- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02865642
Cortical Ischemic Stroke and Serotonin (CISS)
CISS: Cortical Ischemic Stroke and Serotonin - Effects of Serotonergic Neuromodulation on Behavioural Recovery and Motor Network Plasticity After Cortical Ischemic Stroke: a Longitudinal, Placebo-controlled Study
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Neuroplasticity, i.e. the human brain's innate capacity to structurally remodel and functionally reorganize its neural networks, is essential for recovery of impaired sensorimotor function after focal ischemic injury. However, the potential for spontaneous recovery in the adult brain is limited and needs to be augmented through rehabilitative programs, e.g. intensive exercise, brain stimulation or pharmacologic neuromodulation.
Clinical studies have shown that post-stroke recovery can be augmented by long-term administration of selective serotonin reuptake inhibitors (SSRI). Serotonin modulates excitatory glutamatergic neurotransmission and induces long-term potentiation (LTP), an important mediator of neuroplasticity that supports sensorimotor learning in the healthy brain and reorganization in the post-stroke perilesional cortex. Preliminary data indicate that a single dose of the SSRI Escitalopram is sufficient to induce LTP-like effects in the motor cortex of healthy volunteers (measured by repetitive transcranial magnetic stimulation (rTMS)), and to increase the efficiency of large-scale functional connectivity networks engaged in tactile object manipulation ( measured with functional magnetic resonance imaging (fMRI)).
The investigators thus hypothesize that serotonergic neuromodulation might enhance post-stroke recovery through enlarged plasticity and processing efficiency along integrated neuronal networks, leading to reinforced connectivity and behavioural performance.
To test this hypothesis, the investigators aim to conduct a longitudinal, double blind, placebo-controlled trial in two neurological centers. The investigators aim to test the effect of a daily-administered single dose of Escitalopram over a three months period after cortical ischemic stroke to promote plasticity changes in the perilesional zone of primary sensorimotor cortices (S1 and M1). The investigators will apply behavioural measures of hand function, rTMS and advanced magnetic resonance (MR) imaging techniques as outcome variables.
The investigators will measure hand function kinematics with a data glove to better understand the contribution of effort to hand function recovery and brain activation. Moreover, the investigators intend to apply MR-Spectroscopy of the perilesional premotor cortex, guided by real-time fMRI analysis, as a tool to assess local glutamatergic transmission. Measurements of plasma drug levels and determination of genetic polymorphisms of the Escitalopram-metabolizing genes will help them to assess and control for interindividual variance in Escitalopram bioavailability.
The investigators expect that SSRI-augmented neuroplasticity will lead to increased efficiency in the allocation of neuronal resources in the post-stroke brain, resulting in more precise and less effortful movements, facilitation of LTP-like phenomena, increased grey matter volume of spared perilesional premotor cortex and possibly higher glutamate peaks in the same areas, as compared to placebo treatment.
By combining standard and innovative methods, this study will provide mechanistic insight into the processes that drive cortical neuroplasticity in the post-stroke human brain. From a clinical perspective, results from the study are expected to provide a scientific rationale to select patients that might benefit from SSRI-augmented neurorehabilitation.
Study Type
Enrollment (Anticipated)
Phase
- Phase 2
Contacts and Locations
Study Contact
- Name: Manuela Pastore-Wapp
- Phone Number: +41316320006
- Email: manuela.pastore-wapp@insel.ch
Study Contact Backup
- Name: Werner Krammer
- Email: werner.krammer@kssg.ch
Study Locations
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-
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Bern, Switzerland, 3010
- Recruiting
- Support Center of Advanced Neuroimaging Institute for Diagnostic and Interventional Neuroradiology Inselspital, University Hospital Bern
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Contact:
- Roland Wiest, Prof. Dr. med.
- Phone Number: +41316323673
- Email: roland.wiest@insel.ch
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Saint Gallen
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St. Gallen, Saint Gallen, Switzerland, 9007
- Not yet recruiting
- Neurology Department Kantonsspital St. Gallen
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Contact:
- Georg Kägi, Dr. med.
- Phone Number: +41714943594
- Email: georg.kaegi@kssg.ch
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-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- First-ever stroke
- Clinically significant contralesional hand plegia or paresis as a main symptom
- Involvement of the pre-and/or postcentral gyri confirmed on diffusion-weighted (DWI) and fluid attenuated inversion recovery (FLAIR) scans.
- Written informed consent
Exclusion Criteria:
- Aphasia or cognitive deficits severe enough to preclude understanding of study purposes
- Prior cerebrovascular events
- Significant stenosis (70-99% according to NASCET) or occlusion of the carotid and intracranial arteries on MR-angiography
- Purely subcortical stroke
- Known brain lesion (tumour, old cerebral haemorrhage)
- Other medical conditions interfering with task performance or SSRI-treatment, specifically: prolonged corrected QT interval (QTc) on electrocardiogram, ongoing drug / alcohol abuse
- Simultaneous intake of medications which can lead to prolonged QTc syndrome known or or suspected hypersensitivity (allergic) to one of the ingredients of Cipralex® or Placebo
- Simultaneous administration of: antidepressants, irreversible non- selective Monoamine Oxidase (MAO) inhibitors, reversible selective MAO inhibitors, reversible non-selective MAO inhibitors, irreversible selective MAO inhibitors, N-methyl-D-aspartate(NMDA)-receptor antagonists/-agonists, dopamine antagonists/-agonists, levodopa, benzodiazepines, amphetamines, methylphenidate, foscarnet, ganciclovir, ritonavir, mianserin, chloroquine, mefloquine, imipenem, penicillin, ampicillin, cephalosporins, metronidazole, isoniazid, levofloxacin, cyclosporin, chlorambucil, vincristine, methotrexate, cytosine arabinoside, lithium, anticholinergics,systemic antihistamines, systemic sympathomimetics
- Conditions interfering with MRI such as patients with magnetic (metallic) particles in the scull or brain, patients with a cardiac pacemaker, deep brain stimulators or cochlear implant.
- Women who are pregnant or breastfeeding
- Women in childbearing age without sufficient birth control (at least 2 contraceptive methods)
Eligibility Criteria for healthy volunteers:
- Normal test-scores at the baseline visit (see section 5.2.2)
- Normal neurological status
- No known brain lesion
- No pregnancy
- Written informed consent
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Supportive Care
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Quadruple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Serotonin Uptake Inhibitors
Treatment 1: Starting with Escitalopram 5mg/day at the baseline-visit (day 14 (+-7) post stroke) for 7 days followed by a weekly dosage increase of 5mg/day till target dose of Escitalopram 20mg/day. Subjects will remain on Escitalopram 20mg/day until visit 3 (day 90 (+-14) post stroke) followed by dosage reduction of Escitalopram 10mg/day for one week. |
Other Names:
|
Placebo Comparator: Placebo
Treatment 2: Starting with Placebo 5mg/day at the baseline-visit (day 14 (+-7) post stroke) for 7 days followed by a weekly dosage of 5mg/day till target dose of Placebo 20mg/day. Subjects will remain on Placebo 20mg/day until visit 3 (day 90 (+-14) post stroke) followed by Placebo 10mg/day for one week. |
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Effect of escitalopram on sensorimotor network
Time Frame: fMRI at month 9
|
To verify higher expression of the sensorimotor network engaged in motor control in the blood oxygenation level dependent (BOLD) response of task-related fMRI (act-fMRI) in patients treated with escitalopram compared to patients treated with placebo after nine months
|
fMRI at month 9
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Imaging patterns of rs-fMRI
Time Frame: rs-fMRI (baseline, month 3, month 9)
|
To compare imaging patterns of rs-fMRI and associated behavioral parameters of the verum and placebo group with those of healthy volunteers in the longterm in order to assess the degree of recovery.
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rs-fMRI (baseline, month 3, month 9)
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Imaging patterns of act-fMRI
Time Frame: act-fMRI, performance of tactile manipulation of objects (baseline, month 3, month 9)
|
To compare imaging patterns act-fMRI and associated behavioral parameters of the verum and placebo group with those of healthy volunteers in the longterm from baseline until month 3 and 9 in order to assess the degree of recovery and the associated efficiency in performing tactile manipulation of objects.
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act-fMRI, performance of tactile manipulation of objects (baseline, month 3, month 9)
|
Jebsen-Taylor Test (JTT)
Time Frame: JTT, monthly from baseline to month 9
|
To calculate the recovery trajectories of subjects post-stroke, relying on motor subtests of the JTT which will be carried out monthly from baseline to month 9.
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JTT, monthly from baseline to month 9
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Mean cortical volume changes
Time Frame: T1 from baseline, month 3, month 9
|
To delineate overall mean cortical volume changes in the longterm from baseline until 9 months in high-resolution T1-images to detect structural reorganization post-stroke both perilesional and in distributed large scale networks specifically related to hand motor skill in the verum and placebo group.
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T1 from baseline, month 3, month 9
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Serum concentration of escitalopram
Time Frame: Serum concentration at month 3
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To explore the serum concentration (µg/L) of escitalopram as possibly confounding factors impacting on the study results.
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Serum concentration at month 3
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Genetic polymorphisms in genes
Time Frame: Genetic polymorphisms in genes at month 3
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To explore the number of patients with genetic polymorphisms in genes (CYP2P19, ABCB1, CYP3A4 or CYP3A5) as possibly confounding factors impacting on the study results.
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Genetic polymorphisms in genes at month 3
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Glutamate/Glutamine concentration
Time Frame: Spectroscopy at baseline, month 3, month 9
|
Substudy Center 1: To measure Glutamate/Glutamine concentration post-stroke by MR-Spectroscopy in predefined brain areas (i.e. in the ipsilesional sensorimotor cortex and dorsolateral prefrontal cortex) as possible factor interfering with the recovery process
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Spectroscopy at baseline, month 3, month 9
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rTMS
Time Frame: TMS at baseline, month 3, month 9
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Substudy Center 2: To assess for facilitation in the motor system after application of escitalopram, using rTMS in the verum group related to the placebo group.
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TMS at baseline, month 3, month 9
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Number of adverse events due to study medication
Time Frame: Baseline, monthly until month 9
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Number of adverse events due to study medication Safety Endpoint: Experiencing at least one serious adverse event (e.g.
death, life-threatening, requires inpatient hospitalization)
|
Baseline, monthly until month 9
|
Collaborators and Investigators
Collaborators
Investigators
- Principal Investigator: Roland Wiest, Support Center of Advanced Neuroimaging Institute for Diagnostic and Interventional Neuroradiology Inselspital, University Hospital Bern
- Principal Investigator: Georg Kägi, Neurology Department Kantonsspital St. Gallen
Publications and helpful links
Study record dates
Study Major Dates
Study Start
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
- Cardiovascular Diseases
- Vascular Diseases
- Cerebrovascular Disorders
- Brain Diseases
- Central Nervous System Diseases
- Nervous System Diseases
- Stroke
- Ischemic Stroke
- Physiological Effects of Drugs
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Psychotropic Drugs
- Neurotransmitter Uptake Inhibitors
- Membrane Transport Modulators
- Serotonin Agents
- Antidepressive Agents
- Serotonin Receptor Agonists
- Antidepressive Agents, Second-Generation
- Citalopram
- Serotonin
- Serotonin Uptake Inhibitors
Other Study ID Numbers
- 3070
- 2016-00417 (Other Identifier: KEK)
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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