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February 16, 2021; 96 (7) Article

Efficacy and Safety of Intravenous Mesenchymal Stem Cells for Ischemic Stroke

Jong-Won Chung, Won Hyuk Chang, Oh Young Bang, View ORCID ProfileGyeong Joon Moon, Suk Jae Kim, Soo-Kyoung Kim, Jin Soo Lee, View ORCID ProfileSung-Il Sohn, Yun-Hee Kim, for the STARTING-2 Collaborators
First published January 20, 2021, DOI: https://doi.org/10.1212/WNL.0000000000011440
Jong-Won Chung
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Won Hyuk Chang
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Oh Young Bang
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Gyeong Joon Moon
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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  • ORCID record for Gyeong Joon Moon
Suk Jae Kim
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Soo-Kyoung Kim
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Jin Soo Lee
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Sung-Il Sohn
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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  • ORCID record for Sung-Il Sohn
Yun-Hee Kim
From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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From the Department of Neurology (J.-W.C., O.Y.B., S.J.K.), Samsung Medical Center, Sungkyunkwan University; Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B., G.J.M.) and Stem Cell and Regenerative Medicine Institute (G.J.M.), Samsung Medical Center; Department of Physical and Rehabilitation Medicine (W.H.C., Y.-H.K.), Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; School of Life Sciences (G.J.M.), BK21 plus KNU Creative BioResearch Group, Kyungpook National University, Daegu; Department of Neurology (S.-K.K.), Gyeongsang National University School of Medicine, Jinju; Department of Neurology (J.S.L.), Ajou University Hospital, School of Medicine, Suwon; and Department of Neurology (S.-I.S.), Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea. Dr. Moon is currently affiliated with the Stem Cell Center, Asan Institute for Life Science and the Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Efficacy and Safety of Intravenous Mesenchymal Stem Cells for Ischemic Stroke
Jong-Won Chung, Won Hyuk Chang, Oh Young Bang, Gyeong Joon Moon, Suk Jae Kim, Soo-Kyoung Kim, Jin Soo Lee, Sung-Il Sohn, Yun-Hee Kim, for the STARTING-2 Collaborators
Neurology Feb 2021, 96 (7) e1012-e1023; DOI: 10.1212/WNL.0000000000011440

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Abstract

Objective To test whether autologous modified mesenchymal stem cells (MSCs) improve recovery in patients with chronic major stroke.

Methods In this prospective, open-label, randomized controlled trial with blinded outcome evaluation, patients with severe middle cerebral artery territory infarct within 90 days of symptom onset were assigned, in a 2:1 ratio, to receive preconditioned autologous MSC injections (MSC group) or standard treatment alone (control group). The primary outcome was the score on the modified Rankin Scale (mRS) at 3 months. The secondary outcome was to further demonstrate motor recovery.

Results A total of 39 and 15 patients were included in the MSC and control groups, respectively, for the final intention-to-treat analysis. Mean age of patients was 68 (range 28–83) years, and mean interval between stroke onset to randomization was 20.2 (range 5–89) days. Baseline characteristics were not different between groups. There was no significant difference between the groups in the mRS score shift at 3 months (p = 0.732). However, secondary analyses showed significant improvements in lower extremity motor function in the MSC group compared to the control group (change in the leg score of the Motricity Index, p = 0.023), which was notable among patients with low predicted recovery potential. There were no serious treatment-related adverse events.

Conclusions IV application of preconditioned, autologous MSCs with autologous serum was feasible and safe in patients with chronic major stroke. MSC treatment was not associated with improvements in the 3-month mRS score, but we did observe leg motor improvement in detailed functional analyses.

Classification of Evidence This study provides Class III evidence that autologous MSCs do not improve 90-day outcomes in patients with chronic stroke.

ClinicalTrials.gov Identifier NCT01716481.

Glossary

BBB=
blood-brain barrier;
CI=
confidence interval;
CST=
corticospinal tract;
DTI=
diffusion tensor imaging;
FAC=
Functional Ambulatory Category;
FBS=
fetal bovine serum;
FMA=
Fugl-Meyer Assessment;
FMA-LL=
FMA lower limb;
FMA-T=
FMA total;
FMA-UL=
FMA upper limb;
ITT=
intention-to-treat;
MEP=
motor evoked potential;
MI=
Motricity Index;
mRS=
modified Rankin Scale;
MSC=
mesenchymal stem cell;
NIIHSS=
NIH Stroke Scale;
STARTING=
Stem Cell Application Researches and Trials in Neurology

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • STARTING-2 coinvestigators are listed in appendix 2 at the end of the article.

  • Editorial, page 301

  • Class of Evidence: NPub.org/coe

  • Received January 17, 2020.
  • Accepted in final form October 8, 2020.
  • © 2021 American Academy of Neurology
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