William J. Powers, MD - US grants

positron emission tomography; cerebral ischemia /hypoxia; platelets; thrombosis; arteriosclerosis; anticoagulants; platelet aggregation inhibitors; platelet aggregation; human subject; histochemistry /cytochemistry;

Measurement of cerebral glucose metabolism (CMR-Glu) with 14C-deoxyglucose (DG) and 10F-fluorodeoxyglucose (FDG) has proven to be a valuable technique for studying both normal cerebral function and a variety of neurological diseases. However, this method is not quantitatively accurate under conditions of ischemia or hypoglycemia due to changes in the value of the isotope correction factor (lumped constant). The use of 11C-glucose labeled specifically at the 1-carbon position (1-22C-glucose) has several advantages: First, no correction factor is required. Second, almost all of the radioactive label is trapped as metabolites of intermediary metabolism within the first 5-10 minutes after injection providing adequate time for data collection. Development of a method to measure CMR-Glu with 1-22C glucose and positron emission tomography (PET) is critical for studies of blood brain glucose transport and cerebral glucose metabolism under conditions of cerebral ischemia and hypoglycemia. The specific hypothesis to be tested is: PET employing 1-22C-glucose can be use to measure cerebral glucose metabolism (CMR-Glu) accurately under a wide variety of physiological and pathological conditions, including cerebral ischemia and hypoglycemia. The specific aim of this project is to compare paired, simultaneous determinations of CMR-Glu in non-human primates by PET with 1-22C-glucose and by direct measurement of arterial-jugular venous (A- V) glucose differences assayed by mass spectrometry under conditions of cerebral ischemia, hypoglycemia, and hypoxemia as well as pharmacologically induced reductions and increased oxidative glycolysis. The accuracy of the PET method using two different models (four compartment and distributed parameter) under these various conditions will be determined. Under those conditions for which one particular model may provide a consistently accurate measurement of CMR-Glu, the estimated rate constants will be analyzed to determine what changes in forward and reverse glucose transport and phosphorylation have taken place. This analysis will provide insight into compensatory mechanisms used by the brain to maintain glucose metabolism under conditions of reduced supply or increased demand.

Modulation of blood-brain barrier glucose transport is postulated to be of clinical importance in insulin dependent diabetes mellitus (IDDM)). When plasma glucose concentrations fall, patients with poorly controlled IDDM experience symptoms and activation of counterregulatory hormones at higher plasma glucose levels than do non-diabetic subject. A single two-hour episode of hypoglycemia the previous afternoon in patients with IDDM will lower the plasma glucose level at which symptoms and hormonal counterregulation occur the next morning. Hypothesis; Changes in behavioral and counterregulatory hormonal responses to hypoglycemia that occur in subjects with IDDM are associated with reduced blood-to-brain glucose transport (Jin) which normalizes after antecedent hypoglycemia. Specific Aim IA: Measure Jin with positron emission tomography (PET) and 1-11C-D-glucose (1-11CG) during hyperinsulinemic hypoglycemic clamp (3.6 muml 1) in patients with poorly controlled IDDM and in nondiabetic subjects. Specific Aim IB: Measure J in with PET and 1-11 CG during hyperinsulinemic hypoglycemic clamp (2.8 mumol ml 1) in patients with IDDM on two occasions, once following clamped hypoglycemia (2.8mumol ml 1) in patients with IDDM on two occasions, once following clamped hypoglycemia (2.8 mumol ml 1) the previous afternoon and once following otherwise identical clamped hyperglycemia (11.1 mumol mml1) the previous afternoon. A better understanding of the adaptive capacity of BBB glucose transport and its relationship to warning symptoms of hypoglycemia and the hormonal counterregulatory response would be of great value in designing better therapeutic strategies to minimize the deleterious effects of iatrogenic hypoglycemia. Under conditions of increased neuronal activity, local CMRG1u increases markedly. Data regarding concomitant changes in J in are inconsistent. PET with 1-11CG has demonstrated accuracy for measurements in resting brain during local physiologic brain activation when production of 11C=-lactate may increase is unknown. Hypothesis; PET with 1-11CG provides accurate measurement of CMRGlu during local physiologic brain activation. Specific Aim II: Perform paired PE T measurements of CMRGlu with 1-11CG and 18F- fluorodeoxyglucose (18FDG) during visual stimulation on successive days in normal subjects. The ability to measure j in and CMRGlu with 1-11CG during physiologic brain activation under normal conditions and in abnormal states would provide valuable information regarding the relationship between glucose supply and demand during a variety of physiological and pathological conditions in humans.

Spontaneous intracerebral hemorrhage (ICH) comprises approximately 10% of all strokes with an annual incidence of approximately 15/100,000. Current treatment results are disappointing. Initial mortality remains high and survivors often have significant residual disability. New therapeutic approaches are difficult to pursue because little is known about the pathophysiologic mechanisms of brain injury. The goal of this research is to determine whether pharmacologic reduction in mean arterial pressure within 24 hours after acute ICH produces or exacerbates ischemia. We will test the specific null hypothesis: Pharmacologic blood pressure reduction of 15+5% in patients with spontaneous supratentorial ICH does not produce regional cerebral ischemia potentially severe enough to cause tissue injury. We will perform this Specific Aim: Thirty patients with acute ICH within 24 hours of onset and initial mean arterial pressure of 120-150 mm Hg who have just completed measurements of regional cerebral blood flow (rCBF), regional cerebral metabolic rate of oxygen (rCMRO2), regional oxygen extraction fraction (rOEF) and regional cerebral venous oxygen content (rCvO2) using positron emission tomography (PET) as part of Project 3 will be randomized into 3 groups of 10 patients each. One groups will receive no antihypertensive medication. The second and third groups will receive either labetalol (Group II) or nicardipine (Group III) to lower MAP by 15 plus minus % within 60 minutes. We will repeat PET measurements after target MAP is reached or, for the control group, approximately 60 minutes later. We will determine the effect of pharmacologic reduction in MAP on average hemispheric CBF and we will also determine if there re critical shifts from safe to dangerous or lethal ranges of rCBF, rCMRO2 and rCvO2. This research will provide fundamentally important pathophysiologic information about the possible role of iatrogenic ischemic in producing secondary brain injury in patients with ICH which will be of enormous value in planning future therapeutic investigations.

Spontaneous intracerebral hemorrhage (ICH) comprises approximately 10% of all strokes with an annual incidence of approximately 15/100,000. Current treatment results are disappointing. Initial mortality remains high and survivors often have significant residual disability. New therapeutic approaches are difficult to pursue because little is known about the pathophysiologic mechanisms of brain injury. The goal of this research is to determine importance of cerebral ischemia as a mechanism of secondary tissue damage in human subjects with acute ICH. We will test the specific null hypothesis: Spontaneous supratentorial ICH does not produce regional cerebral ischemia potentially severe enough to cause tissue injury. We will perform this Specific Aim: We will measure regional cerebral blood flow (rCBF), regional cerebral metabolic rate of oxygen (rCMRO2), regional oxygen extraction fraction (rOEF) and regional cerebral venous oxygen content (rCvO2) using positron emission tomography (PE) in 60 patients with spontaneous supratentorial ICH. Initial measurements will be made within the first 24 hours and repeated 24-72 hours later. We will determine the proportion of patients with regional cerebral ischemia potentially severe enough to cause tissue injury and how this changes during the first few days after acute ICH. This research will provide fundamentally important pathophysiologic information about the possible role of ischemia in producing secondary brain injury in patients with ICH which will be of enormous value in planning future therapeutic investigations.

The PET Facilities Core will co-ordinate those aspects of the initial acquisition, reconstruction and archiving of the PET, clinical and CT data that are shared among the four projects. Dr. Powers will the Director of this Core. All PET studies will be done on the Siemens 961 ECAT EXACT HR 47 PET scanner located in the Neurocritical Care PET Research Facility in the Neurology Neurosurgery Intensive Care Unit. This facility is dedicated to scientific research with studies of a cute brain injury given top priority. it is outfitted with al the life support equipment available elsewhere in the NNICU. Currently, all oxygen-15 radiopharmaceuticals necessary for performance of the PET measurements are prepared in the Washington University Medical Center Cyclotron Facility staffed by trained operators from 0700-1700, Monday through Friday. In order to successfully recruit patients with acute traumatic brain injury for Projects 1 and 2, it will be necessary to expand working hours of the Neurocritical Care PET Research Facility outside the current working hours. In year 1, we will construct a delivery system from a Tandem Cascade Accelerlator currently operating in the Rast Building Imaging Center two blocks away. This system will provide the flexibility to study patients during off-hours without the need for a cyclotron operator. Each of the four projects involves acquisition and recording of clinical and diagnostic laboratory information on patients with traumatic brain injury and intracerebral hemorrhage. In our preliminary studies we have used data sheets filled out by hand for this purpose. During year 1, we will continue to use our paper data forms to collect data. This will allow us to gain experience with the data collection and modify the forms accordingly to improve accuracy and efficiency. These revised and modified forms will serve as the basis for modifications to an existing computerized database system to be carried out in year 2. Modification and implementation of this clinical database to serve th needs of this program project should provide improvement in the efficiency, standardization and integrity of data collection and retrieval.

The overall goal of this Program project is to investigate ischemia as a secondary mechanism of tissue damage in the early period following acute brain injury. Secondary mechanisms, occurring in a delayed manner, provide the best opportunity for successful therapeutic intervention. A better understanding of the pathophysiology of secondary tissue damage following acute brain injury is important if improvements are to be made in current therapy. We will investigate two types of acute brain injury head trauma and intracerebral hemorrhage. In project 1, Drs. Michael Diringer and Robert Grubb will use positron emission tomography (PET) to investigate the occurrence and duration of focal cerebral ischemia in acute traumatic brain injury in project 2, Drs. Michael Diringer and Robert Grubb will use PET to determine the effect of hyperventilation on regional cerebral blood flow and brain oxygenation in acute traumatic brain injury. In project 3, Drs. William Powers and Michael Diringer will use PET to investigate the occurrence and duration of focal cerebral ischemia in acute intracerebral hemorrhage. In project 4, Drs. William Powers and Michael Deringer will use PET to determine th effect of pharmacologic reduction of systemic arterial pressure on regional cerebral blood flow and brain oxygenation in acute intracerebral hemorrhage. The PET Facilities Core directed by Dr Powers will coordinate those aspects of the initial acquisition, reconstruction and archiving of the PET, clinical and CT data. The PET Image Analysis Core directed by Dr. Tom Videen will implement and validate improved methods for analysis of PET images. This Program Project draws on a combination of facilities and expertise at Washington University that is unique. It combines state-of-the-artPET equipment for quantitative neuroimaging located in an intensive car unity, expertise in the care of critically ill neurological patients and many years experience in studying cerebral blood flow and metabolism. This research will provide fundamentally important pathophysiologic information about the role of ischemia in producing secondary tissue damage in patients with acute brain injury due to head trauma and intracerebral hemorrhage. This information is will provide new understanding of the pathophysiology of these conditions which will be important in guiding future research toward the most fruitful approaches for ameliorating the devastating impact of acute brain injury. The results of these studies will have immediate and direct applicability to the thousands of patients each year who suffer from these diseases.

[unreadable] DESCRIPTION (provided by applicant): Ipsilateral increased oxygen extraction fraction (OEF) measured by PET is a powerful independent risk factor for subsequent stroke in patients with symptomatic carotid occlusion. The St. Louis Carotid Occlusion Study found that the relative risk conferred by increases OEF was 7.3 (95% Cl 1.6 - 33.4) for ipsilateral ischemic stroke corresponding to two year rates for ipsilateral stroke of 5.3% in 42 patients with normal OEF and 26.5% in 39 patients with increased OEF (p=.004). In patients with hemispheric symptoms within 120 days, the two year ipsilateral stroke rates were 12% in patients with normal OEF and 40% in patients with increased OEF. Previous PET studies have demonstrated that surgical anastomosis of the superficial temporal artery to the middle cerebral artery (STA-MCA) can restore OEF to normal. The Carotid Occlusion Surgery Study (COSS) will test the hypothesis that STA-MCA surgical anastomosis when added to best medical therapy can reduce by 40%, despite perioperative stroke and death, subsequent ipsilateral ischemic stroke (fatal and non-fatal) at two years in patients with recent (<120 days) symptomatic internal carotid artery occlusion and increased OEF. Clinically eligible patients with unilateral carotid artery occlusion demonstrated by any vascular imaging will be asked to consent to PET and treatment randomization if PET shows increased OEF. If necessary, consent for a supplemental arteriogram to confirm occlusion or demonstrate that extracranial and intracranial vessels will be sought as well. Those who agree and meet both arteriographic and PET criteria will be randomized 1:1 to undergo STA-MCA bypass surgery followed by medical management or medical management alone. All randomized patients will be followed at three month intervals for two years. The primary endpoint in the surgical group is the combination of the following: (1) 30 day post-operative (surgical group) or post-randomization (non-surgical group) occurrence of all stroke and death and (2) the occurrence of ipsilateral ischemic stroke within two years of randomization. Adjusting for anticipated 2 year mortality, 372 patients (186 in each group) will provide 90% power to detect the anticipated difference (40% vs. 24.2%). 91 have been randomized. Assuming 25-30% of PET scans will demonstrate increased OEF, this will require enrolling a total of 1400 clinically eligible subjects for PET. This proposal covers the second 5 years of this trial. [unreadable] [unreadable] [unreadable]

DESCRIPTION (Adapted from the abstract provided by the applicant): Several lines of evidence suggest that Huntington's disease (HD) and Parkinson's disease (PD) have defects in mitochondrial function that impair oxidative phosphorylation and play a key role in the mechanism of neuronal death. To date, however, there have been no direct measurements of cerebral oxygen to glucose metabolic ratios to demonstrate an in vivo defect in cerebral mitochondrial metabolism in these diseases. We will use positron emission tomography (PET) to measure in vivo regional cerebral oxygen metabolism (CMR02) and cerebral glucose metabolism (CMRglc) to test two primary hypotheses: 1) Patients with HD have a generalized defect in cerebral mitochondrial metabolism. To test this hypothesis, we will measure whole brain CMR02/CMRgIc in 15 gene-positive pre-symptomatic patients with HD, 15 gene-positive patients with HD and definite motor signs and 30 age/gender-matched normal controls. 2) Patients with PD have a generalized defect in cerebral mitochondrial metabolism. To test this hypothesis, we will measure whole brain CMR02/CMRgIc in 15 never-medicated, early PD patients and 15 age/gender-matched normal controls. In the same subjects, we also will test two secondary hypotheses: 3) Regions vulnerable to pathologic insult have larger magnitude or selective defects in cerebral mitochodrial metabolism - caudate and putamen in HD and substantia nigra and putamen in PD. 4) In PD and HD, the degree of dysfunction in platelet electron transport complex function measured in vitro correlates with the degree of abnormal cerebral mitochondrial metabolism measured in vivo. At this time it is not clear how the abnormalities in electron transport chain activity measured in vitro in these two diseases correspond to cerebral mitochondrial metabolism in vivo. Direct in vivo regional PET measurements of CMR02 and CMRglc will allow us to demonstrate the extent and magnitude of mitochondrial dysfunction in vivo. Establishing the existence of cerebral mitochondrial dysfunction early in the course of these diseases will not only provide insights into the pathogenesis, but it will provide a measurable biological abnormality that can be monitored to determine the effect of treatments aimed at slowing or halting the progression of neuronal loss. The opportunity to determine the relation between platelet mitochondrial function and cerebral mitochondrial metabolism in patients with PD and HD is uniquely important. If such a relationship can be established in untreated patients in this study, then we would pursue further studies to determine the effects on cerebral mitochondrial metabolism of agents that alter platelet mitochondrial function. If such studies yield consistent results, they will establish the basis for the utilization of platelet rnitochondrial function assays to monitor cerebral mitochondrial metabolism.

DESCRIPTION (provided by applicant): The overall goal of this Program Project is to investigate the pathophysiological changes that occur during injury and treatment in human subjects with acute brain damage. We will investigate three types of acute brain injury: intracerebral hemorrhage, ischemic stroke and head trauma. In Project 1, Dr. Allyson Zazutia will investigate the mechanism, extent and clinical importance of edema following intracerebral hemorrhage. In Project 2, Drs. William Powers and Venkatesh Aiyagari will use PET to determine the effect of pharmacologic reduction of systemic arterial pressure on regional cerebral blood flow in acute ischemic stroke. In Project 3, Drs. Michael Diringer and Robert Grubb will investigate the pathophysiological effects of mannitol and hypertonic saline on brain edema due to ischemic stroke and head trauma. The Imaging Core will perform acquisition, reconstruction, processing and archiving of the PET, MR and CT data for Projects 1,2 and 3 as well as validate recently developed MR methods of CBF and OEF estimation against gold-standard techniques. The Radiochemistry Core will provide radiopharmaceuticals for Projects 1,2 and 3 as well as construct a steady state oxygen-15 gas inhalation system to permit PET studies in subjects who are not endotracheally intubated or who cannot actively inhale. This Program Project draws on a combination of facilities and expertise at Washington University that is unique. It combines state-of-the art quantitative neuroimaging, expertise in the care of critically ill neurological patients and many years experience in studying cerebral blood flow and metabolism. This research will provide fundamentally important pathophysiological information to guide future research toward the most fruitful approaches for ameliorating the devastating impact of acute brain injury.

Hypertension is one of the most significant risk factors for ischemic stroke. Long term treatment of hypertension after stroke has been shown to reduce the incidence of recurrent stroke by 28% and major cardiovascular complications by 26%. However, in the setting of acute ischemic stroke it has been difficult to determine the appropriate treatment of elevated blood pressure due to the overwhelming concern that lowering blood pressure in this setting might worsen cerebral ischemia. These concerns are based primarily on studies of CBF in animal models. Very few studies of the effect of pharmacological reduction of elevated blood pressure on CBF following acute ischemic stroke in humans have been done and they do not provide adequate data to settle this issue. The goal of this research project is to determine the effect of controlled, graded pharmacologic reduction of blood pressure on rCBF following acute ischemic stroke using positron emission tomography (PET) and to carefully monitor the clinical effects and safety of treatment. This specific null hypothesis will be tested: Pharmacological reduction of mean arterial blood pressure (MAP) by 15 +/- 5 mm Hg in patients with a recent cerebral infarction and elevated blood pressure does not produce a statistically significant reduction in regional cerebral blood flow. This Specific Aim will be carried out: Between day 3-14 after onset, sixty patients with a hemispheric cerebral infarction and mean arterial blood pressure of 120-150 mm Hg will undergo a detailed neurological examination and measurements of rCBF, regional cerebral metabolic rate (rCMRO2), and regional oxygen extraction fraction (rOEF) using PET. Blood pressure will then be lowered pharmacologically in two steps of 7.5 +/- 5 mm Hg each using intravenous labetalol. The neurological examination and CBF measurements will be repeated after each step. This study is not designed to provide data on whether blood pressure in the acute setting improves outcome. This can only be done by randomized treatment trials with clinical outcome measures. These data can, however, be used to help design such a trial and, in the meantime, provide helpful guidelines when reduction in arterial pressure is deemed to be necessary for other reasons. This study will provide esssential information necessary to translate data from animal studies into treatment for human cerebrovascular disease.

[unreadable] DESCRIPTION (provided by applicant): [unreadable] [unreadable] This is an application for supplemental funding of Program Project Grant P01 NS035966, "Clinical Pathophysiology of Acute Brain Injury," directed by William J. Powers. The application requests support for the Administrative and Training Core (Core A) to establish web-based resources which promote its research and education aims, (a) by development of the Stroke Trials Directory, an on-line registry of randomized clinical trials in cerebrovascular disease, and (b) by formation of a web-based data sharing archive. Funded by two previous administrative supplements to the current P01 project, the Stroke Trials Directory is a registry of randomized clinical trials in cerebrovascular disease. It is freely available on the internet at www.stroketrials.org. This function will be administered as part of the Core facility (Core A) which currently supports education in clinical stroke research, and will be guided by regular interaction with the PPG faculty investigators and trainees. The directory presently includes listings for over 200 interventions (drugs and procedures) and nearly 600 current and past clinical stroke trials. The web site also provides information about the most commonly used scales for clinical stroke research assessment, and comprehensive directories of major stroke conferences, on-line stroke consensus statements, research funding sources, and other useful links. This application also requests support to develop an internet repository for clinical imaging data (CT, MR, PET), in accordance with the NIH policy on data sharing. We will utilize an existing architecture for retrieval and display of patient-protected image data obtained in past and future PPG research projects. Support of these web initiatives will allow us to better fulfill the PPG educational aims by reaching a wider audience in a cost efficient manner using up-to-date electronic methodology. [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Alzheimer's Disease (AD) is the most common cause of dementia in the elderly. While acknowledging the important role of abnormal protein deposition in the pathogenesis of AD, there exists a considerable body of evidence indicating that both cerebral vascular and cerebral metabolic mechanisms play a role in the development of pathological AD and in the development of dementia in subjects with pathological AD. This project will address 3 specific aspects of these mechanisms in AD. Specific Aim 1 will test the hypothesis that patients with clinically diagnosed AD have impaired autoregulation of cerebral blood flow to reductions in systemic mean arterial pressure. Specific Aim 2 will test the hypothesis that patients with clinically diagnosed AD have an abnormality in cerebral oxidative energy metabolism. In Specific Aim 3 we will develop and optimize a method to label the synthetic amyloid peptide A-beta (1-40) with C-11 and perform animal studies to prepare for eventual studies in human subjects. The hypotheses that we will test are soundly based on mechanisms described in animal models and in vitro studies of human tissue. To bridge the gap between the laboratory bench and the patient, we will rigorously test these hypotheses in human AD in vivo by well-designed studies. This translational approach will allow us to determine the importance of these mechanisms in the human disease and potentially provide the information necessary for designing future treatment strategies. We will employ precise, accurate and well-validated techniques to measure cerebral blood flow and metabolism as well as innovative new neuroimaging techniques to evaluate brain amyloid deposition and BBB transport of amyloid. This proposal brings together accomplished investigators from the Alzheimer's Disease Research Center and the Division of Radiological Sciences with complementary expertise. Through the use of the unique resources and personnel at Washington University Medical Center, we have the opportunity to provide answers to important clinical and mechanistic questions in AD.

Age; Alzheimer's Disease; amyloid imaging; benzothiazole; blood flow measurement; Blood Vessels; Brain; Cerebrovascular Circulation; Cerebrum; Diagnosis; Energy Metabolism; Evaluation; glucose metabolism; Homeostasis; Image; Magnetic Resonance Imaging; Measurement; Metabolic; Metabolism; Neurologic; Oxygen; Participant; Patients; Positron-Emission Tomography; pressure; Testing; uptake; white matter

Hypertension is one of the most significant risk factors for ischemic stroke. Long term treatment of hypertension after stroke has been shown to reduce the incidence of recurrent stroke by 28% and major cardiovascular complications by 26%. However, in the setting of acute ischemic stroke it has been difficult to determine the appropriate treatment of elevated blood pressure due to the overwhelming concern that lowering blood pressure in this setting might worsen cerebral ischemia. These concerns are based primarily on studies of CBF in animal models. Very few studies of the effect of pharmacological reduction of elevated blood pressure on CBF following acute ischemic stroke in humans have been done and they do not provide adequate data to settle this issue. The goal of this research project is to determine the effect of controlled, graded pharmacologic reduction of blood pressure on rCBF following acute ischemic stroke using positron emission tomography (PET) and to carefully monitor the clinical effects and safety of treatment. This specific null hypothesis will be tested: Pharmacological reduction of mean arterial blood pressure (MAP) by 15 +/- 5 mm Hg in patients with a recent cerebral infarction and elevated blood pressure does not produce a statistically significant reduction in regional cerebral blood flow. This Specific Aim will be carried out: Between day 3-14 after onset, sixty patients with a hemispheric cerebral infarction and mean arterial blood pressure of 120-150 mm Hg will undergo a detailed neurological examination and measurements of rCBF, regional cerebral metabolic rate (rCMRO2), and regional oxygen extraction fraction (rOEF) using PET. Blood pressure will then be lowered pharmacologically in two steps of 7.5 +/- 5 mm Hg each using intravenous labetalol. The neurological examination and CBF measurements will be repeated after each step. This study is not designed to provide data on whether blood pressure in the acute setting improves outcome. This can only be done by randomized treatment trials with clinical outcome measures. These data can, however, be used to help design such a trial and, in the meantime, provide helpful guidelines when reduction in arterial pressure is deemed to be necessary for other reasons. This study will provide esssential information necessary to translate data from animal studies into treatment for human cerebrovascular disease.

in the past continuing input into the activities of this program project. We expect that the IAC will convene annually to review the progress of research in the PPG. A formal report of the conclusions of the IAC will be included in the annual report to NINDS. We will also appoint an External Advisory Committee if this program project is funded. While we could select members of this in advance of funding we would like not to do so in order to maintain maximal flexibility in choosing the most appropriate and distinguished individuals available. We hope that the review committee will understand our position on this matter. All of us involved in the work of this Program Project have long maintained national and international contacts within the scientific community that have served us well in formulating and guiding our research efforts. In selecting the most appropriate members of our EAC we will definitely be calling upon some of these individuals. If, as we hope, we are funded we will convene our EAC twice during the next period of funding, in year 2 and again in year 4. In our revised budget for the Administrative Core we have asked for funds to cover the cost of these visits. As with the IAC, the reports of our EAC will be made part of our annual reports of progress to the NINDS. Research Meetings Weekly research meetings among the Investigators and Pis of this program project have been a tradition for more than 25 years. The Pis of all three projects and the PI of Core B all reside in offices in common space in the East Building Imaging Center of the Washington University Medical Center. Their assistants, fellows and graduate students share common open space adjacent to these offices. This atmosphere has and will continue to foster a most unique collaborative environment that has resulted in more than 3 decades of significant research in the area of brain circulation, metabolism and brain function. Record Keeping The Administrative Core is responsible for extensive record keeping on all human subjects required by the Washington University Human Studies Committee (RDRC), Radioactive Drug Research Committee and Animal Studies Committee. All details concerning the administration of radiopharmaceuticals to patients and normal subjects (all three projects) must be compiled quarterly and submitted to the RDRC. Detailed yearly summaries must be prepared for the FDA in accordance with our approved protocols under the RDRC. In accordance with the latest HIPAA regulation, to which this laboratory is now fully compliant, secure files and PHS 398/2590 (Rev. 09/04) Pageat 33 Continuation Format Page CONTINUATION PAGE Principal Investigator/Program Director (Last, First, Middle): Raichle, MarCUS E. computer records are maintained for all information obtained in the course of the proposed experiments. The Administrative Core has always performed these and other duties as they have expanded in both volume and complexity over the years and will continue to do so in the future. Administrative Staff The administrative staff of this program project consists of a single person, Mrs. Shari Macke. The other person on this Core is Dr. Fred Prior. His presence signifies the commitment of the Program PI and other members of this program project to not only comply with the request for the public sharing of research data but to actually promote this as a standard of practice. In this regard it should be noted that Dr. Raichle has Chaired the Scientific Advisory Board of the Dartmouth fMRI Database since its inception 5 years ago. As detailed below, this program project is proud to be the first major neuroscience program at Washington University to participate in the new public data sharing infrastructure being developed by Drs. Fred Prior and David Van Essen (see below). It should be noted that the Pis of the projects and Cores form the Steering Committee for this program project. Together they have amassed a total of 92 years of research at Washington University in the areas directly related to the science being pursued in this program project. Beginning in 1983 with Dr. Mintun and joined by Dr. Powers in 1984 and Dr. Snyder in 1986 the Pis have been working and publishing together ever since. It should therefore come as no surprise that the steering committee of this program project is composed of these individuals. Because of the close and highly collegia! working atmosphere among these individuals, the temporary absence of any one could easily be filled by the others. Public Data Sharing A hardware and software infrastructure exists within the Mallinckrodt Institute of Radiology to support internet publication of research results. The hardware was jointly purchased by the Department of Radiology and the Department of Neuroscience at Washington University Medical School with partial funding being provided by the McDonnell Center for Higher Brain Function. The hardware comprises a computer server cluster that includes high availability (minimizing lapses in database access);good load-balancing for computation- intensive applications;excellent backup for large amounts of data;and the ability to incrementally expand to support additional databases. This configuration, schematized in Figures x, includes five major components: [unreadable] Fiber channel SAN (Storage Area Network) for high storage capacity (Dell/EMC CX300, 1.6 TB storage) [unreadable] Two quad-processor servers (Dell 6650, 2.7 GHz) running PostgrSQL databases in a primary/secondary redundant mode. [unreadable] Two dual-processor servers (Dell 1750, 2.8 GHz) act as web and application servers. [unreadable] A Fiber Channel switch (SAN) (McData Spherion 4500). [unreadable] A load-balancing switch (BigIP) to distribute the workload among the Web/Application servers [unreadable] A high-speed automatic backup system (Dell Power Vault 775 NAS [network-attached storage] server plus 14 x 146 GB SCSI Discs) PHS 398/2590 (Rev. 09/04) Paqeol3*/ Continuation Format Page CONTINUATION PAGE Principal Two Dell PowerEdge 6650's running RedHat Linux AS 3 x wilh redundant HBA's , and TwoDell PowerEdge 1750's'runmng Redhat Linux ES 3 x with single HBA's ![unreadable]8- Dell|EMCCX300wilh 11 X 146GB Fibre Channel disks (1 6TB raw capacity) ^ * Investigator/Program Director (Last, First, Middle): Raichle, MarCUS E. McData Spnenon 4500 (Dell|EMC Flexport) switch with 16 ports active (expandable to 24 ports) Figure x. Existing hardware infrastructure to support public access to research results. When a research paper is published either on the publisher's

Safety and Feasibility Study of Transvenous Limb Perfusion with Normal Saline in Human Muscular Dystrophy Due to their genetic basis and the current lack of curative therapy, the muscular dystrophies are excellent candidate diseases for gene therapies. An essential step in this development of such therapies is delivery of genetic material to a single limb to demonstrate safety and efficacy prior to systemic administration. Of the various methods of single limb delivery studied in experimental animals, high-pressure, high-volume transvenous limb perfusion shows the greatest potential to be an effective, clinically practical and generally applicable. In this project, we will perform a safety and feasibility study of transvenous single limb perfusion with normal saline in human subjects with muscular dystrophy. The study is designed as a dose-escalation safety study with the perfusion parameters increased in a stepwise manner and careful monitoring for both bcal and systemic toxicity. This design will also permit us to address the multiple logistical aspects inherent in going from animals to humans with muscular dystrophy including analgesia, vascular access and larger infusion volumes. In Specific Aim 1, we will study young adults with limb-girdle or Becker muscular dystrophy beginning with infusions of .05 mL saline /ml of limb volume and escalating to a maximum of .40 mL/mL. An independent safety monitor will review data on each subject (perfusion parameters, laboratory and clinical testing) and must approve planned perfusion parameters for the next subject. From this study, we will determine the maximum perfusion parameters that are safe and document the degree of fluid delivery into muscle by T2 MRI. In Specific Aim 2, we will carry out a similar dose escalation study in children with Duchenne muscular dystrophy beginning at .05 ml saline /ml of limb volume and escalating to the maximum volume determined from Specific Aim 1 as posing no greater than minimal risk. This study will provide the necessary safety and feasibility data on the perfusion technique itself to provide the basis for future regional limb delivery studies of active gene therapy. The results will be generally applicable to the single limb delivery of many different agents (oligonucleotides, plasmid-DNA and viral delivery systems) and to patients of different ages with diverse types of muscular dystrophy.

The overall goal of the MDCRC Training and Education Core is to provide trainees with the skills necessary to translate advances in basic science muscular disease research into well-designed human clinical trials. To be successful the trainees must have an understanding of the concepts, features, and limitations of the interventions to be used in clinical studies, the biology of the inherited disease target to be approached, the ethics of human and animal research and the importance of well designed clinical trials to answer specific questions. These concepts will be taught through a series of formal courses and seminars, discussions with scientists and ethicists, regular interactions with clinical scientists and interactions with basic scientists. Mentored research under the direction of the MDCRC director and co-director will present trainees with the practical skills needed to pursue careers in translational research.

The overall goal of the MDCRC Training and Education Core is to provide trainees with the skills necessary to translate advances in basic science muscular disease research into well-designed human clinical trials. To be successful the trainees must have an understanding of the concepts, features, and limitations of the interventions to be used in clinical studies, the biology of the inherited disease target to be approached, the ethics of human and animal research and the importance of well designed clinical trials to answer specific questions. These concepts will be taught through a series of formal courses and seminars, discussions with scientists and ethicists, regular interactions with clinical scientists and interactions with basic scientists. Mentored research under the direction of the MDCRC director and co-director will present trainees with the practical skills needed to pursue careers in translational research.