Investigation of Blood-Brain-Barrier Breakdown Using Manganese Magnetic Resonance Imaging in Drug-Resistant Epilepsy

Study Overview
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Brief Summary
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Background: - The blood-brain barrier separates the brain from the rest of the body. Epilepsy is a neurological disease that causes seizures. It can affect this barrier. Researchers think a contrast agent called mangafodipir might be better able to show areas of the brain that epilepsy affects. Objective: - To see if mangafodipir is well tolerated and safe. To see if it can show, on an MRI, areas of the brain that epilepsy affects. Eligibility: People ages 18-60 who: Have epilepsy not controlled by drugs Prior or concurrent enrollment in 18-N-0066 is required Design: Participants will be screened with: Medical history Physical exam Blood and urine tests Participants will have up to 6 visits in 1-3 months. Those with epilepsy will have an inpatient stay lasting 2-10 days. Visits may include: Video-EEG monitoring for participants with epilepsy An IV catheter put in place: a needle guides a thin plastic tube into an arm vein. Getting mangafodipir through the IV. 5 MRI scans over a 10-day period: a magnetic field and radio waves take pictures of the brain. Participants lie on a table that slides into a metal cylinder. They are in the cylinder for 45-90 minutes, lying still for up to 10 minutes at a time. The scanner makes loud knocking sounds. Participants will get earplugs. A final MRI at least 2 weeks after receiving mangafodipir. Gadolinium is given through an IV catheter.

Detailed Description
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Objective: The primary goals of this pilot study is to (1) describe the safety profile of administration of mangafodipir in patients with epilepsy and (2) determine if peri-ictal administration will allow focal entry of mangafodipir through the blood-brain-barrier and manganese enhanced magnetic resonance imaging (MEMRI) visualization of seizure foci. Secondary objectives are further exploration of MEMRI properties in patients with epilepsy. Study population: 16 patients with drug-resistant epilepsy. Design: Screening of enrolled participants will include a medical history, physical exam, blood and urine laboratory testing. Patients will be imaged interictally with a gadolinium enhanced MRI session. The administration of mangafodipir will be done as an inpatient during long-term video EEG recording, to ensure administration in the periictal period. Patients will receive a baseline MRI scan, IV mangafodipir injection and will then be serially scanned with non-contrast MRI scans. Outcome measures: The primary outcomes are (1) description of the safety profile of mangafodipir administration in patients with epilepsy, and (2) evaluation of the difference between T1-weighted signal intensity in the brain measured after mangafodipir administration in the seizure onset zone identified by standard clinical, EEG, and imaging studies, and the homologous contralateral region.

Official Title
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Investigation of Blood-Brain-Barrier Breakdown Using Manganese Magnetic Resonance Imaging in Drug-Resistant Epilepsy

Conditions
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Epilepsy

Intervention / Treatment
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* Drug: Mangafodipir


Participation Criteria
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Eligibility Criteria
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INCLUSION CRITERIA: Age 18-60 Able to give written informed consent directly. Drug resistant epilepsy participants will be defined as having clinically documented seizures with consistent EEG evidence as defined by the 1981 International Classification of Epileptic Seizures, refractory to standard anti-seizure treatment for at least one year prior to enrolling in this study and with an average of at least one seizure per month. This criterion will be established by preliminary screening in NINDS Clinical Epilepsy Service under protocol 18-N-0066. Seizure focus localization will be determined by standard clinical, neurophysiologic, and imaging studies. Prior or concurrent enrollment in 18-N-0066 is required. EXCLUSION CRITERIA: General exclusions: Patients with epilepsy who are not surgical candidates Positive test for HIV. History of post-ictal psychosis or post-ictal aggression Significant structural brain abnormality such as a brain tumor, stroke, brain damage from head trauma or blood vessel abnormalities, on the baseline MRI scan. Pregnancy or breast-feeding. Planning to get pregnant in the next 2 months Claustrophobia to a degree that the subject would feel uncomfortable in the MRI machine. Cannot lie on their back for at least two hours. Risk for MRI scan, (e.g., any non-organic implant or other device such as a cardiac pacemaker or infusion pump or other metallic implants, objects or body piercings that cannot be removed, or history of being a welder or metal worker due to small metal fragments in the eye) History of clinically significant liver or kidney disease, that could potentially increase the risk of CNS damage due to manganese exposure A history of drug or alcohol abuse/dependence (subjects scoring 8 or higher on the AUDIT scale) Screening lab abnormalities, demonstrating values more than 2 times the upper limit of normal for AST, ALT, bilirubin, alkaline phosphatase, BUN, creatinine Previous presumed occupational exposure to manganese (i.e., having worked in a mine, foundry, smelter, dry cell battery manufacturing facility, or agriculture) Allergy to manganese On-going treatment with calcium-channel blocker Iron-deficiency anemia Personal history of Parkinson's Disease or Parkinsonism or presence of this disease in a 1st degree relative Unwilling to allow sharing and/or use in future studies of coded data that are collected for this study Gadolinium enhanced MRI component specific exclusions (not applicable for patients opting out of this portion of the study): Estimated GFR < 60, tested within 1 week of scan Allergy to gadolinium

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: 1<br>Patients will be given the study drug | Drug: Mangafodipir<br>* Patients will be imaged interictally with a gadolinium enhanced MRI session. The administration of mangafodipir will be done as an inpatient during long-term video EEG recording, to ensure administration in the peri-ictal period.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| evaluation of the difference between T1-weighted signal intensity in the brain measured after mangafodipir administration in the seizure onset zone identified by standard clinical, EEG, and imaging studies, and the homologous contralateral regio... | evaluation of the difference between T1-weighted signal intensity in the brain measured after mangafodipir administration in the seizure onset zone identified by standard clinical, EEG, and imaging studies, and the homologous contralateral region. | after mangafodipir administration | 
| description of the safety profile of mangafodipir administration in patients with epilepsy | safety profile | after mangafodipir adminstration | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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MRI, Manganese Enhanced MRI, Seizure Disorder, Seizures, Epileptic Focus