnostic procedures). However, some patients have a rare condition wherein the spinal cord terminates below the L2 vertebral level (tethered cord). In such cases, injections administered at the lumbar level may potentially result in spinal cord damage and irreversible paraplegia if the physician performing the intervention does not recognize the intramedullary position of the needle. OBJECTIVE The aim of this study is to describe and analyze an unintentional L2-L3 injection of contrast medium into a tethered spinal cord. Many physicians may consider lumbar injections "safe" because the spinal cord usually terminates at or above the L2 vertebral level. However, complacency stemming from this false impression of safety contributes to nonadherence to practice guidelines, which may lead to catastrophic neurological complications. Presented here is the first published occurrence of paraplegia that resulted from contrast medium injection into the spinal cord during a myelography study performed below the L2 vertebral level. CONCLUSIONS Disregard of the procedural guidelines by the physicians performing an elective diagnostic intervention may cause devastating neurological complications. The described casualty occurred because of failure to review previous imaging studies, injection of the contrast medium despite unsuccessful attempts to aspirate cerebrospinal fluid, and an unwillingness to terminate the procedure immediately when the patient reported an unusual sensation in both of his lower extremities. Consequently, we suggest that not only for cervical and thoracic but also for lumbar interlaminar ESIs, previous imaging studies should be reviewed before the injection.
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Affiliation(s)
- Adarsh B Shukla
- Penn State College of Medicine, Department of Physical Medicine & Rehabilitation, Pennsylvania
| | - To-Nhu Vu
- Hershey Medical Center/Penn State College of Medicine, Department of Anesthesiology & Perioperative Medicine, Pennsylvania
| | - Yakov Vorobeychik
- Hershey Medical Center/Penn State College of Medicine, Department of Anesthesiology & Perioperative Medicine; Department of Neurology, Pennsylvania, USA
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Affiliation(s)
- Cheryl Mele
- Drexel University, PA, United States of America; Community Hospice and Palliative Care, FL, United States of America.
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Abraham ME, Gold J, Dondapati A, Gendreau J, Mammis A, Herschman Y. Intrathecal and intracerebroventricular dopamine for Parkinson's disease. Clin Neurol Neurosurg 2020; 200:106374. [PMID: 33290887 DOI: 10.1016/j.clineuro.2020.106374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/12/2020] [Accepted: 11/14/2020] [Indexed: 10/22/2022]
Abstract
While CDD directly to the CSF can provide a constant delivery of the dopaminergic drug resulting in a more stable treatment effect without the limitations of traditional oral therapy without peripheral effects, it is still young and longitudinal data is lacking. These experimental therapies show promise and further investigation into their efficacy and safety could extend the frontiers for management of PD.
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Affiliation(s)
- Mickey E Abraham
- Department of Neurological Surgery, Doctor's Office Center, Rutgers New Jersey Medical School, 90 Bergen Street, 07101-1709, Newark, NJ, United States
| | - Justin Gold
- Department of Neurological Surgery, Doctor's Office Center, Rutgers New Jersey Medical School, 90 Bergen Street, 07101-1709, Newark, NJ, United States.
| | - Akhil Dondapati
- Department of Neurological Surgery, Doctor's Office Center, Rutgers New Jersey Medical School, 90 Bergen Street, 07101-1709, Newark, NJ, United States
| | - Julian Gendreau
- Department of Neurological Surgery, Doctor's Office Center, Rutgers New Jersey Medical School, 90 Bergen Street, 07101-1709, Newark, NJ, United States
| | - Antonios Mammis
- Department of Neurological Surgery, Doctor's Office Center, Rutgers New Jersey Medical School, 90 Bergen Street, 07101-1709, Newark, NJ, United States
| | - Yehuda Herschman
- Department of Neurological Surgery, Doctor's Office Center, Rutgers New Jersey Medical School, 90 Bergen Street, 07101-1709, Newark, NJ, United States
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Hogan MJ, Stephens K, Smith E, Jalazo ER, Hendriksz CJ, Edwards LJ, Bjoraker KJ. Toileting Abilities Survey as a surrogate outcome measure for cognitive function: Findings from neuronopathic mucopolysaccharidosis II patients treated with idursulfase and intrathecal idursulfase. Mol Genet Metab Rep 2020; 25:100669. [PMID: 33101985 PMCID: PMC7578548 DOI: 10.1016/j.ymgmr.2020.100669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/12/2020] [Indexed: 10/31/2022] Open
Abstract
An outcome measure of toileting skills, the Toileting Abilities Survey or TAS, with sensitivity to detect change in a neurodegenerative disorder such as MPS II, was developed. The TAS was used in a research study of patients (n = 86) with the neuronopathic form of MPS II to measure treatment benefit of intrathecal idursulfase. Treatment with idursulfase and intrathecal idursulfase is associated with significantly higher individual and overall toileting skills versus treatment with idursulfase alone.
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Affiliation(s)
| | | | - Erin Smith
- Backpack Health, a Konica Minolta Service, Boston, MA, USA
| | - Elizabeth R Jalazo
- Division of Genetics and Metabolism, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christian J Hendriksz
- Department of Paediatrics and Child Health at the Steve Biko Academic Unit, University of Pretoria, South Africa
| | - Lloyd J Edwards
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
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Bergman J, Burman J, Bergenheim T, Svenningsson A. Intrathecal treatment trial of rituximab in progressive MS: results after a 2-year extension. J Neurol 2020; 268:651-657. [PMID: 32901316 PMCID: PMC7880973 DOI: 10.1007/s00415-020-10210-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 10/29/2022]
Abstract
OBJECTIVES To evaluate the effect of intrathecally (IT) delivered rituximab as a therapeutic intervention for progressive multiple sclerosis (PMS) during a 3-year follow-up period. METHODS Participants of a 1-year open-label phase 1b study of IT delivered rituximab to patients with PMS were offered extended treatment with follow-up for an additional 2 years. During the extension phase, treatment with 25 mg rituximab was administered every 6 months via a subcutaneous Ommaya reservoir connected to the right frontal horn with a ventricular catheter. RESULTS Mild to moderate vertigo and nausea occurred in 4 out of 14 participants as temporary adverse events associated with IT rituximab infusion. During the entire 3-year period, two cases of low-virulent bacterial meningitis occurred, which were successfully treated. Walking speed deteriorated significantly during the study. CONCLUSIONS IT administration of rituximab via a ventricular catheter was well tolerated. Considering the meningitis cases, the risk of infection was not negligible. The continued loss of walking speed indicates that IT rituximab was not able to stop disease progression. CLASSIFICATION OF EVIDENCE This study provides class IV evidence that intraventricularly administered rituximab in progressive MS is associated with a risk for bacterial meningitis and does not halt disease progression. EU CLINICAL TRIAL REGISTER EudraCT; 2008-002626-11 and 2012-000721-53.
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Affiliation(s)
- Joakim Bergman
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Joachim Burman
- Department of Neurosciences, Uppsala University, Uppsala, Sweden
| | | | - Anders Svenningsson
- Department of Clinical Science, Umeå University, Umeå, Sweden. .,Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Danderyd Hospital, 182 88, Stockholm, Sweden.
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Í Dali C, Sevin C, Krägeloh-Mann I, Giugliani R, Sakai N, Wu J, Wasilewski M. Safety of intrathecal delivery of recombinant human arylsulfatase A in children with metachromatic leukodystrophy: Results from a phase 1/2 clinical trial. Mol Genet Metab 2020; 131:235-244. [PMID: 32792226 DOI: 10.1016/j.ymgme.2020.07.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/01/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Metachromatic leukodystrophy (MLD) is an autosomal recessive disorder caused by deficient arylsulfatase A (ASA) activity and characterized by neurological involvement that results in severe disability and premature death. We examined the safety and tolerability of intrathecally delivered recombinant human ASA (rhASA; SHP611, now TAK-611) in children with MLD (NCT01510028). Secondary endpoints included change in cerebrospinal fluid (CSF) sulfatide and lysosulfatide levels, and motor function (assessed by Gross Motor Function Measure-88 total score). METHODS Twenty-four children with MLD who experienced symptom onset aged ≤ 30 months were enrolled. Patients received rhASA every other week (EOW) for 38 weeks at 10, 30, or 100 mg (cohorts 1-3; n = 6 per cohort), or 100 mg manufactured using a revised process (cohort 4; n = 6). RESULTS No rhASA-related serious adverse events (SAEs) were observed; 25% of patients experienced an SAE related to the intrathecal device or drug delivery method. Mean CSF sulfatide and lysosulfatide levels fell to within normal ranges in both 100 mg cohorts following treatment. Although there was a general decline in motor function over time, there was a tendency towards a less pronounced decline in patients receiving 100 mg. CONCLUSION Intrathecal rhASA was generally well tolerated at doses up to 100 mg EOW. These preliminary data support further development of rhASA as a therapy for patients with MLD.
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Affiliation(s)
- Christine Í Dali
- Department of Clinical Genetics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | | | - Ingeborg Krägeloh-Mann
- Department of Neuropediatrics, University Children's Hospital Tübingen, Tübingen, Germany.
| | - Roberto Giugliani
- Medical Genetics Service, HCPA, Department of Genetics, UFRGS, and INAGEMP, Porto Alegre, Brazil.
| | | | - James Wu
- Shire, a member of the Takeda group of companies, Lexington, MA, USA.
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Nagano T, Sakura S, Imamachi N, Saito Y. Ultrasound-assisted intrathecal injection of nusinersen in a patient with severe vertebral deformity: a case report. JA Clin Rep 2020; 6:61. [PMID: 32783149 DOI: 10.1186/s40981-020-00367-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/04/2020] [Indexed: 11/12/2022] Open
Abstract
Background Spinal muscular atrophy (SMA) is a mostly autosomal recessive genetic disease characterized by progressive muscle weakness from anterior horn degeneration. Nusinersen has recently been approved as a disease-modifying drug for SMA that needs to be administered intrathecally. Its injection is often associated with extreme difficulty since patients with SMA have severe vertebral deformity and may be with vertebral instrumentation. Case description A 21-year-old female with type 2 SMA and spinal deformity underwent a series of intrathecal injections of nusinersen. The intrathecal injections have been safely and successfully done by using computed tomography imaging and ultrasonography-assisted technique. Conclusion This the first report in which ultrasound-assisted technique has been used for the injection of nusinersen through a lumbar puncture in patients with severe spinal deformity. Use of preprocedural ultrasound imaging is highly recommended for treatments that repeatedly require intrathecal access.
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Sullivan JM, Mazur C, Wolf DA, Horky L, Currier N, Fitzsimmons B, Hesterman J, Pauplis R, Haller S, Powers B, Tayefeh L, DeBrosse-Serra B, Hoppin J, Kordasiewicz H, Swayze EE, Verma A. Convective forces increase rostral delivery of intrathecal radiotracers and antisense oligonucleotides in the cynomolgus monkey nervous system. J Transl Med 2020; 18:309. [PMID: 32771027 PMCID: PMC7414676 DOI: 10.1186/s12967-020-02461-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/28/2020] [Indexed: 01/09/2023] Open
Abstract
Background The intrathecal (IT) dosing route introduces drugs directly into the CSF to bypass the blood–brain barrier and gain direct access to the CNS. We evaluated the use of convective forces acting on the cerebrospinal fluid as a means for increasing rostral delivery of IT dosed radioactive tracer molecules and antisense oligonucleotides (ASO) in the monkey CNS. We also measured the cerebral spinal fluid (CSF) volume in a group of cynomolgus monkeys. Methods There are three studies presented, in each of which cynomolgus monkeys were injected into the IT space with radioactive tracer molecules and/or ASO by lumbar puncture in either a low or high volume. The first study used the radioactive tracer 64Cu-DOTA and PET imaging to evaluate the effect of the convective forces. The second study combined the injection of the radioactive tracer 99mTc-DTPA and ASO, then used SPECT imaging and ex vivo tissue analysis of the effects of convective forces to bridge between the tracer and the ASO distributions. The third experiment evaluated the effects of different injection volumes on the distribution of an ASO. In the course of performing these studies we also measured the CSF volume in the subject monkeys by Magnetic Resonance Imaging. Results It was consistently found that larger bolus dose volumes produced greater rostral distribution along the neuraxis. Thoracic percussive treatment also increased rostral distribution of low volume injections. There was little added benefit on distribution by combining the thoracic percussive treatment with the high-volume injection. The CSF volume of the monkeys was found to be 11.9 ± 1.6 cm3. Conclusions These results indicate that increasing convective forces after IT injection increases distribution of molecules up the neuraxis. In particular, the use of high IT injection volumes will be useful to increase rostral CNS distribution of therapeutic ASOs for CNS diseases in the clinic.
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Affiliation(s)
| | - Curt Mazur
- Ionis Pharmaceuticals, Inc., 2855 Gazelle Court, Carlsbad, CA, 92010, USA.
| | | | | | | | | | | | | | | | - Berit Powers
- Ionis Pharmaceuticals, Inc., 2855 Gazelle Court, Carlsbad, CA, 92010, USA
| | - Leighla Tayefeh
- Ionis Pharmaceuticals, Inc., 2855 Gazelle Court, Carlsbad, CA, 92010, USA
| | - Bea DeBrosse-Serra
- Ionis Pharmaceuticals, Inc., 2855 Gazelle Court, Carlsbad, CA, 92010, USA
| | | | - Holly Kordasiewicz
- Ionis Pharmaceuticals, Inc., 2855 Gazelle Court, Carlsbad, CA, 92010, USA
| | - Eric E Swayze
- Ionis Pharmaceuticals, Inc., 2855 Gazelle Court, Carlsbad, CA, 92010, USA
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Hong J, Feng J, Lee J, Lee H, Sim Y, Park J, Suh H. The role of spinally located dopamine D 2 receptors in the regulation of the blood glucose level in mice. Pharmacol Rep 2020; 72:1666-75. [PMID: 32627115 DOI: 10.1007/s43440-020-00126-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The possible role of dopamine D2 receptors located in the spinal cord in the regulation of the blood glucose level have not been investigated before. METHODS In the present study, the effect of D2 receptor agonist and antagonist administered intrathecal (it) injection on the blood glucose level were examined in the Institute of Cancer Research (ICR) mice. RESULTS We found that it injection with carmoxirole (D2 receptor agonist) caused an elevation of the blood glucose level in a dose-dependent manner. Carmoxirole-induced increase of the blood glucose was significantly attenuated by L-741,626 (D2 receptor antagonist). Previously, we indicated that intrathecal (it) treatment with 0.1 μg/5 μl pertussis toxin (PTX, a Gi/Go inhibitor) produces a hypoglycemic effect in ICR in a long-term manner. In the present study, it pretreatment with PTX for 6 days almost abolished the hyperglycemic effect induced by carmoxirole. The plasma insulin level was elevated by carmoxirole, and L-741,626 or PTX pretreatment reduced carmoxirole-induced increment of the insulin level. In addition, the plasma corticosterone level was increased by carmoxirole but it pretreatment with L-741,626 or PTX did not affect carmoxirole-induced increment of the corticosterone level. CONCLUSION Our results suggest that D2 receptors located in the spinal cord play an important role in the elevation of the blood glucose level. Spinally located inhibitory G-proteins appear to be involved in hyperglycemic effect induced by carmoxirole.
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Dogan SN, Salt V, Korkmazer B, Arslan S, Islak C, Kocer N, Kizilkilic O. Intrathecal use of gadobutrol for gadolinium-enhanced MR cisternography in the evaluation of patients with otorhinorrhea. Neuroradiology 2020; 62:1381-1387. [PMID: 32535661 DOI: 10.1007/s00234-020-02463-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/20/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Intrathecal gadolinium-enhanced MR cisternography (IGE-MRC) has a high sensitivity to detect accurate localization of cerebrospinal fluid (CSF) leakage in otorhinorrhea patients. Our purpose in this study was to describe our experience in analyzing clinically suspected CSF leakage by IGE-MRC by using gadobutrol with emphasis on its safety and diagnostic performance. METHODS We retrospectively reviewed our imaging and clinical database for the evaluation of patients admitted to our clinic with complaints of otorhinorrhea between 2017 and 2019. Two radiologists evaluated the imaging studies independently. Consensus data was used in the analysis. Medical record review and phone call were used for the follow-up. RESULTS Of the 85 patients included in the retrospective analysis, 82 (96.5%) had rhinorrhea and 3 (3.5%) had otorrhea. Overall, 29 patients (34.1% of all patients) underwent operation for repair of the CSF leakage site. Beta-transferrin test was available and positive in 33 patients (38.8%). Five (5.9%) patients complained headaches after the procedure and complaints were resolved with increased water intake. Postprocedurally, 3 patients (3.5%) had vertigo and 1 patient (1.2%) complained nausea but spontaneous regression were observed in a few hours. None of the patients experienced a significant complication or adverse reaction during follow-up period. Sixty-seven patients (78.8%) had medical record and telephone follow-up. Mean follow-up duration with call was 14.2 months. CONCLUSION IGE-MRC is a minimally invasive and highly sensitive imaging technique. The current results during our follow-up demonstrate the relative safety and feasibility of IGE-MRC by using gadobutrol to evaluate CSF leakage.
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Affiliation(s)
- Sebahat Nacar Dogan
- Gaziosmanpaşa Training and Research Hospital, Department of Radiology, University of Health Sciences Turkey, 34098, Istanbul, Turkey
| | - Vefa Salt
- Department of Radiology, Division of Neuroradiology, Istanbul University-Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Bora Korkmazer
- Department of Radiology, Division of Neuroradiology, Istanbul University-Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Serdar Arslan
- Department of Radiology, Division of Neuroradiology, Istanbul University-Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Civan Islak
- Department of Radiology, Division of Neuroradiology, Istanbul University-Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Naci Kocer
- Department of Radiology, Division of Neuroradiology, Istanbul University-Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Osman Kizilkilic
- Department of Radiology, Division of Neuroradiology, Istanbul University-Cerrahpasa Medical Faculty, Istanbul, Turkey.
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Dyke JP, Xu HS, Verma A, Voss HU, Chazen JL. MRI characterization of early CNS transport kinetics post intrathecal gadolinium injection: Trends of subarachnoid and parenchymal distribution in healthy volunteers. Clin Imaging 2020; 68:1-6. [PMID: 32544736 DOI: 10.1016/j.clinimag.2020.04.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/10/2020] [Accepted: 04/30/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE To quantify CSF transport kinetics and brain glymphatic distribution using MRI following intrathecal injection of gadolinium contrast in healthy adults. SUBJECTS AND METHODS Eight completely healthy volunteer subjects underwent intrathecal injection of gadolinium via image guided lumbar puncture and serial MRI's at six subsequent time points up to 11 h post-injection. Rate of enhancement and deposition were calculated for various regions and lobes of the brain. RESULTS Normalized cranial data revealed that gadolinium in the intracranial CSF spaces peaked within 1-3 h and started to decrease at 7 h. In some regions of the brain parenchyma, such as the cerebral cortex and white matter, enhancement was increasing after 11 h. Differential rates of uptake between the parietal and frontal (p = 0.0003), cingulate (p = 0.002) and temporal (p = 0.018) lobes were shown as well as a several fold change between various cortical regions. Lastly, a linear regression comparing laterality between 35 cortical regions yielded (R2 = 0.90, p < 0.001) with a slope of 1.01 showing symmetry in uptake. CONCLUSIONS Gadolinium enhancement after lumbar intrathecal injection demonstrated differential CSF flow and brain parenchymal penetration, which illustrated the distributory function of the glymphatic system.
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Affiliation(s)
- Jonathan P Dyke
- Citigroup Biomedical Imaging Center, Weill Cornell Medicine, New York, NY, United States of America; Department of Radiology, Weill Cornell Medicine, New York, NY, United States of America.
| | - Helen S Xu
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States of America
| | - Ajay Verma
- Biogen, Inc., Cambridge, MA, United States of America
| | - Henning U Voss
- Citigroup Biomedical Imaging Center, Weill Cornell Medicine, New York, NY, United States of America; Department of Radiology, Weill Cornell Medicine, New York, NY, United States of America
| | - J Levi Chazen
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States of America
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Abstract
The following case report documents the presentation of a 28 year old male who presented to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) trauma unit following a single gunshot wound to the spine. He presented walking, with no neurological dysfunction. On further investigation he was found to have a retained bullet at the L3 level of the spinal canal, which migrated within the canal from its initial point of entry. He was subsequently taken for a laminectomy and bullet removal under fluoroscopic guidance. Post operatively he was noted to have reduced proprioception bilaterally.
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Affiliation(s)
- Nolitha Morare
- Corresponding author at: Private Bag X39, Parktown, Johannesburg 2193, South Africa.
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Puntillo F, Giglio M, Preziosa A, Dalfino L, Bruno F, Brienza N, Varrassi G. Triple Intrathecal Combination Therapy for End-Stage Cancer-Related Refractory Pain: A Prospective Observational Study with Two-Month Follow-Up. Pain Ther 2020; 9:783-92. [PMID: 32350753 DOI: 10.1007/s40122-020-00169-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Indexed: 01/16/2023] Open
Abstract
Introduction In cancer-related pain refractory to systemic opioids, intrathecal (IT) administration of morphine can be a useful strategy. In clinical practice, IT morphine is usually combined with other drugs with different mechanisms of action, in order to obtain a synergistic analgesic effect. However, the discussion on efficacy and safety of IT combination therapy is still ongoing. The aim of this observational study was to report the effects of an IT combination of low doses of ziconotide, morphine, and levobupivacaine in end-stage cancer refractory pain. Methods Sixty adult patients, 21 females and 39 males, were enrolled to an IT device implant. The mean visual analogue scale of pain intensity (VASPI) score was 88 ± 20 mm. All patients started with a triple combination therapy: the initial IT dose of morphine was calculated for each patient based on the equivalent daily dose of morphine; an oral/IT ratio of 400/1 was used. For ziconotide, a standard slow titration schedule was started at 1.2 μg/day and the initial dose of levobupivacaine was 3 mg/day. Results The initial IT mean doses of morphine, ziconotide, and levobupivacaine were 0.8 ± 0.3 mg/day, 1.2 mcg/day and 3 mg/day, respectively. At day 2, a significant reduction in VASPI score was registered (49 ± 17, p < 0.001), and this significant reduction persisted at 56 days (mean VASPI score 44 ± 9, p < 0.001), with mean doses of morphine 2 ± 1 mg/day, ziconotide 2.8 ± 1 mcg/day, and levobupivacaine 3.8 ± 2 mg/day. Very few adverse effects (AEs) were observed. Patients’ satisfaction was very high during the entire study period. Conclusions Our results, within the limit of the study design, suggest that the IT combination of ziconotide, morphine, and levobupivacaine, at low doses, allows safe and rapid control of refractory cancer pain, with high levels of patient satisfaction.
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Bailey RM, Rozenberg A, Gray SJ. Comparison of high-dose intracisterna magna and lumbar puncture intrathecal delivery of AAV9 in mice to treat neuropathies. Brain Res 2020; 1739:146832. [PMID: 32289279 DOI: 10.1016/j.brainres.2020.146832] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023]
Abstract
Gene therapy clinical trials for neurological disorders are ongoing using intrathecal injection of adeno-associated virus (AAV) vector directly into the cerebral spinal fluid. Preliminary findings from these trials and results from extensive animal studies provides compelling data supporting the safety and benefit of intrathecal delivery of AAV vectors for inherited neurological disorders. Intrathecal delivery can be achieved by a lumbar puncture (LP) or intracisterna magna (ICM) injection, although ICM is not commonly used in clinical practice due to increased procedural risk. Few studies directly compared these delivery methods and there are limited reports on transduction of the PNS. To further test the utility of ICM or LP delivery for neuropathies, we performed a head to head comparison of AAV serotype 9 (AAV9) vectors expressing GFP injected into the cisterna magna or lumbar subarachnoid space in mice. We report that an intrathecal gene delivery of AAV9 in mice leads to stable transduction of neurons and glia in the brain and spinal cord and has a widespread distribution that includes components of the PNS. Vector expression was notably higher in select brain and PNS regions following ICM injection, while higher amounts of vector was found in the lower spinal cord and peripheral organs following LP injection. These findings support that intrathecal AAV9 delivery is a translationally relevant delivery method for inherited neuropathies.
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Affiliation(s)
- Rachel M Bailey
- Gene Therapy Center, University of North Carolina at Chapel Hill, United States; Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States; Center for Alzheimer's and Neurodegenerative Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States.
| | - Alejandra Rozenberg
- Gene Therapy Center, University of North Carolina at Chapel Hill, United States
| | - Steven J Gray
- Gene Therapy Center, University of North Carolina at Chapel Hill, United States; Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Ophthalmology, University of North Carolina School of Medicine, Chapel Hill, NC, United States; Department of Molecular Biology, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States.
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Mégarbane B, Weinberg GL. Hypotension and status epilepticus in relation to intrathecal morphine administration. Am J Emerg Med 2020; 38:1682-3. [PMID: 32278571 DOI: 10.1016/j.ajem.2020.03.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/31/2020] [Indexed: 11/23/2022] Open
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