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Imaging Laterality in Chronic Stroke Patients

Primary Purpose

Stroke, Motor Cortex; Lesion

Status

Completed

Phase

Early Phase 1

Locations

United States

Study Type

Interventional

Intervention

Rasch modified version of the Fugl-Meyer Motor assessment

Anatomical image acquisition

Functional MRI task and acquisition

About this trial

This is an interventional diagnostic trial for Stroke focused on measuring BOLD Signal, Functional Magnetic Resonance Imaging, MR Spectroscopy, Anatomical Imaging, Kinematics

Eligibility Criteria

21 Years - 80 Years (Adult, Older Adult)All SexesAccepts Healthy Volunteers

Inclusion Criteria For Both Groups:

21-80 years old of any race and ethnicity
At least 2 cardiovascular risk factors (smoking, high blood pressure, high cholesterol, diabetes, overweight, age (>55 for men, >65 for women), family history of stroke).

Inclusion Criteria For Stroke Patients:

Left middle cerebral artery ischemic stroke with at least 6 month chronicity
Right upper extremity weakness with a Rasch-modified Fugl-Meyer upper extremity score of 20 to 50
Ability to voluntarily flex the affected elbow and shoulder from 10-75% of the normal range
Ability to make a fist and relax the affected hand (note: this motion will be required in the functional MRI task)

Exclusion Criteria For Both Groups:

Primary intracerebral hematoma or subarachnoid hemorrhage
Bi-hemispheric ischemic strokes
History of prior right-sided stroke or old infarct demonstrated on the CT or MRI or documented in medical records
Other concomitant neurological disorders affecting upper extremity motor function
Documented history of dementia before or after stroke
Presence of any MRI, TMS, or transcranial direct current stimulation risk factors such as an electrically, magnetically or mechanically activated metal or nonmetal implant including cardiac pacemaker, intracerebral vascular clips or any other electrically sensitive support system
Pregnancy as the effect of MRI on the fetus is unknown, females of child bearing age must undergo a pregnancy test to confirm eligibility
History of seizure disorder or post-stroke seizure
Preexisting scalp lesion or wound or bone defect or hemicraniectomy
Left-hand dominance (before the stroke in the stroke patients) as the typical pattern of laterality is not as strong in left-handed healthy individuals
Current nicotine dependence (Note: nicotine use is not an exclusionary criteria as there is no known association between acute use and BOLD signal changes in non-dependent smokers)

Sites / Locations

Medical University of South Carolina

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Arm Label

Healthy Controls

Stroke Participants

Arm Description

Subjects will undergo the following diagnostic tasks and assessments: Rasch Modified Version of the Fugl-Meyer Motor Assessment, Anatomical Image Acquisition, and the Functional MRI Task and Acquisition

Outcomes

Primary Outcome Measures

Compare the ratio of gluatamte and gaba concentrations within the contralesional primary motor cortex

Using spectroscopy investigators will determine if the ratio of glutamate/GABA is higher in stroke patients than controls. Furthermore, in healthy controls prepulse inhibition will be positively correlated with the concentration of GABA, and prepulse facilitation will be positively correlated with the concentration of glutamate. Although we expect this relationship to be true in both the controls and the stroke patients, variation from this pattern in the stroke patients would suggest that there is another factor beyond simple within-hemisphere measurements that is affecting the contralesional cortex activity.

Secondary Outcome Measures

Quantify the relationship between neural activity and motor performance using the Rasch modified version of the Fugl-Meyer motor assessment battery to acquire three aspects of motor performance for all individuals in both groups.

Impairment on bimanual tasks will be related to the outcome measures of previous Aims. That is, individuals with less transcallosal inhibition will perform worse on the bimanual task (less efficiency and smoothness) than individuals with transcallosal inhibition closer to healthy controls. This is based on pilot data from Dr. Woodbury of the Quantitative Behavioral Assessment and Rehabilitation Core that suggests during bimanual tasks the kinetics of the impaired arm remain the same but the previously unimpaired limb performs worse. This suggests that loss of inhibition 'infects' the arm movement typically controlled by the contralesional hemisphere.

Full Information

NCT ID

NCT03584425

First Posted

June 15, 2018

Last Updated

July 22, 2019

Sponsor

Medical University of South Carolina

Collaborators

MUSC Center for Biomedical Research Excellence in Stroke Recovery

1. Study Identification

Unique Protocol Identification Number

NCT03584425

Brief Title

Imaging Laterality in Chronic Stroke Patients

Official Title

Investigating the Neurobiologic Basis for Loss of Cortical Laterality in Chronic Stroke Patients

Study Type

Interventional

2. Study Status

Record Verification Date

July 2019

Overall Recruitment Status

Completed

Study Start Date

December 15, 2014 (Actual)

Primary Completion Date

May 30, 2019 (Actual)

Study Completion Date

May 30, 2019 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title

Sponsor

Name of the Sponsor

Medical University of South Carolina

Collaborators

MUSC Center for Biomedical Research Excellence in Stroke Recovery

4. Oversight

Studies a U.S. FDA-regulated Drug Product

Studies a U.S. FDA-regulated Device Product

Product Manufactured in and Exported from the U.S.

Yes

Data Monitoring Committee

Yes

5. Study Description

Brief Summary

In healthy individuals, unimanual movement (with either the left or right hand) is associated with activity in a network of predominantly contralateral brain regions, including the primary motor cortex (PMC). This laterality is often compromised following a middle cerebral artery (MCA) stroke. Neuroimaging studies of these patients have shown that unimanual movements with the effected hand are associated with elevated Blood Oxygen-Level Dependent (BOLD) signal in both the lesioned and the nonlesioned primary motor cortices. Elevated activity in the contralesional PMC is well-established in chronic stroke patients and is associated with poor motor rehabilitation outcomes. Yet the neurobiologic basis for this aberrant neural activity is equivocal. The overarching goal of this project is to determine the neurobiologic basis for elevated activity in the contralesional primary motor cortex.

Detailed Description

One factor that may contribute to elevated activity in the contralesional PMC is increased cortical excitatory tone within the contralesional hemisphere (Aim 1). While approximately 80% of the descending corticospinal neurons that control the right hand originate in the left PMC, 20% originate in the right PMC. Elevated activity in the right PMC of left-sided stroke patients may reflect compensatory activity of these descending fibers. Neural activity in the PMC reflects the balance of local excitatory (glutamatergic) and inhibitory (GABAergic) processing. It can be measured in two manners: 1) electrophysiologically, using single hemisphere paired pulse transcranial magnetic stimulation (TMS), and 2) neurochemically, using magnetic resonance spectroscopy (MRS). Another factor that may contribute to elevated activity in the contralesional PMC is a loss of transcallosal inhibition between the hemispheres (Aim 2). During right hand movement, the left PMC of healthy individuals actively inhibits the right PMC via inhibitory projections through the corpus callosum. In left MCA stroke patients, elevated activity in the contralesional (right) PMC when moving the right hand may reflect a loss of typical inhibition from the left PMC. The integrity of inter-hemispheric information transfer can be measured in two manners: 1) using bi-hemispheric paired-pulse TMS, and 2) using a multimodal brain stimulation/brain imaging approach, interleaved TMS/MRI. Through interleaved TMS/MRI, the investigators can selectively stimulate the ipsilesional PMC and quantify the amount of TMS-induced activity in the contralesional PMC. These two explanations will be tested through a cross-sectional investigation of neural function in left MCA stroke patients with mild-moderate right upper extremity impairment and controls matched for age and cardiovascular risk factors. To assess the clinical relevance of these factors on motor dysfunction, the investigators will perform a detailed kinematic assessment of movement efficiency, smoothness and compensation (Aim 3).

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study

Stroke, Motor Cortex; Lesion

Keywords

BOLD Signal, Functional Magnetic Resonance Imaging, MR Spectroscopy, Anatomical Imaging, Kinematics

7. Study Design

Primary Purpose

Diagnostic

Study Phase

Early Phase 1

Interventional Study Model

Parallel Assignment

Model Description

The investigators will enroll a total of 30 chronic stroke patients and 30 neurologically healthy controls matched for age and with at least 2 cardiovascular risk factors

Masking

None (Open Label)

Allocation

Non-Randomized

Enrollment

44 (Actual)

8. Arms, Groups, and Interventions

Arm Title

Healthy Controls

Arm Type

Experimental

Arm Description

Arm Title

Stroke Participants

Arm Type

Experimental

Arm Description

Intervention Type

Diagnostic Test

Intervention Name(s)

Rasch modified version of the Fugl-Meyer Motor assessment

Intervention Description

All participants will receive a comprehensive clinical assessment of motor function including the Rasch modified version of the Fugl-Meyer Motor assessment and a kinematic assessment of unimanual and bimanual movements using a 45 sensor 3D active marker based motion capture system. The three primary measures investigated in the kinematics include: 1) movement efficiency, 2) movement smoothness, and 3) motor compensation.

Intervention Type

Diagnostic Test

Intervention Name(s)

Anatomical image acquisition

Intervention Description

High-resolution structural scans will be obtained using an inversion recovery 3D spoiled gradient echo (3DSPGR) sequence using a matrix size of 256 x 256, field of view of 24 cm, section thickness of 1.5 mm with no gap between sections, and 128 slices, giving an in-plane resolution of 0.94 mm. This sequence will be used for anatomic overlays of the functional data and for spatial normalization to a standard atlas.

Intervention Type

Diagnostic Test

Intervention Name(s)

Functional MRI task and acquisition

Intervention Description

Briefly, patients will be given two pressure-sensitive bulbs (one to be held in each hand and fastened lightly to their wrists with Velcro such that they do not drop it during the scan. During two 2½ minute runs they will be prompted to squeeze the bulb in either their affected or unaffected hand in blocks of 15 seconds. These blocks will be interspersed with blocks of rest. The pressure from the bulbs will be digitally recorded and quantified offline in order to: 1) verify that the patient was squeezing the ball, and 2) assess the presence of 'mirror movements' from the opposing hand that may inform the imaging results regarding loss of laterality).

Primary Outcome Measure Information:

Title

Compare the ratio of gluatamte and gaba concentrations within the contralesional primary motor cortex

Description

Time Frame

Through study completion, an average of two weeks

Secondary Outcome Measure Information:

Title

Description

Time Frame

Through study completion, an average of two weeks

10. Eligibility

Sex

All

Minimum Age & Unit of Time

21 Years

Maximum Age & Unit of Time

80 Years

Accepts Healthy Volunteers

Eligibility Criteria

Inclusion Criteria For Both Groups: 21-80 years old of any race and ethnicity At least 2 cardiovascular risk factors (smoking, high blood pressure, high cholesterol, diabetes, overweight, age (>55 for men, >65 for women), family history of stroke). Inclusion Criteria For Stroke Patients: Left middle cerebral artery ischemic stroke with at least 6 month chronicity Right upper extremity weakness with a Rasch-modified Fugl-Meyer upper extremity score of 20 to 50 Ability to voluntarily flex the affected elbow and shoulder from 10-75% of the normal range Ability to make a fist and relax the affected hand (note: this motion will be required in the functional MRI task) Exclusion Criteria For Both Groups: Primary intracerebral hematoma or subarachnoid hemorrhage Bi-hemispheric ischemic strokes History of prior right-sided stroke or old infarct demonstrated on the CT or MRI or documented in medical records Other concomitant neurological disorders affecting upper extremity motor function Documented history of dementia before or after stroke Presence of any MRI, TMS, or transcranial direct current stimulation risk factors such as an electrically, magnetically or mechanically activated metal or nonmetal implant including cardiac pacemaker, intracerebral vascular clips or any other electrically sensitive support system Pregnancy as the effect of MRI on the fetus is unknown, females of child bearing age must undergo a pregnancy test to confirm eligibility History of seizure disorder or post-stroke seizure Preexisting scalp lesion or wound or bone defect or hemicraniectomy Left-hand dominance (before the stroke in the stroke patients) as the typical pattern of laterality is not as strong in left-handed healthy individuals Current nicotine dependence (Note: nicotine use is not an exclusionary criteria as there is no known association between acute use and BOLD signal changes in non-dependent smokers)

Overall Study Officials:

First Name & Middle Initial & Last Name & Degree

Colleen A Hanlon, PhD

Organizational Affiliation

Medical University of South Carolina

Official's Role

Principal Investigator

Facility Information:

Facility Name

Medical University of South Carolina

City

Charleston

State/Province

South Carolina

ZIP/Postal Code

29425

Country

United States

12. IPD Sharing Statement

Plan to Share IPD

Yes

IPD Sharing Plan Description

Yes The data from the primary outcome measurement will be shared via manuscripts and after study completion by request to the Principal Investigator

IPD Sharing Time Frame

The data will be available immediately after first publication of the results. This is estimated to be at the end of 2018.

IPD Sharing Access Criteria

Interested parties should contact the Principal Investigator directly

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Imaging Laterality in Chronic Stroke Patients

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