The link doesn't work, so here's the
article, minus the tables, pictures and
references (all of which were boring
anyway
)
Cell transplantation therapy in
reanimating severely head-injured
patients
Abstract
The results of controlled, retrospective
clinical investigation of applying cell
transplantation (CT) therapy in 38
severely head-injured patients are
presented. The patients initially were in
state of coma (Glasgow coma scale score
3–7), owing to their traumatic brain
injuries. Cells prepared from fetal
nervous and hematopoietic tissues were
grafted subarachnoidally via lumbar
puncture. The control group consisted of
38 patients and was clinically comparable
with the trial one. From the results
obtained it appears that CT treatment
promoted both wakening consciousness of
the patients and their following
neurological rehabilitation. A death-rate
in the trial and control group was 5% (two
cases) and 45% (17 cases), respectively.
According to a Glasgow scale, favorable
(good + satisfactory) outcomes of a
disease were noted in 33 (87%)
cell-grafted and only in 15 (39%) control
patients. Statistical analysis revealed
that CT treatment generally improved the
outcomes by 2.5-fold. No serious
complications of CT therapy were noted.
The results point out a possible
rationality of applying CT therapy in
severely head-injured patients as early as
within acute period of a disease.
Keywords: Cell transplantation; Brain
injury; Coma
Abbreviations: BC, brain contusion; CNS,
central nervous system; CT, cell
transplantation; DAI, diffuse-axonal
injury; EEG, electroencephalography; EH,
epidural hematoma; GCS, Glasgow coma
scale; IH, intraventricular hematoma; MRI,
magnetic resonance imaging; SH, subdural
hematoma; TUDG, transcranial ultrasonic
dopplerography
Article Outline
1. Introduction
2. Materials and methods
3. Results
3.1. Case 1
3.2. Case 2
4. Discussion
References
1. Introduction
A severe head-injury remains is one of
main reason for mortality and disability
among able-bodied citizens. Outcomes of
treating severely head-injured patients
are largely defined within in an acute
period of a disease. In this period
medical interventions are aimed at
preventing the injure-triggered, second
pathological processes that result in
additional damages of a brain tissue and
are frequently associated with
life-threatening complications. Clinical
effects of neuroprotective drugs in acute
brain-injured patients are often unclear
and doubtful (reviewed in [10]), and there
is an apparent necessity to search new
approaches to recovery of life-saved,
brain functions in such patients.
Cell-based technologies allowing to repair
injured organs at a cellular level open up
fundamentally new opportunities in
treating many problem diseases, including
neurological ones. The central nervous
system (CNS) is an “immune-privileged”
organ where there are substantial barriers
to developing alloantigen-induced, immune
processes. In fact, the grafted neural
cells have been convincingly documented to
be able to survive in the major
histocompatibility complex
(MHC)-incompatible CNS for relatively long
period of time. There is also ample
evidence from various experimental studies
indicating abilities of the transplanted
cells to proliferate and elaborate cell
growth factors in brain lesions and to
markedly intensify, thereby, brain tissue
reparation processes (reviewed in [2] and
[4]).
In this paper we present the results of
applying a subarachnoidal fetal cell
transplantation (CT) in 38 acute, severely
head-injured patients with a high risk of
a poor outcome of a disease.
2. Materials and methods
The study was performed in the exact
accordance with the protocol approved by
the Scientific Council and Ethics
Committee at the Institute of Clinical
Immunology. Informed consent was obtained
from the closest relations of each subject
who has been enrolled in the study.
The fetal brain neural and hemopoietic
liver tissues were isolated from human
fetuses (gestational age 16–22 weeks)
after spontaneous or therapeutic abortion,
and then prepared in the form of cell
suspension, as described earlier [16]. The
cells were further cryopreserved in the
standard way in 90% fetal bovine serum
containing 10% dimethyl sulfoxide, and
stored in liquid nitrogen until use. On
the day of transplantation, the cell
suspensions were thawed at 37 °C, washed
extensively, and assayed for cell
viability by a erythrosine exclusion
method in the routine way. The overall
number of viable cells in the suspension
intended for a single administration was
2.0 × 108; the neural to liver tissue
cell ratio in such suspension was of 10:1.
The cells were grafted subarachnoidally
via lumbar puncture.
Thirty-eight patients (10 females and 28
males) aged from 18 to 63 years (an
average age 3
have been enrolled
in the study. These patients were admitted
to the clinic in a state of coma, owing to
severe traumatic brain injury. We did not
enter onto the study the patients who had
extracranial injuries which, by
themselves, were life-threatening. Glasgow
coma scale (GCS) scores of trial patients
were in the range of 3–7. A
diffuse-axonal injury (DAI) was diagnosed
in 23 (60%) patients that in 19 (50%)
cases was compatible with a
hematoma-associated brain compression. In
the remaining 15 (40%) patients there was
a severe brain contusion that also
associated with a brain compression. In
all patients a brain compression was
remedied in an emergency order. The
further intensive therapy allowed the
patients to stabilize their cardiovascular
and respiratory activities. However, in
spite of all therapeutic interventions,
the patients did not recover their
consciousness. In these cases a magnetic
resonance imaging (MRI) typically revealed
diffuse-atrophic alterations of both white
and gray brain matter; an
electroencephalography (EEG) demonstrated
the strong decrease in functional brain
activity and the disappearance of
α-rhythm; a transcranial ultrasonic
dopplerography (TUDG) exhibited the
significant reduction in linear brain
blood flow velocity. In general, the state
of the patients was characterized by a
high risk of developing a long-term
vegetative status and lethal outcome. CT
treatment was undertaken when
consciousness of a patient did not exhibit
signs of its recovering as long as at
5–8 weeks post-injury. Twenty-five
patients were cell-grafted once. Other 12,
and one patients were cell-grafted twice,
and thrice, respectively, at a 10–14 day
interval.
The control group included 38 patients
aged 19–60 years (an average age 3
and was formed
retrospectively on a pair basis. Each
control patient was randomly selected to
be a clinically comparable counterpart of
a trial patient (Table 1). The median GCS
score in the control and trial group was
of 4.6 and 4.1, respectively. Both the
control and trial patients received a
similar standard therapy in equivalent
conditions during the same time.
Clinical outcomes for both trial and
control patients were assessed in terms of
the Glasgow outcome classification at
18–24 months post-injury. For
statistical analysis, it was accepted that
a lethal, unsatisfactory, satisfactory,
and good outcome was coincided with 0–3
points, respectively. A paired Student's
test was used to determine the
significance of differences between trial
and control values.
3. Results
In 33 of 38 trial patients the signs of
awakening consciousness in the form of
opening eyes and performing the simplest
tasks occurred as early as at 3–7 days
post-grafting. During following 5 days
those patients became contacting their
relations and a medical personal. A
restoration of their main psychical
functions was observed at 15–20 days
after CT treatment. By that time an
α-rhythm appeared and a brain blood flow
attained a lower limit of the norm.
The other three cell-grafted patients also
exhibited awakening consciousness after CT
treatment. However, they further retained
significant defects in their
psychoemotional sphere and were in need of
an extraneous assistance. Those patients
were cell-grafted once again. The
appreciable benefits from CT treatment
were noted in those cases. Nevertheless,
these subjects remained neurological
defects that significantly limited their
functional abilities.
The remaining two cell-grafted patients
exhibited only some signs of awakening
consciousness after CT treatment. In spite
of all medical interventions undertaken,
they both died later from extracranial
complications.
With CT treatment positive changes in stem
brain symptoms were noted in the patients,
indicating restoration of their vitally
important, brain functions (Table 2).
On the whole, suckers in Table 3, CT
treatment enabled to considerably decrease
a death-rate among severely head-injured
persons and to increase a proportion of
the patients with favorable (good +
satisfactory) clinical outcomes. suckers
in Fig. 1, the outcome value (M ± m) for
CT-treated patients exceeded the analogous
value for control patients by 2.5-fold (P
< 0.001).
No significant changes on MRI scans of the
patients was typically observed within
acute period of disease. However, 1–1.5
years later MRI signs of brain atrophy
almost completely disappeared in all
patients with favorable outcomes of a
disease (Fig. 2).
By present, the follow-up time for 25
cell-grafted patients is of 4–6 years.
Of these 20 persons were ultimately
rehabilitated to an extent to be able to
continue their working activity in full
measure. No CT-related complications was
noted over the whole follow-up period.
Two cases of applying CT are described in
detail below.
3.1. Case 1
An 18-year-old female patient D was
injured in a vehicular accident. On
admission her pulse rate was 120–128
bpm, arterial blood pressure 100/60; there
was a psychomotor excitation,
hyperhidrosis, and hyperthermia (up to 40
°C); a depressed fracture of temporal was
seen on the right. Because of inefficiency
of self-dependent respiration, the patient
was transferred on artificial pulmonary
ventilation. Her GCS score was 4. On MRI a
subdural hematoma was revealed on the
left; cisterns and ventricles of the brain
were not visualized. The hematoma was
removed in a surgery way. Intensive
therapy enable the patient to normalize
her vital functions including respiration.
However, in spite of all medical
interventions undertaken, patient's
consciousness was not recovered. For this
reason, the patient was cell-grafted on 37
and 48 days postinjury. Signs of awakening
patients's consciousness appeared as early
as at 4 days after the first CT. On 7 days
after the second CT the consciousness was
recovered to the level of light
obnubilation. Three months later a
completed recovery of her psychical
functions was noted under a control
examination. As early as at 6 months after
CT treatment, MRI signs of her brain
atrophy almost completely disappeared
(Fig. 1A, B). The Glasgow outcome of her
disease was good. At 1.5 years post-injury
she became a student of the university
faculty. By the time of preparing this
manuscript she was an excellent student in
her third year.
3.2. Case 2
A 24-year-old male patient B was admitted
to the Emergency City Hospital after a
vehicular accident. On admission his pulse
rate was 110 bpm, arterial blood pressure
150/90; respiration was superficial,
arrhythmical, at 28 per min; there was a
psychomotor excitation with periodic
hormetonic convulsions. His GCS score was
5. The patient was transferred on
artificial pulmonary ventilation. MRI
revealed an intracranial hematoma in the
right temporoparietal area. This hematoma
(120 ml) was removed in a surgery way.
Intensive therapy enable the patient to
restore adequate self-dependent
respiration on 5 days after trauma. A
repeated MRI revealed contusion focuses of
III type in frontotemporal-basilar brain
areas. In spite of conducting intensive
rehabilitation therapy, the patient did
not recovery his consciousness over 28
days. The patient was cell-grafted twice
on 28 and 40 days post-injury. Recovering
patient's consciousness to the level of
light obnubilation occurred as early as on
6 days after the last CT. Recovery of his
directional sense was noted 5 days later,
whereas recovery of his time sense took
significantly more time. The patient was
discharged on 52 days post-injury. The
Glasgow outcome of his disease was good.
Three years later he became a student of
the university faculty, successfully
managing his educational task.
4. Discussion
The results presented herein suggest that
cells from nervous and hemopoietic fetal
tissues, when subarachnoidally grafted,
are able to promote recovering useful
consciousness of a severely head-injured
patient. Patient's consciousness
awakening, by itself, may be an important
trigger signal for activation of multiple
mechanisms which are capable of both
reducing an incidence of potentially
life-threatening complications and
ameliorating neurological functional
defects.
Since apparent sighs of recovering of
patient's consciousness typically occurred
as early as within 7 days after CT
treatment, the effects of a CT therapy on
brain functionality in this period are
most likely due to a release by grafted
cells of mediators stimulating
coordinative work of various brain
structures. This suggestion is consistent
with the published data indicating an
ability of neural progenitor cells to
elaborate essential neurotrophic factors
and promote, thereby, both survival and
functionality of degenerating neurons
after traumatic brain injury [6].
suckers in this paper, CT treatment not
only reduce a death-rate of severely
head-injured patients but also
substantially increased proportion among
them of persons with favorable outcomes of
a disease. To our opinion, the latter
might be explained by a long-term
influence of grafted cells upon reparative
processes occurring in a nervous tissue in
response to injury. As a matter of fact
the brain is a plastic system able to
integrate transplanted, fetal-derived,
allogeneic stem/progenitor cells. On one
hand, donor cells may be long-acting
producers of neurotrophic mediators, on
the other hand they may be directly
implicated in newly forming nervous
communications (reviewed in [2] and [4]).
A subarachnoidal pathway of cell
transplantation into CNS is safe and well
tolerated. As experimentally shown [19],
the cells of immature nervous tissue, when
grafted within subarachnoidal cavity, are
capable of migrating into brain lesions
and intensifying there reparative
processes. An effective CNS repair
requires the presence in injured sites of
not only neural cells potentially able to
provide axonal growth, but also the other
cells capable of creating the
microenvironment favorable to both growth
and myelination of nerve fibers. In fact,
schwann cells grafted in a brain lesion
have been found to be able to stimulate
axonal growth [1]. In a brain lesion donor
oligodendrocytes can synthesize a myelin
[9], whereas donor astrocytes are capable
of inhibiting the development of a glial
scar tissue [8], [13] and [18] that can
become a insuperable obstacle to axonal
growth. In our own investigation we
transplanted into the patients not only
the cells isolated from immature nervous
tissue, but also the fetal liver cells.
The human liver of gestational age of
16–22 weeks is a hematopoietic organ
with relatively high contents of immature
multipotent cells [5]. Evidence is
accumulating that fetal hematopoietic
tissues contain the stem cells capable of
ameliorating functional neurological
defects [15]. These cells are able to be
differentiated into neurons and astrocytes
[3] and [7], and may contribute to
neovascularization of ischemized tissues
[12]. Moreover, they are able to inhibit
scar connective tissue development [11].
In general, to our opinion, the cell
transplantat composed of various types of
stem and progenitor cells may be much more
effective in repairing an injured tissue
in comparison with the transplantat
consisting only of one type of stem or
progenitor cells.
Noticeable benefits from CT-based
technologies in treating have been
previously noted in patients with ultimate
(chronic) consequences of traumatic brain
injury [14] and [17], when not only prime,
but also second, injury-induced,
pathological processes may be already
developed. Induction of donor-specific
immune reactions was found in part of
these patients. At the same time no
laboratory and clinical signs of
developing tissue-destructive, autoimmune
processes were observed [17].
The date presented in this paper suggest
clinical reasonability of using CT therapy
for a severely head-injury as early as
within acute period of a disease, when a
patients is unconscious. Such timely
treatment is likely to be able to
prevent/reduce the development of the
second pathological processes that are
disabling and potentially
life-threatening. Importantly, no serious
complications which might limit
application of CT-based technologies in
head-injured patients were noted.
On the whole the results presented in this
paper are undoubtedly promising. Although
much greater clinical experience is needed
to determine a place and clinical
relevance of CT-based therapy in overall
complex treatment of the patients with
brain. It is reasonable to anticipate that
developing CT-based approaches may provide
much progress in the management of
multiple neurological diseases including
those which are now considered as
uncurable. Novel techniques of preparation
and propagation of multi- and unipotent
cells, which are being now actively
developed, enable to solve not only
technical, but also ethical problems
confronting progress in cell
transplantology (reviewed in [3]) and,
thereby, may promote widespread adoption
of CT-based advances in clinical practice.
