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Role of Brain Specific Biomarkers in Hydrocephalus

Primary Purpose

Hydrocephalus, Normal Pressure, Biochemical Lesions Head Region, Brain Damage

Status
Not yet recruiting
Phase
Not Applicable
Locations
Czechia
Study Type
Interventional
Intervention
Lumbar puncture
External lumbar drainage
Ventriculo-peritoneal shunt placement
Prechamber puncture
Blood sampling #1
Blood sampling #2
Blood sampling #3
Blood sampling #4 and #5
Sponsored by
University Hospital Hradec Kralove
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Hydrocephalus, Normal Pressure focused on measuring Hydrocephalus, Brain biomarkers, Neurofilament Light Chain, Neurofilament Heay Chain, Tau protein, beta-amyloid, Neuron specific enolase, Shunt responsivity

Eligibility Criteria

50 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: Patients with diagnosed communicating hydrocephalus mini-mental state examination test > 10 points Absence of any structural lesion on MRI or CT Accepted Informed consent Exclusion Criteria: Non-communicating hydrocephalus Structural lesion on MRI or CT (tumour, contusion, aneurysm) mini-mental state examination test < 10 points Life-expectancy shorter than 1 year Pre-existing other type of dementia (m. Alzheimer, vascular dementia) Surgery lasting more than 120 minutes Blood loss more than 500 ml Adverse events during general anesthesia: mean arterial pressure < 60 mm Hg more than 5 minutes, arrythmia with need for pharmacological treatment

Sites / Locations

  • University Hospital Hradec Kralove

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Experimental

Arm Label

Study group "Responders"

Study group "Non-responders"

Arm Description

Patients with diagnosed hydrocephalus undergoing surgery (VP shunt placement) in general anesthesia. Before surgery patients undergo lumbar puncture or external lumbar drainage placement to confirmed the diagnosis and responsivity to VP shunt placement.

Patients with diagnosed hydrocephalus. VP shunt non-responsivity confirmed.

Outcomes

Primary Outcome Measures

Comparison of levels of the mentioned biomarkers
Comparison of levels of the mentioned biomarkers between patients with clinically proven shunt-responsive and shunt-nonresponsive hydrocephalus

Secondary Outcome Measures

Comparison of levels of the biomarkers during follow-up
To follow-up the development of the mentioned biomarker levels during follow-up, comparing them to the evolution of the clinical condition, and exploring the correlation between the levels of individual biomarkers in relation to the monitored parameters of the clinical condition (gait measured by 5-meter-walking test, mini-mental state examination, hydrocephalus parameters by computed tomography or magnetic resonance)

Full Information

First Posted
October 8, 2023
Last Updated
October 13, 2023
Sponsor
University Hospital Hradec Kralove
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1. Study Identification

Unique Protocol Identification Number
NCT06083233
Brief Title
Role of Brain Specific Biomarkers in Hydrocephalus
Official Title
Role of Brain Specific Biomarkers in Hydrocephalus
Study Type
Interventional

2. Study Status

Record Verification Date
October 2023
Overall Recruitment Status
Not yet recruiting
Study Start Date
November 1, 2023 (Anticipated)
Primary Completion Date
August 31, 2024 (Anticipated)
Study Completion Date
December 31, 2024 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
University Hospital Hradec Kralove

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
Normal pressure hydrocephalus (NPH) is a neurodegenerative disease of unclear etiology characterized by a clinical trias named after the neurosurgeon Hakim. It includes cognitive impairment (dementia), gait disturbance, and urinary incontinence. These symptoms, which frequently occur in the elderly population, often overlap with the symptoms of "other" neurodegenerative diseases, especially Alzheimer's disease and other (pre)senile dementias. To distinguishing NPH from "other" dementias is crucial in determining whether a patient will benefit from a surgical procedure (ventriculoperitoneal shunt placement) or not. At the same time, the options for assessing the patient's condition's progression and distinguishing between the progression of neurodegeneration in a broader sense or malfunction of the drainage system are very limited. Therefore, the role of a biomarker that could meet these expectations mentioned above is highly desirable.
Detailed Description
Currently, several biomarkers of nerve tissue damage are being studied, which could potentially serve as sensitive and specific biomarkers in the future. These include Neurofilament Light Chain (NfL), Neuron-Specific Enolase (NSE), S100 protein, and tau protein. A) Neurofilament Light Chain (NfL) and Neurofilament Heavy Chain (NfH): Neurofilaments (Nfs) are cylindrical proteins found exclusively in neuronal cytoplasm. Under normal conditions, only low levels of the Neurofilament Light Chain (NfL) are released from axons. Elevated levels of NfL have been observed in response to axonal damage in the central nervous system (CNS) due to inflammatory, neurodegenerative, traumatic, or vascular causes, especially in older individuals. NfL is the most soluble subunit of neurofilaments, making its measurement more reliable than other subunits. The concentration of NfL in cerebrospinal fluid is higher in patients with neurological disorders compared to healthy controls. Similar findings have been reported regarding NfL levels in serum. The role of NfL as a biomarker has been established in conditions such as multiple sclerosis (MS), Alzheimer's disease (AD), frontotemporal dementia (FTD), amyotrophic lateral sclerosis (ALS), atypical parkinsonian disorders (APD), and traumatic brain injury (TBI). It has also been studied to a lesser extent in Creutzfeldt-Jakob disease and neurological complications of HIV infection, where it reaches very high concentrations in cerebrospinal fluid, as well as in Huntington's disease (HD) and normotensive hydrocephalus (NPH or iNPH). Therefore, its implementation in clinical practice is gaining wider acceptance. There is a stronger correlation observed between NfL levels and ALS compared to NfH, although the role of NfH has not been as extensively established yet. B) Protein S100: S100 protein belongs to a large family of calcium-binding proteins and is a well-established biomarker in many areas of medicine. In particular, S100B protein is a recognized biomarker in neurodegenerative diseases. Several studies have shown a significant elevation in the levels of S100B in cases of hydrocephalus. However, the relationship between S100B levels and clinical course is not sufficiently explored. C) Neuron-Specific Enolase (NSE) NSE is an isoenzyme in the glycolytic pathway. Increased levels of NSE have been described in patients with brain injury or stroke. Its half-life in serum is approximately 48 hours. Elevated levels of both S100B and NSE after injuries are associated with an unfavorable outcome and a greater extent of brain tissue damage. In a recent study by Mehmedika-Suljić et al., a non-significantly lower level of NSE was found in patients with hydrocephalus compared to healthy controls. There is a limited number of studies focused on the significance of NSE and its clinical relevance in NPH. D) Tau Protein and Beta-Amyloid: There is a close overlap between idiopathic normal pressure hydrocephalus (iNPH) and Alzheimer's disease (AD) because both conditions involve abnormal deposition of toxic byproducts of cerebral metabolism in the brain, such as amyloid-beta 1-42 (amyloid-β 1-42) and Tau protein. Evidence from brain tissue studies even suggests that iNPH could be considered a disease model for Alzheimer's disease. It has also been demonstrated that Alzheimer's disease is a strong predictor of non-responsive iNPH. Recent studies even propose that the final step in neurodegeneration is the pathological cerebral aggregation of toxic brain metabolism byproducts caused by disrupted clearance of these waste products, such as the deposition of amyloid-β 1-42 and Tau in Alzheimer's disease and α-synuclein in Parkinson's disease. Due to the close association between iNPH and other dementias like Alzheimer's disease and Parkinson's disease, biomarker levels of neurodegeneration in cerebrospinal fluid or blood could potentially be used to differentiate between responsive iNPH and shunt non-responsive iNPH. In this regard, biomarkers such as total Tau (T-Tau) and amyloid-β 1-42 have previously been suggested to assist in this differentiation. In conclusion, NfL, Tau protein, and beta-amyloid appear to be promising biomarkers that, in many cases, fulfill the role of a marker not only for identifying neuronal damage, such as in the case of postoperative delirium, but also for the regular monitoring of their levels. For conditions like multiple sclerosis (MS), regular monitoring of these biomarkers could serve as a guide in treatment monitoring, medication adjustments, or early identification of subclinical disease relapses. This principle could theoretically be applied to other neurodegenerative diseases as well. According to some authors, these biomarkers seem to be more sensitive and specific for neuronal damage than, for example, C-reactive protein. Therefore, they hold promise not only for treatment monitoring but also as early identifiers of subclinical disease relapse. Available literature does not suggest significant gender variability in these biomarkers. However, there is a known baseline value that varies with age. Furthermore, all of the mentioned biomarkers have the potential to distinguish between shunt-responsive and non-responsive iNPH, which is a crucial predictive role in the diagnostic and therapeutic process of iNPH.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Hydrocephalus, Normal Pressure, Biochemical Lesions Head Region, Brain Damage
Keywords
Hydrocephalus, Brain biomarkers, Neurofilament Light Chain, Neurofilament Heay Chain, Tau protein, beta-amyloid, Neuron specific enolase, Shunt responsivity

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderInvestigator
Allocation
Randomized
Enrollment
20 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Study group "Responders"
Arm Type
Experimental
Arm Description
Patients with diagnosed hydrocephalus undergoing surgery (VP shunt placement) in general anesthesia. Before surgery patients undergo lumbar puncture or external lumbar drainage placement to confirmed the diagnosis and responsivity to VP shunt placement.
Arm Title
Study group "Non-responders"
Arm Type
Experimental
Arm Description
Patients with diagnosed hydrocephalus. VP shunt non-responsivity confirmed.
Intervention Type
Diagnostic Test
Intervention Name(s)
Lumbar puncture
Intervention Description
Standardized lumbar puncture in L3/4 or L4/5 in diagnosis of hydrocephalus and cerebrospinal fluid sampling (sample 1 in measurement)
Intervention Type
Diagnostic Test
Intervention Name(s)
External lumbar drainage
Intervention Description
External lumbar drainage placement for assessing responsivity of external derivation of cerebrospinal fluid. It is test of responsivity to ventriculo-peritoneal shunt placement
Intervention Type
Procedure
Intervention Name(s)
Ventriculo-peritoneal shunt placement
Intervention Description
Surgical procedure based on implantation a thin catheter into brain lateral ventricle (placed through a burrhole from Kocher point) and connection to prechamber and valve (placed behind the ear under skin) and similar thin catheter pushed under skin of neck, chest and abdomen (where put intraperitoneally).
Intervention Type
Procedure
Intervention Name(s)
Prechamber puncture
Intervention Description
Puncture of prechamber (place behind the ear under the skin) by thin needle and aspiration of 5 mL of cerebrospinal fluid (5 days, 1 month a 2 months after surgery)
Intervention Type
Procedure
Intervention Name(s)
Blood sampling #1
Intervention Description
Blood sampling to get level of biomarkers (NfL, NfH, NSE, S100, Tau, beta-amyloid) from standardized percutaneous vein puncture by thin needle 24 hours prior surgery
Intervention Type
Procedure
Intervention Name(s)
Blood sampling #2
Intervention Description
Blood sampling to get level of biomarkers (NfL, NfH, NSE, S100, Tau, beta-amyloid) from standardized percutaneous vein puncture by thin needle 24 hours after surgery
Intervention Type
Procedure
Intervention Name(s)
Blood sampling #3
Intervention Description
Blood sampling to get level of biomarkers (NfL, NfH, NSE, S100, Tau, beta-amyloid) from standardized percutaneous vein puncture by thin needle 5 days after surgery
Intervention Type
Procedure
Intervention Name(s)
Blood sampling #4 and #5
Intervention Description
Blood sampling to get level of biomarkers (NfL, NfH, NSE, S100, Tau, beta-amyloid) from standardized percutaneous vein puncture by thin needle 1 and 2 months after surgery (only in interventional group)
Primary Outcome Measure Information:
Title
Comparison of levels of the mentioned biomarkers
Description
Comparison of levels of the mentioned biomarkers between patients with clinically proven shunt-responsive and shunt-nonresponsive hydrocephalus
Time Frame
6 month
Secondary Outcome Measure Information:
Title
Comparison of levels of the biomarkers during follow-up
Description
To follow-up the development of the mentioned biomarker levels during follow-up, comparing them to the evolution of the clinical condition, and exploring the correlation between the levels of individual biomarkers in relation to the monitored parameters of the clinical condition (gait measured by 5-meter-walking test, mini-mental state examination, hydrocephalus parameters by computed tomography or magnetic resonance)
Time Frame
6 month

10. Eligibility

Sex
All
Minimum Age & Unit of Time
50 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patients with diagnosed communicating hydrocephalus mini-mental state examination test > 10 points Absence of any structural lesion on MRI or CT Accepted Informed consent Exclusion Criteria: Non-communicating hydrocephalus Structural lesion on MRI or CT (tumour, contusion, aneurysm) mini-mental state examination test < 10 points Life-expectancy shorter than 1 year Pre-existing other type of dementia (m. Alzheimer, vascular dementia) Surgery lasting more than 120 minutes Blood loss more than 500 ml Adverse events during general anesthesia: mean arterial pressure < 60 mm Hg more than 5 minutes, arrythmia with need for pharmacological treatment
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Miroslav Cihlo, M.D.
Phone
+420495832550
Email
miroslav.cihlo@fnhk.cz
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Miroslav Cihlo, M.D.
Organizational Affiliation
University Hospital Hradec Kralove
Official's Role
Principal Investigator
Facility Information:
Facility Name
University Hospital Hradec Kralove
City
Hradec Králové
ZIP/Postal Code
50005
Country
Czechia
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Miroslav Cihlo, M.D.
Phone
+420495832550
Email
miroslav.cihlo@fnhk.cz

12. IPD Sharing Statement

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Role of Brain Specific Biomarkers in Hydrocephalus

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