Alzheimer DiseasePhase 1/2BOREAL1NCT03119961
Blood Brain Barrier Opening in Alzheimer' Disease
A Phase 1/2 study testing SONOCLOUD® in people with Alzheimer Disease, run by Assistance Publique - Hôpitaux de Paris at 1 site in France.
Trial summary
In Alzheimer's disease (AD) an imbalance between the production and clearance of the ß-amyloid peptide is hypothesized as the driving event of the disease. The decreased clearance of Aß could be partly linked to a progressive dysfunction of the brain vasculature and of the blood brain barrier (BBB). Read more about this study
- Who is it for?
- Ages 50 to 85 years
- Conditions the study is for
- Alzheimer Disease
- What is being tested?
- SONOCLOUD®
- Type of treatment
- Medical device
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 10 participants
- Where
- 1 siteFrance
- Study dates
- 26 Jun 2017to 7 Oct 2020
- Phase
- Phase 1/2
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 50 to 85 years
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Age between 50 and 85 years old
- Alzheimer's disease, typical or atypical according to International Working Group-2 (IWG-2) criteria,
- diagnosed on the basis of a cognitive assessment and an MRI, showing one of the three most frequent phenotypic presentations of the disease (hippocampal amnesia or logopenic aphasia or syndrome of posterior cortical atrophy)
- certified by the CSF assay of biomarkers of the AD ratio PTau / Aβ> 0.11.
- Mild disease (MMSE 20-26) but presently pejorative outcome: relatively young subject (<80 years), "rapid" cognitive decline and high CSF tau rate (> 600pg / mL, for A diagnostic threshold of Alzheimer's disease of 450pg / mL). The evaluation of the pejorative evolution will be validated by the Committee of Experts of the Memory Center (IM2A at Pitié-Salpêtrière Hospital)
- Patients under stable Alzheimer's treatment for at least 3 months prior to entry into the study and in which no change is envisaged in the next months in order to avoid a loss of chance for the patient and to consider an aggravation at cessation of treatment as an adverse event due to the opening of the BBB.
- Affiliate or beneficiary of Affiliated to the French Health care system
- Patient and caregiver (undertaking to accompany the participant to the various necessary medico-surgical visits and spending at least 3 hours per day with the patient) having signed, free and informed consent.
Who cannot join
- Allergy to Gadolinium, Xylocaine or any contraindication to contrast products used for brain imaging, or to drugs used in perioperative procedures.
- Contraindications to SonoVue®
- hypersensitivity to sulfur hexafluoride
- recent acute coronary syndrome or unstable ischemic heart disease
- heart failure, chronic or acute stage III or IV,
- patient undergoing drug therapy incorporating dobutamine,
Show all 24Show fewer
- severe pulmonary arterial hypertension
- uncontrolled systemic hypertension,
- respiratory distress syndrome
- Severe renal impairment with glomerular filtration rate (GFR) <30 mL / min / 1.73 m2 (Gadolinium IC)
- Hepatic impairment characterized by international normalized ratio (INR)> 1.5 or Factor V <50% of the standard.
- Patient taking an associated treatment considered potentially toxic to the central nervous system (CNS).
- Patient included or having participated in the 5 years preceding the inclusion in this study in another research protocol on Alzheimer's (medical treatment or medical device).
- Epilepsy or potentially pro-convulsive medication
- Ischemic or haemorrhagic stroke consisting of supracentimetric vascular leucopathy with a grade greater than 2 in the classification of Fazekas and Schmidt
- Presence of at least one lobar micro-bleeding identified in MRI performed in current care prior to inclusion (SWI sequence) in the sonication zone (left supramarginal gyrus)
- Chronic and abusive consumption of toxic (alcohol or drugs) except tobacco.
- Contra-indication to MRI (intracorporeal metallic material, claustrophobia)
- Hemostasis disorders (thrombocytopenia <75,000, prothrombin ratio (PR) <60%, INR> 1.5, antiplatelet therapy or anticoagulant in progress)
- Phlebitis or active pulmonary embolism
- Patient unable to perform cognitive tests (less than 7 years of study, mother tongue different from French, severe unpaired sensory disorder).
- Patient under judicial protection
- Absence of accompanying person
- Patient with an ongoing infection clinically characterized by febrile syndrome and possible calling points (cough, pain, skin lesion, etc.) OR biologically suspected on C-reactive protein(CRP)> 10, Procalcitonin> 0.1, positive examination of the urine (CBEU).
Trial locations and contacts
1 site in 1 country.
About this study
Official title: Phase 1/2 Open Single-arm Monocentric Study Evaluating the Tolerance and Interest of Transient Opening of the Blood-Brain Barrier by Low Intensity Pulsed Ultrasound With the SONOCLOUD® Implantable Medical Device in Mild Alzheimer's Disease Patients (MMSE 20-26)
In Alzheimer's disease (AD) an imbalance between the production and clearance of the ß-amyloid peptide is hypothesized as the driving event of the disease. The decreased clearance of Aß could be partly linked to a progressive dysfunction of the brain vasculature and of the blood brain barrier (BBB). Among many possible explanations for these failures of the multiple clinical trials evaluating innovative drugs in AD, one is the lack of target engagement, as none of these drugs is able to readily cross BBB. This barrier acts as a wall that actively and passively prevents the crossing of molecules between the blood and the brain parenchyma compartments. Only 0.3% of intravenously injected anti-Aß immunoglobulins reach the brain despite a half-life of 15-20 days. Low intensity Focal ultrasound associated to microbubble injection can open the BBB in a non invasive way. These openings are reversible in 2 hours to 2 days depending on the intensity of the ultrasound. Ultrasound opening of the BBB was initially used in a transgenic mouse model of AD to increase the brain delivery of an anti-Aß antibody. In this article, the Aß load was reduced in ultrasound treated brain region. Surprisingly it was then demonstrated that the simple opening of the BBB without any adjunct anti-Aß treatment was able to drive the same Aß clearance effects. This is probably linked to endogenous antibodies that are able to penetrate the brain parenchyma and target Aß plaques. Four opening sessions elicited positive promnesic effects in these mice. Our group conceived and developed a mean to easily, reproductively and innocuously open the BBB. A unique extra-dural ultrasound emitter (sonoCloud®) is surgically implanted in the skull under local anesthesia. It emits low intensity contact ultrasound (LICU) that are not deterred by bone and thus are able to open the BBB.Preclinical studies show the SonoCloud® device is safe and efficient as it allowed reproducible and repeatable opening of the BBB in rabbits, dogs and non human primates. Drugs up to 2000 Kilo Daltons (kDa) are able to cross the BBB to reach the brain parenchyma in which the concentration of Carboplatin was increased by 700% in the BBB opened region. No adverse event was evidenced both clinically, by EEG, Evoked potential, MRI, 18 Fluorodeoxyglucose (FDG) PET and histology in the primates after 7 bi-monthly sessions of LICU BBB opening. SonoCloud® and its external generator have been certified by the academic start-up CarThéra (APHP, UPMC). Our multidisciplinary skills (neurology, neurosurgery, neuroimaging, basic science departments in the same University hospital setting) and our previous experience of BBB opening in Man give us the unique opportunity to translate this procedure from neuro-oncology to AD which could 1) Have a positive effect on brain lesion load and symptoms by itself and 2) allow anti-AD (or more broadly, central nervous system) drugs to engage their targe
Read the detailed description
Background:
Alzheimer's disease is the most prevalent neurodegenerative disease totalizing 33 million patients worldwide. If nothing is done to decrease the incidence of 1.8 Million patient/year, the prevalence will double in the next 20 years.
Physiopathologically, the amyloid cascade remains the predominant hypothesis. It states that an imbalance between the production and clearance of the ß-amyloid peptide is the driving event of the disease, leading to Tau hyperphosphorylation and accumulation in neurons as neurofibrillary tangles, neurodegeneration (synaptic and neuronal loss) and cognitive impairment. The decreased clearance of Aß could be partly linked to a progressive dysfunction of the brain vasculature and of the BBB.
New sets of diagnosis criteria for AD have been proposed to address the low specificity (70%) of the previous ones, that could be one of the causes of failure of previous clinical trials. Among these new criteria, cerebrospinal fluid (CSF) biomarkers and positon emission tomography (PET) with new ligands of amyloid plaques and more recently tau deposition are indicators of the underlying histopathology of the disease, and can also be used to evaluate early intervention efficacy as they are pathologic in the preclinical phase of AD, its prodromal phase.
the investigators aim to test an innovative BBB opening procedure that could drastically decrease AD patients' brain lesion load and alleviate their symptomatology.
Scientific/medical questions:
- What is the tolerance of LICU and the SonoCloud® device in a population of patients with mild AD? 2) What are the physiopathological impact of LICU BBB opening in these patients as asserted by amyloid and 18FDG PET-MRI?
Objectives:
For the first phase I clinical trial in the world using LICU in AD to repeatedly open the BBB.
Primary objective: To evaluate the tolerance of the BBB opening session in 5 AD patients (Adverse event recording, cognitive and MRI evaluations).
Co-primary objective: To assess the impact of BBB opening on the hallmark lesions of AD (Aß \& Tau) through PET-MRI imaging (decrease of the standardized uptake value ratio (SUVR) after vs. before treatment in the left supramarginal gyrus and left (treated) vs. right (untreated) supramarginal gyrus).
Secondary objective: increase cognitive performance in AD patients through the repeated opening of the BBB in the left supramarginal gyrus
Methods :
Ten patients suffering from mild AD will be included in the study.
Protocol :
Seven BBB opening session will be performed at a bi-monthly rate focusing on the left supramarginal gyrus, a cortical structure known to be affected by both amyloid and tau lesions early on during the evolution of the disease. All adverse events induced by surgery itself or by the LICU will be recorded. Amyloid ß and Tau lesion load will be evaluated benefiting from the PET-MRI that allows to clearly evaluate fine changes in SUVR taking into account loco-regional cortical specificity (cortical thickness). PET image analysis.
Mean Standard Uptake Values Ratios (SUVR) will be calculated with cerebellar gray matter activity as reference in volumes of interest. Voxel-wise uptake will then be divided by this reference value to get SUVR maps. PET images will be corrected for motion and partial volume effect thanks to simultaneous MRI acquisition. To analyze the longitudinal PET data, each follow-up T1-weighted MRI will be co-registered to the baseline MRI, and a within-subject template image will be calculated by averaging the coregistered T1-weighted images. This mean image will be used to calculate optimal transformation parameters to Montreal Neurological Institute (MNI) space. Next, baseline and follow-up PET images will be co-registered to the baseline MRI, spatially normalized to MNI using this optimal transformation, and scaled with cerebellar gray uptake. Individual percent annual changes maps will be then calculated. These maps will represent the voxel-wise calculation of percent metabolic change after BBB opening.
The investigators think that the clinical trial will be well tolerated by the patients as the rate of local adverse events is expected to be 1% since the SonoCloud device implantation is extra dural (without dura opening). The implantation is performed under local anaesthesia in an outclinic fashion.
Drawbacks and possible solution to overcome the problems :
Among expected drawback the investigators will have to be very vigilant for Amyloid related imaging anomalies (ARIAs) due to the sudden entry of endogenous antibodies in the brain parenchyma of patients with Aß and Tau prevalent lesions. If these ARIAs were to happen, an amendment of the protocol could be devised to add steroids, or reduce ultrasound intensity, or extend time during each opening session, or reduce number of BBB opening session, or in last use immunosuppressive drugs prior to the opening of the BBB.
This is the first study worldwide with the means to safely, repeatedly and reproductively open the BBB in AD, or more broadly, in any neurodegenerative disease. It is noteworthy to consider that it is only a phase I study aiming to demonstrate the feasibility of the technique in a mild form of AD. If this is the case and even in the absence of a positive effect on the lesions and symptoms it will then be possible to propose new projects aiming to associate these safe BBB opening to anti-AD drugs. In fact, this study could pave the way for further treatment venues of various neurodegenerative disease that share a brain accumulation of proteins that cannot be readily targeted in case of BBB integrity.
- Conditions
- Alzheimer Disease
- Being tested
- SONOCLOUD®
- Keywords
- Amyloid Amyloid Plaque, Tau Protein, Sonication
- Medical subject headings
- Alzheimer Disease, Plaque, Amyloid, Frontotemporal Dementia
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
SONOCLOUD®Device
Also called BBB opening
BBB opening by ultrasound
| Study group | Role | What they receive |
|---|---|---|
| SONOCLOUD® | Experimental | BBB opening by ultrasound Receives: Device: SONOCLOUD® |
What is being measured
The primary outcome is the main question the study is designed to answer.
Florbetapir SUVr and Fluorodeoxyglucose MUV changes in BBB opening region of interest (ROI)
PET MRI evaluation
Measured: Change from baseline at 4month and 8 month
Secondary outcomes (1)
Adverse events recording
Clinical and MRI evaluation
Measured: up to 9 months
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted19 Apr 2017
- Study start26 Jun 2017
- Primary completion2 Oct 2020
- Study completion7 Oct 2020
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (33)Papers the sponsor has linked to this study.
- Other trials for Alzheimer DiseaseStudies of the same condition, open and under way.
- More trials run by Assistance Publique - Hôpitaux de ParisThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 1/2
- Primary purpose
- Treatment
- Allocation
- Not applicable
- Intervention model
- Single group
- Masking
- None (open label)
- Enrolment
- 10 participants (actual)
Sponsor and investigators
- Lead sponsor
- Assistance Publique - Hôpitaux de Paris
- Sponsor type
- University, hospital or other
- Collaborators
- CarThera, BPIfrance
- Responsible party
- Sponsor
- Investigators
- Stephane EPELBAUM, MD, PhD, Principal investigator, Assistance Publique Hoptiaux de Paris
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03119961
- Sponsor's protocol ID
- P150101
- Other IDs
- 2016-004145-82, B2016-A01637-44, 2016
- Acronym
- BOREAL1
- Status last verified
- Nov 2020
- First submitted
- 27 Feb 2017
- Last updated
- 12 Apr 2022
- Results posted
- No
- Data monitoring committee
- Yes
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- Undecided
Publications
Carpentier A, Canney M, Vignot A, Reina V, Beccaria K, Horodyckid C, Karachi C, Leclercq D, Lafon C, Chapelon JY, Capelle L, Cornu P, Sanson M, Hoang-Xuan K, Delattre JY, Idbaih A. Clinical trial of blood-brain barrier disruption by pulsed ultrasound. Sci Transl Med. 2016 Jun 15;8(343):343re2. doi: 10.1126/scitranslmed.aaf6086.
PubMed 27306666Horodyckid C, Canney M, Vignot A, Boisgard R, Drier A, Huberfeld G, Francois C, Prigent A, Santin MD, Adam C, Willer JC, Lafon C, Chapelon JY, Carpentier A. Safe long-term repeated disruption of the blood-brain barrier using an implantable ultrasound device: a multiparametric study in a primate model. J Neurosurg. 2017 Apr;126(4):1351-1361. doi: 10.3171/2016.3.JNS151635. Epub 2016 Jun 10.
PubMed 27285538Goldwirt L, Canney M, Horodyckid C, Poupon J, Mourah S, Vignot A, Chapelon JY, Carpentier A. Enhanced brain distribution of carboplatin in a primate model after blood-brain barrier disruption using an implantable ultrasound device. Cancer Chemother Pharmacol. 2016 Jan;77(1):211-6. doi: 10.1007/s00280-015-2930-5. Epub 2015 Dec 8.
PubMed 26645405Beccaria K, Canney M, Goldwirt L, Fernandez C, Piquet J, Perier MC, Lafon C, Chapelon JY, Carpentier A. Ultrasound-induced opening of the blood-brain barrier to enhance temozolomide and irinotecan delivery: an experimental study in rabbits. J Neurosurg. 2016 Jun;124(6):1602-10. doi: 10.3171/2015.4.JNS142893. Epub 2015 Nov 13.
PubMed 26566207Beccaria K, Canney M, Goldwirt L, Fernandez C, Adam C, Piquet J, Autret G, Clement O, Lafon C, Chapelon JY, Carpentier A. Opening of the blood-brain barrier with an unfocused ultrasound device in rabbits. J Neurosurg. 2013 Oct;119(4):887-98. doi: 10.3171/2013.5.JNS122374. Epub 2013 Jun 21.
PubMed 23790118Jordao JF, Ayala-Grosso CA, Markham K, Huang Y, Chopra R, McLaurin J, Hynynen K, Aubert I. Antibodies targeted to the brain with image-guided focused ultrasound reduces amyloid-beta plaque load in the TgCRND8 mouse model of Alzheimer's disease. PLoS One. 2010 May 11;5(5):e10549. doi: 10.1371/journal.pone.0010549.
PubMed 20485502Jordao JF, Thevenot E, Markham-Coultes K, Scarcelli T, Weng YQ, Xhima K, O'Reilly M, Huang Y, McLaurin J, Hynynen K, Aubert I. Amyloid-beta plaque reduction, endogenous antibody delivery and glial activation by brain-targeted, transcranial focused ultrasound. Exp Neurol. 2013 Oct;248:16-29. doi: 10.1016/j.expneurol.2013.05.008. Epub 2013 May 21.
PubMed 23707300Goldwirt L, Beccaria K, Carpentier A, Farinotti R, Fernandez C. Irinotecan and temozolomide brain distribution: a focus on ABCB1. Cancer Chemother Pharmacol. 2014 Jul;74(1):185-93. doi: 10.1007/s00280-014-2490-0. Epub 2014 May 28.
PubMed 24867782Goldwirt L, Beccaria K, Carpentier A, Idbaih A, Schmitt C, Levasseur C, Labussiere M, Milane A, Farinotti R, Fernandez C. Preclinical impact of bevacizumab on brain and tumor distribution of irinotecan and temozolomide. J Neurooncol. 2015 Apr;122(2):273-81. doi: 10.1007/s11060-015-1717-1. Epub 2015 Jan 13.
PubMed 25794638Helmer C, Peres K, Letenneur L, Guttierez-Robledo LM, Ramaroson H, Barberger-Gateau P, Fabrigoule C, Orgogozo JM, Dartigues JF. Dementia in subjects aged 75 years or over within the PAQUID cohort: prevalence and burden by severity. Dement Geriatr Cogn Disord. 2006;22(1):87-94. doi: 10.1159/000093459. Epub 2006 May 18.
PubMed 16710088Prince M, Bryce R, Albanese E, Wimo A, Ribeiro W, Ferri CP. The global prevalence of dementia: a systematic review and metaanalysis. Alzheimers Dement. 2013 Jan;9(1):63-75.e2. doi: 10.1016/j.jalz.2012.11.007.
PubMed 23305823Hardy J, Selkoe DJ. The amyloid hypothesis of Alzheimer's disease: progress and problems on the road to therapeutics. Science. 2002 Jul 19;297(5580):353-6. doi: 10.1126/science.1072994.
PubMed 12130773Hardy JA, Higgins GA. Alzheimer's disease: the amyloid cascade hypothesis. Science. 1992 Apr 10;256(5054):184-5. doi: 10.1126/science.1566067. No abstract available.
PubMed 1566067Zlokovic BV. The blood-brain barrier in health and chronic neurodegenerative disorders. Neuron. 2008 Jan 24;57(2):178-201. doi: 10.1016/j.neuron.2008.01.003.
PubMed 18215617Dubois B, Feldman HH, Jacova C, Dekosky ST, Barberger-Gateau P, Cummings J, Delacourte A, Galasko D, Gauthier S, Jicha G, Meguro K, O'brien J, Pasquier F, Robert P, Rossor M, Salloway S, Stern Y, Visser PJ, Scheltens P. Research criteria for the diagnosis of Alzheimer's disease: revising the NINCDS-ADRDA criteria. Lancet Neurol. 2007 Aug;6(8):734-46. doi: 10.1016/S1474-4422(07)70178-3.
PubMed 17616482
Study at a glance
From the registry record, last updated by the sponsor on 12 Apr 2022. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Phase 1/2 Open Single-arm Monocentric Study Evaluating the Tolerance and Interest of Transient Opening of the Blood-Brain Barrier by Low Intensity Pulsed Ultrasound With the SONOCLOUD® Implantable Medical Device in Mild Alzheimer's Disease Patients (MMSE 20-26)
- ClinicalTrials.gov ID
- NCT03119961
- Acronym / sponsor ID
- BOREAL1 / P150101
- Conditions
- Alzheimer Disease
- Keywords
- Amyloid Amyloid Plaque, Tau Protein, Sonication
- Phase
- Phase 1/2
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 10 participants (actual)
- Lead sponsor
- Assistance Publique - Hôpitaux de ParisUniversity, hospital or other
- Collaborators
- CarThera, BPIfrance
- Study start
- 26 Jun 2017 (actual)
- Primary completion
- 2 Oct 2020 (actual)
- Study completion
- 7 Oct 2020 (actual)
- First posted
- 19 Apr 2017 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
In Alzheimer's disease (AD) an imbalance between the production and clearance of the ß-amyloid peptide is hypothesized as the driving event of the disease. The decreased clearance of Aß could be partly linked to a progressive dysfunction of the brain vasculature and of the blood brain barrier (BBB). Among many possible explanations for these failures of the multiple clinical trials evaluating innovative drugs in AD, one is the lack of target engagement, as none of these drugs is able to readily cross BBB. This barrier acts as a wall that actively and passively prevents the crossing of molecules between the blood and the brain parenchyma compartments. Only 0.3% of intravenously injected anti-Aß immunoglobulins reach the brain despite a half-life of 15-20 days. Low intensity Focal ultrasound associated to microbubble injection can open the BBB in a non invasive way. These openings are reversible in 2 hours to 2 days depending on the intensity of the ultrasound. Ultrasound opening of the BBB was initially used in a transgenic mouse model of AD to increase the brain delivery of an anti-Aß antibody. In this article, the Aß load was reduced in ultrasound treated brain region. Surprisingly it was then demonstrated that the simple opening of the BBB without any adjunct anti-Aß treatment was able to drive the same Aß clearance effects. This is probably linked to endogenous antibodies that are able to penetrate the brain parenchyma and target Aß plaques. Four opening sessions elicited positive promnesic effects in these mice. Our group conceived and developed a mean to easily, reproductively and innocuously open the BBB. A unique extra-dural ultrasound emitter (sonoCloud®) is surgically implanted in the skull under local anesthesia. It emits low intensity contact ultrasound (LICU) that are not deterred by bone and thus are able to open the BBB.Preclinical studies show the SonoCloud® device is safe and efficient as it allowed reproducible and repeatable opening of the BBB in rabbits, dogs and non human primates. Drugs up to 2000 Kilo Daltons (kDa) are able to cross the BBB to reach the brain parenchyma in which the concentration of Carboplatin was increased by 700% in the BBB opened region. No adverse event was evidenced both clinically, by EEG, Evoked potential, MRI, 18 Fluorodeoxyglucose (FDG) PET and histology in the primates after 7 bi-monthly sessions of LICU BBB opening. SonoCloud® and its external generator have been certified by the academic start-up CarThéra (APHP, UPMC). Our multidisciplinary skills (neurology, neurosurgery, neuroimaging, basic science departments in the same University hospital setting) and our previous experience of BBB opening in Man give us the unique opportunity to translate this procedure from neuro-oncology to AD which could 1) Have a positive effect on brain lesion load and symptoms by itself and 2) allow anti-AD (or more broadly, central nervous system) drugs to engage their targe
Detailed description
Background:
Alzheimer's disease is the most prevalent neurodegenerative disease totalizing 33 million patients worldwide. If nothing is done to decrease the incidence of 1.8 Million patient/year, the prevalence will double in the next 20 years.
Physiopathologically, the amyloid cascade remains the predominant hypothesis. It states that an imbalance between the production and clearance of the ß-amyloid peptide is the driving event of the disease, leading to Tau hyperphosphorylation and accumulation in neurons as neurofibrillary tangles, neurodegeneration (synaptic and neuronal loss) and cognitive impairment. The decreased clearance of Aß could be partly linked to a progressive dysfunction of the brain vasculature and of the BBB.
New sets of diagnosis criteria for AD have been proposed to address the low specificity (70%) of the previous ones, that could be one of the causes of failure of previous clinical trials. Among these new criteria, cerebrospinal fluid (CSF) biomarkers and positon emission tomography (PET) with new ligands of amyloid plaques and more recently tau deposition are indicators of the underlying histopathology of the disease, and can also be used to evaluate early intervention efficacy as they are pathologic in the preclinical phase of AD, its prodromal phase.
the investigators aim to test an innovative BBB opening procedure that could drastically decrease AD patients' brain lesion load and alleviate their symptomatology.
Scientific/medical questions:
- What is the tolerance of LICU and the SonoCloud® device in a population of patients with mild AD? 2) What are the physiopathological impact of LICU BBB opening in these patients as asserted by amyloid and 18FDG PET-MRI?
Objectives:
For the first phase I clinical trial in the world using LICU in AD to repeatedly open the BBB.
Primary objective: To evaluate the tolerance of the BBB opening session in 5 AD patients (Adverse event recording, cognitive and MRI evaluations).
Co-primary objective: To assess the impact of BBB opening on the hallmark lesions of AD (Aß \& Tau) through PET-MRI imaging (decrease of the standardized uptake value ratio (SUVR) after vs. before treatment in the left supramarginal gyrus and left (treated) vs. right (untreated) supramarginal gyrus).
Secondary objective: increase cognitive performance in AD patients through the repeated opening of the BBB in the left supramarginal gyrus
Methods :
Ten patients suffering from mild AD will be included in the study.
Protocol :
Seven BBB opening session will be performed at a bi-monthly rate focusing on the left supramarginal gyrus, a cortical structure known to be affected by both amyloid and tau lesions early on during the evolution of the disease. All adverse events induced by surgery itself or by the LICU will be recorded. Amyloid ß and Tau lesion load will be evaluated benefiting from the PET-MRI that allows to clearly evaluate fine changes in SUVR taking into account loco-regional cortical specificity (cortical thickness). PET image analysis.
Mean Standard Uptake Values Ratios (SUVR) will be calculated with cerebellar gray matter activity as reference in volumes of interest. Voxel-wise uptake will then be divided by this reference value to get SUVR maps. PET images will be corrected for motion and partial volume effect thanks to simultaneous MRI acquisition. To analyze the longitudinal PET data, each follow-up T1-weighted MRI will be co-registered to the baseline MRI, and a within-subject template image will be calculated by averaging the coregistered T1-weighted images. This mean image will be used to calculate optimal transformation parameters to Montreal Neurological Institute (MNI) space. Next, baseline and follow-up PET images will be co-registered to the baseline MRI, spatially normalized to MNI using this optimal transformation, and scaled with cerebellar gray uptake. Individual percent annual changes maps will be then calculated. These maps will represent the voxel-wise calculation of percent metabolic change after BBB opening.
The investigators think that the clinical trial will be well tolerated by the patients as the rate of local adverse events is expected to be 1% since the SonoCloud device implantation is extra dural (without dura opening). The implantation is performed under local anaesthesia in an outclinic fashion.
Drawbacks and possible solution to overcome the problems :
Among expected drawback the investigators will have to be very vigilant for Amyloid related imaging anomalies (ARIAs) due to the sudden entry of endogenous antibodies in the brain parenchyma of patients with Aß and Tau prevalent lesions. If these ARIAs were to happen, an amendment of the protocol could be devised to add steroids, or reduce ultrasound intensity, or extend time during each opening session, or reduce number of BBB opening session, or in last use immunosuppressive drugs prior to the opening of the BBB.
This is the first study worldwide with the means to safely, repeatedly and reproductively open the BBB in AD, or more broadly, in any neurodegenerative disease. It is noteworthy to consider that it is only a phase I study aiming to demonstrate the feasibility of the technique in a mild form of AD. If this is the case and even in the absence of a positive effect on the lesions and symptoms it will then be possible to propose new projects aiming to associate these safe BBB opening to anti-AD drugs. In fact, this study could pave the way for further treatment venues of various neurodegenerative disease that share a brain accumulation of proteins that cannot be readily targeted in case of BBB integrity.
Study design
- Primary purpose
- Treatment
- Allocation
- Not applicable
- Intervention model
- Single group
- Masking
- None (open label)
- Number of arms
- 1
| Arm | Type | Receives |
|---|---|---|
| SONOCLOUD® | Experimental | Device: SONOCLOUD®BBB opening by ultrasound |
Who may qualify
- Ages
- 50 to 85 years
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (8 listed)
- Age between 50 and 85 years old
- Alzheimer's disease, typical or atypical according to International Working Group-2 (IWG-2) criteria,
- Mild disease (MMSE 20-26) but presently pejorative outcome: relatively young subject (<80 years), "rapid" cognitive decline and high CSF tau rate (> 600pg / mL, for A diagnostic threshold of Alzheimer's disease of 450pg / mL). The evaluation of the pejorative evolution will be validated by the Committee of Experts of the Memory Center (IM2A at Pitié-Salpêtrière Hospital)
- Patients under stable Alzheimer's treatment for at least 3 months prior to entry into the study and in which no change is envisaged in the next months in order to avoid a loss of chance for the patient and to consider an aggravation at cessation of treatment as an adverse event due to the opening of the BBB.
- Affiliate or beneficiary of Affiliated to the French Health care system
Key exclusion criteria (24 listed)
- Allergy to Gadolinium, Xylocaine or any contraindication to contrast products used for brain imaging, or to drugs used in perioperative procedures.
- Contraindications to SonoVue®
- Severe renal impairment with glomerular filtration rate (GFR) <30 mL / min / 1.73 m2 (Gadolinium IC)
- Hepatic impairment characterized by international normalized ratio (INR)> 1.5 or Factor V <50% of the standard.
- Patient taking an associated treatment considered potentially toxic to the central nervous system (CNS).
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| SONOCLOUD®Also: BBB openingBBB opening by ultrasound | Device | SONOCLOUD® |
Primary outcome
Florbetapir SUVr and Fluorodeoxyglucose MUV changes in BBB opening region of interest (ROI)
Time frame: Change from baseline at 4month and 8 month
PET MRI evaluation
1 secondary outcome
Adverse events recording
Time frame: up to 9 months
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 12 Apr 2022.
- Background: PubMed 27306666Carpentier A, Canney M, Vignot A, Reina V, Beccaria K, Horodyckid C, Karachi C, Leclercq D, Lafon C, Chapelon JY, Capelle L, Cornu P, Sanson M, Hoang-Xuan K, Delattre JY, Idbaih A. Clinical trial of blood-brain barrier disruption by pulsed ultrasound. Sci Transl Med. 2016 Jun 15;8(343):343re2. doi: 10.1126/scitranslmed.aaf6086.
- Background: PubMed 27285538Horodyckid C, Canney M, Vignot A, Boisgard R, Drier A, Huberfeld G, Francois C, Prigent A, Santin MD, Adam C, Willer JC, Lafon C, Chapelon JY, Carpentier A. Safe long-term repeated disruption of the blood-brain barrier using an implantable ultrasound device: a multiparametric study in a primate model. J Neurosurg. 2017 Apr;126(4):1351-1361. doi: 10.3171/2016.3.JNS151635. Epub 2016 Jun 10.
- Background: PubMed 26645405Goldwirt L, Canney M, Horodyckid C, Poupon J, Mourah S, Vignot A, Chapelon JY, Carpentier A. Enhanced brain distribution of carboplatin in a primate model after blood-brain barrier disruption using an implantable ultrasound device. Cancer Chemother Pharmacol. 2016 Jan;77(1):211-6. doi: 10.1007/s00280-015-2930-5. Epub 2015 Dec 8.
- Background: PubMed 26566207Beccaria K, Canney M, Goldwirt L, Fernandez C, Piquet J, Perier MC, Lafon C, Chapelon JY, Carpentier A. Ultrasound-induced opening of the blood-brain barrier to enhance temozolomide and irinotecan delivery: an experimental study in rabbits. J Neurosurg. 2016 Jun;124(6):1602-10. doi: 10.3171/2015.4.JNS142893. Epub 2015 Nov 13.
- Background: PubMed 23790118Beccaria K, Canney M, Goldwirt L, Fernandez C, Adam C, Piquet J, Autret G, Clement O, Lafon C, Chapelon JY, Carpentier A. Opening of the blood-brain barrier with an unfocused ultrasound device in rabbits. J Neurosurg. 2013 Oct;119(4):887-98. doi: 10.3171/2013.5.JNS122374. Epub 2013 Jun 21.
- Background: PubMed 20485502Jordao JF, Ayala-Grosso CA, Markham K, Huang Y, Chopra R, McLaurin J, Hynynen K, Aubert I. Antibodies targeted to the brain with image-guided focused ultrasound reduces amyloid-beta plaque load in the TgCRND8 mouse model of Alzheimer's disease. PLoS One. 2010 May 11;5(5):e10549. doi: 10.1371/journal.pone.0010549.
- Background: PubMed 23707300Jordao JF, Thevenot E, Markham-Coultes K, Scarcelli T, Weng YQ, Xhima K, O'Reilly M, Huang Y, McLaurin J, Hynynen K, Aubert I. Amyloid-beta plaque reduction, endogenous antibody delivery and glial activation by brain-targeted, transcranial focused ultrasound. Exp Neurol. 2013 Oct;248:16-29. doi: 10.1016/j.expneurol.2013.05.008. Epub 2013 May 21.
- Background: PubMed 24867782Goldwirt L, Beccaria K, Carpentier A, Farinotti R, Fernandez C. Irinotecan and temozolomide brain distribution: a focus on ABCB1. Cancer Chemother Pharmacol. 2014 Jul;74(1):185-93. doi: 10.1007/s00280-014-2490-0. Epub 2014 May 28.
- Background: PubMed 25794638Goldwirt L, Beccaria K, Carpentier A, Idbaih A, Schmitt C, Levasseur C, Labussiere M, Milane A, Farinotti R, Fernandez C. Preclinical impact of bevacizumab on brain and tumor distribution of irinotecan and temozolomide. J Neurooncol. 2015 Apr;122(2):273-81. doi: 10.1007/s11060-015-1717-1. Epub 2015 Jan 13.
- Background: PubMed 16710088Helmer C, Peres K, Letenneur L, Guttierez-Robledo LM, Ramaroson H, Barberger-Gateau P, Fabrigoule C, Orgogozo JM, Dartigues JF. Dementia in subjects aged 75 years or over within the PAQUID cohort: prevalence and burden by severity. Dement Geriatr Cogn Disord. 2006;22(1):87-94. doi: 10.1159/000093459. Epub 2006 May 18.
- Background: PubMed 23305823Prince M, Bryce R, Albanese E, Wimo A, Ribeiro W, Ferri CP. The global prevalence of dementia: a systematic review and metaanalysis. Alzheimers Dement. 2013 Jan;9(1):63-75.e2. doi: 10.1016/j.jalz.2012.11.007.
- Background: PubMed 12130773Hardy J, Selkoe DJ. The amyloid hypothesis of Alzheimer's disease: progress and problems on the road to therapeutics. Science. 2002 Jul 19;297(5580):353-6. doi: 10.1126/science.1072994.
- Related InfoLink provided by the sponsor.
- Related InfoLink provided by the sponsor.
- Individual participant dataSharing planned: Undecided
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Stephane EPELBAUM, MD, PhD principal investigator
Assistance Publique Hoptiaux de Paris
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 1/2 study testing SONOCLOUD® in people with Alzheimer Disease, run by Assistance Publique - Hôpitaux de Paris at 1 site in France.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 8 inclusion and 24 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 12 Apr 2022. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in France. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
What does this combined phase mean?
Phase 1 studies test a treatment in a small group of people for the first time or in a new way, mainly to check safety and find the right dose.
Phase 2 studies give the treatment to a larger group to see whether it has the intended effect and to keep checking safety.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Florbetapir SUVr and Fluorodeoxyglucose MUV changes in BBB opening region of interest (ROI) (time frame: Change from baseline at 4month and 8 month). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT03119961, which also lists 33 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 12 Apr 2022.