Neonatal Estimation Of Brain Damage Risk And Identification of Neuroprotectants (NEOBRAIN)

The number of surviving extremely low gestational age newborns (ELGAN) is
steadily incerasing with limit of viability going down to 23 or even 23 weeks
gestation in some countries. With this increase in survivors and a decrease in
mortality, we are faced with an ever increasing number of infants with mild to
severe disabilities
Prevention of perinatal brain damage is of major importance for public health
and obviously for individual well being. Both white and grey brain matter are
affected in perinatal brain damage observed in preterm infants.
Longterm-consequences of extreme prematurity are devastating, and perinatal
brain damage clearly plays a role in this scenario. The current pathogenetic
paradigm of perinatal brain damage in preterm infants has multiple
inter-related aspects and includes
infection/inflammation, hypoxia-ischemia, excitotoxicity, and free radicals. It
is likely that these mechanisms do not act alone, but in concert.
The absolute number of neurological handicap of perinatal origin is increasing
in Western countries due to increasing survival of preterm infants. The major
brain lesions associated with cerebral palsy (CP) and cognitive impairment are
white matter damage (WMD) mostly occurring in very preterm infants (born below
32 weeks of gestation) and cortico-subcortical lesions mostly observed in term
infants. For financial, technical, and ethical reasons, the pharmaceutical
industry has difficulties in making substantial investments in this area, which
has left perinatologists with a limited therapeutic
arsenal. At the present time, despite major improvements in neonatal care,
there are no established therapeutic regimens that are successful for the
prevention or treatment of perinatal brain lesions.
Nevertheless, epidemiological and experimental data have allowed identifying
potential targets for neuroprotection. New animal models, such as those
employed in NEOBRAIN, will help identify neuroprotective strategies in the
newborn.

Objective #1: Implement clinical platform. We see the need to implement a
clinical platform for two purposes. First, we want to design a biomarker
profile of perinatal brain damage in human newborns (see above). Thus, we have
established a functional network of institutions caring for newborns that can
serve as the basis for such a clinical study designed to identify human
biomarker profiles based on genetic and biochemical markers,
electroencephalographic
(EEG) patterns, and magnetic resonance imaging (MRI). Second, we will use and
expand this platform for clinical drug testing both within the 36 months of
NEOBRAIN and thereafter.
Objective #2: Prepare for drug testing
NEOBRAIN is going to pave the way for clinical drug development. In essence, it
is our 3rd objective to design our clinical platform in a fashion that allows
for quick expansion (i.e., recruitment of further centers), so that
bench-to-bedside translational steps (i.e., a clinical trial) can be taken
quickly after NEOBRAIN is finished. Indeed, we will prepare for the possibility
that this might be the case even within the three years of NEOBRAIN.

Cohort study
The clinical component of NEOBRAIN will aim at recruiting between months 12 and
24 a first small cohort of 300 newborns with a gestational age <28wks. These
infants will come from intensive care units in Hannover, Gothenburg, Paris,
Geneva, Berlin, Utrecht, Siena, Innsbruck, Lund and Uppsala (Partners 1, 2, and
7-13).
For biomarker measurement, it will be our foremost goal to obtain the smallest
possible sample in order not to burden the baby beyond what is absolutely
necessary. The exact procedures were determined in a discussion about these
issues at the kick-off general assembly meeting (October 2006), where we
devoted considerable time and energy to optimize the amount and timing of blood
sampling for the NEOBRAIN clinical study. We are confident that we can measure
all the biomarkers we need in a few cc*s (ml*s) of blood.
Since we need early postnatal risk information, we will obtain samples for
biomarker measurements at birth (cord blood), and within the first 3 days of
postnatal life. To monitor changes, a third sample will be obtained at term for
all infants. Since we wish to be cost-effective, the hypothesis-generating
component will include genomic (mRNA) analysis only for the first 150 infants.
Once we have identified markers of interest, we will use stored samples for
further analyses in the hypothesis-testing component using all samples
available. Metabolomic and proteomic sampling will be performed in all infants
recruited to the study.
Obviously, genetic (single nucleotide polymorphism, SNP) information needs to
be obtained only once. We will attempt also to receive permission from parents
for parental SNP sampling. In this fashion, we can restrict SNP analyses to
markers of interest, identified in the hypothesis-generating component of the
study.
Ultrasound scanning and MRI-scans, as well as electroencephalographic (EEG)
measurements will be performed according to protocols to be developed over the
first months of NEOBRAIN by respective colleagues from/in the pertinent Work
Packages.
At baseline and during the hospitalization of these infants, demographic,
socio-economic, clinical, and
morbidity information will be entered from each site using a remote data entry
(RDE) system to be developed for NEOBRAIN in a custom-tailored fashion (see
below). Imaging- and EEG-related information, and biomarker information from
the laboratory partners/SMEs (mainly Partners 2, 4, and 12) will also be
entered into a central database to be maintained in Hannover (P1). The goal is
to have all information generated within the clinical component of NEOBRAIN
available in one centralized database, so that data management and clean-up can
be performed centrally.

We ensure the Ethics Review Committee and the European Commission that the
clinical component of our research will not lead to an increased clinical risk
for the preterm babies included in our study population.
Extremely preterm infants are routinely at risk by being exposed to a large
number of clinically indicated noxious stimuli during the neonatal period,
including blood sampling and care procedures such as suctioning of the
endotracheal tube. It is important to note that our scientific studies attempt
not to add to this burden by having the current project designed in a fashion
that avoids any additional distress as possible by using clinically indicated
examinations and time-points for blood sampling.
The studies and examinations described in the NEOBRAIN proposal constitute
parts of standard neonatal intensive care for extremely preterm infants in a
majority of the included centers. These methods include ultrasonography,
long-term EEG and MRI at term.
Ultrasonography
Ultrasound has for a long time been a standard method, since these infants are
at increased risk for developing brain damage, and is usually repeated at least
twice during the first week of life and then every week to every second week
depending on findings and local standards. In NEOBRAIN, we will systematically
collect clinical information from clinically indicated studies. The structured
way of performing ultrasonography (using protocols to be developed specifically
for the NEOBRAIN project) will contribute to improved clinical performance and
be beneficial for the infants. The *(c)linical risks
when performing neurosonography (*) include tissue damage from mechanical
compression, desiccation or surface trauma; increased risks of infection during
patient handling; and increased risk of hypothermia in neonates* (Barr LL.
Clinical concerns in the ultrasound exposure of the developing central nervous
system. Ultrasound Biol Med 2001;27:889-892). We assure the Commission that *by
instituting a standardized examination and following appropriate patient
handling guidelines, the risk of an adverse outcome associated with
neurosonography is minimized. The goal in performing a
standardized examination is to apply the ALARA (as low as reasonably
achievable) principle to examinations while increasing reproducibility between
studies.* (cit.op.)
Long-term EEG monitoring
This method is increasingly used in neonatal intensive care units for clinical
intensive-care monitoring of both term and preterm infants at high risk for
compromised brain function. The reduced number of electrodes in the EEG-monitor
(usually 1 or 2 channels of EEG requiring 3 or 5 electrodes, respectively)
gives information on overall brain function as shown by the electrocortical
background activity and epileptic seizure activity (which is often entirely
subclinical). The EEG will be recorded
through standard disc electrodes or hydrogel (stick-on) electrodes, after brief
preparation (light scrubbing of the skin) with Nuprep cream or similar, both
are standard procedures (hydrogel electrodes were recently described: West et
al. Early Hum Dev 2006;82:43-51). These methods for application of EEG
electrodes have been used in a large number of infants without any reported
side effects. They are usually easy and quick to apply and do not seem to
disturb the infants.
Magnetic resonance imaging
Neonatal magnetic resonance imaging (MRI) is performed for clinical purposes in
many, if not all, participating NEOBRAIN centers for several years. Therefore,
we have accumulated considerable collective expertise in MRI techniques, and
its associated practical issues. We confirm that MRI performed within NEOBRAIN
using a specified protocol to be developed and agreed upon the consortium (see
deliverable D6.1 in our proposal). Moreover, we confirm that this protocol will
be
designed in a fashion that ensures minimal clinical risk. It goes without
saying that we will obtain parental consent.