A Phase 1/2a Dose Escalation Study of AST-OPC1 in Subjects With Subacute Cervical Spinal Cord Injury
Phase: PHASE1
Conditions: Cervical Spinal Cord Injury, Spine Injury, Spinal Cord Trauma
Sponsor: Lineage Cell Therapeutics, Inc.

 
 
CLINICAL STUDY PROTOCOL AST-OPC1-01 
 
A Phase 1/2a Dose Escalation Study of AST-OPC1  
in Subjects with Subacute Cervical Spinal Cord Injury 
 
Investigational Product: 
AST-OPC1 (oligodendrocyte progenitor cells) 
Protocol Number: 
AST-OPC1-01  
Development Phase: 
Phase 1/2a 
IND No: 
BB-IND 13673 
Sponsor: 
Asterias Biotherapeutics, Inc. 
6300 Dumbarton Circle 
Fremont, CA 94555 
Medical Monitor 
Susy Chen, MD 
Senior Medical Director 
Phone:  510-456-3851 or 650-400-3924 
Email:  schen@asteriasbio.com  
Original Protocol Date: 
21 August 2014 
Amendment 1: 
20 February 2015 
Amendment 2: 
03 May 2016 
Amendment 3: 
07 July 2017 
 
Confidentiality Statement 
This document contains confidential information.  It is provided for the sole use of the Principal Investigator, Co-
Investigators, Staff, Institutional Review Board or Independent Ethics Committee, and Regulatory Authorities.  By 
accepting this document, you agree to maintain the information as confidential and to use it only for the purpose 
of conducting the study.   
 

 
 
SIGNATURE PAGE 
STUDY TITLE:  A Phase 1/2a Dose Escalation Study of AST-OPC1 in Subjects with 
Subacute Cervical Spinal Cord Injury 
 
 
 
By signing this protocol acceptance page, I confirm I have read, understand, and agree to 
conduct the study in accordance with the current protocol. 
 
 
Protocol Number: 
AST-OPC1-01 
Sponsor: 
Asterias Biotherapeutics, Inc. 
6300 Dumbarton Circle 
Fremont, CA 94555 
Original Protocol Date: 
21 August 2014 
Amendment 1: 
20 February 2015 
Amendment 2 
03 May 2016 
Amendment 3 
07 July 2017 
 
 
Principal Investigator: 
 
 
________________________________ 
 
Print Name 
 
 
________________________________ 
___________ 
Signature 
Date 
 
 
 
 
 
 
 

 
Asterias Biotherapeutics, Inc. 
 
Protocol AST-OPC1-01 
 
Amendment 3: 07 July 2017 
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PROTOCOL SYNOPSIS 
Name of 
Sponsor/Company: 
Asterias Biotherapeutics, Inc. 
Title of Study: 
A Phase 1/2a Dose Escalation Study of AST-OPC1 in Subjects with 
Subacute Cervical Spinal Cord Injury 
Study center(s): 
Multi-Center 
Study duration 
(years): 
Approximately 4 years for this protocol with an additional 14 years under a 
separate long term follow-up companion protocol 
Objectives 
 
Primary: 
• 
The primary objective of this study is to evaluate the safety of 3 
sequential escalating doses of AST-OPC1 administered at a single 
time-point between 21 and 42 days post-injury, inclusive, to subjects 
with subacute cervical spinal cord injuries (SCI). 
 
Secondary: 
• 
The secondary objective is to evaluate changes in neurological 
function following administration of AST-OPC1. 
Endpoints 
 
Primary: 
• 
The primary endpoint is safety, as measured by the frequency and 
severity of adverse events within 1 year (365 days) of AST-OPC1 
injection that are related to AST-OPC1, the injection procedure used 
to administer AST-OPC1, and/or the concomitant 
immunosuppression administered. 
 
Secondary: 
• 
The secondary endpoint is neurological function as measured by 
upper extremity motor scores and motor level on International 
Standards for Neurological Classification of Spinal Cord Injury 
(ISNCSCI) examinations at 30, 60, 90, 180, 270, and 365 days after 
injection of AST-OPC1. 
 
Exploratory: 
 
Potential improvements in arm/hand function, self-care ability, and overall 
volitional ability will be evaluated by changes from baseline on the following 
endpoints: 
 
• 
Graded and Redefined Assessment of Strength, Sensibility, and 
Prehension (GRASSP) is a quantitative measure of upper limb 
function in cervical SCI 
 
• 
Spinal Cord Independence Measure (SCIM), particularly the SCIM 
self-care subscale, assesses the recovery of the ability of individuals 
with SCI to perform basic everyday tasks 
  
• 
Spinal Cord Ability Ruler, which is a quantitative linear measure of 
volitional performance inclusive of all subjects in the study 
population.  The Spinal Cord Ability Ruler is derived from the 
ISNCSCI and SCIM assessments. 

 
Asterias Biotherapeutics, Inc. 
 
Protocol AST-OPC1-01 
 
Amendment 3: 07 July 2017 
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Name of 
Sponsor/Company: 
Asterias Biotherapeutics, Inc. 
Title of Study: 
A Phase 1/2a Dose Escalation Study of AST-OPC1 in Subjects with 
Subacute Cervical Spinal Cord Injury 
Study Design: 
An open label, dose escalation, cross-sequential, multi-center study 
Investigational 
product, dosage 
and mode of 
administration: 
 
• 
AST-OPC1 - Cryopreserved human embryonic stem cell-derived 
oligodendrocyte progenitor cells (OPCs), supplied to clinical sites in 
sterile, single-dose, single-use, 2.0 mL Corning cryovials. The 
cryopreserved drug product will be thawed, washed, re-suspended 
in Isolyte®S and 1% human serum albumin (HSA) and loaded into 
the injection syringe at the clinical site. 
• 
Doses to be studied: one administration of 2 x 106, 1 x 107, or 2 x 107 
AST-OPC1 cells suspended in the injection medium as shown in the 
dose table below. 
• 
AST-OPC1 must be injected directly into the spinal cord using the 
Syringe Positioning Device (SPD), which includes the syringe and 
needle. 
• 
Subjects who receive AST-OPC1 will also receive a short course of 
low-dose tacrolimus to prevent immunological rejection. Tacrolimus 
will be initiated 6-12 hours after AST-OPC1 injection, continued for 
46 days, tapered from Day 46 to Day 60, and discontinued at Day 
60. 
Doses to be Studied 
Dose 
(# of cells) 
Concentration 
(cells/µL) 
Volume 
per 
injection 
Number of 
Injections 
Total Volume 
Administered 
2 x 106 
4 x 104 
50 µL 
1 
50 µL 
1 x 107 
2 x 105 
50 µL 
1 
50 µL 
2 x 107 
2 x 105 
50 µL 
2 
100 µL 
Study Population: 
 
 
Number of Subjects Planned: Up to 35 subjects across five cohorts will be 
enrolled and receive AST-OPC1 as shown in the table below.  Enrollment 
within each cohort will be staggered, and advancement to Cohorts 2-5 will 
follow the rules described in the section immediately below the table. 
 
Cohort 
ASIA Impairment 
Scale (AIS) Grade 
AST-OPC1 Dose 
(# of cells) 
Number of 
Subjects 
1 
A 
2 x 106 
3 
2 
A 
1 x 107 
5-8 
3 
A 
2 x 107 
5-8 
4 
B 
1 x 107 
5-8 
5 
B 
2 x 107 
5-8 
 
 
Staggered Enrollment within each cohort:  Enrollment in Cohort 1 will be 
staggered such that there are at least 10 days between administration of 

 
Asterias Biotherapeutics, Inc. 
 
Protocol AST-OPC1-01 
 
Amendment 3: 07 July 2017 
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Name of 
Sponsor/Company: 
Asterias Biotherapeutics, Inc. 
Title of Study: 
A Phase 1/2a Dose Escalation Study of AST-OPC1 in Subjects with 
Subacute Cervical Spinal Cord Injury 
AST-OPC1 to each subject.  Enrollment within Cohorts 2-5 will be staggered 
after the initial subject in each cohort is dosed, with at least 8 days between 
administration of AST-OPC1 to the first and second subjects.  If the first two 
subjects are successfully dosed with no serious adverse events (SAEs) that 
would trigger study suspension (per the study Suspension Rules), then the 
remaining subjects in that cohort may be dosed without further staggering. 
An additional staggering rule for Cohorts 2-5 is that a minimum of 14 days 
must elapse between the dosing of any two consecutive subjects who both 
have a C4 neurological level of injury (NLI).  This 14-day stagger for 
consecutive C4 NLI subjects applies throughout each of these cohorts and 
also would supersede the 8-day stagger noted above if the first two subjects 
in any cohort both have a C4 NLI. 
 
Rules for Advancement to Cohorts 2-5: 
• 
Enrollment in Cohort 2 may commence after all three subjects in 
Cohort 1 have completed 30 days of follow up after AST-OPC1 
administration AND the safety data for Cohort 1 have been reviewed 
by the Data Monitoring Committee (DMC). 
 
• 
Enrollment in Cohort 3 may commence after at least five subjects in 
Cohort 2 have completed 30 days of follow up after AST-OPC1 
administration AND the safety data from Cohorts 1 and 2 have been 
reviewed by the DMC.  
 
• 
Enrollment in Cohort 4 may commence after at least two subjects in 
Cohort 2 have completed 30 days of follow up after AST-OPC1 
administration AND if there are no SAEs that would trigger study 
suspension. 
 
• 
Enrollment in Cohort 5 may commence after at least two subjects in 
Cohort 3 AND at least five subjects in Cohort 4 have completed 30 
days of follow up after AST-OPC1 administration AND if there are no 
SAEs that would trigger study suspension. 
 
For the planned DMC reviews noted above, the DMC will recommend 
whether enrollment of the next dose cohort can commence or whether 
additional follow up of the current cohort is needed prior to commencing 
enrollment in the next cohort. 
 
Maximum Number of Subjects: A maximum of 35 subjects will receive 
AST-OPC1. 
Inclusion Criteria: 
 
• 
Sensorimotor complete, traumatic SCI (ASIA Impairment Scale A) 
for Cohorts 1, 2, and 3 
• 
Sensorimotor incomplete, traumatic SCI (ASIA Impairment Scale B) 

 
Asterias Biotherapeutics, Inc. 
 
Protocol AST-OPC1-01 
 
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Name of 
Sponsor/Company: 
Asterias Biotherapeutics, Inc. 
Title of Study: 
A Phase 1/2a Dose Escalation Study of AST-OPC1 in Subjects with 
Subacute Cervical Spinal Cord Injury 
for Cohorts 4 and 5 
• 
ISNCSCI Neurological Level of Injury (NLI) from C-5 to C-7 or a C4 
NLI with an upper extremity motor score (UEMS) ≥ 1 
• 
From 18 through 69 years of age at time of consent 
• 
Single spinal cord lesion on a post-stabilization magnetic resonance 
imaging (MRI) scan, with sufficient visualization of the spinal cord 
injury epicenter and lesion margins to enable post-injection safety 
monitoring 
• 
Informed consent for this protocol and the companion long term 
follow-up protocol must be provided and documented (i.e., signed 
informed consent forms) no later than 37 days following injury 
• 
Able to participate in an elective surgical procedure to inject AST-
OPC1 21-42 days following SCI 
Exclusion Criteria: 
 
• 
SCI due to penetrating trauma 
• 
Traumatic anatomical transection or laceration of the spinal cord 
based on prior surgery or MRI 
• 
Spinal cord lesion with anteroposterior (AP) diameter of the spinal 
cord < 2 mm at point of maximal compression on a midline sagittal 
image from a post-stabilization MRI 
• 
Any concomitant injury that interferes with the performance, 
interpretation or validity of neurological examinations, such as 
multiple spinal cord lesions, brachial/lumbar plexus injury, cauda 
equina injury or traumatic brain injury 
• 
Any treatment or pre-existing condition that interferes with the 
performance, interpretation or validity of neurological examinations, 
such as polyneuropathy, focal or multi-focal neuropathy, myelopathy 
or radiculopathy 
• 
Inability to communicate effectively with neurological examiner such 
that the validity of patient data could be compromised 
• 
Significant organ damage or systemic disease that would create an 
unacceptable risk for surgery or immunosuppression 
• 
Acute, symptomatic pulmonary embolism that would create an 
unacceptable risk for surgery 
• 
Concomitant use at baseline of other immunosuppressive agents, 
such as corticosteroids, that would create an unacceptable risk for 
additional immunosuppression with tacrolimus 
• 
Need for mechanical support of ventilation (ventilator, continuous 
positive airway pressure [CPAP], bi-level positive airway pressure 
[BiPAP]), excluding supplemental oxygen, at baseline 
• 
History of any malignancy (except non-melanoma skin cancers) 
• 
Pregnant or nursing women. Female subjects of child bearing 
potential must agree to prevent pregnancy by the use of 
contraception for 1 year following AST-OPC1 injection; male 
subjects must agree to use contraception to prevent pregnancy in 

 
Asterias Biotherapeutics, Inc. 
 
Protocol AST-OPC1-01 
 
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Name of 
Sponsor/Company: 
Asterias Biotherapeutics, Inc. 
Title of Study: 
A Phase 1/2a Dose Escalation Study of AST-OPC1 in Subjects with 
Subacute Cervical Spinal Cord Injury 
any female partners of child bearing potential for 1 year following 
AST-OPC1 injection. 
• 
Positive blood test for antibodies to human immunodeficiency virus 
(HIV) types 1 or 2, antibodies to hepatitis B virus (HBV) core antigen 
or antibodies to hepatitis C virus (HCV) 
• 
Panel reactive antibodies (PRA) ≥ 20%; if a site lab reports PRA only 
for HLA Class I or separately for HLA Class I and II, exclusion will be 
based solely on the PRA for HLA Class I 
• 
Serum creatinine >1.5X above the established limit for the normal 
range at individual study center laboratories at baseline 
• 
Blood levels of aspartate aminotransferase (AST) or alanine 
aminotransferase (ALT) > 3X the established upper limit for the 
normal range at individual study center laboratories at baseline 
• 
Hematocrit below the study center lower limit for elective surgery at 
baseline 
• 
Positive blood cultures (48 hour culture results at Day -1) 
• 
Active untreated viral, fungal or bacterial infection at baseline 
• 
Evidence of surgical site infection at intended AST-OPC1 injection 
site at baseline 
• 
Temperature ≥ 38.6°C at two time points from Day -1 through 
Injection Day prior to surgery for AST-OPC1 injection 
• 
Body mass index (BMI) > 35 or weight > 300 lbs. 
• 
Active participation in another experimental procedure/intervention 
• 
Psychoactive substance use disorder (as defined by DSM-5) at any 
time during the 3 months preceding study entry 
• 
History of untreated or poorly controlled major depression, 
schizophrenia, paranoia, or other psychotic disorder as defined by 
DSM-5  
• 
A subject who, in the opinion of the investigator, is unlikely to return 
for all follow-up visits as specified in the protocol 
• 
Any condition that, in the judgment of the investigator, would 
preclude successful participation in the study 
Duration of 
treatment: 
 
Subjects will receive a single administration of AST-OPC1, which must be 
given 21-42 days following SCI.  Subjects will be followed for 1 year post-
injection of AST-OPC1 under this protocol and for an additional 14 years 
under a companion long term follow-up protocol.  Subjects must agree to 
and sign the informed consent for long-term follow-up in order to participate 
in this study. 
 
Subjects who have pharmacological deep vein thrombosis (DVT) prophylaxis 
withdrawn in preparation for surgery, but do not receive AST-OPC1, will be 
followed for safety for 30 days. 
 

 
Asterias Biotherapeutics, Inc. 
 
Protocol AST-OPC1-01 
 
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Name of 
Sponsor/Company: 
Asterias Biotherapeutics, Inc. 
Title of Study: 
A Phase 1/2a Dose Escalation Study of AST-OPC1 in Subjects with 
Subacute Cervical Spinal Cord Injury 
Study assessments: 
 
Safety: 
Measurements to assess safety will include: physical exam, vital signs, 
electrocardiogram (ECG), neurological exam, ISNCSCI exam, MRI, pain 
questionnaire, concomitant medications, adverse events, laboratory tests for 
hematology, blood chemistry, and immunosuppression safety monitoring. 
 
Efficacy: 
Measurements to assess efficacy will include: ISNCSCI examinations at 
baseline and at 30, 60, 90, 180, 270, and 365 days post-injection of AST-
OPC1. 
 
Exploratory: 
Exploratory assessments will be performed to further evaluate upper and 
lower extremity motor function (e.g, GRASSP), bowel and bladder function, 
functional and volitional ability (e.g. SCIM), pain, and donor-specific immune 
responsiveness to AST-OPC1. 
 
Sample size: 
 
The sample size is based on the study design considerations for a Phase 
1/2a study.  Power calculations have not been performed, as the primary 
objective is to collect safety and tolerability information on a limited number 
of subjects per dose level and AIS Grade, and an effect size cannot yet be 
estimated. 
Statistical methods 
 
Populations: 
 
All Subjects Receiving AST-OPC1: 
This population is defined as all subjects who receive AST-OPC1. Primary 
safety and efficacy analysis will be on this population. 
 
All Subjects: 
This population is defined as all subjects who receive AST-OPC1 plus those 
who have pharmacological DVT prophylaxis withdrawn but do not receive 
AST-OPC1. Safety analyses will be presented for this population through 
study Day 30. 
 
Analyses: 
The analyses for safety will be done using descriptive statistics focused on 
the incidence, severity and relatedness of adverse events from AST-OPC1, 
the injection procedure to administer the product and concomitant 
immunosuppression.  Efficacy will be analyzed by change in motor level and 
motor scores based on ISNCSCI examinations, as well as by other 
exploratory assessments of arm/hand function, self-care ability, and overall 
volitional performance. 

 
Asterias Biotherapeutics, Inc. 
 
Protocol AST-OPC1-01 
 
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TABLE OF CONTENTS 
TABLE OF CONTENTS ....................................................................................................... 9 
SUMMARY OF AMENDMENTS ..........................................................................................13 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ................................................17 
1 
INTRODUCTION .....................................................................................................19 
1.1 
Spinal Cord Injury .........................................................................................19 
1.2 
AST-OPC1 ...................................................................................................20 
1.2.1 General Description ..........................................................................20 
1.2.2 Nonclinical Testing ...........................................................................20 
1.2.3 Pharmacology...................................................................................21 
1.2.4 Biodistribution Studies ......................................................................22 
1.2.5 Toxicology ........................................................................................23 
1.2.6 Clinical Experience to Date ...............................................................23 
1.3 
Rationale for Current Study Design ..............................................................24 
1.3.1 Cervical Spinal Cord Injuries .............................................................24 
1.3.2 AST-OPC1 Dose Selection ...............................................................25 
1.3.3 Rationale for AST-OPC1 Administration in Subacute SCI .................26 
1.3.4 Immunosuppression .........................................................................27 
1.4 
Potential Risks .............................................................................................28 
1.4.1 Complications of Spinal Cord Injury ..................................................28 
1.4.2 Surgical Injection Procedures ...........................................................29 
1.4.3 AST-OPC1 .......................................................................................30 
1.4.4 Tacrolimus ........................................................................................31 
2 
STUDY OBJECTIVES .............................................................................................33 
3 
INVESTIGATIONAL PLAN ......................................................................................34 
3.1 
Overall Study Design ...................................................................................34 
3.1.1 Staggered Enrollment within each Cohort .........................................34 
3.1.2 Rules for Advancement to Cohorts 2-5 .............................................35 
3.2 
Number of Subjects ......................................................................................36 
3.3 
Investigational Sites .....................................................................................36 
3.4 
Study Duration .............................................................................................36 
4 
SELECTION OF STUDY POPULATION ..................................................................37 
4.1 
Inclusion Criteria ..........................................................................................37 
4.2 
Exclusion Criteria .........................................................................................37 

 
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5 
ENROLLMENT ........................................................................................................40 
6 
STUDY TREATMENTS ...........................................................................................41 
6.1 
Investigational Product .................................................................................41 
6.2 
Dose Preparation .........................................................................................41 
6.3 
Prepared Dose Release Criteria and Sterility Testing ...................................42 
6.4 
AST-OPC1 Administration ............................................................................43 
6.5 
Immunosuppression with Tacrolimus ...........................................................45 
6.6 
Investigational Product Accountability ..........................................................46 
6.7 
Prior and Concomitant Medications ..............................................................47 
7 
TESTS AND OBSERVATIONS ................................................................................48 
7.1 
Screening (Days –11 to –3) ..........................................................................48 
7.2 
Baseline (Days –2 to –1) ..............................................................................49 
7.3 
Injection Day (Surgery for AST-OPC1 Administration)..................................49 
7.4 
Post-Injection Days 1-6 ................................................................................50 
7.5 
Post-Injection Day 7 (+/- 1 day) ....................................................................50 
7.6 
Post-Injection Days 8-29 ..............................................................................50 
7.7 
Post-Injection Day 30 (+/- 3 days) ................................................................50 
7.8 
Post-Injection Days 31-59 ............................................................................51 
7.9 
Post-Injection Day 60 (+/- 7 days) ................................................................51 
7.10 
Post-Injection Day 90 (+/- 7 days) ................................................................52 
7.11 
Post-Injection Day 180 (+/- 14 days) ............................................................52 
7.12 
Post-Injection Day 270 (+/- 14 days) ............................................................52 
7.13 
Post-Injection Day 365 (+/- 14 days) ............................................................53 
7.14 
Procedural Details ........................................................................................56 
7.14.1 Data Monitoring Committee ..............................................................56 
7.14.2 Suspension Rules .............................................................................56 
7.14.3 ISNCSCI Assessment Tool ...............................................................57 
7.14.4 MRI ...................................................................................................57 
7.14.5 Pain Scale ........................................................................................57 
7.14.6 Spinal Cord Independence Measure .................................................58 
7.14.7 Assessment of Urinary Tract and Bowel Function .............................58 
7.14.8 Immune Response Monitoring ..........................................................58 
8 
TERMINATION ........................................................................................................59 
8.1 
Study Completion .........................................................................................59 

 
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8.2 
Premature Discontinuation from Study .........................................................59 
8.3 
Study Discontinuation at Site........................................................................59 
9 
PLANNED ANALYSES ............................................................................................61 
9.1 
Sample Size Considerations ........................................................................61 
9.2 
Study Endpoints ...........................................................................................61 
9.2.1 Primary .............................................................................................61 
9.2.2 Secondary ........................................................................................61 
9.2.3 Exploratory .......................................................................................61 
9.3 
Data Analysis Methods.................................................................................61 
9.3.1 Safety Analyses ................................................................................62 
9.3.2 Efficacy Analyses .............................................................................62 
10 
ADVERSE EVENTS ................................................................................................64 
10.1 
Adverse Event Reporting .............................................................................64 
10.1.1 Definitions .........................................................................................64 
10.1.2 Grading of Adverse Event .................................................................65 
10.1.3 Relationship of Adverse Event ..........................................................65 
10.2 
Serious Adverse Events ...............................................................................65 
10.2.1 Definitions .........................................................................................65 
10.2.2 Reporting ..........................................................................................66 
10.2.3 Pregnancy ........................................................................................66 
10.3 
Recording of Adverse Events .......................................................................66 
11 
ADMINISTRATIVE AND ETHICAL PROCEDURES ................................................68 
11.1 
Regulatory Authority Approval ......................................................................68 
11.2 
Informed Consent .........................................................................................68 
11.3 
Protocol Amendments ..................................................................................69 
11.4 
Data Management and Study Monitoring .....................................................69 
11.5 
Study Termination ........................................................................................70 
11.6 
Records Retention .......................................................................................71 
11.7 
Confidentiality of Information ........................................................................71 
12 
REFERENCES ........................................................................................................73 
13 
APPENDICES .........................................................................................................75 
Appendix A: 
Compliance with Xenotransplantation Guidelines ......................................... 75 
Appendix B: 
Flow Diagram of AST-OPC1 Dose Preparation ............................................ 77 
Appendix C: 
Site Personnel Training ................................................................................ 78 
Appendix D: 
International Standards for Neurological Classification of Spinal Cord 
Injury ............................................................................................................ 79 

 
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Appendix E: 
Magnetic Resonance Imaging Procedures ................................................... 82 
 
LIST OF TABLES 
Table 6-1: 
AST-OPC1 Dose Cohorts and Injection Preparation .................................... 43 
Table 7-1: 
Summary of Tests and Observations ........................................................... 54 
LIST OF FIGURES 
Figure 3-1:  Study Schematic: ............................................................................................. 35 
Figure 13-1: 
ISNCSCI Scoring System ............................................................................. 80 
 

 
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SUMMARY OF AMENDMENTS 
Amendment 3: 07 July 2017 
Rationale for changes:  The primary changes in this amendment are: 1) expansion of the 
inclusion criteria to patients with a C4 neurological level of injury (NLI) if their upper 
extremity motor score (UEMS) is ≥ 1, and 2) changing the dosing window to 21-42 days 
post-SCI.  The rationale for each of these protocol changes is described below. This 
amendment also includes several minor revisions that are summarized in the table 
immediately following this rationale section. 
Rationale for including patients with a C4 neurological level of injury (NLI) 
The expansion of the inclusion criteria to patients with a C4 NLI is based upon three primary 
factors: i) C4 is the second most common NLI following traumatic SCI, ii) patients with a C4 
NLI have an extremely high unmet medical need due to the complete loss of functional 
movement in all four limbs, and iii) the safety of both AST-OPC1 and the injection procedure 
to date have been very favorable in subjects with a C5-C7 NLI.  In addition, two subjects 
with a C4 NLI have already been dosed in this study under pre-approved protocol deviations 
after concurrence was obtained from both FDA and the clinical site IRB.  There have been 
no intraoperative complications or SAEs related to the injection procedure for any subject in 
the study, including these two C4 subjects.  The first of these two subjects received 10 
million AST-OPC1 cells in Cohort 2 (AIS-A) and has completed nine months of follow up.  
This subject has converted to AIS-C, has improved two motor levels on the left side and one 
motor level on the right side, and has gained 11 points on the upper extremity motor score 
(UEMS) relative to baseline.  The second subject with a C4 NLI was dosed very recently. 
A key safety consideration for patients with a C4 NLI is that an ascending neurological level 
(i.e., to C3 or higher) could result in a loss of one’s ability to breathe without the assistance 
of a ventilator.  To date, a total of 17 subjects have received AST-OPC1 in this study, and 
no subject has had an ascending NLI following AST-OPC1 administration.  In addition, of 
the 12 subjects who have reached the six-month follow up visit, 11 have improved at least 
one motor level on at least one side relative to baseline and 1 has a stable motor level 
relative to baseline.  In order to provide an additional margin of safety, patients with a C4 
NLI must have an UEMS ≥ 1 in order to be eligible for this study and a staggering rule has 
been added for Cohorts 2-5 that requires a 14-day stagger between the dosing of any two 
consecutive subjects who have a C4 NLI. 

 
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Protocol AST-OPC1-01 
 
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Rationale for changing the dosing window to 21-42 days post-SCI 
The current dosing window of 14-30 days was selected to avoid the early hemorrhage and 
inflammation that occurs following SCI, as well as the scar tissue formation that occurs in 
the chronic phase of SCI.  This window was also based on the preclinical data available 
prior to the initiation of this clinical study.  However, Asterias recently completed a new 
preclinical study to further evaluate the appropriate dosing window for AST-OPC1, and the 
findings from this study suggest that the optimal dosing window in human subjects may 
extend to at least 60 days post-SCI (see Investigator’s Brochure for details). 
Asterias reviewed these new preclinical data with the current study investigators and several 
SCI experts to determine whether the dosing window should be adjusted.  Consideration 
was also given to the planned inclusion of patients with a C4 NLI.  Based on these reviews, 
it was determined that a dosing window of 21-42 days post-SCI would still be squarely within 
the subacute period but would also allow more time for patients to be medically stable prior 
to undergoing elective surgery for AST-OPC1 administration. 
 
Amendment 2: 03 May 2016 
The primary changes in this amendment were: 1) reduction of the staggering within each 
cohort to 8 days only between the first two subjects, 2) addition of two cohorts of subjects 
who are AIS-B, and 3) expansion of the acceptable age range to 18-69 years old at the time 
of SCI.  This amendment also included several administrative changes and minor revisions 
to the study endpoints, inclusion/exclusion criteria, and schedule of assessments. 
 
Amendment 1: 17 February 2015 
This amendment contained a few minor administrative updates, corrected several minor 
typographical errors in the original protocol, and eliminated the UAB-IMR assessments.  The 
UAB-IMR was eliminated because the clinical investigators and several expert SCI 
consultants noted that any clinically meaningful return of motor function in the lower 
extremities would be observed on both the ISNCSCI exam and the UAB-IMR exam.  Thus, 
the latter exam was determined to be redundant for this clinical study. 
 

 
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Summary of changes in Amendment 3: 
No. 
Change 
Section(s) 
1 
Study Objectives:  Updated to reflect that the 
dosing window is being changed from 14-30 days 
post-SCI to 21-42 days post-SCI 
Synopsis, Sections 2, 3.1 
2 
Study Population:  Added an additional staggering 
rule for Cohorts 2-5 that requires a 14-day stagger 
between the dosing of any two consecutive subjects 
who have a C4 neurological level of injury (NLI) 
Synopsis, Sections 3.1.1, 
3.1.2 
3 
Inclusion Criteria:  Expanded to include patients 
with a C4 neurological level of injury (NLI) if their 
upper extremity motor score (UEMS) is ≥ 1 
Synopsis, Section 4.1 
4 
Inclusion Criteria:  Changed the age requirement to 
apply at the time of consent rather than at the time of 
injury 
Synopsis, Section 4.1 
5 
Inclusion Criteria:  Changed the requirement for 
obtaining informed consent within 25 days post-SCI 
to within 37 days post-SCI to reflect the new dosing 
window 
Synopsis, Section 4.1 
6 
Inclusion Criteria: Changed the requirement for 
being able to participate in an elective surgical 
procedure to inject AST-OPC1 to 21-42 days post-
SCI to reflect the new dosing window 
Synopsis, Section 4.1 
7 
Exclusion Criteria:  Added an exclusion criterion for 
acute, symptomatic pulmonary embolism that would 
create an unacceptable risk for surgery based on a 
recommendation from the Data Monitoring 
Committee and after consultation with the lead 
neurosurgeon for the study 
Synopsis, Section 4.2 
8 
Duration of Treatment:  Updated to reflect the new 
dosing window 
Synopsis 
9 
Rationale for AST-OPC1 Administration in 
Subacute SCI:  Updated to reflect the new dosing 
window, which is supported by new preclinical data 
that is provided in the accompanying revision to the 
Investigator’s Brochure 
Section 1.3.3 
10 
Complications of Spinal Cord Injury:  Added a 
section that lists these complications to clarify which 
adverse events would be expected due to the fact 
Section 1.4.1 

 
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that all subjects suffered an SCI prior to study entry 
11 
Surgical Injection Procedures:  Updated to note 
that one of the risks is hemorrhage and/or fluid 
collection in tissues between the incision site and the 
spinal cord 
Section 1.4.2 
12 
AST-OPC1 Administration:  Added 
recommendations for placement of an arterial line in 
all subjects and for intraoperative monitoring of 
somatosensory evoked potentials in AIS-B subjects 
based upon consultation with several study 
investigators and surgeons 
Section 6.4 
13 
Tests and Observations:  Deleted testing for 
ionized calcium based on the recommendation of a 
clinical expert and because several site labs were 
unable to perform this test, which resulted in several 
protocol deviations.  In addition, there have been no 
clinically significant abnormalities of ionized calcium 
in any subject to date. 
Section 7 (all subsections in 
which blood chemistry 
testing is performed) 
14 
Tests and Observations: Deleted the GRASSP test 
from post-injection Day 30 and added the GRASSP 
test to post-injection Day 90 based on the advice of 
our expert consultant for GRASSP 
Sections 7.7, 7.10; Table 7-1 
15 
Tests and Observations: Deleted the fasting blood 
glucose test at post-injection Day 60 because 
subjects receive extremely low doses of tacrolimus 
during the Day 46-60 taper period and because there 
have been no clinically significant abnormalities for 
this test in any subject to date 
Section 7.9; Table 7-1 
16 
Efficacy Analyses: Corrected two typographical 
errors 
Section 9.3.2 
 

 
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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
Abbreviation  
or term 
Definition 
AIS 
ASIA Impairment Scale 
ALT 
alanine aminotransferase 
ASIA 
American Spinal Injury Association 
AST 
aspartate aminotransferase 
AST-OPC1 
investigational product (formerly GRNOPC1) 
BBB 
Basso, Beattie, and Bresnahan behavior locomotor score 
BUN 
blood urea nitrogen 
CFR 
Code of Federal Regulations 
CNS 
central nervous system 
CSF 
cerebral spinal fluid 
DLT 
dose-limiting toxicity 
DMC 
Data Monitoring Committee 
DTPA 
diethylenetriamine pentaacetic acid 
ECG 
electrocardiogram 
eCRF 
electronic case report form 
EDTA 
ethylenediaminetetraacetic acid 
ESC 
embryonic stem cells 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practices 
GRASSP 
Graded Redefined Assessment of Strength, Sensibility and 
Prehension 
HBV 
hepatitis B virus 
HCV 
hepatitis C virus 
HIV 
human immunodeficiency virus 
HLA 
human leukocyte antigen 
HSA 
human serum albumin 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
ISNCSCI 
International Standards for Neurologic Classification of Spinal Cord 
Injury 
MCB 
master cell bank 
MedDRA 
Medical Dictionary for Regulatory Activities 
MRI 
magnetic resonance imaging 
MTD 
maximum tolerated dose 
NLI 
Neurological Level of Injury 
OPC 
oligodendrocyte progenitor cell(s) 

 
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Abbreviation  
or term 
Definition 
PPCM 
posttraumatic cystic myelopathy 
SCI 
spinal cord injury 
SCIM 
Spinal Cord Independence Measure 
SCOPE 
Spinal Cord Outcomes Partnership Endeavor 
uhESC 
undifferentiated human ESC 

 
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1 
INTRODUCTION  
1.1 
Spinal Cord Injury 
Spinal cord injury (SCI) is a devastating and currently untreatable condition, aside from 
symptomatic treatments for some of the resulting complications.  SCI results in complete or 
partial loss of motor, sensory and autonomic function.  The morbidities associated with SCI 
are both profound and life-changing and may include pain, bowel and urogenital 
dysfunction, urinary tract infections, hemorrhoids, pressure ulcers, deep vein thrombosis, 
pulmonary embolism, respiratory dysfunction and infections, autonomic dysreflexia, 
spasticity, heterotopic ossification, syringomyelia, anemia, and hypotension.  To date there 
are no FDA-approved treatments to induce neurological recovery following acute SCI.  
Thus, there remains a significant unmet medical need in SCI, particularly in patients with 
more severe injuries who are initially classified as ASIA Impairment Scale Grade A or B 
(Curt 2008). 
Worldwide, the annual incidence of SCI is estimated to be 15 to 40 cases per million of 
population (Sekhon 2001).  In the United States there are approximately 12,000 new cases 
annually (National Spinal Cord Injury Database 2013).  The most common causes of SCI 
are motor vehicle crashes, falls, violence (such as gunshot wounds), and sports injuries.  
SCI predominantly affects men (80.7%), and the average age at time of injury is 42.6 years.  
Since 2010, the most frequent categories of injury are as follows:  incomplete tetraplegia 
(40.6%), incomplete paraplegia (18.7%), complete paraplegia (18.0%), and complete 
tetraplegia (11.6%).  Currently, the leading causes of death for persons with SCI are 
pneumonia and septicemia. 
The pattern of tissue damage after SCI in humans is complex and highly variable (Kakulas 
1999a, Kakulas 1999b), but generally can be grouped into 4 categories:  contusion cyst, 
cord maceration (due to severe compression), cord laceration, and solid cord injury (Bunge 
1993).  Roughly 80% of all human SCI is caused by contusion/compression type injuries as 
opposed to about 20% that are due to laceration (e.g., knife or gunshot wound). 
Even though the patterns of gross pathology are variable, many of the molecular and 
cellular changes after SCI are consistently observed in the acute, subacute, and late phases 
following injury (Kakulas 1999a).  These changes are induced by the initial mechanical insult 
(primary injury) and are collectively referred to as the secondary injury.  The exact 
pathophysiology of secondary injury in human SCI is not known and is thus inferred from 
animal models of SCI that produce similar patterns of histopathological tissue damage.  

 
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Since the majority of human SCI cases are caused by contusion/compression, the majority 
of animal studies on the mechanisms of secondary injury have focused on this type of injury.  
It is also for this reason that the majority of the nonclinical efficacy and safety studies of 
AST-OPC1 were conducted in a rodent contusion SCI model.   
1.2 
AST-OPC1 
1.2.1 
General Description 
AST-OPC1 (formerly known as GRNOPC1) is a cell population that contains a mixture of 
oligodendrocyte progenitor cells (OPCs) and other characterized cell types that are obtained 
following differentiation of undifferentiated human embryonic stem cells (uhESCs).  The 
starting material for the production of AST-OPC1 is an H1 master cell bank produced from 
the H1 uhESC line derived at the University of Wisconsin in 1998.  The H1 line was 
approved on January 29, 2010 for inclusion in the National Institutes of Health Human 
Embryonic Stem Cell Registry and is authorized for research using federal funding. 
AST-OPC1 is manufactured using a controlled and highly specialized differentiation 
protocol.  After the differentiation of uhESC is complete, the cells are harvested and 
cryopreserved, generating the AST-OPC1 investigational product.  AST-OPC1 has been 
characterized by the expression of several molecules associated with oligodendrocyte 
precursors and is further characterized for the expression of markers known to be present in 
other cell types, such as neurons, epithelial cells, astrocytes, endodermal cells, mesodermal 
cells, or uhESCs.  The presence of these cell types is controlled through the manufacturing 
process and through specified limits for their levels.   
AST-OPC1 has been shown to have three potentially reparative functions which address the 
complex pathologies observed at the SCI injury site.  These activities of AST-OPC1 include 
production of neurotrophic factors, stimulation of vascularization, and induction of 
remyelination of denuded axons, all of which are critical for survival, regrowth and 
conduction of nerve impulses through axons at the injury site.  Additional information is 
provided in the Investigator’s Brochure.   
1.2.2 
Nonclinical Testing 
Rigorous nonclinical testing was conducted on AST-OPC1, with an emphasis on evaluating 
the safety and efficacy of the product.  In vitro and in vivo models were utilized to assess: 
• 
phenotype and cellular function 

 
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• 
survival, migration, function and potential therapeutic utility in SCI 
• 
distribution within and outside the CNS after injection directly into a spinal cord contusion 
• 
recognition by the allogeneic human immune system 
• 
potential toxicity to multiple organ systems including the induction of allodynia 
• 
toxicity to neurological function should immunological rejection occur 
• 
potential to form human teratomas or ectopic tissue (defined as tissue types not found in 
the CNS nor intended to be produced by AST-OPC1) 
Results of these studies are provided below and in the Investigator’s Brochure. 
1.2.3 
Pharmacology 
AST-OPC1 was found to have properties that promote repair of the pathology in SCI.  AST-
OPC1 produced neurotrophic factors which, upon implantation in the subacute period after 
injury, could potentially promote survival of damage spinal cord tissue as well as promote 
regeneration of injured axons (Zhang 2005).  AST-OPC1 was also demonstrated to induce 
remyelination of demyelinated axons in rats with either a cervical or thoracic contusion SCI 
and to form compact myelin around dysmyelinated axons in the mutant Shiverer mouse, 
which lacks compact myelin in the CNS.  In nonclinical studies with long term follow up, 
AST-OPC1 was also found to induce the formation of new blood vessels within the 
injury/injection sites. 
When injected into the spinal cords of athymic nude rats 7 days following a cervical or 
thoracic SCI, AST-OPC1 survived in virtually all animals as measured 9 months after 
injection when an anti-asialoGM1 antibody was used to inactivate xenograft reactive, host 
natural killer cells.  Similarly, AST-OPC1 survived for at least 9 months as a xenograft in 
immunocompetent Sprague Dawley rats when appropriate immunosuppression was 
administered.   
AST-OPC1, which contains oligodendrocyte progenitor cells, matured when injected into the 
spinal cord in rats with thoracic SCI.  At 180 days postinjection, human cells that expressed 
markers of differentiated oligodendrocytes were found at the lesion site.  At this point, few 
human cells expressed markers for proliferation, indicating that the proliferative capacity of 
AST-OPC1 diminished as the cells matured.   
Recovery of locomotor activity was improved in rats with moderately severe cervical or 
thoracic contusion injuries that were injected with AST-OPC1 at the lesion site 7 days after 
injury.  Improvement in locomotor activity was measured using a well-established behavioral 

 
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rating scale (Basso 1996) and by unbiased kinematic gait analysis using the TreadScan 
system (CleverSys Inc.).  In these nonclinical efficacy studies, animals were followed for 2-4 
months and significantly improved locomotor function relative to controls was observed at 
both cell doses tested: 2.4 x 105 cells and 1.5 x 106 cells.  There was no obvious dose 
response in these studies. When AST-OPC1 was administered 2 or 10 months postinjury, 
no improvements in locomotor activity were observed.  This lack of functional benefit in 
chronic SCI may have been due to extensive glial scar formation at the injury site. 
Several histological parameters were measured in the spinal cords of injured animals that 
received AST-OPC1.  At 2-4 months postinjection, increased survival of corticospinal tract 
axons immediately adjacent to the lesion epicenter was observed, as well as regeneration of 
rubrospinal and reticulospinal axons through the AST-OPC1 grafts.  Animals that received 
AST-OPC1 7 days after SCI showed significantly less injury-related cavity formation at 9 
months postinjection than was observed in control animals.  In addition, the lesion sites into 
which AST-OPC1 had been injected contained numerous human cells that were traversed 
by multiple fascicles of myelinated axons, and increased oligodendrocyte-mediated 
remyelination was seen in the adjacent white matter. 
1.2.4 
Biodistribution Studies 
Studies were performed to determine the distribution of AST-OPC1 throughout the CNS and 
the rest of the body upon injection into the SCI site using the product as formulated for 
clinical trials.  AST-OPC1 was injected at doses of 2.4 x 105 and 2.4 x 106 cells into a 
moderately severe cervical or thoracic contusion injury in athymic nude rats 7 days after 
injury.  At time points ranging from 2 days to 6 months posttransplantation, both CNS and 
peripheral tissues were harvested and tested for the presence of human cells as detected 
by quantitative polymerase chain reaction (PCR).  A parallel study examined the distribution 
of AST-OPC1 in the CNS using a histological endpoint.  The major findings from these 
studies were: 
• 
AST-OPC1 was retained primarily within 2 cm rostral and caudal to the injection sites in 
the cervical or thoracic spinal cord 
• 
AST-OPC1 was detected in the spinal cord white matter up to 5 cm rostral and caudal to 
the injection sites, and the number of human cells progressively decreased as the 
distance from the injection site increased 
• 
At supraspinal levels, AST-OPC1 was restricted to white matter tracts in the brainstem 
and pons/medulla 

 
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• 
In a few cases, detectable but not quantifiable amounts of human DNA were found in the 
cerebellum, hippocampus, or peripheral tissues, ranging from approximately 0.1 to 1 
human cell per 1,000,000 rat cells 
• 
Human cells were detectable in the meninges directly over the injection site 
• 
Human cells were detectable in cerebral spinal fluid (CSF) 2 days after injection, but not 
at 14 or 180 days 
• 
Dose did not appear to influence the distribution of the cells within or outside the CNS 
Acute biodistribution of AST-OPC1 was also assessed following injection of 1 x 107 cells at 
C6 in the in the uninjured spinal cord of the Gottingen pig using the clinical syringe 
positioning device.  Survival of AST-OPC1 was observed at 2 and 14 days post-
implantation.  AST-OPC1 was not observed in the brain by histological examination.  
Administration of AST-OPC1 did not affect mortality rates and was well tolerated. 
1.2.5 
Toxicology 
Multiple nonclinical studies were conducted to evaluate the potential toxicity and 
tumorigenicity associated with the administration of AST-OPC1 to the spinal cord.  The 
results of these studies are summarized in the Investigator’s Brochure.  The only significant 
finding was the formation of ectopic tissue (atypical glandular structures or cartilaginous 
tissue) at the spinal cord lesion site in some animals administered AST-OPC1.  Pooled 
analysis of the studies that used 9-month follow up and AST-OPC1 that passed all current 
release testing for clinical use showed a 2-3% incidence of ectopic tissue with the injection 
sites.  These ectopic tissue foci were all very small and there was no evidence of adverse 
effects in the adjacent spinal cord tissue.  There was also no evidence of any clinical 
adverse effects related to the ectopic tissue.  In addition, very few proliferative cells were 
present in these foci of ectopic tissue, which suggests that the potential for continued 
enlargement via cellular proliferation is very low. 
1.2.6 
Clinical Experience to Date 
Five subjects with thoracic SCI have received AST-OPC1 (formerly GRNOPC1) injections in 
a previous open-label Phase 1 safety study (Geron Protocol CP35A007).  All subjects had a 
last fully preserved neurological level from T3 – T11 and received a single injection of 2 x 
106 cells between 7 and 14 days after the injury.  Subjects received temporary 
immunosuppression with tacrolimus, which was tapered at Day 46 of follow up and 
discontinued at Day 60 per protocol.  There were no serious or unexpected adverse events 
related to AST-OPC1, tacrolimus, or the injection procedure.  There were 5 AEs judged to 
be possibly related to AST-OPC1.  One of these AEs was a brief mild elevation of body 

 
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temperature.  The remaining four AEs all occurred in 1 subject and were primarily 
neuropathic pain reported as a burning sensation in the trunk and lower extremities.  Pain of 
this type and distribution is also a common complication of SCI. 
There were no reports of cyst formation or enlarging masses at the injection sites on MRI 
scans.  All 5 subjects completed 1 year of follow up under protocol CP35A007 and are 
continuing long-term follow up under a companion protocol, CP35A008.  Additional 
information is provided in the Investigator’s Brochure.   
1.3 
Rationale for Current Study Design 
1.3.1 
Cervical Spinal Cord Injuries 
As the initial safety profile for AST-OPC1 at a dose of 2 x 106 cells is favorable in thoracic 
SCI, the next target patient population in which to clinically test AST-OPC1 are subjects with 
severe cervical spinal cord injuries who are initially classified as ASIA Impairment Scale 
(AIS) Grade A or B.  There is a strong medical and scientific rationale for the transition to 
subjects with cervical SCI.  Individuals with severe cervical SCI have an enormous unmet 
medical need due to the loss of function in all four limbs as well as multiple additional 
sequelae such as impaired bowel and bladder function, reduced sensation, spasticity, 
autonomic dysreflexia, deep vein thromboses, sexual dysfunction, increased infections, 
decubitus ulcers and chronic pain.  These individuals frequently require significant 
assistance for self-care and activities of daily living.  They also have a significantly 
decreased lifespan - the life expectancy of an individual suffering a C5-C8 cervical spinal 
cord injury at age 20 is 20 years less than that of a similarly aged individual with no SCI 
(Spinal 
Cord 
Injury 
Facts 
and 
Figures 
at 
a 
Glance, 
February 
2013, 
https://www.nscisc.uab.edu/). 
Scientifically, the injured cervical spinal cord is a much better location than the upper or 
middle thoracic spinal cord to test the safety and potential activity of AST-OPC1. This is 
partly due to the fact that denervated neuronal pools in the lumbar enlargement can be 
many levels below a thoracic injury whereas lower levels of the cervical enlargement are 
only a short distance from the epicenter of a cervical injury (Sharp 2010).  Therefore, 
regeneration and/or repair of damaged axons mediated by AST-OPC1 could theoretically 
result in substantial reinnervation of lower cervical segments and have a significant impact 
on upper extremity motor function.  

 
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The advantages of conducting clinical trials in patients with severe cervical SCI were 
recently reported by Steeves et al. (2011, 2012) together with the Spinal Cord Outcomes 
Partnership Endeavor (SCOPE).  These studies analyzed several large SCI databases and 
found that only 21% and 26% of people living with C4-C7 cervical AIS-A spinal cord injury 
recovered ≥2 upper extremity motor levels at 24 and 48 weeks after injury, respectively.  
These studies further showed that a ≥2 level improvement in motor score led to a 
statistically significant increase in the Spinal Cord Independence Measure (SCIM) self-care 
subscore, suggestive of a measurable association between improvement in neurological 
function and a clinically meaningful functional outcome.  The SCIM will also be used as an 
exploratory endpoint on its own since recent studies have shown that AIS-A and AIS-B 
patients exhibit a similar degree of recovery on the SCIM with current standard of care (Curt 
2008). 
Additional new outcome measures and endpoints will be explored that can further elucidate 
recovery of function across both complete and incomplete cervical SCI patients.  One of 
these measures is the Graded Redefined Assessment of Strength, Sensibility, and 
Prehension (GRASSP).  It has been shown that a baseline GRASSP exam conducted at 1 
month post-SCI can predict upper limb function and self-care ability at 6 and 12 months 
post-SCI (Velstra 2014).  Another new exploratory endpoint that will be utilized is the Spinal 
Cord Ability Ruler, which is a quantitative linear measure of volitional performance inclusive 
of all subjects in the study population (Reed, submitted).  The Spinal Cord Ability Ruler is 
derived from the ISNCSCI and SCIM assessments. 
1.3.2 
AST-OPC1 Dose Selection 
1.3.2.1 
Dose Selection with Respect to Potential Efficacy 
Rats with cervical contusion injuries that received a low dose of 2.4 x 105 AST-OPC1 cells in 
a pivotal nonclinical cervical efficacy study exhibited significantly greater recovery of 
locomotor function as assessed by the TreadScan system than vehicle control animals (p = 
0.045) after 1 month of follow up.  Since each segment of the human spinal cord has 
roughly a 50-fold larger volume than the corresponding rat spinal cord segment, it is 
estimated the human equivalent dose (HED) for efficacy is approximately 1.2 x 107 AST-
OPC1 cells (= 50 x [2.4 x 105]).  However, it is anticipated that the optimal therapeutic dose 
in humans could be lower or higher than the estimated HED because AST-OPC1 has 
several potential mechanisms of action and it is unclear how these scale separately and 
collectively from rodents to humans.  Therefore, three doses of 2 x 106, 1 x 107, and 2 x 107 

 
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cells were selected for the proposed trial in order to bracket the estimated HED with a 
sufficient range to maximize the probability of detecting potential efficacy while maintaining 
an acceptable safety profile based on the nonclinical and clinical data acquired to date. 
1.3.2.2 
Dose Selection with Respect to Safety 
The first proposed dose of 2 x 106 cells has already been evaluated for safety in the previous 
thoracic SCI trial.  No complications due to the injection procedure were noted in the 
thoracic trial, and the adverse events deemed possibly related were all Grade 1 or 2, and 
were all postoperative symptoms commonly seen after spine surgery (e.g., transient pain or 
fever). 
The increase from the first dose (2 x 106 cells in 50 µL) to the second dose (1 x 107 cells in 
50 µL) only entails increasing the concentration of AST-OPC1 such that both of these doses 
will be delivered via a single injection with a 50 µL volume.  Therefore, the neurosurgeons 
consulted for this protocol view this initial dose escalation as a very small step with respect 
to the potential risks associated with the injection procedure.  In addition, the safety of 
administering the second dose (1 x 107 cells in 50 µL) was demonstrated in the uninjured pig 
cervical spinal cord at C6.  This study confirmed the minimal expected tissue damage 
associated with injections into the uninjured spinal cord, and no evidence of efflux or cellular 
dissemination via the CSF was observed.   
The third dose represents an additional injection of 1 x 107 cells in 50 µL at a second site 
within the lesion in a manner similar to that used for the rodent safety studies.  This dose still 
represents a 6-12X safety margin relative to the highest dose tested in the rat safety studies, 
particularly with respect to the total volume injected.  Also, as noted in Section 3.1.2 of this 
protocol, dose escalation will occur in accordance with the rules for cohort advancement. 
1.3.3 
Rationale for AST-OPC1 Administration in Subacute SCI 
It is hypothesized that the subacute phase of SCI is the optimal time window in which to 
administer AST-OPC1.  This phase avoids the early damage that leads to apoptosis of 
endogenous oligodendrocytes and occurs soon enough to allow OPCs to migrate to 
denuded axons before extensive glial scarring has occurred.  This hypothesis is supported 
by studies in rodent models of SCI that have shown functional benefits when AST-OPC1 or 
similar cells are injected 7 days after SCI, but no benefit if the interval between injury and 
injection is greater than 8 weeks (Keirstead 2005, Karimi-Abdolrezaee 2006).  Since 
spontaneous functional recovery in rats with contusion SCI begins to plateau at about 6 

 
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weeks post-injury, injection of AST-OPC1 at 7 days corresponds to about 1/6 (17%) of the 
time elapsed between injury and the onset of recovery plateau. 
The subacute phase of SCI is thought to be much longer in humans given that the rate of 
spontaneous recovery typically begins to plateau at about 6 months after SCI (Fawcett 
2006).  Extrapolating from the nonclinical efficacy data in rodents, injection of AST-OPC1 
when 1/6 of the time to onset of recovery plateau has elapsed in humans would correspond 
to about 30 days post-injury. 
The original dosing window of 14-30 days was selected to avoid the early hemorrhage and 
inflammation that occurs following SCI, as well as the scar tissue formation that occurs in 
the chronic phase of SCI.  This window was also based on the preclinical data available 
prior to the initiation of this clinical study.  However, Asterias recently completed a new 
preclinical study to further evaluate the appropriate dosing window for AST-OPC1, and the 
findings from this study suggest that the optimal dosing window in human subjects may 
extend to at least 60 days post-SCI (see Investigator’s Brochure for details). 
Asterias reviewed these new preclinical data with the current study investigators and several 
SCI experts to determine whether the dosing window should be adjusted.  Consideration 
was also given to the planned inclusion of patients with a C4 NLI.  Based on these reviews, 
it was determined that a dosing window of 21-42 days post-SCI would still be squarely within 
the subacute period but would also allow more time for patients to be medically stable prior 
to undergoing elective surgery for AST-OPC1 administration.  Therefore, AST-OPC1 will be 
administered to subjects in this study at 21-42 days after SCI – a timeframe during which the 
patient should have stabilized from the acute injury but still within a window when clinical 
benefit might be anticipated based on extrapolation from nonclinical studies. 
1.3.4 
Immunosuppression 
In vitro studies were also performed to assess the immunogenicity of AST-OPC1 with 
respect to the allogeneic human immune system (Okamura 2007).  These experiments 
demonstrated that AST-OPC1 was capable of only weakly stimulating allogeneic T-cell 
proliferation in a mixed lymphocyte reaction assay.  Although AST-OPC1 was found to 
express Class I human leukocyte antigens, Class II expression was not detected.  Further 
experiments in this study indicated that AST-OPC1 is resistant to lysis by human natural 
killer cells as well as antibodies contained in normal human serum.  These in vitro studies 

 
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suggest that AST-OPC1 may be a poor target for immune-mediated responses in an 
allogeneic setting. 
Based upon these results, it was hypothesized that if an immune response against AST-
OPC1 were to occur in a human subject, it would likely consist of a weak T-cell attack.  
Therefore, the previous trial of AST-OPC1 utilized a low dose of tacrolimus for 
immunosuppression.  In addition, the tacrolimus dose was tapered beginning at Day 46, and 
tacrolimus was withdrawn completely at Day 60.  Since it was not known whether this 
immunosuppression regimen was sufficient to prevent donor-specific immune responses to 
AST-OPC1, extensive immune monitoring was performed. 
The immune monitoring of subjects who received AST-OPC1 focused on identifying 
responses from the humoral and cellular components of the immune system.  Blood and 
CSF were collected from subjects at baseline and at either multiple time points after AST-
OPC1 injection (for blood) or at Day 60 after injection (for CSF).  Serum and CSF samples 
were used to assay for the presence of donor specific antibodies.  Peripheral blood 
mononuclear cells were used to detect reactive T cells against AST-OPC1.  The results of 
the immune monitoring assays showed no detectable humoral or cellular immune responses 
against AST-OPC1 that were sustained at successive time points through 1 year of follow 
up for any of the five subjects in that study. 
Therefore, tacrolimus administration and tapering will follow the procedure used in the 
previous clinical study (see Section 6.5 for details).  This study will also include an 
immunological monitoring plan similar to the one used in the previous clinical study to 
evaluate whether an immune response to AST-OPC1 will occur following 
immunosuppression withdrawal. 
1.4 
Potential Risks 
1.4.1 
Complications of Spinal Cord Injury 
There are many medical complications that affect individuals who have suffered a traumatic 
spinal cord injury.  These risks include, but are not limited to: 
• 
allodynia 
• 
anemia 
• 
autonomic dysreflexia 
• 
bowel dysfunction 
• 
deep vein thrombosis (DVT) with or without pulmonary embolism 

 
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• 
hemorrhoids 
• 
heterotopic ossification 
• 
hyperthermia 
• 
hypotension 
• 
hypothermia 
• 
pain 
• 
pressure ulcers 
• 
respiratory depression/dysfunction 
• 
respiratory infections 
• 
spasticity 
• 
syringomyelia 
• 
tachycardia 
• 
urinary tract infections 
 
Development of any one or more of the complications noted above will be considered an 
anticipated (expected) adverse event (AE) in this study.  Risks that are specific to AST-
OPC1 are described below, and they fall into three categories: 1) risks related to the surgical 
procedure for AST-OPC1 injection, 2) risks secondary to immunosuppression, and 3) 
potential risks of the AST-OPC1 cells. 
1.4.2 
Surgical Injection Procedures 
AST-OPC1 is injected directly into the spinal cord during an open surgical procedure under 
general anesthesia.  The procedure requires a posterior approach, laminectomy, and 
opening of the dura.  These steps are common in intradural spinal cord operations, and 
have several known risks, including: 
• 
anesthesia-associated risks  
• 
compression of nerve roots 
• 
CSF leak 
• 
deep vein thrombosis and pulmonary embolus 
• 
further tissue damage to the spinal cord 
• 
hemorrhage and/or fluid collection in tissues between the incision site and the spinal 
cord 
• 
infection (incision site, intraspinal/CNS, pneumonia, urinary tract) 

 
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• 
intraspinal hemorrhage 
• 
pain 
• 
spinal cord tethering 
These risks will be minimized as much as possible by selecting participating sites with highly 
qualified spine surgeons and ensuring good perioperative care.  In the previous thoracic 
study of AST-OPC1 (Geron Protocol CP35A007), there were no serious or unexpected 
adverse events related to the injection procedure.  There were 9 AEs in that study that were 
judged to be possibly related to the injection procedure.  These were all Grade 1 or Grade 2 
in severity and were predominantly transient postoperative pain, one brief, mild, elevated 
temperature, and one urinary tract infection. 
1.4.3 
AST-OPC1 
As outlined in Section 1.2.6, clinical experience has been obtained in 5 subjects with 
thoracic SCI in Geron Protocol CP35A007.   There were no serious or unexpected adverse 
events related to AST-OPC1, nor was there any evidence of cyst formation or enlarging 
masses at the injection sites on MRI scans.  At this stage, all potential risks discussed below 
are theoretical.   
Based on the results of nonclinical studies, the potential risks of AST-OPC1 include the 
formation of ectopic tissue (atypical glandular structures and/or cartilaginous tissue) at the 
injection site and/or teratomas.  Since no teratomas were observed in any animals injected 
with AST-OPC1 from lots that are intended for clinical use, the estimated likelihood of this 
risk in human subjects is very low.  In addition, the foci of ectopic tissue that were observed 
were all contained within AST-OPC1 grafts and were much smaller (< 1 mm diameter) than 
the lesion cavities in control animals. 
If an area of ectopic tissue develops, it is possible that this ectopic tissue may not reach a 
size that is detectable on magnetic resonance imaging (MRI) (about 1–2 mm in length) until 
after 1 year following AST-OPC1 injection.  In contrast, many individuals with SCI have 
lesion cavities in the spinal cord that are at least several millimeters in length and/or 
damaged spinal tissue that may exhibit areas of heterogeneous signal on MRI.  In addition, 
approximately 21–28% of all individuals with SCI will develop progressive posttraumatic 
cystic myelopathy (PPCM), also known as posttraumatic syringomyelia (Brodbelt 2003) in 
which the initial lesion cavity expands and causes further destruction of spinal tissue above 
and/or below the original injury level.  Development of PPCM is usually slow, with a median 
time of onset at 20 months after injury (Edgar 1994).  Only about 1–9% of individuals with 

 
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SCI will develop clinical symptoms due to PPCM (Brodbelt 2003).  These symptoms might 
include asymmetrical motor loss, increased pain or temperature sensitivity above the level of 
the lesion, increased spasticity, and autonomic dysreflexia. 
In over 95% of PPCM cases, the cystic cavity attains a length of at least 4 cm before clinical 
symptoms become evident (Edgar 1994).  No treatments are recommended for patients who 
have evidence of PPCM on MRI scans but do not have clinical symptoms. 
1.4.3.1 
Xenotransplantation Related Risks 
Another theoretical risk of AST-OPC1 is that it may contain heretofore unknown and 
currently undetectable murine viral or retroviral adventitious agents.  This theoretical risk is a 
consequence of the original culturing of the H1 uhESC line on a layer of irradiated murine 
(mouse) embryonic feeder cells.  However, the H1 line was adapted to feeder-free culture 
conditions prior to generating the H1 Master Cell Bank (MCB) from which AST-OPC1 is 
produced.  This MCB has been demonstrated to be free from known murine viral and 
retroviral adventitious agents.  Precautions with regard to xenotransplantation that will be 
taken in this study are described in Appendix A.   
Additional warnings and precautions are outlined in the Investigator’s Brochure.  
1.4.3.2 
Reproductive Risks 
Nonclinical studies of AST-OPC1 biodistribution following injection into the spinal cord have 
not shown evidence of quantifiable AST-OPC1 cells outside of the CNS.  Thus, the potential 
reproductive risks of AST-OPC1 are unknown, but would theoretically decrease as the cells 
mature into adult oligodendrocytes, which are not found outside the CNS.  In addition, very 
few proliferative cells are present in the AST-OPC1 grafts beyond six months post-injection. 
The effects of AST-OPC1 on a fetus or nursing child are unknown.  Pregnant or nursing 
women are excluded from this study because participation requires immunosuppression 
with tacrolimus and multiple MRI scans with gadolinium-DTPA contrast, both of which 
present potential additional risk to a pregnant subject. 
1.4.4 
Tacrolimus 
Common adverse reactions to tacrolimus may be found in the package insert for tacrolimus 
and can include infection, malignancy, nephrotoxicity, hypertension, diabetes, neurotoxicity, 
and potassium imbalance (http://www.astellas.us/docs/prograf.pdf).  Tacrolimus will be given 
for a finite duration (up through Day 60) and dose will be tapered after Day 46.  Blood levels 

 
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of drug will be monitored throughout and doses adjusted accordingly to maintain levels 
between 3 and 7 ng/mL.  Concomitant medications and food products will be monitored to 
avoid untoward interactions. 
The tacrolimus regimen in this study is identical to that used in the previous thoracic SCI trial 
of AST-OPC1 (Geron Protocol CP35A007).  There were no serious or unexpected adverse 
events related to tacrolimus in that study and all five subjects completed the course of 
tacrolimus per protocol.  There were 16 adverse events reported as possibly related to 
immunosuppression with tacrolimus. These were all Grade 1 or Grade 2 in severity and 
were consistent with the common adverse reactions to tacrolimus including: nausea, urinary 
tract infection, and decreased magnesium blood level.  

 
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2 
STUDY OBJECTIVES  
The primary objective of this study is to evaluate the safety of 3 sequential escalating doses 
of AST-OPC1 administered at a single time-point between 21 and 42 days post-injury, 
inclusive, to subjects with severe, subacute cervical spinal cord injuries (SCI). 
The secondary objective is to evaluate changes in neurologic function following 
administration of AST-OPC1.     

 
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3 
INVESTIGATIONAL PLAN 
3.1 
Overall Study Design  
This clinical development program includes 2 proof-of-concept companion trials that are 
designed to explore the safety and potential efficacy of AST-OPC1 in subjects with recent 
cervical spinal cord injuries, i.e., occurring between 21 and 42 days prior to AST-OPC1 
administration.  Study AST-OPC1-01 is a Phase 1/2a dose-escalation protocol 
encompassing injection (2 x 106, 1 x 107, or 2 x 107 AST-OPC1 cells) and 1 year of follow-up 
as described herein (See Figure 3-1).  Study AST-OPC1-02 is a long-term follow-up 
protocol presented separately.      
AST-OPC1-01 is an open-label, dose escalation, cross-sequential, multicenter Phase 1/2a 
study.  Subjects with cervical AIS-A SCI will receive 1 of 3 sequential dose levels of AST-
OPC1 injected directly into the spinal lesion within 21 and 42 days after the original injury.  
Subjects with cervical AIS-B SCI will receive 1 x 107, or 2 x 107 AST-OPC1 cells.  All 
subjects will also receive tacrolimus for 60 days following injection to prevent immune 
rejection.  Subjects will be followed for safety and neurologic function for 1 year under this 
protocol and will then be required to participate in a separate long-term safety follow-up 
protocol for 14 years.  In addition, eligible subjects who were enrolled and had DVT 
prophylaxis withdrawn prior to Day 1 but who never received the AST-OPC1 injection will be 
followed for safety for 30 days and assessed separately.  All adverse events will be 
monitored in an ongoing fashion by the Sponsor’s medical monitor and by an independent 
Data Monitoring Committee (see Section 7.14.1).   
3.1.1 
Staggered Enrollment within each Cohort 
Enrollment in Cohort 1 will be staggered such that there are at least 10 days between 
administration of AST-OPC1 to each subject.  Enrollment within Cohorts 2-5 will be 
staggered after the initial subject in each cohort is dosed, with at least 8 days between 
administration of AST-OPC1 to the first and second subjects.  If the first two subjects are 
successfully dosed with no serious adverse events (SAEs) that would trigger study 
suspension (per the study Suspension Rules), then the remaining subjects in that cohort 
may be dosed without further staggering. 
An additional staggering rule for Cohorts 2-5 is that a minimum of 14 days must elapse 
between the dosing of any two consecutive subjects who both have a C4 neurological level 
of injury (NLI).  This 14-day stagger for consecutive C4 NLI subjects applies throughout 

 
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each of these cohorts and also would supersede the 8-day stagger noted above if the first 
two subjects in any cohort both have a C4 NLI. 
 
Figure 3-1:  Study Schematic: 
 
 
 
3.1.2 
Rules for Advancement to Cohorts 2-5  
Enrollment in Cohort 2 may commence after all three subjects in Cohort 1 have completed 
30 days of follow up after AST-OPC1 administration AND the safety data for Cohort 1 have 
been reviewed by the Data Monitoring Committee (DMC). 
Enrollment in Cohort 3 may commence after at least five subjects in Cohort 2 have 
completed 30 days of follow up after AST-OPC1 administration AND the safety data from 
Cohorts 1 and 2 have been reviewed by the DMC.  
Enrollment in Cohort 4 may commence after at least two subjects in Cohort 2 have 
completed 30 days of follow up after AST-OPC1 administration AND if there are no SAEs 
that would trigger study suspension. 
Enrollment in Cohort 5 may commence after at least two subjects in Cohort 3 AND at least 
five subjects in Cohort 4 have completed 30 days of follow up after AST-OPC1 
administration AND if there are no SAEs that would trigger study suspension. 
For the planned DMC reviews noted above, the DMC will recommend whether enrollment of 
the next dose cohort can commence or whether additional follow up of the current cohort is 
needed prior to commencing enrollment in the next cohort. 

 
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The rationale for the 8-day stagger (or the 14-day stagger between consecutive subjects 
with a C4 NLI) is that nearly all of the potential surgical complications, if they occur, will 
become clinically evident within the first few days after surgery.  Thus, any serious 
complications (i.e., SAEs) would be evident within the first few days after surgery and would 
be reported within 24 hours of their occurrence (as required for all SAEs). 
In addition, subjects in this study will receive a complete neurological exam and MRI scan 
for safety monitoring at 7 days after AST-OPC1 injection.  The study suspension rules (See 
Section 7.14.2) include several rules that could be triggered by potential complications of the 
AST-OPC1 injection procedure, such as: death or unexpected neurological deterioration, 
evidence of direct spinal cord damage related to the volume of injection, or any CSF 
infection or inflammation that is more than a transient reaction to AST-OPC1 injection. 
3.2 
Number of Subjects 
A total of 23-35 subjects are planned to receive AST-OPC1.  A maximum of 35 of subjects 
will receive AST-OPC1. 
3.3 
Investigational Sites 
This is a multicenter study with approximately 8 institutions participating.    
3.4 
Study Duration 
Enrollment is expected to take approximately 36 months.  The treatment and observation 
period for individual subjects on this study (excluding long-term follow-up study) is 
approximately 12 months.  The total duration of this study is about 4 years.   

 
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4 
SELECTION OF STUDY POPULATION 
Prior to completing any protocol-specific tests or procedures, the subject will sign informed 
consent both for the primary protocol AST-OPC1-01 and the long-term follow-up protocol 
AST-OPC1-02.   
4.1 
Inclusion Criteria 
1. Sensorimotor complete, traumatic SCI (ASIA Impairment Scale A) for Cohorts 1, 
2, and 3 
2. Sensorimotor incomplete, traumatic SCI (ASIA Impairment Scale B) for Cohorts 4 
and 5 
3. ISNCSCI Neurological Level of Injury (NLI) from C-5 to C-7 or a C4 NLI with an 
upper extremity motor score (UEMS) ≥ 1 
4. From 18 through 69 years of age at time of consent 
5. Single spinal cord lesion on a post-stabilization magnetic resonance imaging 
(MRI) scan, with sufficient visualization of the spinal cord injury epicenter and 
lesion margins to enable post-injection safety monitoring 
6. Informed consent for this protocol and the companion long term follow-up 
protocol must be provided and documented (i.e., signed informed consent forms) 
no later than 37 days following injury 
7. Able to participate in an elective surgical procedure to inject AST-OPC1 21-42 
days following SCI 
  
4.2 
Exclusion Criteria 
1. SCI due to penetrating trauma 
2. Traumatic anatomical transection or laceration of the spinal cord based on prior 
surgery or MRI 
3. Spinal cord lesion with anteroposterior (AP) diameter of the spinal cord < 2 mm 
at point of maximal compression on a midline sagittal image from a post-
stabilization MRI 
4. Any concomitant injury that interferes with the performance, interpretation or 
validity of neurological examinations, such as multiple spinal cord lesions, 
brachial/lumbar plexus injury, cauda equina injury or traumatic brain injury 
5. Any treatment or pre-existing condition that interferes with the performance, 
interpretation or validity of neurological examinations, such as polyneuropathy, 
focal or multi-focal neuropathy, myelopathy or radiculopathy 

 
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6. Inability to communicate effectively with neurological examiner such that the 
validity of patient data could be compromised 
7. Significant organ damage or systemic disease that would create an unacceptable 
risk for surgery or immunosuppression 
8. Acute, symptomatic pulmonary embolism that would create an unacceptable risk for 
surgery 
9. Concomitant use at baseline of other immunosuppressive agents, such as 
corticosteroids, that would create an unacceptable risk for additional 
immunosuppression with tacrolimus 
10. Need for mechanical support of ventilation (ventilator, continuous positive airway 
pressure [CPAP], bi-level positive airway pressure [BiPAP]), excluding 
supplemental oxygen, at baseline 
11. History of any malignancy (except non-melanoma skin cancers) 
12. Pregnant or nursing women. Female subjects of child bearing potential must 
agree to prevent pregnancy by the use of contraception for 1 year following AST-
OPC1 injection; male subjects must agree to use contraception to prevent 
pregnancy in any female partners of child bearing potential for 1 year following 
AST-OPC1 injection. 
13. Positive blood test for antibodies to human immunodeficiency virus (HIV) types 1 
or 2, antibodies to hepatitis B virus (HBV) core antigen or antibodies to hepatitis 
C virus (HCV) 
14. Panel reactive antibodies (PRA) ≥ 20%; if a site lab reports PRA only for HLA 
Class I or separately for HLA Class I and II, exclusion will be based solely on the 
PRA for HLA Class I 
15. Serum creatinine >1.5X above the established limit for the normal range at 
individual study center laboratories at baseline 
16. Blood levels of aspartate aminotransferase (AST) or alanine aminotransferase 
(ALT) > 3X the established upper limit for the normal range at individual study 
center laboratories at baseline 
17. Hematocrit below the study center lower limit for elective surgery at baseline 
18. Positive blood cultures (48 hour culture results at Day -1) 
19. Active untreated viral, fungal or bacterial infection at baseline 
20. Evidence of surgical site infection at intended AST-OPC1 injection site at 
baseline 
21. Temperature ≥ 38.6°C at two time points from Day -1 through Injection Day prior 
to surgery for AST-OPC1 injection 

 
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22. Body mass index (BMI) > 35 or weight > 300 lbs. 
23. Active participation in another experimental procedure/intervention 
24. Psychoactive substance use disorder (as defined by DSM-5) at any time during 
the 3 months preceding study entry 
25. History of untreated or poorly controlled major depression, schizophrenia, 
paranoia, or other psychotic disorder as defined by DSM-5 
26. A subject who, in the opinion of the investigator, is unlikely to return for all follow-
up visits as specified in the protocol 
27. Any condition that, in the judgment of the investigator, would preclude successful 
participation in the study 
 

 
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5 
ENROLLMENT 
Site personnel should notify the Sponsor when screening initiates for an individual subject in 
order to ensure that the protocol specified rules for staggering within cohorts and for 
advancement to Cohorts 2-5 are followed correctly.  This notification will also enable the 
Sponsor to ensure that the maximum number of subjects per each cohort is not exceeded.    
After signing informed consent, potential subjects will be assigned a subject identification 
containing the site number and a sequential enrollment number.  After eligibility assessment, 
subjects who are deemed eligible in accordance with the inclusion/exclusion criteria (Section 
4) will be enrolled into the study. 

 
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6 
STUDY TREATMENTS 
6.1 
Investigational Product 
AST-OPC1 is a cryopreserved cell population containing a mixture of oligodendrocyte 
progenitor cells and other characterized cell types that are obtained following differentiation 
of uhESCs.   At the time of cryopreservation, each vial contains 7.5 x 106 viable cells in 1.2 
mL of cryoprotectant solution. 
AST-OPC1 is supplied in 2.0 mL cryovials and is shipped to the clinical sites in the vapor 
phase of liquid nitrogen.  The cryopreserved vials of AST-OPC1 should be stored in the 
vapor phase of liquid nitrogen in a validated storage tank.   
Each clinical site will be supplied with AST-OPC1 starter kits and dose preparation kits by 
the Sponsor.  These kits consist of reusable or disposable laboratory items required for the 
preparation of AST-OPC1 doses and are assembled by a contract manufacturing 
organization.  Sites will also receive a reusable syringe positioning device that is required for 
AST-OPC1 injection.  The starter kits, dose preparation kits, and syringe positioning devices 
should be stored at room temperature. 
6.2 
Dose Preparation 
Prior to administration, AST-OPC1 will be thawed and prepared according to instructions for 
preparation by study personnel who have been trained in the AST-OPC1 dose preparation 
procedure.  The dose preparation procedure is shown graphically in a process flow diagram 
provided in Appendix B and is described below.  AST-OPC1 dose preparation may only be 
performed in a facility qualified for this purpose by the Sponsor and only by personnel who 
were previously trained and qualified by the Sponsor. 
Dose preparation kits consist of presterilized, single-use disposable items required to 
prepare the AST-OPC1 dose.  Dose preparation begins with the thawing of an appropriate 
number of vials of AST-OPC1.  The thawed cells are washed and suspended in Isolyte®S 
and 1% HSA.  A sufficient number of cells will be loaded into the 0.25 mL delivery syringe 
using an 18-gauge blunt loading needle in order to enable delivery of the assigned dose 
while taking into account the residual dead volume in the syringe and needle. 
The loaded delivery syringe is sealed using a syringe Luer-Lok® cap, and labeled with the 
date prepared, drug name, dose concentration, and expiration time for the dose.  The 
syringe is then placed in a sealable sterile pouch.  The cap protects the prepared dose from 
unintentional ejection of cells.  The pouch containing the secured syringe is then placed 

 
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inside a refrigerated (2-8°C) AcuTemp® PX1L container.  The AcuTemp® container is 
secured by the use of a one-way plastic zip-tie mechanism with a tag label containing the 
subject information, date prepared, drug name, dose concentration, and expiration time for 
the dose. 
Based upon data from stability studies of prepared doses, AST-OPC1 formulated in 
Isolyte®S and 1% HSA may be stored for up to 12 hours at refrigerated temperature (2-8°C) 
in the AcuTemp® PX1L container plus up to an additional 3 hours at room temperature prior 
to administration. 
6.3 
Prepared Dose Release Criteria and Sterility Testing 
The AST-OPC1 dose preparation process at the clinical site is controlled by the verification 
of cell count and sterility.  An initial cell count and viability test are performed and samples 
taken for both Gram stain testing and 14-day sterility testing.  The dose is released from the 
preparation laboratory and administered to the subject based on a negative Gram stain 
result.  The 14-day sterility test result will not be available by the time of transplantation.  In 
the event of a positive result from the 14-day sterility test, the procedures to be followed are 
described below. 
AST-OPC1 must be administered within 15 hours of preparation, which may include no 
more than 12 hours of storage at 2–8°C and an additional 3 hours at room temperature.  
Once the prepared AST-OPC1 dose is released from the dose preparation lab, the 
AcuTemp® PX1L container containing the dose is delivered to the operating room where the 
operating room staff ensures administration before this expiration time.   
In the event of a positive 14-day sterility result, the testing laboratory will notify the dose 
preparation laboratory, the investigators, and the Sponsor within 24 hours.  Organism 
identification and antibiotic sensitivity will be initiated immediately and the results will be 
communicated to the above personnel as soon as available.  The subject will be notified of 
the results of the sterility test failure and will be monitored for evidence of infection.  
Additional testing may be performed and/or empiric antibiotic therapy may be initiated at the 
Investigator's discretion.  The Investigator and the Sponsor’s Medical Monitor will determine 
whether any additional action should be taken.  The Sponsor will notify the FDA of the 
sterility failure, results of the investigation of cause, and any corrective actions within 30 
calendar days after the Sponsor’s initial receipt of the positive culture test result.  If the 
subject experiences any serious or unexpected adverse event that could have resulted from 

 
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administration of contaminated product, the Sponsor will report this information to the FDA 
in an IND safety report no more than 15 calendar days (7 calendar days if fatal or life 
threatening) from the initial receipt of the sterility failure, in accordance with 21CFR312.32. 
6.4 
AST-OPC1 Administration 
One day prior to the planned injection of AST-OPC1 (i.e., Day –1), subjects should have any 
ongoing pharmacological DVT prophylaxis suspended in preparation for surgery.  These 
may be restarted on Day 1.   
Surgery to inject AST-OPC1 must be delayed if the subject has a temperature ≥ 38.6°C at 
any 2 time points between Day –1 and Injection Day prior to surgery.  Depending upon the 
duration of the delay of treatment, the Medical Monitor may request that certain baseline 
tests be repeated.   
On Injection Day subjects will receive the dose of AST-OPC1 as determined by cohort 
assignment (Table 6-1).  AST-OPC1 may only be administered by a licensed surgeon who 
has both training and experience in performing intradural surgical procedures on the spine.  
In addition, each surgeon must be trained and qualified by the Sponsor on the use of the 
SPD and the injection procedure prior to their first administration of AST-OPC1 (see 
Appendix C).   
Table 6-1: 
AST-OPC1 Dose Cohorts and Injection Preparation 
Cohort 
Dose 
(# of cells) 
Concentration 
(cells/µL) 
Volume per 
Injection (µL) 
Number of 
Injections 
Total Volume 
Administered 
(µL) 
1 
2 x 106 
4 x 104 
50 
1 
50 
2 
1 x 107 
2 x 105 
50 
1 
50 
3 
2 x 107 
2 x 105 
50 
2 
100 
4 
1 x 107 
2 x 105 
50 
1 
50 
5 
2 x 107 
2 x 105 
50 
2 
100 
The injection procedure requires an open or minimal-access surgical exposure from a 
posterior approach with the subject sedated under general endotracheal anesthesia.  
Neuromuscular paralyzing agents will also be administered to prevent subject movement 
during the injection procedure.  This is necessary because if a subject moves while the 
needle is in the spinal cord, additional damage to the adjacent spared spinal cord tissue 
could occur. 

 
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It is recommended that the surgeon and anesthesiologist consider the placement of an 
arterial line for intraoperative blood pressure monitoring, since this could facilitate rapid 
detection and management of an episode of intraoperative autonomic dysreflexia.  For 
subjects with incomplete SCI (i.e., AIS-B), intraoperative monitoring of somatosensory 
evoked potentials is recommended to determine whether these are adversely affected by 
the injection procedure. 
The target injection site is the caudal portion of the spinal cord injury epicenter and within a 
region of damaged but nonhemorrhagic spinal tissue.  The target level and site should be 
confirmed by review of the baseline MRI scan and other radiological studies, as needed.  
For dose Cohorts 3 and 5, the two injections should both be in the caudal half of the lesion 
epicenter, if possible, and should be spaced at least several millimeters apart in both the 
lateral and rostral-caudal directions.  If it is not possible to perform both injections in the 
caudal half of the lesion epicenter, then the second injection may be performed in the rostral 
half of the lesion epicenter. 
Due to the migratory ability of the cells in AST-OPC1, targeting of the injection site does not 
need to be performed in a stereotactic fashion.  However, the surgeon should ensure that 
the target site is sufficiently deep (at least 6–7 mm) within the spinal cord to minimize the 
chance of AST-OPC1 efflux.  
Once the target spinal level is exposed, direct visualization of the spinal cord surface at the 
target level should be obtained by laminotomy or laminectomy and opening of the dura.  
When the dura is opened, CSF will efflux and will not typically continue to flow over the 
posterior surface of the spinal cord.  If needed, gentle aspiration may be used to prevent 
CSF from flowing directly over the injection site while the dura is open.  The spinal cord 
target site should be confirmed by direct or endoscopic visualization and by intraoperative 
ultrasound (if available and of sufficient quality). 
The syringe positioning device is then set up and a syringe/needle assembly containing 
AST-OPC1 is loaded.  The syringe positioning device is then used to advance the needle tip 
to the target injection site within the spinal cord.   
If the surgeon observes substantial deformation of the spinal cord at the onset of attempted 
needle penetration, the surgeon may elect to raise the needle, use a scalpel to make a small 
(~1 mm) longitudinal incision of the pia at the intended penetration site, and then reattempt 
to insert the needle using the syringe positioning device. 

 
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If spinal cord motion is deemed to be a problem, the surgeon will consult with the 
anesthesiologist, who may adjust the ventilator settings to decrease tidal volume and 
increase respiratory rate to minimize spine motion.  If the surgeon deems that spinal motion 
will still interfere with delivery of AST-OPC1, ventilation can be suspended for several 
minutes while the needle is in the spinal cord. 
Once the needle is at the target position, the surgeon will inject the AST-OPC1 dose over a 
period of 2 minutes.  The surgeon should observe the needle entry site during injection 
using a surgical microscope or magnifying loupes to monitor for possible efflux of AST-
OPC1, which would appear as an opaque liquid on the spinal cord surface.  If efflux from the 
spinal cord is noted at the beginning of injection, the surgeon may consider advancing the 
needle deeper into the spinal cord.  If efflux is still noted or if it occurs after a delay but prior 
to delivery of the specified volume, the surgeon should stop injection and record the amount 
delivered.  The surgeon may then consider repositioning the needle a few millimeters caudal 
to the initial site and making an additional attempt to complete injection.  However, the total 
volume of AST-OPC1 delivered to the spinal cord cannot be increased.  In the previous 
clinical study of AST-OPC1 in thoracic SCI, efflux was not observed during the injection in 
any of the 5 subjects. 
The injection needle is left in place for 1 additional minute following injection and then 
withdrawn using the syringe positioning device.  If ventilator settings were altered during 
injection, normal ventilation should be resumed immediately after needle withdrawal.  The 
surgical procedure is then completed according to the usual standard procedures. 
If the surgeon determines that completion of the injection in any location may cause an 
unacceptable safety risk to the subject, the entire volume may not be delivered.  The 
location(s) and volume(s) of AST-OPC1 actually delivered should be recorded in the eCRF.   
6.5 
Immunosuppression with Tacrolimus 
Between 6 and 12 hours after the AST-OPC1 dose, subjects will commence a course of the 
immunosuppressant tacrolimus, given orally at a starting dose of 0.03 mg/kg/day (divided 
into 2 daily doses) Days 1 through 46, tapered by 50% between Days 47 and 52 (rounding 
to the nearest 0.5 mg), tapered by another 50% on Day 53, and discontinued after Day 60.   
If a subject is unable to take oral medication, tacrolimus may be given intravenously at a 
dose of 0.01 mg/kg/day as a continuous infusion, switching over to oral medication as soon 
as practicable.  During intravenous infusion of tacrolimus, standard monitoring for acute 

 
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anaphylaxis will be observed in accordance with approved labeling.  Subjects will not be 
allowed to eat any grapefruit-containing food items through Day 60 as this may alter the 
pharmacokinetics of tacrolimus.   
Blood samples will be taken for monitoring blood levels of tacrolimus (immediately prior to 
the first daily dose if given orally) twice per week starting on Day 3 (+/- 1 day) and continuing 
through Day 30, decreasing to once per week through Day 60 (or through termination of 
tacrolimus) (see Section 7).  Dosing of tacrolimus will be adjusted in order to maintain blood 
levels between 3 and 7 ng/mL.  Additional monitoring of blood chemistry for possible 
tacrolimus toxicity will be as outlined in Section 7.   
Tacrolimus dosing may be decreased or discontinued for unacceptable toxicity at the 
investigator’s discretion; this might include infection or uncontrolled fever, liver function test 
elevation, creatinine elevation, seizure, or thrombotic thrombocytopenic purpura.  
6.6 
Investigational Product Accountability 
AST-OPC1 will only be dispensed to subjects enrolled in the study who have signed 
informed consent and will only be administered by investigators designated on the Form 
FDA 1572.  The Investigator must ensure that subjects receive AST-OPC1 only from 
personnel who fully understand the procedures for dose preparation and for administering 
the investigational product.   
Each shipment of investigational product will contain inventory documentation to assist the 
investigator and dose preparation laboratory in maintaining current and accurate study drug 
accountability records.  The designated recipient will visually inspect the shipment, verify the 
quantity and condition of investigational product received, and provide written confirmation 
of receipt of the investigational product shipment as instructed by the Sponsor.  Records at 
the institution will document shipment dates, lot numbers, and quantity of investigational 
product received.   
Investigational product must be stored in a secure area at the institution.  Only authorized 
personnel should have access to the investigational product.  The investigator or dose 
preparation laboratory will maintain dispensation records including the  identity of subjects to 
whom investigational product is dispensed, identity of authorized study personnel receiving, 
dispensing and disposing of investigational product, the dates of all activity, the lot number, 
and the quantity of investigational product.  These records must be readily available for 
inspection by the Sponsor or regulatory authorities at any time. 

 
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Return of investigational product must be coordinated with the Sponsor prior to shipment.  
Accountability records should include the lot number(s) and quantity being returned.   
Upon completion of the study, site personnel should ensure that all unused investigational 
product has either been returned or destroyed, as instructed by the Sponsor.  Return and/or 
destruction of all investigational product must be documented in the accountability records.  
A copy of the institution’s drug disposal or destruction policy will be provided to the Sponsor 
prior to disposal or destruction of investigational product.  A copy of the accountability 
records must be returned to the Sponsor at the end of the study. 
6.7 
Prior and Concomitant Medications 
There is no restriction on medications prescribed to the subject during participation in this 
trial, with the exception of additional immunosuppressive agents such as corticosteroids 
during the period of tacrolimus administration.  In addition, pharmacological DVT prophylaxis 
must be discontinued from the day before until the day after surgery for AST-OPC1 
injection.  Subjects who received methylprednisolone immediately after the SCI, prior to 
study entry, will not be excluded.  All concomitant medications will be recorded in the 
electronic case report form (eCRF).   

 
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7 
TESTS AND OBSERVATIONS 
All required tests and observations with their schedules are summarized in Table 7-1 and 
are described in more detail below.  Prior to initiating screening tests, the Investigator or 
approved designee must obtain a signed informed consent for this protocol and the 
companion long term follow-up protocol.  The day on which AST-OPC1 is injected is 
designated as Injection Day.  The days prior to this are designated with negative numbers 
and the days following injection have positive numbers. 
7.1 
Screening (Days –11 to –3) 
Tests and procedures to confirm eligibility (see Section 4) are summarized below.  Tests 
may be conducted between 11 and 3 days prior to the planned day of surgery for AST-
OPC1 injection unless otherwise noted. 
Note: if the day of injection is subsequently delayed, all screening tests and procedures that 
are not repeated will still be deemed to have been collected within the appropriate pre-
operative window. 
• 
Obtain demographic data 
• 
Past and current medical history 
• 
Complete physical exam and vital signs 
• 
ISNCSCI exam  
• 
MRI (cervical spine and brain, with and without gadolinium-DTPA contrast) between 
Days –7 and –3 
• 
ECG 
• 
Hematology (CBC with differential, RBCs, hematocrit, platelets) 
• 
Blood chemistry (albumin, alkaline phosphatase, ALT, AST, BUN, calcium, chloride, 
creatinine, glucose, magnesium, phosphorus, potassium, total protein, sodium, total 
bilirubin) 
• 
Serology for HIV antibody, Antibody to Hepatitis B core antigen, and Hepatitis C virus 
antibody 
• 
Panel reactive antibodies 
• 
Serum pregnancy test for females of childbearing potential 
• 
48-hour blood cultures (to be drawn on Day -3) 
• 
Concomitant medications  
• 
Adverse events   

 
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7.2 
Baseline (Days –2 to –1) 
Note: As indicated below, some of the baseline assessments may be performed as early as 
Day -4 if required to accommodate clinical site staff availability. 
• 
Brief physical exam and vital signs (check vital signs both days) 
• 
Standard neurological exam (may be performed on Day -4 to -1) 
• 
ISNCSCI exam (may be performed on Day -3 to -1, unless the screening ISNCSCI was 
performed on Day -3.) 
• 
Partial Graded Redefined Assessment of Strength, Sensibility and Prehension 
(GRASSP; may be performed on Day -4 to -1) 
• 
Spinal Cord Independence Measure (SCIM; may be performed on Day -4 to -1) 
• 
Hematology (as before) 
• 
Blood chemistry (as before) 
• 
Fasting blood glucose (may be done pre-op on injection day) 
• 
Blood for HLA typing (may be obtained on Day -4 to -1) 
• 
Blood for immune response monitoring (may be obtained on Day -4 to -1) 
• 
Blood for xenotransplantation archival (may be obtained on Day -4 to -1) 
• 
Withhold pharmacological DVT prophylaxis on Day -1 
• 
Concomitant medications 
• 
Adverse events 
If the day of injection is delayed, some or all of the following tests and procedures may need 
to be repeated prior to the new Injection Day.  The determination of which tests and 
procedures to be repeated will be made by the Investigator after consultation with the 
Sponsor’s Medical Monitor. 
Note: baseline tests and procedures that are not repeated will still be deemed to have been 
collected within the appropriate pre-operative window. 
• 
Brief physical exam and vital signs 
• 
Brief ISNCSCI exam 
• 
MRI (cervical spine, non-contrast only) 
• 
Hematology (as before) 
• 
Blood chemistry (as before) 
• 
Concomitant medications 
• 
Adverse events 
7.3 
Injection Day (Surgery for AST-OPC1 Administration) 
• 
Vital signs 

 
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• 
CSF sample by lumbar puncture during pre-op or after induction of general anesthesia 
but prior to AST-OPC1 injection (~10 mL for white blood cell count, glucose, total protein, 
oligoclonal banding, myelin basic protein, and IgG index) 
• 
AST-OPC1 Injection 
• 
Begin tacrolimus administration 6 to 12 hours following AST-OPC1 injection 
• 
Concomitant medications 
• 
Adverse events 
7.4 
Post-Injection Days 1-6 
• 
Brief physical exam on Day 1 
• 
Vital signs daily 
• 
Hematology (as before) on Day 1 
• 
Restart DVT prophylaxis on Day 1 (if applicable) 
• 
Blood chemistry (as before) daily  
• 
Tacrolimus blood level on Day 3 (+/- 1 day) 
• 
Concomitant medications 
• 
Adverse events 
7.5 
Post-Injection Day 7 (+/- 1 day) 
• 
Brief physical exam and vital signs 
• 
Neurological exam 
• 
ISNCSCI exam 
• 
MRI (cervical spine, with and without gadolinium-DTPA contrast) 
• 
ECG 
• 
Hematology (as before) 
• 
Blood chemistry (as before) 
• 
Tacrolimus blood level 
• 
Blood for immune response monitoring 
• 
Concomitant medications 
• 
Adverse events 
7.6 
Post-Injection Days 8-29 
• 
Blood chemistry (as before) twice per week 
• 
Tacrolimus blood level twice per week 
7.7 
Post-Injection Day 30 (+/- 3 days) 
• 
Brief physical exam and vital signs 

 
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• 
Neurological exam 
• 
ISNCSCI exam 
• 
SCIM questionnaire 
• 
Pain questionnaire 
• 
Bowel and Bladder questionnaire 
• 
MRI (cervical spine, with and without gadolinium-DTPA contrast) 
• 
Hematology (as before) 
• 
Blood chemistries (as before) 
• 
Fasting blood glucose 
• 
Tacrolimus blood level 
• 
Blood for immune response monitoring 
• 
Blood for xenotransplantation archival 
• 
Concomitant medications 
• 
Adverse events 
7.8 
Post-Injection Days 31-59 
• 
Blood chemistry (as before) once per week 
• 
Tacrolimus blood level once per week 
• 
Decrease tacrolimus dose by 50% (rounded to the nearest 0.5 mg, since this is the 
smallest capsule size available) on Day 46 
• 
Decrease tacrolimus dose by another 50% (rounded to the nearest 0.5 mg) on Day 53; if 
the rounded total daily dose is 0.5 mg or lower, the subject will receive 0.5 mg once per 
day until tacrolimus is discontinued 
• 
Concomitant medications 
• 
Adverse events 
7.9 
Post-Injection Day 60 (+/- 7 days) 
• 
Brief physical exam and vital signs 
• 
Neurological exam 
• 
ISNCSCI exam 
• 
SCIM questionnaire 
• 
Hematology (as before) 
• 
Blood chemistry (as before) 
• 
Tacrolimus blood level 
• 
Blood for immune response monitoring 
• 
Discontinue tacrolimus 

 
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• 
CSF via lumbar puncture 
• 
Concomitant medications 
• 
Adverse events 
7.10 
Post-Injection Day 90 (+/- 7 days) 
• 
Brief physical exam and vital signs 
• 
Neurological exam 
• 
ISNCSCI exam 
• 
GRASSP 
• 
SCIM questionnaire 
• 
Pain questionnaire 
• 
Hematology (as before) 
• 
Blood chemistry (as before) 
• 
Blood for immune response monitoring 
• 
Concomitant medications 
• 
Adverse events 
7.11 
Post-Injection Day 180 (+/- 14 days) 
• 
Brief physical exam and vital signs 
• 
Neurological exam 
• 
ISNCSCI exam 
• 
GRASSP 
• 
SCIM questionnaire 
• 
Pain questionnaire 
• 
Bowel and Bladder questionnaire 
• 
MRI (cervical spine, with and without gadolinium-DTPA contrast) 
• 
Hematology (as before) 
• 
Blood chemistries (as before) 
• 
Blood for immune response monitoring 
• 
Concomitant medications 
• 
Adverse events 
7.12 
Post-Injection Day 270 (+/- 14 days) 
• 
ISNCSCI exam 
• 
GRASSP 

 
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• 
SCIM questionnaire 
• 
Concomitant medications 
• 
Adverse events 
7.13 
Post-Injection Day 365 (+/- 14 days) 
• 
Complete physical exam and vital signs 
• 
Neurological exam 
• 
ISNCSCI exam 
• 
GRASSP 
• 
SCIM questionnaire 
• 
Pain questionnaire 
• 
Bowel and Bladder questionnaire 
• 
MRI (cervical spine and brain, with and without gadolinium-DTPA contrast) 
• 
Hematology (as before) 
• 
Blood chemistries (as before) 
• 
Blood for immune response monitoring 
• 
Blood for xenotransplantation archival 
• 
Concomitant medications 
• 
Adverse events 

 
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Table 7-1: 
Summary of Tests and Observations 
Part A 
 
Screen 
Baseline 
Surgery 
Post-Injection 
 
Days –11  
to –3 
Days –2 
to –1 
Injection 
Day 
Days 
1-6 
Day 
7 
Days 
8-29 
Procedure 
 
 
 
 
(+/- 1 
day) 
 
Demographic data 
X 
 
 
 
 
 
Past and current medical history 
X 
 
 
 
 
 
Complete physical exam 
X 
 
 
 
 
 
Brief physical exam 
 
X 
 
Day 1 
X 
 
Vital signs 
X 
X3 
X 
Daily 
X 
 
Neurological exam 
 
X5 
 
 
X 
 
ISNCSCI exam 
X 
X1 
 
 
X 
 
GRASSP 
 
X5 
 
 
 
 
SCIM 
 
X5 
 
 
 
 
MRI2 
Day -7 to -3 
 
 
 
X 
 
ECG 
X 
 
 
 
X 
 
Hematology 
X 
X 
 
Day 1 
X 
 
Blood chemistry 
X 
X 
 
Daily 
X 
2/week 
Serology for HIV, HBV, HCV 
X 
 
 
 
 
 
Panel reactive antibodies 
X 
 
 
 
 
 
Pregnancy test, if applicable 
X 
 
 
 
 
 
48-hour blood culture 
Day –3 
 
 
 
 
 
Fasting blood glucose 
 
X4 
 
 
 
 
Blood for HLA typing 
 
X5 
 
 
 
 
Blood for immune response 
monitoring 
 
X5 
 
 
X 
 
Blood for xenotransplantation 
archival 
 
X5 
 
 
 
 
Withhold DVT prophylaxis 
 
Day -1 
 
 
 
 
CSF via lumbar puncture 
 
 
X 
 
 
 
Begin tacrolimus 
 
 
X 
 
 
 
Restart DVT prophylaxis 
 
 
 
Day 1 
 
 
Tacrolimus blood levels 
 
 
 
Day 36 
X 
2/week 
Concomitant medications 
 
 
 
 
 
 
Adverse events 
 
 
 
 
 
 

 
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Table 7-1: 
Summary of Tests and Observations 
Part B 
 
Day 
30 
Days 
31-59 
Day 
60 
Day 
90 
Day 
180 
Day 
270 
Day 
365 
Procedure 
(+/- 3 
days) 
 
(+/- 7 
days) 
(+/- 7 
days) 
(+/- 14 
days) 
(+/- 14 
days) 
(+/- 14 
days) 
Complete physical exam 
 
 
 
 
 
 
X 
Brief physical exam 
X 
 
X 
X 
X 
 
 
Vital signs 
X 
 
X 
X 
X 
 
X 
Neurological exam 
X 
 
X 
X 
X 
 
X 
ISNCSCI exam 
X 
 
X 
X 
X 
X 
X 
GRASSP 
 
 
 
X 
X 
X 
X 
SCIM questionnaire 
X 
 
X 
X 
X 
X 
X 
Pain questionnaire 
X 
 
 
X 
X 
 
X 
Bowel/Bladder questionnaire  
X 
 
 
 
X 
 
X 
MRI2 
X 
 
 
 
X 
 
X 
Hematology 
X 
 
X 
X 
X 
 
X 
Blood chemistry 
X 
1/week 
X 
X 
X 
 
X 
Fasting blood glucose 
X 
 
 
 
 
 
 
Blood for immune response 
monitoring 
X 
 
X 
X 
X 
 
X 
Tacrolimus blood level 
X 
1/week 
X 
 
 
 
 
CSF via lumbar puncture 
 
 
X 
 
 
 
 
Blood for xenotransplantation 
archival 
X 
 
 
 
 
 
X 
Concomitant medications 
 
 
 
 
 
 
 
Adverse events 
 
 
 
 
 
 
 
 
Footnotes for Table 7-1 Parts A and B 
1 
ISNCSCI exam (may be performed on Day -3 to -1, unless the screening ISNCSCI was performed on Day -3)  
2 
MRI of cervical spine and brain at Screen & Day 365; MRI of cervical spine only at Days 7, 30, 180 
3 
Vitals on day -2 and -1 
4 
May be done pre-op on Injection Day 
5 
May be performed as early as Day -4 if required to accommodate clinical site staff availability 
6 
Tacrolimus blood level on Day 3 may be obtained +/- 1 day 
 

 
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7.14 
Procedural Details 
7.14.1 
Data Monitoring Committee 
An independent DMC will be appointed at study initiation and will be comprised of 
physicians with extensive clinical trial experience and clinical expertise in either spinal 
neurosurgery or spinal cord injury rehabilitation.  Members of the DMC will be independent 
of the investigators and the Sponsor and will have no financial, scientific, or other conflict of 
interest with the trial. 
After all subjects in Cohort 1 have completed 30 days of follow up after AST-OPC1 
administration, the safety data will be submitted to the DMC for review.  The DMC will review 
these data and recommend whether enrollment of Cohort 2 can commence or whether 
additional follow up of the current dose cohort is needed prior to dose escalation.  This 
process will be repeated after at least five subjects in Cohort 2 have completed 30 days of 
follow up, at which time the DMC will recommend whether enrollment in Cohort 3 can 
commence.  Thereafter, the DMC will meet at least twice yearly for a trial overview.  The 
DMC will also monitor the study for overall safety and for potential trends in efficacy.     
Additionally, the DMC will also be notified of any fatal or life-threatening experiences 
associated with the use of AST-OPC1 within 7 calendar days of the Sponsor’s initial receipt 
of the information.  Serious, unexpected, and possibly related adverse events that are not 
fatal or life-threatening will be reported to the DMC within 15 days.  The DMC will also 
receive all reports and images of a possible mass or ectopic tissue.   
7.14.2 
Suspension Rules 
The DMC will receive rapid notification of all SAEs associated with the use of AST-OPC1 
and of all reports of cyst/cavity formation.  The DMC will operate under a high degree of 
flexibility and will tend to err on the side of protecting subjects’ safety until satisfactory 
resolution of potential problems is obtained.  Any event that triggers study suspension will 
be reported to the FDA and to the IRBs.  If study suspension occurs, both enrollment of new 
subjects and administration of AST-OPC1 will be suspended. 
The following events will be used as study suspension rules: 
• 
Death or unexpected neurological deterioration, possibly related to AST-OPC1, the 
injection procedure used to administer AST-OPC1, and/or the concomitant 
immunosuppression administered 

 
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• 
Evidence of direct spinal cord damage related to the volume of injection 
• 
Development of an enlarging mass or expanding ectopic tissue within the central 
nervous system, other than the expected filling of the lesion cavity by AST-OPC1 
• 
Any CSF infection or inflammation that is more than a transient reaction to AST-
OPC1 injection. 
7.14.3 
ISNCSCI Assessment Tool  
The ISNCSCI was developed by the American Spinal Injury Association (ASIA) in 1982 in 
order to promote common definitions of neurological levels and the extent of complete 
injuries in patients with SCI and to achieve more consistent and reliable data among centers 
participating in the National Spinal Cord Injury Database.  This tool is described in detail in 
Appendix D.   
The ISNCSCI data forms will be reviewed periodically by an independent expert.  The 
reviewer will look for inter- or intra-subject trends that may trigger a repeat examination or a 
DMC review. 
7.14.4 
MRI 
General guidance on the objectives and procedures of the serial MRI scans is provided in 
Appendix E. 
If a subject becomes pregnant, the decision to perform subsequent MRI scans will be made 
in consultation between the Investigator, the local radiologist, the Sponsor, and the subject.  
The decision about performing an MRI will be based on findings from previous MRIs, clinical 
findings, the risk/benefit ratio, and timing (e.g., whether the MRI can safely be postponed 
until the subject is no longer pregnant).  If an MRI is performed on a pregnant subject, 
gadolinium-DTPA contrast will not be used. 
   
7.14.5 
Pain Scale 
Pain assessment will be performed using the International Spinal Cord Injury Pain Basic 
Data Set (http://www.iscos.org.uk/international-sci-data-sets).  The purpose of the Basic 
Data Sets is to promote uniform data collection in a standard format, with precise 
instructions for each question (Biering-Sørensen 2006).  The Basic Data Sets are intended 
to be collected with information from the Core Data Set, which includes information such as: 

 
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date of birth and injury, gender, cause of spinal cord lesion and neurological status, whether 
surgery was performed, and whether associated injuries are present (DeVivo 2006).  Three 
questions have been added to the Pain Basic Data Set to assess allodynia based on expert 
recommendation.   
Baseline pain assessments will not be performed due to proximity with the original SCI and 
surgery.  Posttreatment analyses of changes in pain over time will be exploratory in nature. 
7.14.6 
Spinal Cord Independence Measure 
The SCIM was developed as a comprehensive rating scale specifically for persons with SCI.  
The instrument assesses activities of daily living, capturing the economic burden as well as 
the impact on a subject’s overall medical condition and comfort.  Reliability and validity of 
the SCIM Version III were recently established in a multicenter international study (Itzkovich 
2007).  As with pain assessment, analyses of changes in SCIM will be exploratory.     
7.14.7 
Assessment of Urinary Tract and Bowel Function 
Assessment of lower urinary tract function and bowel function will be performed using the 
respective International Spinal Cord Injury Basic Data Sets 
(http://www.iscos.org.uk/international-sci-data-sets).  Basic Data Set information for lower 
urinary tract function and bowel function will be collected at key posttreatment intervals to 
assess changes in function; analyses will be exploratory.     
7.14.8 
Immune Response Monitoring 
As described in Section 1.3.4, no acute or chronic immune responses to AST-OPC1 have 
been observed to date in the previous trial.  Therefore, this study will utilize a similar 
immunological monitoring plan, but with a slightly reduced frequency of blood sample 
collection at earlier time points.  Donor-specific responsiveness to AST-OPC1 will be 
evaluated using the mixed lymphocyte reaction to monitor T cell responses (Okamura 2007) 
and panel reactive tests to measure AST-OPC1-specific alloantibodies.  Additional assays 
may include cytokine and RNA changes analysis. 
In addition, CSF will be collected via lumbar puncture immediately prior to AST-OPC1 
injection and at study Day 60.  The CSF will be tested for donor-specific responsiveness to 
AST-OPC1 and for evidence of inflammation, based upon total protein, IgG index, and 
oligoclonal bands. 

 
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8 
TERMINATION 
8.1 
Study Completion 
At the time of study completion, subjects will transition from this protocol to the long-term 
follow-up protocol AST-OPC1-02.  Subjects will be reconsented at the time of transition.   
8.2 
Premature Discontinuation from Study 
Subjects can withdraw from the trial on their own volition or be withdrawn by the Investigator 
at any time.  If a subject who received AST-OPC1 is considering withdrawing from the study, 
the Investigator should discuss the implications of withdrawing and work with the subject to 
collect as much safety data as possible, including a final safety visit.  If a subject who 
received AST-OPC1 voluntarily withdraws from this study, they will be nevertheless asked to 
participate in the long-term follow-up companion protocol AST-OPC1-02. 
Specific instances that may precipitate discontinuation of individual subjects from the study 
are as follows: 
• 
intercurrent illness precluding the continuation of protocol observations 
• 
withdrawal of consent by the subject 
• 
loss to follow-up 
• 
death of subject 
If the Investigator is unable to contact a subject for follow-up, the Investigator will attempt to 
contact the subject 3 times by phone.  If unable to reach the subject by phone, a registered 
letter will be sent.  If the Investigator is still unable to reach the subject, the subject will be 
considered lost to follow-up.   
8.3 
Study Discontinuation at Site   
The study will be completed when all subjects who received AST-OPC1 have either 
completed the Day 365 visit, discontinued participation, or were lost to follow up. 
The Sponsor retains the right to terminate the study at an individual institution and remove 
all the study materials from the study site for reasons including the following: 
• 
completion of the study at the site 
• 
unanticipated safety information indicating a potential and unacceptable health hazard 
caused by the investigational product 

 
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• 
significant protocol deviation or noncompliance on the part of the Investigator for 
reasons such as informed consent violations, other regulatory or ethical irregularities, 
unsatisfactory enrollment, or inaccurate data handling or reporting 
• 
withdrawal of investigational product from research use 
• 
termination of this study by the Sponsor 

 
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9 
PLANNED ANALYSES 
All analyses will be descriptive in nature.  No inferential statistical tests will be conducted.   
9.1 
Sample Size Considerations 
This trial employs a cross-sequential cohort design for Phase 1 dose escalation in cervical 
AIS-A and AIS-B subjects.  Power calculations have not been performed, as the primary 
objective is to collect safety and tolerability information on a limited number of subjects per 
dose level and AIS grade.   
9.2 
Study Endpoints 
The primary endpoint of this Phase 1/2a study is safety and includes observations related to 
AST-OPC1 tolerance, the injection procedures, and the protocol-specified 
immunosuppression regimen.  Secondary and exploratory endpoints focus on preliminary 
evidence of efficacy. 
9.2.1 
Primary 
• 
Incidence and severity of adverse events 
• 
Changes in laboratory variables    
• 
Changes at the injection site as monitored by MRI 
9.2.2 
Secondary 
• 
Changes in neurologic function as assessed by the ISNCSCI 
9.2.3 
Exploratory 
• 
Changes in posttreatment pain as assessed by the International Spinal Cord 
Injury Pain Basic Data Set 
• 
Changes in aspects of daily living as assessed by the SCIM scale 
• 
Changes in lower urinary tract and bowel function 
• 
Changes in hand function on the GRASSP assessment 
• 
Changes in volitional performance using the Spinal Cord Ability Ruler 
9.3 
Data Analysis Methods 
For all safety and efficacy analyses, the All Treated population will be used, comprised of all 
subjects who received an injection of AST-OPC1.  The 30-day safety data from subjects 
who had their DVT prophylaxis withdrawn but who never received AST-OPC1 will be 
assessed separately.   

 
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Conventional descriptive statistics will be used to summarize subject demography, baseline 
characteristics, disposition, and history.  Discrete variables will be expressed with number 
and percentage and continuous variables with mean, standard deviation, median, and range 
as appropriate.  Due to the small sample sizes per dose level and AIS grade planned for this 
study, data tabulations may be supplemented with subject narratives.     
9.3.1 
Safety Analyses 
All reported adverse events will be coded to a preferred term and classified by System 
Organ Class using the current version of MedDRA.  Adverse events will be listed by subject 
and will include preferred term, verbatim term, severity, seriousness, relationship, action 
taken, and outcome.  Relationship will address attribution to the investigational product 
(AST-OPC1), the surgical procedure, and/or the immunosuppressive agent.  Tabulations will 
be prepared for all adverse events, related events, Grade 3 and higher events, and serous 
events.  Designated adverse events of special interest will be tabulated separately as 
appropriate.    
Summary statistics of individual clinical laboratory parameters will be prepared by time 
period.  Shift tables comparing baseline versus most abnormal value will be generated for 
selected analytes with standard toxicity grades.  For selected laboratory analytes, the 
frequency of abnormal values and/or the incidence of Grades 3 and 4 values may be 
tabulated if appropriate. 
Clinically significant changes in physical examination findings and ECGs will be presented 
descriptively.  Vital signs will be summarized and listed by subject.  Findings from 
immunological assessments will be presented appropriately.   
Concomitant medications will be coded to generic term using the World Health Organization 
Drug Dictionary and will be tabulated across subjects and listed by subject.  
9.3.2 
Efficacy Analyses 
Neurological function will be evaluated by characterizing upper extremity motor scores and 
motor level on the ISNCSCI exam (point estimate and 95% CI) by time point.  The 
percentage of AIS-A subjects within Cohorts 2 and 3 who recover at least 2 motor levels at 
180 days and at 365 days will be evaluated and compared to recent historical controls 
(Steeves, 2011 & 2012).   

 
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The results from the exploratory assessment tools (GRASSP, SCIM, Spinal Cord Ability 
Ruler, urinary tract and bowel function) will be tabulated and analyzed using statistical 
methods appropriate for each type of data set.  Efficacy results will be presented by dose 
level and AIS grade, and across all subjects as appropriate.   

 
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10 
ADVERSE EVENTS 
The collection period for adverse events for the purposes of this protocol begins once the 
subject has signed the informed consent form and ends after 365 days of observation.  
Adverse events will be assessed at each clinic visit; all adverse events occurring between 
visits will be reported by the subject and recorded by the site staff.  All unresolved events 
should be followed by the Investigator until resolved, deemed a chronic/irreversible 
condition, or the subject is lost to follow-up.   
10.1 
Adverse Event Reporting 
The Investigator or designee is responsible for evaluating all adverse events, obtaining 
supporting documents, and determining that documentation of the event is adequate.  All 
adverse events must be promptly entered into the eCRF.  Details of the event must include 
description, severity, seriousness, relationship to investigational product, duration, action 
taken, and outcome.      
10.1.1 
Definitions 
An adverse event is any untoward medical event that occurs to a study subject once the 
informed consent has been signed and until the subject’s last study visit, whether or not the 
event is considered related to the investigational product.  Examples include: 
• 
Any sign, symptom, physical examination finding, or laboratory result that worsens in 
nature, severity or frequency compared with baseline 
• 
All reactions from the investigational product including those occurring as a result of an 
overdose, abuse, withdrawal phenomena, sensitivity, or toxicity 
• 
Concurrent illness 
• 
Injury or accident 
A preexisting condition is one that is present prior to or at the start of the study and is to be 
reported as part of the subject’s medical history.  Preexisting conditions should be reported 
as an adverse event only if the frequency, intensity, or the character of the condition 
worsens during the study.     
An unexpected adverse event is one not identified in nature, severity, or frequency in the 
current protocol or Investigator’s Brochure. 

 
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10.1.2 
Grading of Adverse Event 
Adverse event severity will be grade according to the following criteria:   
• 
Grade 1, Mild:  Awareness of symptom, but easily tolerated; usually transient requiring 
no special treatment; does not interfere with usual status or activities 
• 
Grade 2, Moderate:  May be ameliorated by simple therapeutic measures; may interfere 
with usual activities 
• 
Grade 3, Severe:  Incapacitating, inability to perform usual activities 
• 
Grade 4, Life-threatening/Disabling:  Subject at risk of death or significant disability at 
the time of the event 
• 
Grade 5, Fatal 
10.1.3 
Relationship of Adverse Event  
Relationship of the adverse event either to the investigational product, the surgical 
procedure, and the immunosuppressive agent will be determined by the Investigator, and 
will be categorized as: 
• 
Unrelated:  The occurrence of the event is not reasonably related in time OR the event is 
considered unlikely to be related to use of the investigational product, the surgical 
procedure, and/or the immunosuppressive agent.  Other factors or evidence explain the 
occurrence of the event, such as the underlying condition, other medical conditions, 
concomitant medications, etc.  
• 
Related:  The investigational product, the surgical procedure, and/or the 
immunosuppressive agent are reasonably related in time to the adverse event.  
10.2 
Serious Adverse Events 
10.2.1 
Definitions 
A serious adverse event is one that meets any of the following criteria: 
• 
Results in death 
• 
Is life threatening 
• 
Requires inpatient hospitalization or prolongation of an existing hospitalization  
• 
Results in persistent or significant disability/incapacity 
• 
Is a congenital anomaly/birth defect in the offspring of an exposed subject  
An important medical event that may not result in death, be life-threatening, or require 
hospitalization, may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, it jeopardizes the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. 

 
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A life-threatening adverse event is defined as any adverse experience that places the 
patient or subject, in the view of the Investigator, at immediate risk of death from the 
reaction as it occurred, i.e., it does not include a reaction that, had it occurred in a more 
severe form, might have caused death. 
10.2.2 
Reporting 
The Investigator must notify the Sponsor by telephone or fax of any serious adverse event 
within 24 hours of the Investigator’s knowledge of the event.  Telephone reports must be 
followed by a written report within 24 hours.  Follow-up reports must be submitted in a timely 
fashion as additional information becomes available.   
The Sponsor will notify the FDA and/or other regulatory authorities and all participating 
Investigators of any adverse event that is serious, unexpected and possibly related to the 
use of the investigational product, in accordance with 21CFR312.32 (c), IND Safety Reports.  
Regulatory authorities will be notified of any fatal and life-threatening experiences 
associated with the use of the investigational product as soon as possible but in no event 
later than 7 calendar days after the Sponsor’s initial receipt of the information.  Serious, 
unexpected and possibly related adverse events that are not fatal or life-threatening will be 
reported as soon as possible but in no event later than 15 calendar days after the Sponsor’s 
initial receipt of the information.  
The Investigator is responsible for notifying their IRB/IEC of all serious, related and 
unexpected adverse events.   
10.2.3 
Pregnancy 
Pregnancy itself is not considered an adverse event.  However, for any pregnancy that 
occurs during the study period, the Sponsor must be notified within 24 hours of the 
Investigator learning of the pregnancy.  The site should maintain contact with the subject 
and obtain pregnancy outcome information.  The Investigator must report follow-up 
information to the Sponsor regarding the course of the pregnancy, including perinatal and 
neonatal outcome.   
10.3 
Recording of Adverse Events 
All adverse events, including observed problems, complaints, or symptoms, are to be 
recorded on the appropriate eCRF whether or not considered related to the investigational 
product.  Documentation must be supported by an entry in the subject’s source document.  

 
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Laboratory test abnormalities considered by the Investigator to be clinically relevant should 
be reported on the eCRF.  Each event is to be evaluated for duration, severity, and causal 
relationship with the investigational product or other factors. 

 
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11 
ADMINISTRATIVE AND ETHICAL PROCEDURES 
11.1 
Regulatory Authority Approval 
The Investigator will ensure that the study is conducted in compliance with the protocol, the 
Declaration of Helsinki, and according to International Conference on Harmonization (ICH) 
Guidance for Industry, Good Clinical Practice (GCP): Consolidated Guidance (ICH E6) and 
all other regulatory and institutional requirements, including those for subject privacy, 
informed consent, Institutional Review Board (IRB) or Independent Ethics Committee (IEC) 
approval, and record retention  
This study must have the approval of a properly constituted IRB/IEC.  Before the 
investigational product is shipped to the study site under this protocol, the Investigator will 
provide the Sponsor with a copy of the IRB/IEC approval letter stating that the study protocol 
and informed consent form have been reviewed and approved for both this protocol and the 
companion long term follow up protocol. 
11.2 
Informed Consent 
A properly written and executed informed consent form, in compliance with the Declaration 
of Helsinki, ICH E6 Section 4.8, 21 CFR Part 50.20, and other applicable local regulations, 
must be obtained for each subject prior to entering the subject into the study.  According to 
21 Code of Federal Regulations (CFR) Part 50.20, no Investigator may involve a human 
being as a subject in research covered by these regulations unless the Investigator has 
obtained the legally effective informed consent of the subject or the subject’s legally 
authorized representative.  An Investigator shall seek such consent only under 
circumstances that provide the prospective subject or the subject's legally authorized 
representative sufficient opportunity to consider whether or not to participate and that 
minimize the possibility of coercion or undue influence.  The information that is given to the 
subject or the representative shall be in language understandable to the subject or the 
representative. 
The Sponsor will provide the Investigator with a study-specific template for the informed 
consent form.  State and local laws and/or institutional requirements may require the 
disclosure of additional information in the consent form.  The proposed consent form must 
be submitted to the Sponsor prior to submission to the IRB/IEC to ensure that it meets the 
Sponsor’s standards for informed consent forms. 

 
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The IRB/IEC must approve the informed consent form.  A copy of the approved consent 
form must be submitted to the Sponsor prior to subject screening. 
Prior to the initiation of any procedures relating to the study, informed consent shall be 
documented by the use of a written consent form approved by the IRB/IEC and signed and 
dated by the subject or the subject’s legally authorized representative at the time of consent.  
A copy of the signed informed consent form will be given to the person signing the form.  
The Investigator must keep each subject’s signed consent form on file for inspection by 
authorized representatives of the Sponsor, the IRB/IEC, or a regulatory authority at any 
time.   
11.3 
Protocol Amendments 
Any changes to this protocol will be initiated by the Sponsor in writing as a protocol 
amendment.  The amendment must be submitted to the IRB/IEC, together with a revised 
informed consent form, if applicable.  Written documentation of IRB/IEC approval must be 
received before the amendment may take effect. 
11.4 
Data Management and Study Monitoring 
Clinical data will be recorded on eCRFs provided by the Sponsor.  Entry of data onto eCRFs 
must be recorded accurately and complete.  eCRFs must be completed on a timely basis 
and as requested by the Sponsor or its authorized representative in preparation for site 
monitoring.  The investigator will retain an electronic copy of the eCRFs and the sponsor will 
have an electronic copy of the eCRFs.  The Investigator will review all completed eCRFs 
and will verify the accuracy of the completed eCRFs. 
The study will be monitored by employees or authorized representatives of the Sponsor.  
Each site will be monitored on a periodic basis to perform the following, and other activities 
as required: 
• 
to ensure regulatory compliance 
• 
to perform verification of source documentation for each subject to ensure accurate and 
complete collection of required data, and accurate and complete recording of data on 
eCRFs 
• 
to ensure adherence to the requirements of the protocol including, but not limited to,  
required study procedures and safety reporting 
The frequency of monitoring may vary depending on protocol compliance, enrollment rate 
and/or quality of the data.  The Investigator and staff are expected to cooperate by preparing 

 
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and providing all requested study documentation at each site visit.  The Investigator and 
staff are responsible for being present or available for consultation during routinely 
scheduled site visits.  Between site visits, the site may also be routinely contacted by phone 
to assess enrollment, subject status and to address study-related issues. 
Employees or authorized representatives of the Sponsor may conduct an audit of a clinical 
site at any time during or after completion of the study.  The Investigator will be informed if 
an audit is to take place and advised of the audit scope.  Representatives of the FDA or 
other regulatory agencies may also conduct an audit of the study.  If informed of such an 
audit, the Investigator should notify the Sponsor immediately.  The Investigator will ensure 
that auditors have access to the, study site facilities, original source documentation, eCRFs, 
and all other study files. 
11.5 
Study Termination 
Upon completion of the study, the following activities, when applicable, will be conducted by 
the study monitor and the Investigator: 
• 
return of all study data to the Sponsor 
• 
data clarifications and/or resolutions 
• 
accounting, reconciliation, and final disposition of used and unused investigational 
product; and 
• 
review of site study records for completeness 
In addition, the Sponsor reserves the right to temporarily suspend or prematurely terminate 
this study for any reason. 
If the study is suspended or terminated for safety reasons, the Sponsor will promptly inform 
the Investigator, and will also inform the regulatory authorities of the suspension or 
termination of the study and the reasons for the action.  The Investigator is responsible for 
promptly informing the IRB/IEC and providing the reasons for the suspension or termination 
of the study. 
If the study is prematurely terminated, all study data must be returned to the Sponsor. In 
addition, the clinical site must conduct the final disposition of all unused investigational 
product in accordance with the Sponsor’s procedures for the study. 

 
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11.6 
Records Retention 
The Investigator must retain all study records required by the Sponsor and by the applicable 
regulations in a secure and safe facility.  The Investigator must consult an appropriate the 
Sponsor representative before disposal of any study records, and must notify the Sponsor of 
any change in the location, disposition or custody of the study files.  The 
Investigator/institution must take measures to prevent accidental or premature destruction of 
essential documents, that is, documents that individually and collectively permit evaluation 
of the conduct of a study and the quality of the data produced, including paper copies of 
study records (e.g., subject charts) as well as any original source documents that are 
electronic as required by applicable regulatory requirements.  All study records must be 
retained for at least 2 years after the last approval of a marketing application in the US or an 
ICH region and until (1) there are no pending or contemplated marketing applications in the 
US or an ICH region or (2) at least 2 years have elapsed since the formal discontinuation of 
clinical development of the investigational product.  The Investigator/institution should retain 
subject identifiers for at least 15 years after the completion or discontinuation of the study.  
Subject files and other source data must be kept for the maximum period of time permitted 
by the hospital, institution or private practice, but not less than 15 years.  These documents 
should be retained for a longer period, however, if required by the applicable regulatory 
requirements or by the Sponsor agreement.  The Sponsor must be notified and will assist 
with retention should Investigator/institution be unable to continue maintenance of subject 
files for the full 15 years.  It is the responsibility of the Sponsor to inform the 
Investigator/institution as to when these documents no longer need to be retained. 
11.7 
Confidentiality of Information 
Subject medical information obtained for the purposes of this study is confidential; 
disclosure to third parties, other than those noted below, is prohibited.  Upon the subject’s 
request and written permission, medical information may be given to his/her personal 
physician or other appropriate medical personnel responsible for the subject’s welfare. 
Data generated for this study must be available for inspection on request to representatives 
of the FDA, other national or local health authorities, the Sponsor, and the associated 
IRB/IEC. 
Release of research results or data that reveal subject names or other identifiers, such as 
photographs, audio or videotapes, must be carried out in accordance with Department of 
Health and Human Services Final Standards for Privacy of Individual Health Information, 

 
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45 CFR 164.508.  Written authorization must be obtained from the subject and IRB/IEC prior 
to the release of such information.  Identifiable subject data may not be used for purposes of 
promoting the investigational product. 

 
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12 
REFERENCES 
American Spinal Injury Association.  International standards for neurological and functional 
classification of spinal cord injury.  Chicago IL: American Spinal Injury Association; 2002.  
American Spinal Injury Association.  Reference manual for the International Standards for 
Neurological Classification of Spinal Cord Injury.  Chicago, IL:  American Spinal Injury 
Association; 2003.   
Basso DM, Beattie MS, Bresnahan JC. Graded histological and locomotor outcomes after 
spinal cord contusion using the NYU weight-drop device versus transection.  Exp Neurol 
1996; 139(2): 244–256. 
Biering-Sørensen F, Charlifue S, DeVivo M, et al. International Spinal Cord Injury Data Sets. 
Spinal Cord 2006; 44(9): 530–534.   
Brodbelt AR, Stoodley MA. Post-traumatic syringomyelia: a review. J Clin Neurosci 2003; 
10(4): 401–408.   
Bunge RP, Puckett WR, Becerra JL, et al. Observations on the pathology of human spinal 
cord injury. A review and classification of 22 new cases with details from a case of chronic 
cord compression with extensive focal demyelination.  Adv Neurol 1993; 59: 75–89.   
Cao Y, Chen Y, DeVivo M.  Lifetime direct costs after spinal cord injury. Top Spinal Cord Inj 
Rehabil 2011;16(4):10–16. 
CBER Guidance for Industry: Source Animal, Product, Preclinical and Clinical Issues 
Concerning the Use of Xenotransplantation Products in Humans 2003; 
http://www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinform
ation/guidances/xenotransplantation/ucm092707.pdf 
Curt A, Van Hedel HJ, Klaus D, Dietz V; EM-SCI Study Group.  Recovery from a spinal cord 
injury: significance of compensation, neural plasticity, and repair.  J Neurotrauma. 2008 
Jun;25(6):677-85. 
DeVivo M, Biering-Sørensen F, Charlifue S, et al.  Executive Committee for the International 
SCI Data Sets Committees.  International Spinal Cord Injury Core Data Set. Spinal Cord. 
2006; 44(9): 535–540. 
Edgar R, Quail P. Progressive post-traumatic cystic and non-cystic myelopathy. Br J 
Neurosurg 1994; 8(1): 7–22.   
Itzkovich M, Gelernter I, Biering-Sorensen F, et al. The Spinal Cord Independence Measure 
(SCIM) version III:  Reliability and validity in a multi-center international study. Disabil 
Rehabil 2007; 29(24): 1926–1933.   
Kakulas BA. The applied neuropathology of human spinal cord injury. Spinal Cord 1999a; 
37(2) :79–88.   
Kakulas BA.  A review of the neuropathology of human spinal cord injury with emphasis on 
special features.  J Spinal Cord Med 1999b; 22(2): 119–124. 

 
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National Spinal Cord Injury Statistical Center.  Spinal Cord Injury Facts and Figures at a 
Glance, February 2013.  
https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202013.pdf   
Okamura RM, Lebkowski J, Au M, et al. Immunological properties of human embryonic stem 
cell-derived oligodendrocyte progenitor cells. J Neuroimmunol 2007; 192(12): 134–144. 
Public Health Services Guidelines on Infectious Disease Issues in Xenotransplantation 
(2001); 
http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInfor
mation/Guidances/Xenotransplantation/UCM092858.pdf   
Reed R, Mehra M, Kirshblum S, et al.  Spinal Cord Ability Ruler: An inclusive measure of 
volitional performance in spinal cord injury.  Submitted. 
Sekhon LH, Fehlings MG.  Epidemiology, demographics, and pathophysiology of acute 
spinal cord injury. Spine 2001; 26(24 Suppl): S2–12. 
Steeves JD, Kramer JK, Fawcett JW, et al.  Extent of spontaneous motor recovery after 
traumatic cervical sensorimotor complete spinal cord injury.  Spinal Cord. 2011 
Feb;49(2):257-65. 
Steeves JD, Lammertse DP, Kramer JL, et al.  Outcome Measures for Acute/Subacute 
Cervical Sensorimotor Complete (AIS-A) Spinal Cord Injury During a Phase 2 Clinical Trial. 
Top Spinal Cord Inj Rehabil. 2012 Winter;18(1):1-14. 
Velstra IM, Bolliger M, Tanadini LG, Baumberger M, Abel R, Rietman JS, Curt A.  Prediction 
and stratification of upper limb function and self-care in acute cervical spinal cord injury with 
the graded redefined assessment of strength, sensibility, and prehension (GRASSP).  
Neurorehabil Neural Repair. 2014 Sep;28(7):632-42. 
Zhang YW, Denham J, Thies RS.  Oligodendrocyte progenitor cells derived from human 
embryonic stem cells express neurotrophic factors. Stem Cells Dev 2006; 15(6): 943-52. 
 

 
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13 
APPENDICES 
Appendix A: Compliance with Xenotransplantation Guidelines 
AST-OPC1 is produced from the H1 uhESC line, which was originally derived at the 
University of Wisconsin in 1998.  The H1 line was established by isolating the inner cell 
mass from a donated excess embryo and culturing the cells from this mass on a layer of 
irradiated murine embryonic feeder cells. 
As a consequence of this ex vivo contact between H1 undifferentiated cells and murine 
cells, AST-OPC1 meets the Public Health Service definition of a xenotransplantation product 
(Public Health Service 2001, CBER 2003).   However, the Sponsor subsequently adapted 
the H1 uhESC line to feeder-free culture conditions prior to generating the H1 master cell 
bank (MCB) that is used to produce AST-OPC1.  The Sponsor has also performed extensive 
testing of the H1 MCB and this testing has demonstrated that the MCB is free from known 
murine viral and retroviral adventitious agents.  Because of the demonstrated freedom from 
known murine viral and retroviral adventitious agents, the FDA has recommended that a 
subset of the FDA and Public Health Services xenotransplantation guidance be followed.  
The plan below represents compliance with the FDA recommendations with respect to 
xenotransplantation issues:  
• 
The Sponsor will archive vials from each manufactured lot of AST-OPC1 indefinitely for 
xenotransplantation safety monitoring.  These samples may prove useful during 
retroactive investigation of clinically relevant events that might occur in subjects treated 
with AST-OPC1.  The Sponsor will archive these vials at BioStorage Technologies, Inc. 
or an equivalent biorepository that is capable of storing samples in vapor phase liquid 
nitrogen and is fully compliant with applicable industry, regulatory, biosafety, and 
biomaterial handling regulations.  In addition, the contract facility will have an inventory 
tracking system that is compliant with 21 CFR Part 11. 
• 
The sample informed consent form includes language informing subjects that they will 
be receiving a xenotransplantation product. 
• 
The sample informed consent requests that the subject inform their personal physician 
that the subject has received a xenotransplant product. 
• 
At baseline (before AST-OPC1 injection), about 8 mL of blood will be obtained and 
divided into three (3) to five (5) 0.5-mL aliquots of citrated or EDTA-anticoagulated 
plasma and ≥ 2 aliquots of viable, cryopreserved leukocytes (1.0 x 107 cells/aliquot).  
These samples will be frozen on dry ice and sent to the same contract facility noted 
above.  The samples will be archived indefinitely at -80oC. 
• 
At postinjection Days 30 and 365, additional blood samples will be obtained, divided into 
aliquots, and archived indefinitely as noted above. 

 
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• 
In the event of a subject death, an autopsy will be requested and, if granted, a biopsy of 
the treatment site and any major organs related to the clinical circumstances resulting in 
death will be collected as: snap-frozen samples stored at -70°C; paraffin embedded 
tissue; and tissue that may be used for performing electron microscopy.  Samples will be 
stored at BioStorage Technologies, Inc. or an equivalent biorepository.  The sample 
informed consent form includes language stating that an autopsy will be requested in the 
event of a subject death. 
• 
The Sponsor will maintain a database that captures the following information: 
o link between the lot number for the final product and the subject identifier 
o identification of dates and location for any archived final product and subject baseline 
samples 
o documentation of clinical events that could be related, potentially, to murine-derived 
infectious agents including fever of unknown etiology, neoplasias and neurological 
disorders 
• 
All subjects who receive AST-OPC1 will receive long-term follow-up under a companion 
protocol, for which informed consent will be requested at the same time that consent for 
this protocol is obtained.  The follow-up plan contains the following elements (see 
companion protocol AST-OPC1-02 for details): 
o request that the subject promptly notifies the Investigator of any change in address 
and/or telephone number 
o evaluation at 2 years after AST-OPC1 administration and annually thereafter through 
5 years.  Evaluation will include a physical exam, neurological exam, MRI scan of the 
spinal cord, and laboratory assessments as indicated. 
o blood sample at year 5 will be obtained and archived for xenotransplantation 
monitoring. 
o annual telephone contact at Years 6–15 for any adverse changes in neurological 
status or serious adverse health problems (if yes, subject will be asked to return to 
clinic for evaluation) 
 

 
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Appendix B: Flow Diagram of AST-OPC1 Dose Preparation 
AST-OPC1 Process Flow Diagram: Dose Preparation at the Clinical Site
Asterias Biotherapeutics – CONFIDENTIAL
Comments
Analytical 
Methods
Unit Operations
Key Materials
AST-OPC1 
Drug Product Vial(s)
Wash and Transfer 
to Sterile
Cryovial
Load syringe
Transfer to patient 
location
Delivery Syringe
Viable Cell 
Count
PASS
FAIL
7
9
10
Dose Prep Buffer
Gram Stain
Notify Asterias 
Clinical Operations
FAIL
Notify Asterias 
Clinical Operations
Consult Clinician
FAIL
No action needed
PASS
PASS
Isolyte® S pH 7.4
Human Serum 
Albumin
Dose Prep Buffer
Centrifuge and 
Aspirate 
Supernatant
6
Dose Prep Buffer
Centrifuge and 
Aspirate 
Supernatant
Key
1
= Process Step
= Process Flow
Unit Operation
Raw Material
= Product Path, 
contingent on test results
= Product Path
Comment
= Decision Maker
Thaw AST-OPC1 
Drug Product
1
Dilute with Dose 
Prep Buffer
2
Filter
3
14 Day 
Sterility Test
Loading Needle
Test, Not an in 
Process Control
Wash
5
Millipore Steriflip® Filter 
(60µm)
4
Centrifuge, 
Remove Calculated 
Volume of 
Supernatant, and 
Resuspend
8
AcuTemp® PX1L Case
 

 
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 Appendix C: Site Personnel Training 
Surgeon Training  
Each surgeon must be trained and qualified on the use of the syringe positioning device 
prior to their first administration of AST-OPC1.  Training will be provided by Sponsor 
personnel and an expert spine neurosurgeon who is familiar with the device.  The training 
and qualification will be conducted using human cadavers at a facility equipped for surgical 
training on spine procedures. 
The training will consist of: (1) an oral review of the Instructions for Use manual and the 
administration procedures, and (2) hands-on demonstration of the syringe positioning device 
setup and administration of AST-OPC1 into the cervical spinal cord in a human cadaver.  
Qualification will be performed by having the surgeon independently set up the syringe 
positioning device and administer AST-OPC1 at 2 spinal levels under the observation of 
Sponsor personnel and an expert spine neurosurgeon.  If the injection(s) are not satisfactory 
in the expert’s opinion, then the trainee must repeat the procedures, as appropriate.   
Satisfactory or unsatisfactory completion of the injection qualification will be documented by 
the expert neurosurgeon. 
Radiologist Training 
MRIs will be read by a small, central neuroradiology group that has been trained and 
achieved consensus on how to interpret pre- and poststabilization images.  Training will 
consist of discussion between radiologists and agreement on image interpretation for 
parameters such as length of contusion, length of edema, amount of spinal cord 
compression, and evidence of laceration or transection. 
ISNCSCI Assessment Training 
In order to perform the International Standards for Neurological Classification of Spinal Cord 
Injury (ISNCSCI) sensory/motor examination for this study, the assessors at each site must 
be therapists and/or physicians with at least 2 years of documented experience (e.g., in their 
curriculum vitae or other appropriate documentation) in frequently conducting the ISNCSCI 
exam.  In addition, all assessors must submit a certificate confirming successful completion 
of the InSTeP training course on the American Spinal Injury Association website within the 
previous two years. 

 
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Appendix D: International Standards for Neurological Classification of Spinal Cord 
Injury 
The ISNCSCI is the most commonly used neurological examination tool for classifying 
severity of SCI for both clinical and research purposes (ASIA 2002).  A reference manual 
was developed to support the motor/sensory examination, as well as scoring, scaling and 
application (ASIA 2003). 
The neurological examination consists of both motor and sensory examinations that have 
been standardized to promote consistency (Figure 13-1).  The ISNCSCI examination 
consists of the following: 
• 
Motor examination: 10 key muscles are tested in each half of the body.  Each muscle is 
graded from 0 to 5 and then the total score is calculated, the maximum being 100. 
• 
Sensory examination: 28 key regions are tested in each half of the body for pinprick and 
light touch sensations.  Each region is given a score of 0 (absent), 1 (impaired), 2 
(normal) or NT (not testable). The total score is then calculated, with a maximum of 112. 
In addition, based on the data collected from the motor and sensory examinations, 
neurological level, completeness of neurological loss, the zone of partial preservation and 
the ASIA Impairment Scale can be determined.   

 
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Figure 13-1: ISNCSCI Scoring System 
Front Side 

 
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Figure 13-1 (contd.): ISNCSCI Scoring System (Back Side) 
 

 
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Appendix E: Magnetic Resonance Imaging Procedures 
 
Background 
MRI will be performed to accomplish several objectives, including: 
• 
determination of eligibility for study participation 
• 
identification of the target site for AST-OPC1 injection 
• 
evaluation of the injection site for safety 
• 
evaluation of distant regions of the CNS for safety 
• 
acquisition of data for possible research analyses 
The imaging protocol for the clinical safety evaluation was designed with consideration given 
to the results of the nonclinical biodistribution studies of AST-OPC1 following injection into 
the cervical spinal cord as described in Section 1.2.4.   
Based on these data, all MRI exams will include imaging of the cervical spine.  Sagittal 
views of the cervical spine will include a field of view that extends from the top of the 
cerebellum to the upper thoracic spine (approximately T1-T2 level).  Selected MRI exams 
(baseline, Day 365) will also include imaging of the brain.  All MRI exams will include 
imaging with and without gadolinium-DTPA contrast to detect, evaluate, and monitor any 
potentially enlarging abnormal cysts or masses. 
Standard Imaging Parameters  
All MR imaging should be performed on systems with a static magnetic field strength of at 
least 1.5 Tesla in order to ensure that high-resolution images with good signal-to-noise can 
be obtained.  All MR images of the spine should be obtained with a phased array receive 
coil (or equivalent) for the same reason as above. 
Suggested imaging sequences for spine MRI include: 
• 
Sagittal T1-weighted spin-echo and T2-weighted fast spin-echo 
o field of view: top of cerebellum to upper thoracic spine (approx. T1-T2) 
o slice thickness: 3 mm + 0.3 mm gap between slices 
o T1 scans: TR/TE/nex: 600/20/2 
o T2 scans: TR/TE/ETL/nex: 2000-3000/80-100/4-8/2-4 
o recommendations to minimize artifacts due metallic implants: turn off fat suppression 
and increase receiver bandwidth to maximum allowed by the system 

 
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• 
Axial T1-weighted spin-echo and T2-weighted fast spin-echo 
o Number of slices: 16, with middle slices at the level of the injury epicenter 
o Slice thickness: 4 mm + 1 mm gap between slices 
o T1 scans: TR/TE/nex: 600/20/2 
o T2 scans: TR/TE/ETL/nex: 2000-3000/80-100/4-8/2-4 
o Recommendations to minimize artifacts due metallic implants: turn off fat 
suppression and increase receiver bandwidth to maximum allowed by the system 
All MRI exams will include postcontrast (gadolinium-DTPA) T1-weighted images in the 
sagittal and axial planes with the same parameters used for the respective pre-contrast 
images (unless the subject is allergic to contrast). 
Suggested MRI scans of the brain include routine T1-weighted and T2-weighted scans in 
the sagittal and axial planes, plus postcontrast T1-weighted images. 
Central Reading of MRI Scans 
All study-driven MRI reading will be performed by a central group of neuroradiologists with 
extensive experience in MRI evaluation of spinal cord trauma.  The images will be sent to 
the central group electronically via an imaging contract research organization. 
The poststabilization screening/baseline MRI scan will be used to determine the whether the 
following eligibility criteria are met: 
• 
single spinal cord lesion on a post-stabilization magnetic resonance imaging (MRI) scan, 
with sufficient visualization of the spinal cord injury epicenter and lesion margins to 
enable post-injection safety monitoring 
• 
absence of anatomical transection or significant laceration 
• 
spinal cord lesion with anteroposterior diameter of the spinal cord ≥ 2 mm at point of 
maximal compression on a midline sagittal image from a poststabilization MRI 
The screening/baseline MRI will also be used to make a preliminary determination of the 
target site for AST-OPC1 injection.  This site should be near the caudal margin of the injury 
epicenter, and within damaged, but nonhemorrhagic tissue. 
Several additional parameters may be measured for future research analyses.  These may 
include: 
• 
Length of contusion (ie, maximal extent of petechial hemorrhages) 
• 
Presence/absence of intramedullary hemorrhage 
• 
Length of intramedullary hemorrhage 

 
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• 
Length of edema 
• 
Percent compression at epicenter 
Following AST-OPC1 injection, the MR images will be assessed according to standard 
practice and with specific attention to the following potential risks: 
• 
intramedullary hemorrhage, CSF leak, epidural abscess, infection 
• 
evidence of expanding cyst or mass at the injection site or elsewhere in CNS 
• 
evidence of inflammatory lesion(s) at injection site or elsewhere in CNS 
• 
evidence of CSF flow obstruction