Allogeneic Stem Cell Therapy for Acute Ischemic Stroke: The Phase 2/3 TREASURE Randomized Clinical Trial.

Importance: Cell therapy is a promising treatment approach for stroke and other diseases. However, it is unknown whether MultiStem (HLCM051), a bone marrow-derived, allogeneic, multipotent adult progenitor cell product, has the potential to treat ischemic stroke. Objective: To assess the efficacy and safety of MultiStem when administered within 18 to 36 hours of ischemic stroke onset. Design, Setting, and Participants: The Treatment Evaluation of Acute Stroke Using Regenerative Cells (TREASURE) multicenter, double-blind, parallel-group, placebo-controlled phase 2/3 randomized clinical trial was conducted at 44 academic and clinical centers in Japan between November 15, 2017, and March 29, 2022. Inclusion criteria were age 20 years or older, presence of acute ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score of 8-20 at baseline), confirmed acute infarction involving the cerebral cortex and measuring more than 2 cm on the major axis (determined with diffusion-weighted magnetic resonance imaging), and a modified Rankin Scale (mRS) score of 0 or 1 before stroke onset. Data analysis was performed between May 9 and August 15, 2022. Exposure: Patients were randomly assigned to either intravenous MultiStem in 1 single unit of 1.2 billion cells or intravenous placebo within 18 to 36 hours of ischemic stroke onset. Main Outcomes and Measures: The primary end points were safety and excellent outcome at day 90, measured as a composite of a modified Rankin Scale (mRS) score of 1 or less, a NIHSS score of 1 or less, and a Barthel index score of 95 or greater. The secondary end points were excellent outcome at day 365, mRS score distribution at days 90 and 365, and mRS score of 0 to 1 and 0 to 2 at day 90. Statistical analysis of efficacy was performed using the Cochran-Mantel-Haenszel test. Results: This study included 206 patients (104 received MultiStem and 102 received placebo). Their mean age was 76.5 (range, 35-95) years, and more than half of patients were men (112 [54.4%]). There were no between-group differences in primary and secondary end points. The proportion of excellent outcomes at day 90 did not differ significantly between the MultiStem and placebo groups (12 [11.5%] vs 10 [9.8%], P = .90; adjusted risk difference, 0.5% [95% CI, -7.3% to 8.3%]). The frequency of adverse events was similar between treatment groups. Conclusions and Relevance: In this randomized clinical trial, intravenous administration of allogeneic cell therapy within 18 to 36 hours of ischemic stroke onset was safe but did not improve short-term outcomes. Further research is needed to determine whether MultiStem therapy for ischemic stroke has a beneficial effect in patients who meet specific criteria, as indicated by the exploratory analyses in this study. Trial Registration: ClinicalTrials.gov Identifier: NCT02961504.

Alternative Bypass Technique Using Radial Artery Graft between V3 Segment of Vertebral Artery and Middle Cerebral Artery: Technical Note.

BACKGROUND: There are some cases where a radial artery (RA) graft is needed for a high-flow extracranial to intracranial (EC-IC) bypass as the external carotid artery (ECA) cannot be utilized as a donor artery. In this report, we describe two cases of extracranial vertebral artery (VA) to middle cerebral artery (MCA) high-flow bypass using an RA graft with an artificial vessel as an alternative bypass technique. METHODS: The patient was placed supine with a head rotation of 80 degrees. After frontotemporal craniotomy, another C: -shaped skin incision was made at the retroauricular region and the V3 portion of the VA was exposed at the suboccipital triangle. Prior to attempting the high-flow bypass, the superficial temporal artery (STA) was anastomosed to the M4 portion of the MCA as an insurance bypass. The RA graft was anastomosed to the V3 portion of the VA that traveled under the periosteum at the supra-auricular region through an artificial vessel. After RA-M2 anastomosis, an alternative EC-IC bypass, the V3-RA-M2 bypass, was achieved. RESULTS: Postoperative angiography demonstrated successful graft patency and no perioperative complications were observed in both cases. CONCLUSIONS: In the cases where a high-flow bypass is required, the V3 portion of the VA is a suitable alternative proximal anastomosis site when the ECA is not a candidate donor. Furthermore, an artificial vessel shows satisfactory protection against graft complications.

Efficacy of 'drive and retrieve' as a cooperative method for prompt endovascular treatment for acute ischemic stroke.

BACKGROUND: Outcomes of endovascular treatment for acute ischemic stroke depend on the time interval from onset to reperfusion. Although the centralized 'mothership' method is considered preferable, the required transportation time increases the risk that a patient with a stroke may not receive intravenous or endovascular therapy. In contrast, 'drive and retrieve' describes a system wherein doctors from comprehensive stroke centers travel to primary stroke centers and provide endovascular treatment for acute ischemic stroke. OBJECTIVE: To describe the drive and retrieve system and verify the effects of this new collaboration on outcomes in patients with acute ischemic stroke among facilities. METHODS: This non-randomized, single-arm study retrospectively analyzed patients who met the inclusion criteria for endovascular treatment provided through a drive and retrieve system. Among the 122 patients treated by this system, we analyzed the time of onset to recanalization as the primary outcome. We also analyzed the efficacy of the drive and retrieve system using geographic information system analysis. RESULTS: The median time from onset to recanalization was 229 min (IQR 170-307 min, 95% CI 201 to 252 min). The upper limit of the 95% CI for the time from onset to recanalization was shorter than the median times reported in two previous trials. Geographic information system analysis revealed an upward trend in the population coverage rate in each secondary medical area after the drive and retrieve method was introduced. CONCLUSION: The drive and retrieve method may be an effective form of cooperation between facilities located within 1 hour of a comprehensive stroke center.

Monitoring Corticocortical Evoked Potentials During Intracranial Vascular Surgery.

BACKGROUND: Monitoring of corticocortical evoked potentials (CCEPs) during brain tumor surgery of patients under anesthesia was recently reported to be effective in assisting in preservation of speech function. The aim of this study was to investigate whether CCEPs can be reproducibly measured between the frontal and temporal lobes during standard intracranial vascular surgery under general anesthesia; whether dynamic changes in CCEPs caused by reduced focal cerebral blood flow can be measured; and whether CCEPs can be used to monitor speech function, particularly associated with the left side of the brain. METHODS: We monitored CCEPs during 58 vascular surgeries (42 clipping procedures; 15 bypasses, 1 of which overlapped with clipping; and 2 hematoma removals from the left frontal and temporal lobe) at Kashiwaba Neurosurgical Hospital from October 2016 to January 2018. RESULTS: CCEPs could be reproducibly and routinely monitored in bilateral vascular surgeries. None of the patients experienced any postoperative symptoms or showed any ischemic lesions on postoperative magnetic resonance imaging; however, 5 patients temporarily demonstrated reduced CCEPs intraoperatively that were caused by transient obstructions of blood flow. Motor evoked potentials and somatosensory evoked potentials were simultaneously monitored intraoperatively and did not show any changes. CONCLUSIONS: The results of our pilot study show that CCEPs can be routinely monitored during bilateral intracranial vascular surgery and that they are sensitive to ischemia. CCEPs on the left side could serve as unique intraoperative monitoring of speech function under anesthesia.

Direct Anastomosis Using Occipital Artery for Additional Revascularization in Moyamoya Disease After Combined Superficial Temporal Artery-Middle Cerebral Artery and Indirect Bypass.

BACKGROUND: The posterior cerebral artery (PCA) is involved in approximately 30% of moyamoya disease (MMD) cases. However, there have been insufficient reports describing revascularization techniques in the posterior portion of the brain, particularly of direct anastomosis. OBJECTIVE: To perform a technical assessment in patients with MMD who underwent either occipital artery (OA)-PCA bypass or OA-middle cerebral artery (MCA) bypass. METHODS: A total of 428 revascularization procedures in 368 patients were retrospectively assessed by reviewing clinical charts and radiological data. RESULTS: Ten patients (3.5%) were treated with direct bypass after the anterior revascularization with a median interval of 30 months (range, 5 months-16 years). Seven patients were < 18 years of age (average age, 17.5 ± 15.6 years). Preoperative symptoms included transient motor deficits involving the lower extremities (n = 5), visual disturbances (n = 6), and cerebral infarctions (n = 6). A favorable outcome (modified Rankin Scale score < 3) was achieved in 9 of these 10 patients. Direct anastomosis was performed in 3 hemispheres with an OA-MCA bypass and in 8 hemispheres with an OA-PCA bypass. Patency of the direct bypass was confirmed on angiogram in 7 of 7 patients who underwent conventional angiogram performed within 1 year after the surgery. None of the 10 patients demonstrated cerebral infarctions after the posterior revascularization. CONCLUSION: In MMD, symptomatic PCA regression after anterior revascularization was found predominantly in children and young adults. Direct anastomosis in the posterior portion of the brain can be successfully achieved and is effective in preventing ischemic events.

Transplanted bone marrow stromal cells protect neurovascular units and ameliorate brain damage in stroke-prone spontaneously hypertensive rats.

This study was aimed to assess whether bone marrow stromal cells (BMSC) could ameliorate brain damage when transplanted into the brain of stroke-prone spontaneously hypertensive rats (SHR-SP). The BMSC or vehicle was stereotactically engrafted into the striatum of male SHR-SP at 8 weeks of age. Daily loading with 0.5% NaCl-containing water was started from 9 weeks. MRIs and histological analysis were performed at 11 and 12 weeks, respectively. Wistar-Kyoto rats were employed as the control. As a result, T2-weighted images demonstrated neither cerebral infarct nor intracerebral hemorrhage, but identified abnormal dilatation of the lateral ventricles in SHR-SP. HE staining demonstrated selective neuronal injury in their neocortices. Double fluorescence immunohistochemistry revealed that they had a decreased density of the collagen IV-positive microvessels and a decreased number of the microvessels with normal integrity between basement membrane and astrocyte end-feet. BMSC transplantation significantly ameliorated the ventricular dilatation and the breakdown of neurovascular integrity. These findings strongly suggest that long-lasting hypertension may primarily damage neurovascular integrity and neurons, leading to tissue atrophy and ventricular dilatation prior to the occurrence of cerebral stroke. The BMSC may ameliorate these damaging processes when directly transplanted into the brain, opening the possibility of prophylactic medicine to prevent microvascular and parenchymal-damaging processes in hypertensive patients at higher risk for cerebral stroke.

Noninvasive transplantation of bone marrow stromal cells for ischemic stroke: preliminary study with a thermoreversible gelation polymer hydrogel.

OBJECTIVE: Recent studies have indicated that bone marrow stromal cells (BMSCs) have the potential to improve neurological function when transplanted into animal models of cerebral infarct. However, it is still undetermined how the BMSCs should be transplanted to obtain the most efficient therapeutic benefits safely. The aim of this study was to assess whether a thermoreversible gelation polymer (TGP) hydrogel acts as a noninvasive, valuable scaffold in BMSC transplantation for infarct brain. METHODS: The mice were subjected to permanent middle cerebral artery occlusion. Vehicle, BMSC suspension, or the BMSC-TGP construct was transplanted onto the ipsilateral intact neocortex at 7 days after the insult. Neurological symptoms were assessed throughout the experiments. The fate of the transplanted BMSC was examined 8 weeks after transplantation with immunohistochemistry. RESULTS: TGP hydrogel completely disappeared and provoked no inflammation in the host brain. Many transplanted cells were widely engrafted in the ipsilateral cerebrum, including the dorsal neocortex adjacent to the cerebral infarct in the BMSC-TGP construct-treated mice. Their number was significantly larger than in the BMSC-treated mice. The majority were positive for both NeuN and MAP2 and morphologically simulated the neurons. CONCLUSION: The findings suggest that surgical transplantation of tissue-engineered BMSCs onto the intact neocortex enhances the engraftment of donor cells around the cerebral infarct. These data may be useful in developing a noninvasive but efficient paradigm in neural tissue engineering. TGP hydrogel can be a promising candidate for valuable scaffolds in BMSC transplantation for central nervous system disorders because of its unique biochemical properties.

Synergistic effects of bone marrow stromal cells and a Rho kinase (ROCK) inhibitor, fasudil on axon regeneration in rat spinal cord injury.

Transplanted bone marrow stromal cells (BMSC) promote functional recovery after spinal cord injury (SCI) through multiple mechanisms. A Rho kinase inhibitor, Fasudil also enhances axonal regeneration. This study was aimed to evaluate whether combination therapy of BMSC transplantation and Fasudil further enhances axonal regeneration and functional recovery in rats subjected to SCI. Fasudil or vehicle was injected for 2 weeks. BMSC or vehicle transplantation into the rostral site of SCI was performed at 7 days after injury. Neurological symptoms were assessed throughout the experiments. Fluoro-Ruby was injected into the dorsal funiculus of the rostral site of SCI at 63 days after injury. The fate of the transplanted BMSC was examined using immunohistochemistry. BMSC transplantation significantly increased the number of Fluoro-Ruby -labeled fibers of the dorsal corticospinal tracts at the caudal site of SCI, enhancing functional recovery of the hind limbs. Some of the engrafted BMSC were positive for Fluoro-Ruby, neuronal specific nuclear protein and microtubule-associated protein-2, suggesting that they acquired neuronal phenotypes and built synaptic connection with the host's neural circuits. Fasudil treatment also improved axonal continuity, but did not promote functional recovery. Combination therapy dramatically increased the number of Fluoro-Ruby-labeled fibers of the dorsal corticospinal tracts at the caudal site of SCI, but did not further boost the therapeutic effects on locomotor function by BMSC transplantation. The findings suggest that BMSC transplantation and Fasudil provide synergistic effects on axon regeneration after SCI, although further studies would be necessary to further enhance functional recovery.

Bone marrow stromal cells and bone marrow-derived mononuclear cells: which are suitable as cell source of transplantation for mice infarct brain?

There are few studies that denote whether bone marrow stromal cells (BMSC) and bone marrow-derived mononuclear cells (MNC) show the same therapeutic effects, when directly transplanted into the infarct brain. This study therefore aimed to compare their biological properties and behaviors in the infarct brain. Mouse BMSC were harvested and cultured. Mouse MNC were obtained through centrifugation techniques. Their cell markers were analyzed with FACS analysis. The MNC (10(6) cells; n = 10) or BMSC (2 x 10(5) cells; n = 10) were stereotactically transplanted into the ipsilateral striatum of the mice subjected to permanent middle cerebral artery occlusion at 7 days after the insult. Their survival, migration, and differentiation in the infarct brain were precisely analyzed using immunohistochemistry 4 weeks after transplantation. The MNC were positive for CD34, CD45, CD90, but were negative for Sca-1. The BMSC were positive for CD90 and Sca-1. The transplanted BMSC, but not MNC, extensively migrated into the peri-infarct area. Approximately 20% of the transplanted BMSC expressed a neuronal marker, NeuN in the infarct brain, although only 1.4% of the transplanted MNC expressed NeuN. These findings strongly suggest that there are large, biological differences between MNC and BMSC as cell sources of regenerative medicine for ischemic stroke.

[Case allocation in the management of ruptured anterior communicating aneurysm using endovascular embolization as a first option].

OBJECTIVE: The management of ruptured anterior communicating aneurysms remains controversial since the results of ISAT have been reported. The aim of our study is to report our decision-making process and outcome in 36 consecutive cases using endovascular coil embolization as a first choice of treatment. PATIENTS AND METHODS: Thirty-six patients were studied. Since April, 2004, the treatment modality has been decided after discussion between the endovascular and cerebrovascular surgeons, taking into account the physiological status, treatment risk and morphology of the aneurysm. RESULTS: Twelve (33%) of 36 patients were allocated to coil embolization. Factors leading to the selection of clipping surgery were decided mostly by the morphology of the aneurysm, namely, tiny in 11 (47.8%), irregular shape in 6 (26.1%), broad neck in 3 (13.0%) and bleb located at the neck in 3 (13.0%). Half of the aneurysms projecting anteriorly were treated coil embolization. CONCLUSION: The allocation rate of endovascular treatment in ruptured anterior communicating aneurysms was 33%. Endovascular treatment was effective in at least half of the anterior the projecting aneurysms.

Transplanted bone marrow stromal cells promote axonal regeneration and improve motor function in a rat spinal cord injury model.

OBJECTIVE: Recent studies have indicated that bone marrow stromal cells (BMSCs) have the potential to improve neurological function when transplanted into animal models of spinal cord injury (SCI). However, it is still unclear how the transplanted BMSCs promote functional recovery after SCI. In this study, therefore, we evaluated how the transplanted BMSCs restore the function of the dorsal corticospinal tracts in the injured spinal cord. METHODS: The rats were subjected to incomplete SCI by means of a pneumatic impact device. BMSC or vehicle transplantation into the rostral site of SCI was performed at 7 days after injury. Neurological symptoms were assessed throughout the experiments. Fluoro-Ruby was injected into the dorsal funiculus of the rostral site of SCI at 63 days after injury. The fate of the transplanted BMSCs was examined using immunohistochemistry. RESULTS: BMSC transplantation significantly enhanced functional recovery of the hind limbs. The number of Fluoro-Ruby-labeled fibers of the dorsal corticospinal tracts at the caudal site of SCI was significantly higher in the BMSC-transplanted animals than in the vehicle-transplanted animals. Some of the engrafted BMSCs were positive for Fluoro-Ruby, NeuN, and MAP2 in the gray matter, suggesting that they acquired neuronal phenotypes and built synaptic connection with the host's neural circuits. Others in the white matter morphologically simulated the astrocytes and were also positive for glial fibrillary acidic protein. CONCLUSION: The findings suggest that the transplanted BMSCs acquire neural cell phenotypes around the injury site and contribute to rebuild the neural circuits, including the corticospinal tract, promoting functional recovery of the hind limbs.

Synergistic effects of granulocyte-colony stimulating factor on bone marrow stromal cell transplantation for mice cerebral infarct.

This study was aimed to assess whether ex vivo treatment with granulocyte-colony stimulating factor (G-CSF) modifies biological properties of bone marrow stromal cells (BMSC) and enhances functional recovery by BMSC transplantation into infarct brain. Immunohistochemistry was conducted to characterize the cultured BMSC. The pharmacological effects of G-CSF on their proliferation, cell cycle, and growth factor production were precisely analyzed, using FACS and ELISA techniques. Non-treated or G-CSF treated BMSC were stereotactically transplanted into the mice brain subjected to cerebral infarct, and its effects on functional and histological aspects were evaluated. The BMSC expressed the receptor for G-CSF. Treatment with 0.1muM of G-CSF significantly enhanced the proliferation of BMSC by increasing their population in S phase, and increased their production of SDF-1alpha, HGF, and NGF. When transplanted into infarct brain, G-CSF treated BMSC significantly improved motor function as early as 2 weeks after transplantation, whereas non-treated BMSC did 4 weeks after transplantation. These findings strongly suggest that G-CSF may enhance the proliferation and growth factor production of the cultured BMSC and accelerate functional restoration by BMSC transplantation. Such pharmacological "activation" of the BMSC may contribute to successful clinical application of BMSC transplantation therapy for ischemic stroke.

Transplanted bone marrow stromal cells improves cognitive dysfunction due to diffuse axonal injury in rats.

Diffuse axonal injury (DAI) often leads to persistent cognitive dysfunction in spite of the lack of gross lesions on MRI. Therefore, this study was aimed to evaluate whether transplanted bone marrow stromal cells (BMSC) can improve DAI-induced cognitive dysfunction or not. The rats were subjected to impact acceleration head injury, using a pneumatic high-velocity impactor. The BMSC were harvested from the mice and were cultured. The BMSC (4.0 x 10(5) cells) or vehicle were stereotactically transplanted into the right striatum at 10 days post-injury. Cognitive function analysis was repeated at 1, 2, and 4 weeks post-injury, using the Morris water maze test. Histological analysis was performed at 2, 8 and 20 weeks post-injury, using double fluorescence immunohistochemistry. Transplanted BMSC were widely distributed in the injured brain and gradually acquired the phenotypes of neurons and astrocytes over 20 weeks. In addition, they significantly improved DAI-induced cognitive dysfunction as early as 2 weeks post-injury, although their processes of neuronal differentiation were not completed at this time point. The findings suggest that the engrafted BMSC may exhibit this early beneficial effect on cognitive function by producing neuroprotective or neurotrophic factors. In conclusion, direct transplantation of BMSC may serve as a novel therapeutic strategy to enhance the recovery from DAI-induced cognitive impairment.

[Motor cortex stimulation for post-stroke pain using neuronavigation and evoked potentials: report of 3 cases].

Although motor cortex stimulation (MCS) has been accepted as an effective therapeutic option for central pain, the efficacy of MCS widely varies among previous reports. In this report, we describe our recent trial for successful MCS in 3 patients with central pain due to cerebral stroke. Medical treatments were transiently effective, but gradually became ineffective in all of the cases. During surgery, the appropriate cortical target was determined by using neuronavigation, somatosensory evoked potential (SEP), and motor evoked potential (MEP). A flat, four-plate electrode was positioned on the dura mater parallel to the motor cortex. After surgery, pain almost resolved in 2 of 3 patients and markedly improved in another. The pain relief depended on their motor function. These findings strongly suggest that both patient selection and intraoperative monitoring for targeting the motor cortex are quite important for successful MCS, although further studies were essential.

[CNS sarcoidosis presenting with intracerebral hemorrhage: case report].

Sarcoidosis is a systemic, chronic inflammatory disease characterized by non-caseating epithelioid granuloma. It is well known that the central nervous system (CNS) is also involved in about 5% of patients with systemic sarcoidosis. Although CNS sarcoidosis presents with various neurological manifestations, intracerebral bleeding is quite rare. In this report, we describe a case in which a patient suffered from intracerebral hemorrhagic due to CNS sarcoidosis. A 57-year-old male who had been diagnosed as having systemic sarcoidosis was admitted to our hospital due to status epilepticus. Plain CT scan showed a subcortical hematoma in the left marginal gyrus. Serial MR imaging revealed that an enhanced mass in the overlying cortex had gradually increased its size. Subsequently, the enhanced mass and hematoma were totally removed, using a navigation system. Pathological examination revealed typical findings of sarcoidosis. We discuss the mechanism of intracerebral bleeding due to CNS sarcoidosis in this report.

[Idiopathic spinal cord herniation which extended remarkably up- and downward from dural defect: case report].

A case of idiopathic spinal cord herniation which extended remarkably up- and downward from a dural defect is described. A 53-year-old woman presented with numbness and pain of the right lower limb. Magnetic resonance (MR) imaging revealed ventral displacement of the spinal cord and dilation of the dorsal subarachnoid space at T4-5. CT Myelography showed ventral deviation of the spinal cord at the T4/5 level. A laminectomy of T3-T5 was performed, and the herniated spinal cord was untethered and wrapped by Goretex membrane. Postoperative MR image revealed normal location of the spinal cord. Among many cases of spinal cord herniations, this one is considered to be a rare case of idiopathic spinal cord herniation which showed marked protrusion up- and downward from a dural defect.