Neuroprotective Goal Directed Hemodynamic Optimization in Post-cardiac Arrest Patients: a Randomized Controlled Trial (the NEUROPROTECT Post-CA Trial)
Phase: NA
Conditions: Cerebral Ischemia, Cardiac Arrest
Sponsor: Universitaire Ziekenhuizen KU Leuven

 
 
 
CONFIDENTIAL CLINICAL TRIAL PROTOCOL 
 
 
 
 
TITLE: 
Neuroprotective goal directed  
hemodynamic optimization in post-cardiac 
arrest patients: a randomized controlled trial 
(the NEUROPROTECT post-CA trial) 
 
INDICATION: 
Post-Cardiac arrest patients 
 
CLASSIFICATION 
Academic, investigator initiated trial 
 
PROTOCOL DATE 
13 May 2015 
 
PROTOCOL VERSION 
2 
 
STUDY INITIATION 
1 July 2015 
 
STUDY DURATION 
2 years 
 
STUDY SPONSOR 
University Hospitals Leuven (UZ Leuven) 
(‘opdrachtgever’, as defined by 
Herestraat 49, 3000 Leuven, Belgium 
Art. 2, 21° of the Belgian Law 
of 7 May 2004) 
 
PRINCIPAL INVESTIGATORS 
Stefan Janssens, MD, PhD 
Koen Ameloot, MD 
Joseph Dens, MD, PHD 
Cathy De Deyne, MD, PHD 
 
FUNDING RESOURCES 
Division of Clinical cardiology and IWT 
Brussels (application for IWT/TBM grant) 
 
GCP: 
These studies will be performed in 
compliance with good clinical practices 
(GCP) guidelines. All essential documents 
will be archived. 
 
 
 
 
 
 
CONFIDENTIALITY STATUS 
The information contained herein is confidential and the proprietary property of 
the principal investigators 
 
 

 
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TABLE OF CONTENTS 
1. 
SYNOPSIS ....................................................................................................................... 6 
2. 
ETHICS ............................................................................................................................ 9 
2.1. 
Independent Ethics Committee (IEC) ......................................................................... 9 
2.2. 
Ethical Conduct of the Study...................................................................................... 9 
2.3. 
Patient Information and Informed Consent ................................................................. 9 
3. 
INVESTIGATORS AND STUDY ADMINISTRATION STRUCTURE ................................ 10 
3.1. 
Investigators ............................................................................................................ 10 
3.2. 
Steering Committee ................................................................................................. 10 
3.3. 
Study Coordinating Centre....................................................................................... 10 
3.4. 
Data Monitoring Committee (DMC) ......................................................................... 10 
4. 
INTRODUCTION ............................................................................................................ 11 
4.1. 
The clinical problem ................................................................................................. 11 
4.2. 
Current state of the art ............................................................................................. 11 
4.3. 
Observational studies on new hemodynamic targets ................................................ 12 
4.4. 
Innovative aspect of the Neuroprotect post-CA trial ................................................. 17 
5. 
STUDY OBJECTIVES .................................................................................................... 17 
6. 
INVESTIGATIONAL PLAN .............................................................................................. 19 
6.1. 
Study Plan and Design ............................................................................................ 19 
6.2. 
Discussion of Study Design ..................................................................................... 19 
6.3. 
Selection of Study Population ................................................................................. 19 
6.4. 
Baseline Characteristics to be collected ................................................................... 21 
6.5. 
Study treatments ..................................................................................................... 21 
6.6. 
Recordings during treatment period ......................................................................... 27 
6.7. 
Neurologic prognostication ...................................................................................... 29 
6.8. 
Efficacy and Safety Variables .................................................................................. 30 
6.9. 
Statistical Methods Planned ..................................................................................... 32 
6.10. Changes in Conduct of the Study or Planned Analyses ........................................... 34 
7. MISCELLANEOUS ............................................................................................................ 34 
7.1. 
Case Report Forms ................................................................................................. 34 
7.2. 
Investigator Requirements ....................................................................................... 34 
7.3. 
Recording of Adverse Events .................................................................................. 35 
7.4. 
Records Retention ................................................................................................... 38 
7.5. 
Monitoring ............................................................................................................... 38 
7.6. 
Amendments to the Protocol .................................................................................... 38 
7.7. 
Termination of Trial .................................................................................................. 38 
7.8. 
Insurance ................................................................................................................ 39 

 
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7.9. 
Intellectual Property ................................................................................................ 39 
APPENDIX 1. INVESTIGATOR AGREEMENT ....................................................................... 40 
 
 
 
 

 
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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
Below is a list of abbreviations that are used in this clinical report. 
 
 
 
6MWD 
6 Minute Walking Distance 
ADC 
Apparent Diffusion Coefficient 
ADL 
Activities Daily Life 
AMI 
Acute Myocardial Infarction 
 
CA 
Cardiac Arrest 
 
CO 
Cardiac Output 
 
COPD 
Chronic Obstructive Pulmonary Disease 
CPC 
Cerebral Performance Category 
CPR 
Cardiopulmonary Resuscitation 
DMC 
Data Safety Monitoring Board 
DW-MRI 
Diffusion Weighted MRI 
ECMO 
Extracorporeal Membrane Oxygenation 
EEG 
Electro-encephalography 
FIO2 
Fraction of inspired oxygen 
 
GCS 
Glasgow Coma Scale 
 
GCP 
Good Clinical Practice 
 
IABP 
Intra-aortic Balloon Pump 
 
ICU 
Intensive Care Unit 
 
IVRS 
Interactive Voice Response System 
IV 
Intravenous 
IEC 
Independent Ethics Committee 
 
LCC 
Leuven Coordinating Centre 
LVEF 
Left Ventricular Ejection Fraction 
MAP 
Mean Arterial Pressure 
MRI 
Magnetic Resonance Imaging 
 
NSE 
Neuron Specific Enolase 
 
NSTEMI 
Non-ST segment elevation myocardial infarction 
OR 
Odds Ratio 
PAC 
Pulmonary Artery Catheter 
 
PCI 
Percutaneous Coronary Intervention 

 
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PEEP 
Positive End-expiratory Pressure 
PPV 
Pulse Pressure Variation 
ROSC 
Resume of Spontaneous Contractions 
SSEP 
Somatosensory Evoked Potential 
STEMI 
ST segment elevation myocardial infarction 
SVO2 
Mixed Venous Oxygen Saturation 
SVV 
Stroke volume Variation 
 
TIA 
Transient ischemic attack 

 
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1. SYNOPSIS 
 
Classification: Academic, Investigator Initiated Trial 
Protocol Version and Date: Version 4, 20 Jan 2017 
Title of Study: Neuroprotective goal directed hemodynamic optimization in post-
cardiac arrest patients: a randomized controlled trial (the NEUROPROTECT post-CA 
trial) 
Participating country: Belgium 
Study Centers: 2 (UZ Leuven and ZOL Genk) 
Study Period: 3 years 
Anticipated start: July 2015  
Anticipated completion: May 2018 
Objectives: 
The primary objective of the trial is to assess whether or not a new goal directed 
hemodynamic optimization strategy can reduce cerebral ischemia in post-cardiac 
arrest (CA) patients as quantified by diffusion weighted MRI (DW-MRI) to be 
performed at day 4-5 with quantification of the percentage of ischemic voxels with 
an apparent diffusion coefficient (ADC) below 0.650 mm2/s. 
 
Secondary efficacy outcomes: 
o Cerebral performance category 3-5 at discharge from the ICU CPC 1: return to 
normal cerebral function and normal living 
CPC 2: Disability but sufficient function for independent activities of daily life 
CPC 3: severe disability CPC 4: Coma 
CPC 5: Death 
o Cerebral performance category 3-5 at 180 days post-CA (assessed by trial 
investigators that are unaware of the treatment assignment) 
o SF36 questionnaire at 180 days post-CA (assessed by trial investigators that 
are unaware of the treatment assignment) 
o Neurocognitive testing at discharge from the hospital 
o Biomarkers: Neuron specific enolase (day 1-2-3-4-5) 

 
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o Functional testing: Activities Daily Life (ADL) and 6 minute walking distance 
(6MWD) at discharge from the hospital 
o Renal function: creatinine day 1-2-3-4-5 and urinary output day 1-2- 3-4-5. 
o Length of stay in the ICU 
o Duration of mechanical ventilation 
o Placement of tracheostomy 
 
Safety outcomes: 
o Incidence of life threatening arrhythmias during intervention period 
o Incidence of new onset atrial fibrillation during intervention period 
o Incidence of pulmonary congestion requiring diuretics during intervention 
period 
Methodology: Prospective, multi-centre, interventional open label investigator 
driven randomized controlled trial.  Randomisation will be stratified by the presence 
of an initial shockable rhythm. 
Number of subjects planned: A total of 112 pts are planned for this study. 
Anticipated duration of trial: 3 years from first patient entered to last patient 
randomized 
Diagnosis and main criteria for inclusion and exclusion: 
Inclusion criteria: 
o Out-of-hospital CA of presumed cardiac cause irrespective of the presenting 
rhythm 
o Unconsciousness (Glasgow coma scale < 8) at hospital admission 
o Age ≥ 18 years 
o Sustained return of spontaneous circulation (ROSC) (=when chest 
compressions have not been required for 20 consecutive minutes) 
Exclusion criteria: 
o Suspected or confirmed intracranial bleeding or stroke 
o Known limitations in therapy or Do Not Resuscitate-order 
o Known disease compromising 180 day survival 
o Known pre-CA cerebral performance category 3-4 
o Previous stroke (TIA can be included) 
o MRI incompatible cardiac or neurosurgical device 

 
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o Systolic blood pressure < 90 mmHg on norepinephrine > 1 mcg/kg/min). 
o Open chest 
o ECMO (extracorporeal membrane oxygenation) 
o Pregnancy 
Interventional hemodynamic optimization protocol: In patients randomized  to 
receive the intervention, the target mixed venous oxygen saturation (SVO2) will be 
between 65-75% and the target mean arterial pressure (MAP) is between 85- 
100mmHg. Fluid administration and hemodynamic support will be adjusted 
according to a flow chart in case SVO2or MAP are below or above the suggested 
targets on an hourly basis. 
Duration of treatment: The study protocol will start at admission in the intensive 
care unit (ICU) and will last 36 hours. 
Reference therapies, dose and mode of administration: In patients randomized 
to receive current standard of care, hemodynamic support will be at the discretion of 
the treating physician with a target MAP of 65mmHg. 
 
 

 
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2. ETHICS 
 
2.1. Independent Ethics Committee (IEC) 
 
The protocols and local Informed Consent Forms must be reviewed and 
approved by each of the participating institution’s Independent Ethics Committee 
(IEC) prior to the initiation of patient accrual. The IEC must be notified of all 
subsequent protocol amendments. In addition, progress reports will be submitted 
to the IEC by the investigator as indicated by IEC’s guidelines. Each IEC must 
meet the applicable regulatory requirements for composition, documentation, and 
operational procedures. 
 
2.2. Ethical Conduct of the Study 
 
The study will be conducted in accordance with the protocol, the principles that 
have their origins in the Declaration of Helsinki, as well as ICH GCP and 
applicable national and local regulatory requirements, including but not limited to 
the Belgian Laws of 7 May 2004 relating to experiments on the human person 
(LEH), of 22 August 2002 on Patients’ Rights and of 8 December 1992 (as 
amended) regarding the Protection of Privacy in relation to the Processing of 
Personal Data. All essential documents will be archived. 
 
2.3. Patient Information and Informed Consent 
 
The informed consent will contain all elements required by ICH GCP. Written 
informed consent will be obtained from a next of kin prior to enrollment and 
participation of the study Subject. If a next of kin or another designated person 
is not available, a procedure for inclusion in the study in emergency situations 
will be applied. A definitive post hoc consent form will ultimately be obtained 
from patients who survived but had been initially treated on the basis of the 
emergency consent. Subjects or legally representatives will be informed of any 
significant new finding developed during the course of the research that may 
affect their decision to continue participation. 
The Study Centers shall use the informed consent forms as approved by the 
appropriate ethics committee. The Study Centers further commit to conduct 
the study only on the basis of prior written consent by the Subjects or their 
legal representatives. The Study Centers shall retain such informed consent 
forms in accordance with the applicable regulatory requirements. 
 

 
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3. INVESTIGATORS AND STUDY ADMINISTRATION STRUCTURE 
 
3.1. Investigators 
 
Two sites (ZOL-Genk and UZ Leuven) will participate in the trial. 
 
3.2. Steering Committee 
 
The Steering Committee will be responsible for the overall design, conduct, and 
supervision of the trial, including the development of the protocol and any 
protocol amendments. The Steering Committee meets periodically to assess the 
progress of the study to ensure subject safety and study integrity. The Steering 
Committee is composed of designated academic leaders and clinical experts. 
 
Prof. Dr. Stefan Janssens 
Prof. Dr. Joseph Dens  
Prof Dr. Peter Sinnaeve 
Prof. Dr. Alexander Wilmer 
Prof. Dr. Cathy DeDeyne 
Dr. K. Ameloot 
And others 
 
The Steering Committee will prepare a manuscript(s) plan to ensure timely and high 
quality presentation and publication of the study results. 
 
3.3. Study Coordinating Centre 
 
The Leuven Coordinating Centre (LCC) will provide services with respect to the 
design and operation of the clinical trial. LCC will interact closely with the 
Principal Investigators and will have operative responsibility for different areas 
like regulatory submissions, randomization, data management and safety 
reporting. 
 
3.4. Data Monitoring Committee (DMC) 
 
A Safety and Data Monitoring Board will be established to provide independent 
oversight to this trial. The primary responsibility of the DSMB will be to review the 
progress and conduct of the trial in order to maintain scientific rigor and to 
ensure the well being of patients participating in the trial. Data will be provided to 
the DSMB after inclusion of the 60th patient. The DSMB consists of Fabio 
Taccone (MD, Chair), Niklas Nielsen (MD) and Karen Hirsch (MD). 
 

 
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4. INTRODUCTION 
 
4.1. The clinical problem 
 
There is absolutely no doubt that sudden cardiac death is a major problem in 
Belgium in terms of numbers of patients, medical impact and socio-economic impact. 
Each day, approximately 30 adults suffer from an unexpected out-of- hospital cardiac 
arrest in Belgium, a number exceeding the incidence of breast or prostate cancer 
with an estimated 25 new patients per day in Belgium. In  addition, many cardiac 
arrest patients are young (mean age in our hospital 60±12 years, 56% of patients 
younger than 65 years) with a large economic potential for society. In the community, 
the occurrence of sudden death often takes center stage through highly mediatized 
cases of cardiac arrest in young sportsmen with or without a previously undiscovered 
cardiac anomaly. Apart from the traumatic experience of these dramatic sudden 
events, only 40% of patients that reach the hospital with spontaneous circulation 
survive without major neurological impairment or care dependency. An additional 5-
10% of the cohort survives with major neurological impairment including a permanent 
vegetative state. These sobering outcome data and the large economic burden for 
society (estimated  cost of a nursing home facility for these patients approximately 
30-50000 €/year) mandate novel treatment strategies that could improve prognosis 
after cardiac arrest. 
 
Apart from temperature management to avoid fever, no single in hospital randomized 
controlled intervention trial has improved outcome of these patients. In this way, 
there is absolutely no doubt that a positive result of the Neuroprotect post-CA trial 
would be a clear added value for this vulnerable and highly under- investigated 
patient group. 
 
4.2. Current state of the art 
 
Current hemodynamic post-CA guidelines state that “Fluid administration as well 
as vasoactive (e.g. norepinephrine), inotropic (e.g. dobutamine) and inodilator 
(e.g. milrinone) agents should be titrated to optimize blood pressure, cardiac output 
and systemic perfusion (class I, level of evidence B). Although human studies have 
not established robust targets for blood pressure or blood oxygenation, a mean 
arterial pressure above 65mmHg is generally considered to be a reasonable goal” 
(Peberdy et al, Circulation 2010). 

 
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It is important to emphasize that these recommendations are not based on mortality 
data in post-cardiac arrest patients. Nor has it been shown or even investigated that 
a blood pressure of 65mmHg would result in optimal brain perfusion in post-cardiac 
arrest patients. Instead, these guidelines are adapted from sepsis guidelines based 
on the unsubstantiated assumption that the post- cardiac arrest syndrome is a sepsis 
like syndrome. Moreover, the true value of goal direct therapy in sepsis has recently 
been questioned (Peake et al, NEJM 2014). All the above emphasize the need for 
objective and properly validated guidelines for hemodynamic support in the post-CA 
setting. 
 
4.3. Observational studies on new hemodynamic targets 
 
During intensive care unit stay after cardiac arrest, the optimal MAP and cardiac 
output should maintain optimal cerebral perfusion to avoid additional cerebral 
ischemic damage caused by cerebral hypo- and hyper perfusion. 
 
In a first study, we showed that there is a large inaccuracy regarding cardiac output 
measurements by conventional continuous thermodilution in CA patients treated with 
therapeutic hypothermia. In contrast, cardiac output calculated by means of 
continuous SVO2 using the Fick equation was shown to be a valuable alternative in 
patients treated with therapeutic hypothermia (Ameloot et al, Resuscitation 2014). 
 
In a second observational trial, we constructed a hemodynamic model to 
determine the optimal MAP and SVO2 range associated with optimal cerebral 
oxygen saturation (Ameloot et al, resuscitation 2015). It was previously shown 
that in a subset of post-CA patients (mainly these with chronic hypertension) the 
lower threshold of cerebral autoregulation is shifted rightward towards higher 
systemic blood pressures and these patients might benefit from resuscitation to 
higher MAP’s to preserve adequate cerebral perfusion (Sundgreen, Stroke 001). 
In contrast, many post-CA patients have a reduced left ventricular function and 
might benefit from afterload reduction to maintain stroke volume and   cerebral 
perfusion. Therefore, we hypothesized that the optimal MAP should maintain 
cerebral perfusion without exposing the damaged myocardium to excessive 
afterload. The relationship between MAP, SVO2 and cerebral saturation is shown 
in the figure below (n=1 635 827 data points obtained in 41 patients during the 
first 24 hours after ICU admission). We found a strong linear relationship between 
MAP and cerebral saturation in the MAP range between 45 and 101mmHg (R2 

 
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0.83). Mean arterial blood pressures above 101mmHg were associated with 
progressively decreasing cerebral saturations (R2 0.72). 
Additionally, MAP’s above 101mmHg were also associated with progressively 
decreasing SVO2’s suggesting that this excessive left ventricular afterload impairs 
cardiac output and by consequence cerebral perfusion. The currently recommended 
MAP of 65mmHg clearly resulted in a submaximal cerebral saturation. The lowest 
optimal MAP based on this hemodynamic model was determined to be 87mmHg 
since the cerebral saturation corresponding with this MAP of 87mmHg was 67.6% 
and almost equal to the average of all calculated cerebral saturations associated with 
higher MAP values (average 67.5%). Cerebral saturation is maximized at a MAP of 
101mmHg. Therefore, the MAP range associated with optimal cerebral oxygenation 
was determined to be between 87-101mmHg. The corresponding SVO2 range 
associated with optimal cerebral oxygenation was determined to be between 70-
75%. Both the suggested MAP (87-101mmHg) and the SVO2 range (70-75%) 
resulted in cerebral saturations between 67-69%. 

 
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Figure 1: Relationship between mean arterial pressure (MAP), mixed venous oxygen 
saturation (SVO2) and cerebral saturation (SctO2). 
 
In a third observational trial, we focussed on cerebral autoregulation. We confirmed 
the previous findings by Sundgreen et al (Stroke 2001) that cerebralutoregulation is 
shifted rightward in 35% of post-cardiac arrest patients.Phenotypically, a higher 
proportion of patients with disturbed autoregulation had pre-cardiac arrest 
hypertension (65±49 vs 31±47%, P=0.02) suggesting that right shifting of 
autoregulation is caused by chronic adaptation of cerebral blood flow  to pre-existing 
higher blood pressures. In multivariate analysis, patients with preserved 
autoregulation had a significantly higher 180-days survival rate (odds ratio 4.62). 
Finally, we defined the optimal MAP range within the autoregulatory zone as defined 
by an index of autoregulation (COX). COX was calculated as a linear correlation 
coefficient between 10 seconds averaged values of brain saturation and MAP, that is 
continuously changing and recorded over 5 minute time windows during the 24 hours 
study period”. In this way, COX is a continuous variable that ranges from -1 to +1 
and that can be used as a robust surrogate marker of autoregulation at a specific 
time point. Intact autoregulation is indicated by negative or near-zero COX because 

 
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small MAP variations will not alter cerebral oxygenation when autoregulation is 
active. When autoregulation becomes impaired, COX becomes positive because 
MAP and SctO2 correlate indicative of MAP-dependency of cerebral saturation. We 
averaged all obtained COX values per 5mmHg MAP bins and generated bar graphs 
to identify the COX predicted optimal MAP range as the MAP bins with negative or 
near-zero COX values. When COX per 5 mmHg bar graphs were pooled and 
averaged over all 51 study patients, the overall COX predicted optimal MAP was 
between 85 and 105mmHg (see figure below). 
 
 
 
 
Figure 2: Pooled COX per 5 mmHg MAP plot. The MAP range associated with 
optimal autoregulation (negative COX values) was defined to be between 85- 
105mmHg. 
 
In summary, we found that the MAP range associated with optimal cerebral perfusion 
corresponds with the MAP range within the autoregulatory zone (85- 100/105mmHg). 
 
Is there any evidence from observational studies that a higher MAP would be 
associated with a better neurological outcome? In our own observational study 
(Ameloot et al, resuscitation 2015), we showed that the MAP range associated with 
the highest odds ratio for survival was 76-86 mmHg (OR 2.63, 95% CI [1.01; 6.88], 
p=0.04). The SVO2 range associated with the highest odds ratio for survival was 67-
72% (OR 8.23, 95% CI [2.07; 32.68], p=0.001). Logistic regression revealed that the 
probability of survival increased with increasing percentage of time within the optimal 
MAP (OR 1.04 per % in the optimal range, 95% CI [1.00; 1.07], p=0.001) and SVO2 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
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range (OR 1.03 per % in the optimal range, 95% CI [1.00; 1.05], p=0.04). An average 
MAP>65 mmHg or SVO2>70% were not associated with increased survival 
highlighting marked limitations of current patient management recommendations. In 
two separate models using backward multiple logistic regression, a mean MAP in the 
optimal range (OR 3.72, 95% CI [1.11; 12.50], p=0.03) and a mean SVO2 in the 
optimal range (OR 10.32, 95% CI [2.03; 52.60], p=0.001) remained independently 
associated with increased survival. 
 
Our findings are in agreement with 2 retrospective and 1 prospective observational 
study on the positive association between higher MAP’s during the first 6 hours post-
ROSC and increased survival in post-cardiac arrest patients (Beylin, ICM 2013; 
Trzeciak, Crit Care Med. 2009; Kilgannon, Crit Care Med. 2014). In contrast with 
these observational trials, in the Neuroprotect post-CA trial the intervention strategy 
will be extended until 36 hours after admission.  Is there any evidence from non-
randomized controlled trials that forcing MAP or SVO2 into the suggested range with 
additional pharmacological support would improve outcome? In a small study by 
Gaieski et al, 20 prospective post-cardiac arrest patients received early goal directed 
hemodynamic optimization with a target central venous saturation above 65% and 
MAP between 80-100mmHg. A trend toward better survival was observed in treated 
patients (50% survival) when compared with 18 historic controls (22% survival) 
(Gaieski, Resuscitation 2009). This study, however, is limited by the small sample 
size and extremely low survival rates in the historic control group. 
 
We have shown that the currently recommended MAP target of 65mmHg results in a 
suboptimal cerebral saturation beyond the autoregulatory range. Moreover, analysis 
of available patient data thus far indicates that an average MAP above 65mmHg is 
not associated with a greater likelihood to survive with good neurological outcome 
compared with an average MAP below 65mmHg. In contrast, both our hemodynamic 
model and our preliminary study on cerebral autoregulation suggest that optimal 
cerebral perfusion is maintained with markedly higher MAP’s (85-100mmHg) and 
normal SVO2’s (70-75%). As shown above, 4 observational studies and one small 
prospective interventional with historic controls suggest that resuscitation to higher 
MAP’s might confer better neurological outcome in post-cardiac arrest patients, 
which needs to be confirmed in adequately powered prospective randomized 
controlled studies. Here, we hypothesize that our proposed neuroprotective 
hemodynamic optimization strategy will reduce cerebral ischemia thereby improving 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
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neurological outcome in post-cardiac arrest patients. 
 
4.4. Innovative aspect of the Neuroprotect post-CA trial 
 
The Neuroprotect post-CA trial will be the first randomized controlled trial to 
investigate whether forcing MAP and SVO2 in the suggested range improves 
cerebral ischemia and neurological outcome in post-cardiac arrest patients. It has 
been shown that targeted temperature management to avoid the deleterious effects 
of fever, somewhat improves outcome of post-CA patients (Nielsen,  NEJM 2014). 
Nevertheless, even with optimal targeted temperature management recovery with 
good functional outcome is limited to 40% of the post-CA patients. Apart from 
targeted temperature management, no single in hospital randomized controlled 
intervention trial has been able to improve outcome in these patients with a major 
unmet clinical need. 
 
5. STUDY OBJECTIVES 
 
The primary objective of the trial is to assess whether or not a new goal  
directed hemodynamic optimization strategy can reduce cerebral ischemia in 
post-CA patients as quantified by diffusion weighted MRI (DW-MRI) to be 
performed at day 4-5 with quantification of the percentage of ischemic voxels with 
an apparent diffusion coefficient (ADC) below 0.650 mm2/s. 
 
Secondary efficacy outcomes: 
 
o Cerebral performance category 3-5 at discharge from the ICU 
CPC 1: return to normal cerebral function and normal living 
CPC 2: Disability but sufficient function for independent activities of 
daily life 
CPC 3: severe disability 
CPC 4: Coma 
CPC 5: Death 
 
o Cerebral performance category 3-5 at 180 days post-CA (assessed 
by trial investigators that are unaware of the treatment assignment) 
o Neurocognitive testing at discharge from the hospital 
 
o Biomarkers: Neuron specific enolase (day 1-2-3-4-5) 
 
o Functional testing: Activities Daily Life (ADL) and 6 minute walking 
distance (6MWD) at discharge from the hospital 
 
 

 
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o Renal function: creatinine day 1-2-3-4-5 and urinary output day 1-2- 
3-4-5 
o Length of stay in the ICU 
 
o Duration of mechanical ventilation 
 
o Placement of tracheostomy 
 
Safety outcomes: 
 
o Incidence of life threatening arrhythmias during intervention period 
o Incidence of new onset atrial fibrillation during intervention period 
 
o Incidence of pulmonary congestion requiring diuretics during 
intervention period 
 
 

 
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6. INVESTIGATIONAL PLAN 
 
6.1. Study Plan and Design 
 
Multicenter randomized controlled open label trial conducted in 2 tertiary care 
hospitals in Belgium (UZ Leuven, and ZOL-Genk). Eligible patients will be 
randomly assigned in a 1:1 ratio to goal directed hemodynamic optimization or 
standard care strategy. Randomization will be performed centrally at the Leuven 
Coordinating Centre for Clinical Trials with the use of a computer-generated 
assignment sequence and an interactive voice response system. Patients will be 
stratified according to the presence of an initial shockable rhythm. Health care 
professionals caring for the trial patients will be aware of the intervention 
assignments because of the inherent problems with blinding of MAP. Physicians 
performing neurologic prognostication, radiologist interpreting MRI’s, study 
personnel assessing final outcomes and statisticians will be unaware of the 
intervention assignments. Unblinding of all data and the final analysis of all 
primary and secondary outcome parameters will be performed after inclusion of 
all study patients. Written informed consent will be obtained from a next of kin. If 
a next of kin or another designated person is not available, a procedure for 
inclusion in the study in emergency situations will be applied. A definitive post 
hoc consent form will ultimately be obtained from patients who survived but had 
been initially treated on the basis of the emergency consent. The ethical 
committees in the participating hospitals will approve the study protocol prior to 
enrolment of the first patient. 
 
6.2. Discussion of Study Design 
 
A multicentre study is necessary to recruit an appropriate number of patients and 
guarantee generalizability of the study results. 
 
6.3. Selection of Study Population 
 
All patients presenting or referred to the investigational site after being 
successfully resuscitated from out of hospital CA will be screened for enrolment. 
All patients will be expected to meet all inclusion and exclusion criteria before 
entering the study. Minor deviations to these criteria may be allowed with prior 
approval of the principle investigator of the study site. 
 

 
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6.3.1. Inclusion Criteria 
 
The patient must meet the following criteria: 
 
1. Out-of-hospital CA of presumed cardiac cause irrespective of the 
presenting rhythm 
2. Unconsciousness (Glasgow coma scale < 8) at hospital admission 
 
3. Age ≥ 18 years 
 
4. Sustained return of spontaneous circulation (ROSC) (=when chest 
compressions have not been required for 20 consecutive minutes) 
 
6.3.2. Exclusion Criteria 
 
Exclusion Criteria: 
 
 
1. Suspected or confirmed intracranial bleeding or stroke 
 
2. Known limitations in therapy or Do Not Resuscitate-order 
 
3. Known disease compromising 180 day survival 
 
4. Known pre-CA cerebral performance category 3-4 
 
5. Previous stroke (TIA can be included) 
 
6. MRI incompatible cardiac or neurosurgical device 
 
7. Systolic blood pressure < 90 mmHg on norepinephrine > 1 mcg/kg/min). 
 
8. Open chest 
 
9. ECMO (extracorporeal membrane oxygenation) 
 
10. Pregnancy 
 
6.3.3. Withdrawal of Patients from Therapy or crossover 
 
In the intervention (“Neuroprotect post-CA”) group, a reduction in vasopressor 
doses to maintain a MAP of 65mmHg is recommended if any of the pre-specified 
serious adverse events that were potentially related to an increased rate of 
vasopressor infusion occurs. These events include: major ventricular arrhythmia 
requiring life support, electrical or pharmacological cardioversion, poorly tolerated 
supraventricular arrhythmia and peripheral limb ischemia. 
Treatment may also be discontinued if the legal representative withdraws their 
consent. 
All patients who are withdrawn from study treatment will have safety 
assessments completed during the entire course of the study. 
 
 

 
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6.3.4. Definition of Randomization and Completion 
 
A patient will be considered ‘randomized’ when a randomization number has 
been assigned by the Interactive Voice Response System. 
 
6.4. Baseline Characteristics to be collected 
 
Baseline characteristics to be collected: 
 
 
• Informed Consent 
 
• Compliance with the inclusion/exclusion criteria will be documented 
 
• Age 
 
• Gender 
 
• Medical history (chronic heart failure, previous AMI, previous cardiac 
surgery, previous arrhythmia, arterial hypertension, diabetes mellitus, 
COPD, chronic kidney disease, stroke) 
• Chronic medication 
 
• Arrest Characteristics (Public vs private place, bystander witnessed, 
bystander CPR performed, presenting rhythm, time to ROSC) 
• Admission Characteristics (MAP, PaCO2, PaO2, Lactate, pupillary 
reflex, corneal reflex, FIO2, dose of norepinephrine and dobutamine) 
• Cause of arrest (STEMI, NSTEMI, arrhythmogenic, hypoxic, unknown) 
 
• Angiography performed (time in hospital, time in cathlab, time in ICU) 
 
• PCI performed 
 
• SOFA score 
 
6.5. Study treatments 
 
6.5.1. Treatments Administered 
 
In patients assigned to the intervention group, placement of an IABP will be 
considered in the catheterization laboratory if the dose of norepinephrine 
necessary to achieve a MAP of 65mmHg exceeds 0.5 mcg/kg/min. In patients 
assigned to the intervention group, a new generation pulmonary artery catheter 
(CCOmbo, Edwards life sciences) will be inserted. Other trial interventions will 
start immediately after ICU admission and a summary flow chart guiding the 
targeted interventions is presented in the figure below. In patients randomized to 
receive the intervention, the target mixed venous oxygen saturation (SVO2) is 
between 65-75% and the target MAP is between 85-100mmHg. Arterial blood 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
22 
gas analysis will be performed on an hourly basis by treating nurses and 
physicians during the first 36 hours after ICU admission. Calibration of the 
continuous SVO2 monitor will be performed per 4 hours by a central venous 
blood gass. In the treatment protocol, we will include specific recommendations 
for uniform and homogeneous interventions across centres in response to 
changing hemodynamic variables. 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
23 
 
 
 
 
 
 
 
 
MAP < 85 mmHg 
MAP 85-100 mmHg 
MAP > 100 mmHg 
SVO2 
< 65 % 
Step1: Fluid responsiveness? 
• 
Sinus: SVV > 12% 
• 
AF: Passive leg raising test 
7 Plasmalyte 500 cc/u (max 
3l/24u) 
Step2: Hemoglobin < 10 g/dl? 
7 Transfusion 1 UPC 
Step3: Heartrate < 40 SPM 
7 Consider Isuprel of Pacing 
Step4: Inotropics/vasopression 
• 
Dobutamine + 5 mcg/kg/min 
(max 20 mcg/kg/min) 
• 
Levophed + 0.05 mcg/kg/min 
per 10 minutes until MAP OK 
(max 1 mcg/kg/min) 
Step1: Fluid responsiveness? 
• 
Sinus: SVV > 12% 
• 
AF: Passive leg raising test 
7 Plasmalyte 500 cc/u (max 
3l/24u) 
Step2: Hemoglobin < 10 g/dl? 
7 Transfusion 1 UPC 
Step3: Heartrate < 40 SPM 
7 Consider Isuprel of Pacing 
Step4: Inotropics/vasopression 
• 
Dobutamine + 5 mcg/kg/min 
(max 20 mcg/kg/min) 
Step1: Fluid responsiveness? 
• 
Sinus: SVV > 12% 
• 
AF: Passive leg raising test 
7 Plasmalyte 500 cc/u (max 
3l/24u) 
Step2: Hemoglobin < 10 g/dl? 
7 Transfusion 1 UPC 
Step3: Heartrate < 40 SPM 
7 Consider Isuprel of Pacing 
Step4: Inotropics/vasopression 
• 
Dobutamine + 5 mcg/kg/min 
(max 20 mcg/kg/min) 
 
 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
24 
 
 
 
 
SVO2 
65-75% 
Levophed + 0.05 mcg/kg/min per 10 
minutes until MAP OK 
(max 1 mcg/kg/min) 
OK (recheck after 1hour) 
Levophed - 0.05 mcg/kg/min per 10 
minutes until MAP OK 
SVO2 
> 75% 
Levophed + 0.05 mcg/kg/min per 10 
minutes until MAP OK 
(max 1 mcg/kg/min) 
Step1: Inotropics 
• 
Dobutamine - 5 mcg/kg/min 
Stap 2: Seloken 5mg/5 min IV 
if HR > 90 SBM 
Step1: Inotropics/Vasopressors 
• 
Dobutamine - 5 mcg/kg/min 
• 
Levophed - 0.05 mcg/kg/min 
per 10 minutes until MAP OK 
Step 2: Seloken 5mg/5 min IV 
if HR > 90 SBM 
 
 
 
Table 1: Hemodynamic interventions 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
25 
 
In case of below target SVO2, fluid status will be optimized if fluid responsiveness 
is anticipated as indicated by stroke volume variation (if sinus rhythm, full 
sedation, normal TV ventilation) or passive leg raising test (step 1), anemia will  
be corrected to maintain a hemoglobin above 10 g/dl (step 2), treatment of 
excessive bradycardia (heart rate <40 BPM) will be considered (step 3) and 
dobutamine will be infused (step 4) according to the study protocol. Additional 
fluid challenge will be limited to 3 liters/24 hours. 
In case of below target MAP but normal SVO2, norepinephrine will be infused. 
 
In case SVO2 exceeds 75%, dobutamine infusion rate will be reduced (step 1) 
and seloken 5mg IV (1mg/min) will be infused if heart rate exceeds 90 BPM and 
MAP 100mmHg in the absence of inotropic or vasopressive support (step 2).    
In case MAP is greater than 100mmHg, norepinephrine infusion rate will be 
reduced (step 1) and seloken 5mg IV (1mg/min) will be infused if heart rate 
exceeds 100 BPM and SVO2 75% in the absence of inotropic or vasopressive 
support (step 2). In the intervention (“Neuroprotect post-CA”) group, a reduction 
in vasopressor doses to maintain a MAP of 65mmHg is recommended if any of 
the pre-specified serious adverse events that were potentially related to an 
increased rate of vasopressor infusion occurs. These events include: major 
ventricular arrhythmia requiring life support, electrical or pharmacological 
cardioversion, poorly tolerated supraventricular arrhythmia and peripheral limb 
ischemia. 
 
In patients randomized to receive current standard of care, hemodynamic 
support will be at the discretion of the treating physician with a target MAP of 
65mmHg. All the drugs used in the study will be purchased from manufacturers 
not involved in the study. 
 
6.5.2. Method of Assigning Patients to Treatment Groups 
 
Randomization will be performed centrally via a centralized telephone Interactive 
Voice Response System (IVRS) at the Leuven Coordinating Centre for Clinical 
Trials with the use of a computer-generated assignment sequence. Patients will 
be stratified according to the presence of an initial shockable rhythm. 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
26 
 
6.5.3. Prior and Concomitant Therapy 
 
All patients will be treated according to the current American heart association 
guidelines (Peberdy et al, Circulation 2010). All patients should be intubated, 
mechanically ventilated and sedated with propofol and remifentanil if 
hemodynamically tolerated. Cisatracurium should be administrated in case of 
shivering during hypothermia and continued until the end of the 36 hours study 
period once started. Doses of sedative and analgetic drugs or muscle relaxants 
will be reassessed at least once every eight hours to achieve values ranging from 
-3 to 0 on the Richmond Agitation-Sedation scale (which ranges from -5 to 4 with 
lower scores indicating deeper sedation and higher scores indicating increasing 
agitation). Unless an obvious non-cardiac cause can be identified, all patients 
should be referred for urgent coronary angiography for prompt revascularization 
of severe culprit coronary lesions. Basic infusions will include glucose 5% (40 
ml/hr) and balanced crystalloids (40ml/hr). 
 
Therapeutic hypothermia will be induced in all patients by endovascular (Icy- 
catheter, CoolGard® 3000, Alsius, Irvine, CA, USA) or surface (ArcticGelTM 
pads, Arctic Sun® 5000, Medivance, Louisville, Colorado, USA) cooling systems 
at 33°C for 24-hours as per existing ESC/AHA guidelines. After rewarming 
(0.3°C/hr) until 36°C, further targeted temperature management to avoid fever 
will be applied for 36 hours by antipyretic drugs and mechanical cooling devices. 
 
Mechanical ventilation will be adjusted guided by hourly blood gas analysis to 
target a PaCO2 between 35-45mmHg and a PaO2 between 70-150mmHg. In 
principle, extreme low-tidal volume will be avoided to exclude interference with 
stroke volume variation measurements. Sedation will be titrated towards patient’s 
comfort. Patients will be extubated after sufficient neurological (GCS>8/15), 
respiratory (successful spontaneous breathing trial) and hemodynamic recovery. 
A uniform and detailed protocol for mandatory testing of these parameters will be 
implemented at both recruiting sites. 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
27 
 
6.5.4. Treatment Compliance 
 
It is the principal investigators responsibility to ensure that the treatment, as 
detailed in the approved protocol, is administered to each enrolled subject. All 
patients will be treated under the principal investigator’s (or responsible sub- 
investigator) direct supervision. All drug used in the study must be accounted for 
and documented in a usage log. 
 
6.6. Recordings during treatment period 
 
6.6.1. Continuous automatic recordings 
 
- 
All patients: 
 
o Continuous invasive arterial blood pressure (MAP, systolic, 
diastolic) 
o Heart rate 
 
o Oxygen saturation 
o Cerebral saturation monitoring (FORE-SIGHTTM technology (CAS 
Medical systems, Branford, CT, USA). This information will be 
blinded to the treating physicians. 
- 
Intervention group: 
 
o Continuous Cardiac output (CCO) by Pulmonary Artery Catheter 
(PAC) (Edwards®, Irvine, California, USA) 
o Continuous SVO2 monitoring 
 
o Continuous stroke volume variation (SVV) by radial artery vigileo 
 
o Continuous Pulse pressure variation (PPV) by radial artery vigileo 
 
6.6.2. Hourly automatic recordings 
 
- 
All patients: 
 
o Dose of norepinephrine 
 
o Dose of dobutamine 
 
o Dose of Isuprel (if applicable) 
 
o Ventilator settings: FIO2, PEEP, Tidal volume, respiratory 
frequency 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
28 
 
6.6.3. Hourly manual recordings 
 
- 
All patients: 
 
o Blood gas analysis with determination of pH, paCO2, paO2, 
hemoglobin and lactate 
o Adverse events: 
 
• 
Incidence of life threatening arrhythmias 
 
• 
Incidence of new onset atrial fibrillation 
 
• 
Incidence of pulmonary congestion requiring diuretics 
 
• 
Presence of limb ischemia 
 
o If applicable 
 
• 
IABP ratio 
 
• 
Temporary pacing (Beats per minute) 
 
- 
Intervention group: 
 
o SVO2 by blood gas per 4 hours to calibrate the continuous SVO2 
monitor 
 
6.6.4. Daily recordings (day 0-5) 
 
- 
Clinical examination 
o Glasgow Coma Scale 
o Pupil and cornea reflex 
- 
ECG 
- 
Chest X-ray (pulmonary edema?) 
- 
Urinary output 
- 
Biochemistry 
o RBC count 
o WBC count 
o Hemoglobin 
o Hematocrit 
o INR 
o Creatinine 
o Urea 
o Liver function 
o Troponin 
o Creatinine Kinase / (MB) 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
29 
o C reactive protein 
o Neuron specific enolase 
o S-100B 
 
Serum samples: All blood specimens will be collected, prepared and handled 
according to the guidelines provided by Gasthuisberg University Clinical 
Laboratory, the central blood chemistry laboratory or the laboratory for 
Experimental Cardiology. 
 
6.6.5. Other recordings 
 
o Day 1: Cardiac ultrasound with determination of the left ventricular 
ejection fraction (LVEF) 
o Day 4: neurologic examination including EEG, SSEP 
 
o Day 4-5: MRI with DWI 
 
o Transcranial Doppler at 3,6,12,24, 36 and 48 hours in a subset of 
patients 
o At ICU discharge: Cerebral performance category score 
 
o At discharge from the hospital: Neurocognitive testing.  
 
• 
Wechsler memory scale (version IV) 
• 
Montreal cognitive assessment (version 7.2) 
• 
Wechsler adult intelligence scale  
 
o At discharge from the hospital: Functional testing: Activities Daily 
Life (ADL) and 6 minute walking distance (6MWD) 
o Length of stay in the ICU 
 
o Duration of mechanical ventilation 
 
o PGF2 alfa (as a marker of reactive oxygen species) will be 
measured on stored serum samples to be collected at baseline and 
after 24 hours 
 
6.7. Neurologic prognostication 
 
All patients will receive full ICU treatment until minimum 5 days after 
admission. At this point, a neurologist who is unaware of the intervention 
assignment will perform a standardized full neurologic evaluation and issue 
a recommendation for the continuation or withdrawal of therapy. The 
neurologic evaluation will be based on clinical signs (including GCS, 
pupillary and corneal reflexes), SSEP and EEG. Findings allowing for earlier 
discontinuation of active intensive care will be (1) patients with myoclonus 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
30 
status during the first 24 hours after admission and a bilateral absence of 
N20-peak on SSEP and (2) patients who become brain death due to 
cerebral herniation. All clinical decisions will remain at the discretion of the 
treating team. 
 
6.8. Efficacy and Safety Variables 
 
6.8.1. Duration of Participation 
 
It is expected that patients will participate in this study for 180 days, including 36 
hours of treatment with study drug, cardiac MRI at day 4-5 and clinical follow-up 
until 180 days after CA. 
Adverse events will be recorded during the period of study drug administration. 
 
 
 
Visit schedule overview: 
 
• At ICU discharge: 
 
o Cerebral performance category score 
o Length of ICU stay 
o Length of mechanical ventilation 
o Tracheostomy (yes/no) 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
31 
 
• At hospital discharge 
 
o Cognitive testing 
o ADL  
o 6 MWD 
o Cerebral performance category score 
 
• At 180 days post-CA 
o Cerebral performance category score 
o SF36 
 
6.8.2. Assessment of outcome 
 
• Primary efficacy outcome: 
 
The primary outcome is the extent of cerebral ischemia as quantified by 
diffusion weighted MRI (DW-MRI) to be performed at day 4-5 with 
quantification of the percentage of ischemic voxels with an apparent 
diffusion coefficient (ADC) below 0.650 mm2/s. 
 
• Secondary efficacy outcomes: 
 
o Cerebral performance category 3-5 at discharge from the ICU 
CPC 1: return to normal cerebral function and normal living 
CPC 2: Disability but sufficient function for independent activities of 
daily life 
CPC 3: severe disability 
CPC 4: Coma 
CPC 5: Death 
 
o Cerebral performance category 3-5 at 180 days post-CA (assessed 
by trial investigators that are unaware of the treatment assignment) 
o SF36 questionnaire at 180 days post-CA (assessed by trial 
investigators that are unaware of the treatment assignment) 
o Neurocognitive testing at discharge from the hospital 
 
o Biomarkers: Neuron specific enolase (day 1-2-3-4-5) 
 
o Functional testing: Activities Daily Life (ADL) and 6 minute walking 
distance (6MWD) at discharge from the hospital 
o Renal function: creatinine day 1-2-3-4-5 and urinary output day 1-2- 
3-4-5. 
o Length of stay in the ICU 
 
o Duration of mechanical ventilation 
 
o Placement of tracheostomy 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
32 
 
• Safety outcomes: 
 
o Incidence of life threatening arrhythmias during intervention period 
o Incidence of new onset atrial fibrillation during intervention period 
o Incidence of pulmonary congestion requiring diuretics during 
intervention period 
 
6.9. Statistical Methods Planned 
 
6.9.1. Sample size 
 
Based on the results of a pilot study at Stanford University in which the standard 
deviation of the percentage ADC < 0.650 mm2/s in comparable post-CA patients was 
8.9%, we estimated that 56 patients would be necessary in each study group to show 
a 40% reduction in the extent of cerebral ischemia with a power of 80% at a two-sided 
alpha level of 0.05. 
 
6.9.2. Interim Analyses 
 
Given the relative small sample size, we will not perform interim analysis. 
 
6.9.3. General statistics 
 
All data will be managed by the LCC in conjunction with the Steering Committee. 
Data will be entered and reviewed on an ongoing basis. Key listings and tables will 
be defined by the Steering Committee. Tables, listings and raw data (as SAS 
transport files) will be made available to the members of the Steering Committee 
upon request. 
 
The statistical analysis of the primary and all secondary efficacy endpoints will be 
performed in the modified Full Analysis Set (FAS), defined as all randomly assigned 
patients except those withdrawing informed consent for use of all trial data and in 
case many protocol violations are observed throughout the study, a Per Protocol Set 
(PPS) will be defined and all efficacy analyses will be repeated on the PPS. 
 
All continuous data will be presented by treatment group using the number of non-
missing observations, mean, standard devation, median and (Q1,Q3).  Categorical 
data will be presented by treatment group using the observed frequencies and 
percentages for each category. 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
33 
 
The primary endpoint (% voxels with ADC < 0.650 mm2/s) will be analyzed by means 
of an analysis of variance (ANOVA) that includes randomized group and initial 
shockable rhythm as factors.  The treatment effect will be estimated by the difference 
between treatment groups and presented along with its corresponding 95% 
confidence interval.  Missing values for patients who die prior to the DW-MRI will be 
imputed on the basis of age, gender, presence of basic life support, presence of initial 
shockable rhythm, duration of advanced life support, neuron specific enolase, 
presence of a malign EEG pattern on day 1, final outcome at ICU discharge and 
allocated treatment arm. 
 
Continuous and normally distributed secondary endpoints will be analyzed by means 
of an ANOVA including randomized treatment and initial shockable rhythm as factors 
in the model.  Estimated treatment differences will be presented with their 95% 
confidence interval. Continuous secondary endpoints that show serious deviations 
from a normal distribution will be analyzed by means of a Van Elteren that includes 
the initial shockable rhythm as stratification factor. Binary secondary endpoints will be 
analyzed by means of a stratified Chi-squared test.  Treatment differences will be 
expressed as risk ratios and presented along with their corresponding 95% 
confidence intervals. 
Censored outcomes will be presented using Kaplan-Meier curves analyzed using a 
stratified long-rank test.  The treatment effect will be expressed as a hazard ratio. 
 
Prespecified subgroup analysis 
 
Prespecified subgroup analysis will be performed for the primary endpoint 
according to age (> or <65 years), gender, time-to-ROSC (> or < 25 min), Initial 
rhythm (shockable or non-shockable), presence of bystander CPR (yes/no), 
presence of chronic hypertension (yes/no) and treatment center. 
 
The interaction will be assessed using an analysis of variance. 
 
The full statistical methods planned for this trial will be written as a separate 
document (Statistical Analysis Plan) prior to the completion of the study. 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
34 
 
6.10. Changes in Conduct of the Study or Planned Analyses 
 
Any change in the conduct of the study or planned analyses instituted after the 
start of the study will be documented. The date, time and reason for the change, 
the procedure used to decide on the change, the person or group responsible for 
the change and the nature and content of the data available when the change is 
made will be documented whether or not the change was documented as a 
formal protocol amendment. 
 
7. MISCELLANEOUS 
 
7.1. Case Report Forms 
 
All case report forms will be electronic using Open Clinica, a web-based tool, 
provided by LCC. The site staff will enter and edit the data via a secure network, 
with secure access. An electronic audit trail will be maintained. The investigator 
will confirm the accuracy of the data by using an electronic signature. ZOL as a 
Study Center shall only provide coded or de-identified study data to the Sponsor. 
 
7.2. Investigator Requirements 
 
All investigators must be qualified by training and experience to undertake the 
proposed clinical trial, and assume responsibility for all aspects of the trial 
conducted at their investigative site. 
 
Prior to study initiation, the investigator will complete and submit to LCC all 
documents required by ICH (E6) section 8.0. Additionally, each investigator must 
assure the following: 
 
7.2.1. Study Staff Training 
 
The study staff is qualified by training and experienced to assist with the 
proposed research. This training must be documented and maintained at the 
study site. 
 
7.2.2. IEC Requirements 
 
An IEC that complies with the requirements set forth in ICH (E6) section 3.0 will 
be responsible for the initial and continuing review and approval of the proposed 
clinical study. 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
35 
 
7.2.3. IEC Reporting of Issues 
 
Prompt reporting to the IEC all changes in research activity and all unanticipated 
problems involving risks to human subjects or others, and that he/she will not 
make any changes in the research until the IEC has approved the changes. 
 
7.2.4. IEC Approvals 
 
Reporting to IEC as required on the progress of the investigation and within three 
months after completion, termination or discontinuation of the study. 
 
7.3. Recording of Adverse Events 
 
Each patient/subject will be assessed for any new or continuing adverse events 
by the clinical investigator and the study coordinator during the intervention 
period. An adverse event is defined as any untoward medical occurrence in a 
patient/subject during the clinical trial. The event need not have a causal 
relationship with the treatment. This includes any events that are not seen at 
baseline or, if present at baseline, have worsened in severity. Any adverse event 
reported by the caregiver or noted by the investigator or study coordinator will be 
recorded on the Adverse Event pages on the case report form. The severity and 
drug relationship will be determined, and any management required will be 
recorded. The investigator will review the clinical laboratory test results in a 
timely fashion. Only those results qualifying as adverse events, as defined 
above, will be recorded on the Adverse Event section of the case report form. An 
effort will be made to determine the final outcome/resolution of adverse events 
that persist at the time of study completion. 
 
7.3.1. Study treatment Relationship 
 
The investigator is responsible for assessing the causal relationship between any 
events and the study treatment. Additionally, the investigator is responsible for 
providing appropriate treatment for the event and for adequately following the 
event until resolution. The clinical investigator should determine the relationship 
between the adverse event and the treatment using the following explanations:  
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
36 
 
Not Related 
The event is clearly related to other factors such as the patient’s/subject’s clinical 
state, therapeutic interventions, or concomitant drugs administered to the 
patient/subject. 
 
Unlikely 
The event was most likely produced by other factors such as the 
patient’s/subject’s clinical state, therapeutic interventions or concomitant drugs 
administered to the patient/subject, and does not follow a known response 
pattern to the study treatment. 
 
Possible 
The event follows a reasonable temporal sequence from the time of drug 
administration and/or follows a known response pattern to the study treatment, 
but could have been produced by other factors such as the patient’s/subject’s 
clinical state, therapeutic interventions or concomitant drugs administered to the 
patient/subject. 
 
Probable 
The event follows a reasonable temporal sequence from the time of drug 
administration and follows a known response pattern to the study treatment and 
cannot be reasonably explained by other factors such as the patient’s/subject’s 
clinical state, therapeutic interventions or concomitant drugs administered to the 
patient/subject. 
 
Definitely 
The event follows a reasonable temporal sequence from the time of treatment 
administration and follows a known response pattern to the study treatment and 
cannot be reasonably explained by other factors such as the patient’s/subject’s 
clinical state, therapeutic interventions or concomitant drugs administered to the 
patient/subject and either occurs immediately following study drug administration, 
or improves on stopping the treatment. 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
37 
 
Temporal sequence is defined as an association between the suspect treatment 
and the observed reaction or event in which the suspect treatment was started 
prior to the reaction or event as defined by history or blood level of drug. 
Study drug(s) includes the drug(s) under evaluation, the reference drug(s), 
placebo, or any other drug(s) required by the protocol. 
Severity of an adverse event will be defined from the qualitative assessment of 
the degree of intensity of the event as determined by the investigator or as 
reported to him/her by the patient/subject. The assessment of severity is made 
irrespective of treatment or seriousness of the event and should be evaluated 
according to the following scales: 
1 = Mild - awareness of the symptom but easily tolerated 
2 = Moderate - discomfort enough to interfere with normal activities 
3 = Severe - Incapacitating with the inability to perform normal activities 
 
7.3.2. Serious Adverse Events 
 
A serious adverse event is defined as any event that at any dose: results in 
death, is life-threatening, results in persistent or significant disability / incapacity, 
requires or prolongs inpatient hospitalization, or is a congenital anomaly. 
Important medical events that without medical or surgical intervention would also 
have resulted in one of the outcomes listed above are also considered a serious 
adverse event. Any serious adverse event must be reported on a Serious 
Adverse Event form to LCC within 24 hours of investigator becoming aware of 
the event by fax to: 
Leuven Coordinating Centre 
Fax to: (32) 16 342100 
 
The patient/subject must be monitored carefully until the condition disappears, 
reaches a clinically stable endpoint, and/or the etiology is identified. The initial 
telephone contact will be followed by detailed descriptions of the event and 
supported as needed with written copies of hospital case reports, autopsy 
reports, and other appropriate documents. 
Follow-up information (including information requested by the Sponsor) should 
be reported within 24-hours. All serious, related and unexpected adverse events 
will be sent from LCC to the principal investigator (blind maintained), who will 
forward these reports to their IEC. All serious adverse events will also be 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
38 
distributed to the Data Safety and Monitoring Board and other investigative sites. 
Serious adverse events will be recorded during the period of study drug 
administration. 
 
7.3.3. Unexpected Adverse Events 
 
An unexpected adverse event is any event that is not identified in nature, severity 
or frequency in the current study protocol. 
 
7.4. Records Retention 
 
In compliance with GCPs and ICH Guidelines, copies of all records (e.g., 
informed consent documents, laboratory data slips, source documents, IND 
safety reports, test article dispensing records, etc.) which support case report 
forms of this study, must be retained in the files of the responsible investigator for 
a minimum of two years following notification by LCC that all investigations at all 
sites are completed, terminated, or discontinued. If the investigator retires, 
relocates, or for other reasons withdraws from the responsibility of keeping the 
study records, custody must be transferred to a person who will accept the 
responsibility. LCC must be notified in writing of the name and address of the 
new custodian. 
 
7.5. Monitoring 
 
The study will be periodically monitored by a CRA. It is the responsibility of the 
principal investigator to provide all study records, including case report forms, 
source documentation, etc., to the monitor at their visit. 
 
7.6. Amendments to the Protocol 
 
Neither the investigator nor the Steering Committee will amend or modify the 
protocol without written notification of the other. All amendments must be 
approved by the Steering Committee prior to implementation. All amendments 
must be submitted to the IEC as required. The IEC must approve major 
amendments prior to implementation at the study site. 
 
7.7. Termination of Trial 
 
It is agreed that, for reasonable cause, either the investigator or the Steering 
Committee may terminate this study, provided written notice is submitted at a 
reasonable time in advance of intended termination. 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
39 
 
7.8. Insurance 
 
In accordance with the LEH Sponsor shall assume, even without fault, the 
responsibility of any damages incurred by a study Subject and linked directly or 
indirectly to the participation to the study, and shall provide compensation 
therefore through its insurance. 
 
7.9. Intellectual Property 
 
Unless arranged for otherwise in the IWT grant agreement, Study Centers 
expressly agree that each Study Center shall remain the owner of its source 
data and results it generates pursuant to the study. In the event of joint results 
the Study Centers shall have joint property thereof 
 
 

 
Neuroprotect protocol, version 4, 20 Jan 2017 
40 
 
APPENDIX 1. INVESTIGATOR AGREEMENT 
 
 
Protocol Neuroprotect 
Version: PROTOCOL version 4, 20 Jan 2017 
 
 
 
 
I have read the protocol, “Neuroprotective goal directed hemodynamic 
optimization in post-cardiac arrest patients: a randomized controlled trial (the 
NEUROPROTECT post- CA trial)”, and agree to conduct the study as outlined 
therein. I will make a reasonable effort to conduct the study in a timely and 
efficient manner and will ensure that all participating staff members are 
adequately trained to carry out the tasks for which they have been assigned. 
 
 
 
 
I will submit this protocol and all other pertinent information to my EC for 
approval. 
 
 
 
 
 
 
 
Principal Investigator’s Signature 
Date 
 
 
 
 
 
 
Name of investigator (printed)