Synaptic Loss in Multiple System Atrophy

Study Overview
=================
Brief Summary
-----------------
In this study the investigators would like to investigate the degree of damage of the synapses, an important part of the neurons vital for the communications between neurons, in Multiple System Atrophy (MSA).

Detailed Description
-----------------
Multiple System Atrophy (MSA) is a chronic and progressive neurological disease, for which unfortunately there is no cure yet. It is known from pathological studies that the synapses (the terminal parts of the neurons) are affected in this disease, but the investigators don't know how, and how much this happens. An imaging tool called Positron Emission Tomography (PET) can study the integrity of the synapses by the use of a dedicated tracer, called [11C]UCB-J. In this study the investigators would like to study how, and how early, the synapse deteriorate in patients with MSA. For this study, patients with the MSA-P form of disease will be enrolled. Participants will be asked to undergo a clinical visit with questionnaires and scales for motor and cognitive symptoms. Then, participants will come for a [11C]UCB-J PET scan, a [18F]FDG PET scan, to check the metabolism of the brain, and a MRI scan, to help the analysis of the PET. The participants will also be asked to perform a Lumbar puncture for a cerebrospinal fluid draw. This procedure will be optional. The results will help in understanding better the mechanisms underlying this disease and open new avenues for its treatment.

Official Title
-----------------
Molecular Imaging of Synaptic Loss in Multiple System Atrophy (MSA)

Conditions
-----------------
Multiple System Atrophy

Intervention / Treatment
-----------------
* Other: Study procedures


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Male or female, aged 45-70 at the time of informed consent. A female subject is eligible to participate if she is (i) of non-childbearing potential, defined as pre-menopausal females with a documented tubal ligation or hysterectomy, or postmenopausal defined as 12 months of spontaneous amenorrhea or (ii) of childbearing potential but not pregnant (as determined by urinary pregnancy test on screening and on each study day), is not lactating and is willing to use one of the contraception methods listed below: Combined (estrogen and progesterone containing) hormonal contraception associated with initiation of ovulation( oral, intravaginal, or transdermal); Progesterone-only hormonal contraception associated with inhibition of ovulation (oral, injectable, implantable); Intrauterine device; Intrauterine hormone releasing system; Bilateral tubal occlusion; Vasectomized partner; Sexual abstinence. Male subject with a female partner of child-bearing potential must use one of the following contraceptive methods for 90 days after each dose of radiotracer: Condom plus partner use of a highly effective contraceptive (see point above) OR Abstinence Subjects must understand the nature of the study and be able to provide signed and dated written informed consent in accordance with local regulations before the conduct of any study-related procedures. They must be able and willing to participate in all scheduled evaluations, abide by all study restrictions, and complete all required tests and procedures. Must have anticipated survival of ≥3 years (in the opinion of the Investigator). Must be able to walk unassisted for at least 10 meters (approximately 30 feet). In the opinion of the investigator, the subject must be considered likely to comply with the study protocol and to have high probability of completing the study. Have received at least one shot of the SARS-CoV2 vaccination, unless deemed medically unsuitable to receive vaccination. Meet criteria for diagnosis of probable or possible MSA-P Medical treatment of MSA and co-morbid medical conditions must be stable for at least 30 days prior to screening and between screening and baseline PET scan. Intermittently administered treatment may be considered stable if the dose and dosing frequency have been unchanged for the greater of 30 days or three dosing intervals (e.g. a treatment given once a month must be at a stable dose and dosing frequency for 3 months). For inclusion in optional CSF sampling, written informed consent must be provided, either by separate signed and dated written informed consent or by specific written acknowledgement on the main study informed consent form, according to local procedure. Failure to participate in optional CSF sampling will have no influence on the subject's ability to participate in the main study. Exclusion Criteria: History of other neurological disorders or intracranial co-morbidities, such as stroke, haemorrhage, space-occupying lesions. Presence of any clinically significant medical condition (including cardiovascular, respiratory, cerebrovascular, hematological, hepatic, renal, gastrointestinal, or other disease) that, based on the judgement of the investigator, is clinically unstable, is likely to deteriorate during the course of the study, could put the patient at risk because of participation in the study, could affect the subject's ability to complete the study, or could influence the study results. Presence of cognitive dysfunction (defined as MoCA score <25). Presence of any of the following MRI contraindications: pacemaker; cardiac defibrillator; spinal cord or vagus nerve stimulator; aneurysm clip; artificial heart valve; recent coronary or carotid stent; ear implant; CSF shunt; other implanted medical device (e.g. Swan-Ganz catheter, insulin pump); or metal fragments or foreign objects in the eyes, skin, or body. If the principal investigator considers the presence of any of the above not to be a contraindication to MRI in a given subject, the investigator may obtain approval from the medical monitor based on a discussion of the case. Negative modified Allen test in both hands. History of claustrophobia or back pain that makes prolonged laying on the MRI or PET scanner intolerable. Pregnancy, lactation, or, if female of childbearing potential, positive urine β-hCG at screening or prior to PET scan. Use of drugs acting on SV2A such as antiepileptics (e.g. levetiracetam or brivaracetam). History of brain surgery for parkinsonism or stem cell treatment. Clinically significant blood clotting or bleeding disorder, including clinically significant abnormal findings in laboratory assessments of coagulation or hematology. Current or recent history of alcohol or drug abuse / dependence (except nicotine dependence). History of cancer within the last 5 years, with the exception of nonmetastatic basal cell carcinoma of the skin. Any clinically important abnormality, as determined by the investigator, on physical examination or vital signs, ECG, or clinical laboratory test results other than abnormality due to a stable, well-controlled medical condition; or any abnormality that could be detrimental to the subject or could compromise the study. Presence of supranuclear gaze palsy. Severe-to-complete dependence on caregivers (score >3 on UMSARS Part IV, Global Disability), severe impairment of swallowing (score ≥3 on UMSARS Part I, Question 2), or frequent falls (score ≥3 on UMSARS Part I, Question 8) at Screening. Hemoglobin A1c (HbA1c) ≥ 6.5% at screening. Uncontrolled/poorly controlled diabetes mellitus. For subjects participating in optional CSF sampling: Any spinal malformation or other aspects (e.g. tattoos) / clinical findings (e.g. papilledema) that may complicate or contraindicate lumbar puncture, as judged by the investigator. Neoplasm or other space-occupying intracranial lesion on MRI.

Ages Eligible for Study
-----------------
Minimum Age: 45 Years
Maximum Age: 70 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Group 1<br>Patients with MSA-P | Other: Study procedures<br>* All participants will undergo a collection of demographic data, a neurological examination and administration of clinical scales relevant for MSA-P. All participants will undergo a collection of venous blood sample for routine analyses. Participants will undergo one PET scan with the tracer [11C]UCB-J, and one PET scan with the tracer [18F]FDG. All participants will also undergo one MRI scan. Participants will also undergo one lumbar puncture (optional). All procedures will be performed at baseline and after one-year follow-up.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To measure the magnitude of longitudinal within-group change in [11C]UCB-J volume of distribution in MSA-P | [11C]UCB-J is a marker of synaptic damage in MSA-P | Baseline to 12 Months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression of brain glucose metabolism in MSA-P | Brain glucose metabolism is assessed with serial [18F]FDG PET scans at baseline and after 12-month follow-up. | Baseline to 12 Months | 
| To investigate differences in MRI structural, microstructural, molecular, and functional parameters in MSA patients. | Magnetic Resonance Imaging change in Magnetization Prepared Rapid Acquisition Gradient Echo [MPRAGE] | Baseline to 12 Months | 
| To investigate differences in structural MRI parameters in MSA patients. | Magnetic Resonance Imaging change in Magnetization Prepared Rapid Acquisition Gradient Echo [MPRAGE] | Baseline to 12 Months | 
| To investigate differences in iron-sensitive MRI in MSA patients. | Magnetic Resonance Imaging change in Susceptibility Weighted Imaging [SWI] | Baseline to 12 Months | 
| To investigate differences in quantitative iron in MSA patients. | Magnetic Resonance Imaging change in Quantitative Susceptibility Mapping [QSM] | Baseline to 12 Months | 
| To investigate differences in microstructural MRI parameters in MSA patients. | Magnetic Resonance Imaging change in Diffusion Tensor Imaging [DTI] | Baseline to 12 Months | 
| To investigate differences in neuromelanin-MRI in MSA patients. | Magnetic Resonance Imaging change in Neuromelanin-MRI | Baseline to 12 Months | 
| To investigate differences in perfusion MRI parameters in MSA patients. | Magnetic Resonance Imaging change in Arterial Spin Labelling [ASL] | Baseline to 12 Months | 
| To investigate differences in functional MRI parameters in MSA patients. | Magnetic Resonance Imaging change in resting state functional MRI [rs-fMRI] | Baseline to 12 Months | 
| To investigate differences in markers of neurite density on MRI in MSA patients. | Magnetic Resonance Imaging change in Neurite Orientation Dispersion and Density Imaging [NODDI] | Baseline to 12 Months | 
| To investigate correlations between imaging and grading of MSA in MSA patients. | Correlations between imaging measures and the grading scale UMSARS | Baseline to 12 Months | 
| To investigate correlations between imaging and staging of MSA in MSA patients. | Correlations between imaging measures and the staging scale Hoehn and Yahr | Baseline to 12 Months | 
| To investigate correlations between synaptic density, regional brain glucose metabolism, and clinical measures in MSA patients. | Correlations between imaging measures and the screening cognitive measure MoCA | Baseline to 12 Months | 
| To investigate correlations between imaging measures and functional scales in MSA patients. | Correlations between imaging measures and the ability scale Schwab & England | Baseline to 12 Months | 
| To investigate correlations between imaging measures and quality of life in MSA patients. | Correlations between imaging measures and the quality of life scale MSA QoL | Baseline to 12 Months | 
| To investigate correlations between imaging measures and symptoms of autonomic dysfunction in MSA patients. | Correlations between imaging measures and the autonomic symptoms scale COMPASS-31 | Baseline to 12 Months | 
| To investigate correlations between imaging measures and symptoms of postural instability and tendency to fall in MSA patients. | Correlations between imaging measures and the balance scale ABC-16 | Baseline to 12 Months | 
| To investigate correlations between imaging measures and symptoms of depression in MSA patients. | Correlations between imaging measures and the depression scale BDI-II | Baseline to 12 Months | 
| To investigate correlations between imaging measures and symptoms suggestive of depression in MSA patients. | Correlations between imaging measures and the depression scale HDRS | Baseline to 12 Months | 
| To investigate correlations between imaging measures and REM sleep behaviour disorder in MSA patients. | Correlations between imaging measures and the sleep scale RBD-SQ | Baseline to 12 Months | 
| To investigate correlations between imaging measures and presence of behavioural symptoms in MSA patients. | Correlations between imaging measures and the behavioural scale NPI | Baseline to 12 Months | 
| To investigate correlations between imaging measures and cognitive decline in MSA patients. | Correlations between imaging measures and the cognitive battery CANTAB | Baseline to 12 Months | 
| To investigate correlations between imaging measures and fluid biomarkers of inflammation in MSA patients. | Correlations between imaging measures and blood biomarkers related to neuroinflammation | Baseline to 12 Months | 
| To investigate correlations between imaging measures and CSF biomarkers in MSA patients. | Correlations between imaging measures and CSF biomarkers related to neuroinflammation and misfolded proteins deposition | Baseline to 12 Months | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Neurodegeneration, Positron Emission Tomography, Multiple System Atrophy, Biomarkers