Clinical and imaging outcomes after Intrathecal injection of umbilical cord tissue mesenchymal stem cells in cerebral palsy: a randomized double-blind sham-controlled clinical trial Study Below:

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Abstract

Background: This study assessed the safety and efficacy of intrathecal injection of umbilical cord tissue mesenchymal stem cells (UCT-MSC) in individuals with cerebral palsy (CP). The diffusion tensor imaging (DTI) was performed to evaluate the alterations in white-matter integrity. Methods: Participants (4–14 years old) with spastic CP were assigned in 1:1 ratio to receive either UCT-MSC or sham procedure. Single-dose (2 × 107) cells were administered in the experimental group. Small needle pricks to the lower back were performed in the sham-control arm. All individuals were sedated to prevent awareness. The primary endpoints were the mean changes in gross motor function measure (GMFM)-66 from baseline to 12 months after procedures. The mean changes in the modified Ashworth scale (MAS), pediatric evaluation of disability inventory(PEDI), and CP quality of life (CP-QoL) were also assessed. Secondary endpoints were the mean changes in fractional anisotropy (FA) and mean diffusivity (MD) of corticospinal tract (CST) and posterior thalamic radiation (PTR).

can also be useful to better understand the underlying mechanisms of stem cells in neuronal repair.

Conclusions

The intrathecal injection of the UCT-MSC may be safe in children diagnosed with CP and improve the clinical and imaging outcomes.

Results: There were 36 participants in each group. The mean GMFM-66 scores after 12 months of intervention were significantly higher in the UCT-MSC group compared to baseline (10.65; 95%CI 5.39, 15.91) and control (β 8.07; 95%CI1.62, 14.52; Cohen’s d 0.92). The increase was also seen in total PEDI scores (vs baseline 8.53; 95%CI 4.98, 12.08; vs control: β 6.87; 95%CI 1.52, 12.21; Cohen’s d 0.70). The mean change in MAS scores after 12 months of cell injection reduced compared to baseline (−1.0; 95%CI −1.31, −0.69) and control (β −0.72; 95%CI −1.18, −0.26; Cohen’s d 0.76).Regarding CP-QoL, mean changes in domains including friends and family, participation in activities, and communication were higher than the control group with a large effect size. The DTI analysis in the experimental group showed that mean FA increased (CST 0.032; 95%CI 0.02, 0.03. PTR 0.024; 95%CI 0.020, 0.028) and MD decreased (CST −0.035 × 10-3; 95%CI −0.04 × 10-3, −0.02 × 10-3. PTR −0.045 × 10-3; 95%CI −0.05 × 10-3, −0.03 × 10-3); compared tobaseline. The mean changes were significantly higher than the control group.

Conclusions: The UCT-MSC transplantation was safe and may improve the clinical and imaging outcomes.

Trial registration: The study was registered with ClinicalTrials.gov (NCT03795974).

Keywords: Cerebral palsy, Stem cell, Diffusion tensor imaging, Gross motor function, Children

Introduction

Stem cells are defined as pluripotent cells with the ability of self-renewal and the capacity of differentiation into the other cell types. There has been greater interest in the use of stem cell therapy in recent years; especially for the treatment of neurological disorders [1]. The central nervous system (CNS) is unable to regenerate new cells and damages to CNS can be permanent. Several studies assessed the safety and efficacy of different stem cells in the treatment of individuals diagnosed with stroke [2], multiple sclerosis [3], Parkinson’s disease[4], Huntington’s disease [5], and spinal cord injury [6].To date, many aspects of cell-based therapy remained unknown. The optimal dose, the most appropriate type of cell, and the best route of cell administration should be identified to provide safe and effective protocols without raising ethical concerns. Different underlying mechanisms of action have been described to justify the potential efficacy of stem cell therapy. Regarding mesenchymal stem cells (MSCs), it is believed that paracrine signaling and immunomodulation have the most critical effects. These cells can release neurotrophic factors, anti-oxidant molecules, angiogenic, anti-inflammatory, anti-fibrotic, and anti-apoptotic agents that enhance tissue repair after injury [7, 8]. The capacity of MSCs to regenerate and differentiate to new cells is another proposed mechanism [9] but studies reported its limited efficacy and showed that migration of cells to the site of injury is not necessary [7]. It is now clear that the mechanism of action for many stem cells is not a consequence of differentiation [10].The umbilical cord derives from the yolk sac and contains two arteries, one vein, and a gelatinous substance composed of sulfated proteoglycans with collagenous fibers; known as Wharton’s jelly [11]. The umbilical cord was found to have great proportions of stem cells. The first successful stem cell transplant was from umbilical cord blood cells on a 6-year-old-boy with Fanconi anemia in 1988 [12]. Low immunogenicity, low risk of graft versus host disease, and ease of cell collection are major advantages of using cells derived from the umbilical cords [11]. Umbilical cord tissue mesenchymal stem cell (UCT-MSC) has been used in recent studies to determine their safety and clinical efficacy [13–15].Cerebral palsy (CP) is the leading cause of physical disability in children and is known as a group of non-progressive permanent CNS disorders that affected movements, muscle tone, and coordination [16]. The global prevalence of CP was estimated to be up to 3 per1000 individuals [17]. Preclinical studies reported that some types of stem cells (e.g., MSC) had neuro protective effects on animal models of neonatal hypoxia-ischemia[18–20]. Few randomized trials demonstrated the promising clinical effects of stem cell therapy in children with CP (reviewed in [21–23]). We conducted this randomized double-blind sham-controlled trial to assess the safety and clinical effects of intrathecal injection of UCT-MSC in CP. To assess the impact of cell therapy on the alteration of white matter integrity, we performed quantitative diffusion tensor imaging (DTI) before and after treatment. DTI is a non-invasive imaging method that can characterize the micro-structural changes in white matter tracts based on the diffusion of water molecules. We hypothesized that the UCT-MSC could significantly improve clinical and imaging outcomes compared to the control group (superiority trial).

Abbreviations

ANOVA: Analysis of variance; CI: Confidence interval; CNS: Central nervoussystem; CP: Cerebral palsy; CP-QoL: Cerebral palsy quality of life;CST: Corticospinal tract; DMEM: Dulbecco’s modified Eagle’s medium;DTI: Diffusion tensor imaging; EEG: Electro-encephalography; FA: Fractionalanisotropy; GEE: Generalized estimating equations; GMFCS: Gross motorfunction classification system; GMFM: Gross motor function measure;LAL: Limulus amebocyte lysate; MD: Mean diffusivity; MAS: ModifiedAshworth scale; MRI: Magnetic resonance imaging; PEDI: Pediatric evaluationof disability inventory; PTR: Posterior thalamic radiation; ROI: Region of interest; SD: Standard deviation; SEM: Standard error of the mean; UCT-MSC: Umbilical cord tissue mesenchymal stem cellSupplementary information The online version contains supplementary material available at https://doi.org/10.1186/s13287-021-02513-4.

Additional file 1: Supplement 1. Levels of gross motor functionclassification system (GMFCS).

Additional file 2: Supplement 2. Modified Ashworth scale

Additional file 3: Supplement 3. Sample size calculation

Additional file 4: Supplement 4. CONSORT 2010 checklist of information to include when reporting a randomised trial*

Acknowledgements The authors are grateful to all parents and patients for their participation inthis study. Our special thanks to Mr. Abolfazl Abdi, Mrs. Asa Fazilat, Dr. SamiraRaminfard, Dr. Houman Alizadeh, and Dr. Neda Pak for analyses of DTI data.

Authors’ contributionsMA, ARM, and MRA conducted the study design. SN and MGA performedthe rehabilitation therapy. HoM, HaM,AM, MZ, MN, RSB, AAH, and MV performed data acquisition. OG, FZ, and MH conducted the brain imaging of participants. MA and ART performed the interpretation of data and statisticalanalysis. MA and MS prepared the draft of the manuscript. AF and AGrevised the paper before submission. The author(s) read and approved thefinal manuscript.

Funding The Research Deputy of Tehran University of Medical Sciences providedfinancial and logistic support for this trial but had no role in study design,the collection, analysis, and interpretation of data, in the writing of thereport, or in the decision to submit the article for publication.

Availability of data and materials The datasets generated and/or analyzed during the current study are notpublicly available but are available from the corresponding author onreasonable request.

DeclarationsEthics approval and consent to participate The procedures were fully explained to the participants and their parents.Ethics committee of Tehran University of Medical Sciences approved thefinal methods (Number: IR.TUMS.VCRREC.1996.2506). Parents of participantshad access to all information. They were informed that participation wasoptional and withdrawal was possible whenever they asked for.Consent for publicationNot applicable.

Competing interests The authors declare that they have no competing interests.

Author details1Department of Science and Research Branch, AJA University of MedicalSciences, Tehran, Iran. 2Pediatrics Center of Excellence, Department of Pediatric Neurology, Children’s Medical Center, Growth and DevelopmentResearch Center, Tehran University of Medical Sciences, Tehran, Iran.3Department of Regenerative Medicine, Cell Science Research Center, RoyanInstitute for Stem Cell Biology and Technology, ACECR, Tehran, Iran.4Department of Pediatric Neurology, Clinical Research Development Centerof Children Hospital, Hormozgan University of Medical Sciences, BandarAbass, Iran. 5Pediatrics Center of Excellence, Department of Radiology,Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran.6Clinical Biomechanics and Ergonomics Research Center, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran. 7Pediatrics Center of Excellence PediatricHematology, Oncology and Stem Cell Transplantation Department, Children’sMedical Center, Tehran University of Medical Sciences, Tehran, Iran.8Psychiatry and Psychology Research Center, Tehran University of MedicalSciences, Tehran, Iran. 9Department of Pediatrics, Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran. 10Departmentof Pediatric Neurology, AJA University of Medical Sciences, Tehran, Iran.11Moser Center for Leukodystrophies, Kennedy Krieger Institute, Baltimore,MD 21205, USA. 12Department of Neurology and Pediatrics, Johns HopkinsUniversity School of Medicine, Baltimore, MD 21287, USA. 13Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. 14Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.Received: 15 December 2020 Accepted: 8 June 2021

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