Autologous bone marrow mononuclear cells to treat severe traumatic brain injury in children

Abstract

Autologous bone marrow mononuclear cells (BMMNCs) infused after severe traumatic brain injury have shown promise for treating the injury. We evaluated their impact in children, particularly their hypothesized ability to preserve the blood-brain barrier and diminish neuroinflammation, leading to structural CNS preservation with improved outcomes. We performed a randomized, double-blind, placebo-sham-controlled Bayesian dose-escalation clinical trial at two children's hospitals in Houston, TX and Phoenix, AZ, USA (NCT01851083). Patients 5-17 years of age with severe traumatic brain injury (Glasgow Coma Scale score ≤ 8) were randomized to BMMNC or placebo (3:2). Bone marrow harvest, cell isolation and infusion were completed by 48 h post-injury. A Bayesian continuous reassessment method was used with cohorts of size 3 in the BMMNC group to choose the safest between two doses. Primary end points were quantitative brain volumes using MRI and microstructural integrity of the corpus callosum (diffusivity and oedema measurements) at 6 months and 12 months. Long-term functional outcomes and ventilator days, intracranial pressure monitoring days, intensive care unit days and therapeutic intensity measures were compared between groups. Forty-seven patients were randomized, with 37 completing 1-year follow-up (23 BMMNC, 14 placebo). BMMNC treatment was associated with an almost 3-day (23%) reduction in ventilator days, 1-day (16%) reduction in intracranial pressure monitoring days and 3-day (14%) reduction in intensive care unit (ICU) days. White matter volume at 1 year in the BMMNC group was significantly preserved compared to placebo [decrease of 19 891 versus 40 491, respectively; mean difference of -20 600, 95% confidence interval (CI): -35 868 to -5332; P = 0.01], and the number of corpus callosum streamlines was reduced more in placebo than BMMNC, supporting evidence of preserved corpus callosum connectivity in the treated groups (-431 streamlines placebo versus -37 streamlines BMMNC; mean difference of -394, 95% CI: -803 to 15; P = 0.055), but this did not reach statistical significance due to high variability. We conclude that autologous BMMNC infusion in children within 48 h after severe traumatic brain injury is safe and feasible. Our data show that BMMNC infusion led to: (i) shorter intensive care duration and decreased ICU intensity; (ii) white matter structural preservation; and (iii) enhanced corpus callosum connectivity and improved microstructural metrics.

Keywords: autologous; bone marrow mononuclear cells; children; magnetic resonance imaging; stem cells; traumatic brain injury.

Figure 1

Patient flow diagram. BMMNC = bone marrow mononuclear cells; PCH = Phoenix Children’s Hospital; UTH = UTHealth Houston.

Figure 2

Glasgow Outcome Score-Extended Peds (GOS-E Peds) scores. Placebo and BMMNC groups at 1 month, 6 months and 1 year. Percentage of participants with good scores (1–4) and bad scores (5–8) at 1 month, 6 months and 1 year after infusion are indicated. GOSE-E Peds scale: 1 = upper good recovery; 2 = lower good recovery; 3 = upper moderate disability; 4 = lower moderate disability; 5 = upper severe disability; 6 = lower severe disability; 7 = vegetative; 8 = dead. BMMNC = bone marrow mononuclear cells. Created with Datawrapper.