Infliximab Therapy for Dolichoectactic Vertebrobasilar Aneurysms
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|ClinicalTrials.gov Identifier: NCT02638701|
Recruitment Status : Recruiting
First Posted : December 23, 2015
Last Update Posted : March 3, 2020
|Condition or disease||Intervention/treatment||Phase|
|Aneurysm Stroke Vasculitis Tumor Necrosis Factor-alpha||Drug: Infliximab||Phase 1 Phase 2|
Dolichoectatic vertebrobasilar (DVB) aneurysms are fusiform in geometry and often large (< 10 cm) in size limiting traditional microsurgical clipping or endovascular coiling strategies. Collectively, DVB aneurysms represent ≤ 0.01% of all aneurysms (~ 600 US) and, consequently, their study is limited to a few small series. Despite their rarity, the location and geometry of DVB aneurysms make surgical intervention, microsurgical or endovascular, nearly uniformly fatal. Therefore, most DVB aneurysms are observed providing greater insight into their natural history than many more surgically amenable aneurysms. One series noted 28% of patients manifesting any neurological deficit, ischemic or hemorrhagic, over a 4 year interval with an overall mortality rate of ~ 20%.
Tumor necrosis alpha (TNFα). From the many implicated genetic pathways in aneurysm formation, tumor necrosis alpha (TNFα) has been noted a pivotal actor. In pre-clinical studies, the ability to inhibit TNFα induction prevents aneurysm rupture and even aneurysm growth altogether. In humans, TNFα inhibitor therapy has proven effective for many types of vascular inflammation including carotid wall thickening in the setting of rheumatoid arthritis. Over 12- and 24-month intervals, others have demonstrated significant decreases in carotid intima-media thickness in patients taking the TNFα inhibitor, infliximab. Furthermore, infliximab therapy has proven effective in refractory Kawasaki's disease, a condition characterized by post-infectious coronary artery inflammation in children. There is also evidence that infliximab therapy is effective in treatment of IVIG-refractory Kawasaki's disease including regressing coronary aneurysms. Despite the multitude of agents and indications both on and off-label, TNFα inhibitor therapy has not been used for the treatment of brain aneurysm.
|Study Type :||Interventional (Clinical Trial)|
|Estimated Enrollment :||8 participants|
|Intervention Model:||Single Group Assignment|
|Masking:||None (Open Label)|
|Official Title:||Infliximab Therapy for Dolichoectactic Vertebrobasilar Aneurysms|
|Actual Study Start Date :||July 1, 2018|
|Estimated Primary Completion Date :||June 2022|
|Estimated Study Completion Date :||December 2023|
Experimental: Infliximab treatment
Administer infliximab intravenously to patients with DVB aneurysms (3 mg/kg at 0, 3 and 7 weeks, then at 8-week intervals x 7) for a total of 12-months. Patients will undergo MR imaging at 0, 12, and 24-month time points.
Please see protocol for details.
Other Name: Remicade
- Reduction in aneurysm volume (ml) [ Time Frame: 12 months ]Our primary outcome for assessing the effectiveness of the infliximab treatment will be the reduction in aneurysm volume over the treatment course based on the 0 and 12 month MR scans. DVB aneurysm volume will be assessed by review of standardized 1.5 mm slices in the axial plane. The contour of the aneurysm using time-of-flight MR angiography sequences will generate a cross-sectional area at each slice level. The volume will be estimated by summing the imputed volume of each slice. Standard T1- and T2-weighted sequences will also be obtained, as well as iron-sensitive sequencing.
- Aneurysm computational fluid dynamic (CFD) metrics: flow velocity (ml/sec) [ Time Frame: 12 months ]The investigators will capture MR-based, quantitative changes in the aneurysm computational fluid dynamics (CFD) metrics including flow velocity post 12-month IV infliximab administration. The investigators will compare pre- and post-treatment flow velocities using baseline and interval MR angiographic data. Such data is important in predication of aneurysm growth.
- Aneurysm computational fluid dynamic (CFD) metrics: shear stress (pascal) [ Time Frame: 12 months ]The investigators will capture MR-based, quantitative changes in the aneurysm computational fluid dynamics (CFD) metrics including wall shear stress post 12-month IV infliximab administration. The investigators will compare pre- and post-treatment CFD metrics using baseline and interval MR angiographic data. Such data is important in predication of aneurysm growth.
- Aneurysm computational fluid dynamic (CFD) metrics: oscillatory index (0 - 0.5) [ Time Frame: 12 months ]The investigators will capture MR-based, quantitative changes in the aneurysm computational fluid dynamics (CFD) metrics including oscillatory shear (OSI) index post 12-month IV infliximab administration. The investigators will compare pre- and post-treatment CFD metrics using baseline and interval MR angiographic data. Such data is important in predication of aneurysm growth. OSI ranges from 0 to 0.5, where 0 describes a total unidirectional WSS and the latter a purely unsteady, oscillatory shear flow with a net amount of zero WSS. Areas of high OSI are predisposed to endothelial dysfunction.
- Aneurysm wall enhancement (ratio of signal post:signal pre contrast) [ Time Frame: 12 months ]Continued improvements in higher field MR imaging have generated series noting the ability to not only resolve aneurysmal wall enhancement, but also the presence of such findings to reliably predict aneurysm growth and correlate with symptomatic events. To perform wall enhancement, the patient will first be scanned at 3T/7T using T1 weighted 3D black blood MRI technique (SPACE). Gadolinium will be injected and a 3D isotropic, high-resolution first-pass contrast-enhanced MR angiogram (CEMRA) will be obtained; immediately following that a post-contrast SPACE will be acquired. Contrast enhancement of the vessel wall will be graded as 0-2 scale or quantified by an enhancement ratio (Signal-post/Sigal-pre). Wall thickness can be estimated by the full width half maximal (FWHM) of the line profile across the vessel wall.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02638701
|Contact: Daniel L Cooke, MD||415 353 email@example.com|
|Contact: Jonathan Graf, MD||415 206 firstname.lastname@example.org|
|United States, California|
|UCSF Medical Center||Recruiting|
|San Francisco, California, United States, 94143|
|Contact: Daniel Cooke, MD|
|Principal Investigator:||Daniel L Cooke, MD||University of California, San Francisco|