The Assessment of Cerebral Haemodynamics in Patients With Transient Ischaemic Attack: A Transcranial Doppler Study
Conditions: Transient Ischemic Attack
Sponsor: University of Leicester

CONFIDENTIAL 
Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
Study Protocol V1.0_20/02/2019 
Page 1 of 43 
 
 
THE ASSESSMENT OF CEREBRAL HAEMODYNAMICS IN PATIENTS WITH 
TRANSIENT ISCHAEMIC ATTACK: A TRANSCRANIAL DOPPLER STUDY 
Date and Version No:  
 
Version 1.0 20th February 2019 
Sponsor Reference No: 
 
UNOLE 0694 
Ethics Reference No: 
 
19/LO/0501 
Chief Investigator: 
 
Professor Thompson Robinson 
Professor of Stroke Medicine 
Department of Cardiovascular Sciences, University of Leicester 
Room 228, Robert Kilpatrick Clinical Sciences Building 
Leicester Royal Infirmary, Leicester, LE2 7LX 
Email: tgr2@le.ac.uk 
 
Tel: 0116 252 3187  
 
Investigators: 
 
 
Mr Angus Batterham 
Intercalated MSc student 
Department of Cardiovascular Sciences, University of Leicester 
Room 237, Robert Kilpatrick Clinical Sciences Building 
Leicester Royal Infirmary, Leicester, LE2 7LX 
Email: ab786@student.le.ac.uk 
Tel: 0116 252 5802 
 
 
Dr Victoria Haunton 
Honorary Senior Lecturer 
Department of Cardiovascular Sciences, University of Leicester 
Room 210, Robert Kilpatrick Clinical Sciences Building 
Leicester Royal Infirmary, Leicester, LE2 7LX 
Email: vjh12@le.ac.uk 
 
Tel: 0116 252 5802  
 
 
Professor Ronney Panerai 
Emeritus Professor 
Department of Cardiovascular Sciences, University of Leicester 
Room 225, Robert Kilpatrick Clinical Sciences Building 
Leicester Royal Infirmary, Leicester, LE2 7LX 
Email: tgr2@le.ac.uk 
 
Tel: 0116 252 3183  

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Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
Study Protocol V1.0_20/02/2019 
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Sponsor: 
 
 
University of Leicester 
 
 
 
 
Research Governance Office 
 
 
 
 
uolsponsor@le.ac.uk 
 
 
 
 
0116 258 4099 / 4867 / 8305 
 
 
Author 
 
Dr Victoria Haunton BM MD DGM MRCP(Geriatric Medicine) 
Honorary Senior Lecturer 
Department of Cardiovascular Sciences, University of Leicester 
Room 210, Robert Kilpatrick Clinical Sciences Building 
Leicester Royal Infirmary, Leicester, LE2 7LX 
Email: vjh12@le.ac.uk 
     Tel: 0116 252 5802 
 
 
Confidentiality Statement 
All information contained within this protocol is regarded as, and must be kept confidential.  No 
part of it may be disclosed by any Receiving Party to any Third Party, at any time, or in any form 
without the express written permission from the Chief Author/Investigator and/or Sponsor. 
 
 
 
Signatures: 
The approved protocol should be signed the author and/or person(s) authorised to sign the 
protocol 
 
 

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Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
Study Protocol V1.0_20/02/2019 
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Signature Page 
 
Chief Investigator Name: 
          _________________________________________ 
Chief Investigator Signature: 
 _________________________________________ 
Date: 
                                                         _________________________________________ 
  
 
 
Sponsor Representative Name: 
          _________________________________________ 
Sponsor Representative Signature: 
 _________________________________________ 
Date: 
                                                        _________________________________________ 
 
 
 
 
 

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Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
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TABLE OF CONTENTS 
1. 
AMENDMENT HISTORY ............................................................................................................... 6 
2. 
SYNOPSIS ................................................................................................................................... 7 
3. 
ABBREVIATIONS ......................................................................................................................... 8 
4. 
BACKGROUND AND RATIONALE ................................................................................................... 9 
5. 
OBJECTIVES .............................................................................................................................. 12 
5.1 
Primary Objective ........................................................................................................... 12 
5.2 
Secondary Objective ....................................................................................................... 12 
6. 
STUDY DESIGN ......................................................................................................................... 13 
6.1 
Summary of Trial Design ................................................................................................ 13 
6.2 
Primary and Secondary Endpoints/Outcome Measures .................................................. 13 
7. TRIAL PARTICIPANTS .............................................................................................................. 14 
7.1 
 Overall Description of Trial Participants ......................................................................... 14 
7.2 
Inclusion Criteria ............................................................................................................. 15 
7.3 
Exclusion Criteria ............................................................................................................ 15 
8. 
STUDY PROCEDURES ................................................................................................................. 16 
8.1     Screening and Eligibility Assessment ............................................................................. 16 
8.2  Informed Consent ........................................................................................................... 16 
8.3 
TCD window insonation check ........................................................................................ 17 
8.4 
Collection of demographic data ....................................................................................... 18 
8.5 
TCD Assessment ............................................................................................................ 19 
8.6 
Definition of End of Trial .................................................................................................. 20 
8.7 
Discontinuation/Withdrawal of Participants from Study Treatment .................................. 20 
8.8  Source Data .................................................................................................................... 21 
9. 
TREATMENT OF TRIAL PARTICIPANTS .......................................................................................... 22 
9.1      Storage of Study Equipment of Related Apparatus ........................................................ 22 
9.2   Clinical Care .................................................................................................................. 22 
10. SAFETY REPORTING .................................................................................................................. 23 

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Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
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10.1  Definitions ....................................................................................................................... 23 
10.2   Reporting procedures for All Adverse Events ................................................................. 24 
10.3   Reporting Procedures for Serious Adverse Events ......................................................... 25 
11. STATISTICS ............................................................................................................................... 26 
11. 1 Statistical analysis .......................................................................................................... 26 
11.2   Sample size calculation .................................................................................................. 26 
11.3 The Level of Statistical Significance ................................................................................ 26 
11.4 Procedure for Accounting for Missing and Unused Data ................................................. 27 
12. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS .......................................................................... 28 
13. QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES ........................................................ 29 
14. CODES OF PRACTICE AND REGULATIONS ..................................................................................... 30 
14.1    Ethics ............................................................................................................................ 30 
14.2  Sponsor Standard Operating Procedures ...................................................................... 30 
14.3   Declaration of Helsinki .................................................................................................... 30 
14.4  ICH Guidelines for Good Clinical Practice ....................................................................... 30 
14.5 Approvals ........................................................................................................................ 30 
14.6  Participant Confidentiality ............................................................................................... 30 
15. DATA HANDLING AND RECORD KEEPING ..................................................................................... 32 
15.1   Data Extraction ............................................................................................................... 32 
15.2 Data Analysis .................................................................................................................. 32 
16. STUDY GOVERNANCE ................................................................................................................ 34 
17. FINANCING AND INSURANCE ..................................................................................................... 35 
18. PUBLICATION POLICY ................................................................................................................ 36 
19. REFERENCES ............................................................................................................................ 37 
20. APPENDIX A: CATEGORISATION OF ETHNICITY ............................................................................. 40 
21. APPENDIX b: EDINBURGH HANDEDNESS INVENTORY .................................................................... 41 
22. APPENDIX C: SCHEDULE OF PROCEDURES .................................................................................... 42 
23. APPENDIX D: EXPECTED EVENTS NOT SUBJECT TO EXPEDITED REPORTING ...................................... 43 
 

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1. 
AMENDMENT HISTORY 
Amendment 
No. 
Protocol 
Version 
No. 
Date issued 
Author(s) of changes 
Details 
of 
Changes 
made 
 
 
 
 
 

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Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
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2. 
SYNOPSIS 
 
Study Title 
THE ASSESSMENT OF CEREBRAL HAEMODYNAMICS IN PATIENTS WITH TRANSIENT 
ISCHAEMIC ATTACK: A TRANSCRANIAL DOPPLER STUDY 
Internal ref. no. 
UNOLE 0694 
Trial Design 
Single-centre, prospective, case control study 
Trial Participants 
Participants with Transient Ischaemic Attack (TIA) and healthy adults (HC) 
Planned Sample 
Size 
40 participants in total; 20 participants with TIA and 20 HC 
Follow-up 
duration 
N/A 
Planned Trial 
Period 
6 months 
Primary Objective 
To determine the beat-to beat cerebral blood flow velocity (CBFv) of both TIA and HC 
subjects during performance of a squat-stand manoeuvre 
 
 
Secondary 
Objective 
To determine other beat-to-beat cerebral haemodynamic parameters, specifically 
autoregulation index (ARI), of both TIA and HC subjects during performance of a squat-
stand manoeuvre 
Outcome 
Measures 
This is not an intervention study, and therefore it would not be appropriate to assess 
classical primary and secondary outcome measures such as death and disability for this 
study. However, we intend to evaluate the following relevant outcomes: 
1. The number of participants successfully recruited 
2. The number of recruited participants able to comply with the full measurement 
protocol. 
3. The number of measurements rejected because of aspects related to data 
quality during the analysis protocol, with recorded reasons. 
4. Overall, the number of recruited subjects in whom values for the following 
parameters can be derived: 
 
% change of cerebral blood flow velocity (CBFv) at baseline in response 
to performance of a squat-stand manoeuvre 
 
Autoregulation index 

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Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
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3. 
ABBREVIATIONS 
AE 
Adverse event 
AR  
Adverse reaction 
ARI  
Autoregulation Index 
BP 
Arterial Blood Pressure 
CA 
Cerebral Autoregulation 
CBF 
Cerebral Blood Flow 
CBFv 
Cerebral Blood Flow Velocity 
CHIASM 
Cerebral Haemodynamics in Ageing and Stroke Medicine 
CI 
Chief Investigator 
CPP 
Cerebral Perfusion Pressure 
CrCP 
Critical Closing Pressure 
CRF 
 
Case Report Form 
CT 
 
Computerised Tomography 
dCA 
 
Dynamic Cerebral Autoregulation 
ECG 
 
Electrocardiogram 
EtCO2 
 
End-Tidal Partial Pressure of Carbon Dioxide 
fMRI 
 
Functional Magnetic Resonance Imaging 
GCP 
Good Clinical Practice 
HC 
Healthy Control 
HR  
Heart Rate 
ICH 
International Conference on Harmonisation of Technical Requirements for 
Registration of Pharmaceuticals for Human Use 
ISF  
Investigator Site File 
LRI 
Leicester Royal Infirmary 
MCA 
Middle Cerebral Artery 
PET 
Positron Emission Tomography 
PIL/S 
Participant Information Leaflet/Sheet 
RAP 
Resistance Area Product 
SAE 
Serious Adverse Event 
SAR 
Serious Adverse Reaction 
SCA 
Static Cerebral Autoregulation 
SSM 
Squat stand manoeuvre 
SOP 
Standard Operating Procedure 
SPECT 
Single photon emission computed tomography 
SUSAR 
Suspected Unexpected Serious Adverse Reactions 
TCD 
Transcranial Doppler Ultrasound 
TFA 
Transfer Function Analysis 
TIA 
Transient Ischaemic Attack 
TMF 
Trial Master File 
UK 
United Kingdom 

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Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
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4. 
BACKGROUND AND RATIONALE 
Adequate cerebral blood flow (CBF) is essential for brain survival and function.  Brain metabolism is 
almost entirely dependent on oxidative mechanisms, particularly the metabolism of glucose, and the 
brain has a very limited capacity for anaerobic function.  Adequacy and constancy of cerebral blood 
flow are therefore vital in ensuring both a steady supply of oxygen, glucose and other nutrients, and 
the removal of waste products of metabolism.   
 
Cerebral autoregulation (CA) refers to the ability of the brain to maintain a relatively constant CBF in 
response to significant changes in cerebral perfusion pressure (CPP).  Thus, in response to an 
increase or decrease in CPP, there is a vasodilatation or vasoconstriction of cerebral vessels. This 
variable resistance to flow occurs mainly in the cerebral arteriolar bed; the major cerebral arteries 
are essentially conductive rather than compliant [Itoh et al 2012, Kuga et al 2009, Kontos et al 1978].  
The classic concept of CA whereby, under normal physiological conditions, CBF is around 
50ml/100g/min, and this is maintained across a wide range of blood pressures (MAP of 60-
160mmHg), was first described by Lassen in 1959.  CA is usually described as being static (sCA), 
reflecting the integrity of such mechanisms over time, or dynamic (dCA), occurring in response to 
sudden fluctuations in perfusion pressure.   CA is accomplished through the complex interplay of a 
variety of myogenic, metabolic and neurogenic mechanisms. 
 
In recent years, there has been growing evidence that CA is altered in various disease states 
including ischaemic stroke [Eames et al 2002], head injury [Czosynka et al 1996], carotid stenosis 
[Reinhard et al 2004], pre-eclampsia [van Veen et al 2013], chronic diabetes mellitus [Chiu et al 
2005], Alzheimer’s dementia [Claassen et al 2011], and idiopathic Parkinson’s disease [Haunton 
2013].   
 
In ischaemic stroke, impaired CA is related to neurological deterioration, the necessity for 
decompressive surgery, and poor prognosis [Aries et al 2010].  CA has also been shown to correlate 
with stroke severity and functional outcomes [Llwyd et al 2018].   
 
Transient ischaemic attack (TIA) is defined as "a transient episode of neurologic dysfunction caused 
by focal brain, spinal cord or retinal ischemia without acute infarction" [Easton et al 2009].  
Approximately 46,000 people in the UK each year have a first TIA [Rothwell et al 2005] and one in 12 
people will have a full stroke within a week of having a TIA [Coull et al 2004].  Urgent assessment in a 
specialist TIA clinic ensures timely and appropriate investigations and rapid interventions (such as 
antiplatelet therapy, blood pressure-lowering medication, statins, anticoagulation and carotid 

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endarterectomy or stenting where appropriate) [Rothwell et al 2007].  TIA and acute ischaemic 
stroke share the same pathophysiological mechanisms and, whilst there have been a significant 
number of studies investigating cerebral haemodynamics and CA in acute stroke, there have been 
very few studies exploring CA and TIA.  A study by Atkins et al reported no impairment of 
cerebrovascular haemodynamic control following TIA [Atkins et al 2010].  However, recent abstract 
level data suggest altered CA is predictive of patients who go on to have further TIAs and strokes 
[Musthak et al 2017].  
 
Cerebral haemodynamics can be studied using techniques such as functional magnetic resonance 
imaging (fMRI), positron emission tomography (PET) or single-photon emission computed 
tomography (SPECT).  However, these techniques are expensive, in the case of SPECT involve 
radiation, and there are feasibility issues including the need to lie still for prolonged periods and to 
have no metal implants.  Transcranial Doppler Ultrasonography (TCD) is a simple, non-invasive 
imaging modality with high temporal resolution which allows for continuous and bilateral recording 
of cerebral blood flow velocity (CBFv) through the major cerebral arteries [Aaslid et al, 1982].  TCD 
has the advantage that CBFv measurements can be made in standing, seated, tilted and supine 
positions.  Continuous measurements of CBFv using TCD have shown that CBFv is affected by 
pertubations in arterial blood pressure (BP) [Aaslid et al 1989].   
 
The most widely used, validated, modelling technique in the analysis of the relationship between 
CBFv and BP is transfer function analysis (TFA) [Claassen et al 2016]. TFA makes it possible to 
examine the effect of changes in (BP) on CBFv.   It quantifies the extent to which the input signal, 
BP, is reflected in the output signal, CBFv, and was first proposed by Giller. 
Cerebral haemodyamic data which can be obtained using TFA include values of coherence, phase, 
gain, autoregulatory index (ARI), critical closing pressure (CrCP) and resistance area product (RAP).   
The ARI was derived in 1995 by Tiecks et al using of equations and curves based on the CBFv 
response to a sudden fall in induced by thigh cuff deflation. These equations and curves allow for 
the calculation of an ARI value from 0 to 9, where 0 represents absence of autoregulation i.e. CBF 
dependent on CPP, (a ‘pressure-passive relationship’) and 9 represents best measurable 
autoregulation.  ‘Normal’ autoregulation is represented by an ARI of 5±1.   
 
Whilst CA can be evaluated using spontaneous fluctuations in BP [Brodie et al 2009], coherence 
between oscillations at these low frequencies (<0.07Hz) is generally low (0.5), which often leads to 
the exclusion of such data from analysis in studies of CA [Claassen et al 2016].  Furthermore, larger 
and induced perturbations of BP allow us to study the CBF response to BP with increased certainty 
that there is a causal relationship.  Larger magnitude BP changes can be induced using challenges 

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such as bilateral thigh cuff inflation to suprasystolic blood pressure and their simultaneous release, 
lower body negative pressure, and the cold pressor stimulus (placing a hand in ice water).  These 
can be uncomfortable for participants.  More recently, squat-stand manoeuvres (SSMs) have also 
been shown to produce large changes in BP and thus CBFv [Claassen et al 2009a, Smirl et al 2015, 
Barnes et al 2017].  Squatting induces a rapid but transient rise in BP with its peak after 
approximately 2-3 seconds (s).  This increase in BP has been attributed to a sudden increase in 
cardiac output from increased venous return from the lower limbs.  The subsequent reduction in 
BP on standing up has been attributed to a combination of reduction in peripheral vascular 
resistance and a reduction in cardiac output due to rapid return of central blood volume to the 
lower limbs [Smirl et al 2015].  SSMs can be more comfortable for participants and are arguably 
more representative of physiological BP challenges in daily life, e.g. bending down to pick 
something up from the floor and standing up after tying a shoelace, than those other BP challenges 
detailed above.  When SSMs are performed repeatedly, large and periodic changes in BP and CBFv 
are created.   SSMs have been shown to be safe and well tolerated in various populations including 
heart transplant recipients [Smirl et al 2014], young and old healthy controls [Oudegeest-Sander et 
al 2014, Barnes et al 2017], and patients with Alzheimer’s dementia [Claassen JA et al 2009b].  It 
has recently been shown that reliable CA data can be obtained from as few as three SSMs [Barnes 
et al 2018].   
 
The proposed study will investigate and compare the beat-to beat CBFv changes observed during 
performance of a SSM protocol in 20 participants with acute (within 7 days) TIA and 20 HC.    
The proposed study will also investigate whether performance of a SSM is associated with 
differences in other beat-to-beat cerebral haemodynamic parameters, specifically autoregulation 
index (ARI), between participants with acute (within 7 days) TIA and 20 HC.    In doing so, it is hoped 
that we will be able to establish if CA is impaired in patients with TIA.   

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5. 
OBJECTIVES 
 
5.1 
Primary Objective 
 
To determine the beat-to beat cerebral blood flow velocity (CBFv) of both TIA and HC subjects during 
performance of a SSM. 
 
 
5.2 
Secondary Objective 
 
To determine other beat-to-beat cerebral haemodynamic parameters, specifically autoregulation 
index (ARI), of both TIA and HC subjects during performance of a SSM. 

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6. 
STUDY DESIGN 
 
6.1 
Summary of Trial Design 
 
This is a single-centre, prospective, case control study which will run for six months.  20 patients with acute 
TIA (within 7 days), and 20 healthy controls will be recruited from the specialist TIA clinic at University 
Hospitals of Leicester NHS Trust.  Participants will be eligible if they are aged over 18 and can consent to 
participate.  They won’t be able to participate if they have severe heart failure, an irregular heartbeat, 
blocked neck blood vessels, severe breathing problems, if they do not understand written or verbal English, 
if they have inadequate ultrasound windows, or if they are pregnant. 
TIA participants will be given a minimum of 1 hour, and a maximum of 48 hours to decide whether or not to 
take part in the study, but must undertake the study assessment within 7 days of their TIA.  Healthy control 
participants will be given a minimum of 1 hour, and a maximum of 7 days to decide whether or not to take 
part in the study.  There is no time restriction on when they undertake the study assessment. 
All participants will undergo an assessment of brain blood flow using TCD, during which their heart rate, 
breathing and blood pressure will also be monitored.  During the assessment participants will sit quietly 
before being asked to stand and then complete a squat-stand manoeuvre in time with a computer 
sequence.  The research visit will take approximately 90 minutes, the TCD assessment itself will take 
approximately 1 hour and participants only need to attend once.   
 
6.2 
Primary and Secondary Endpoints/Outcome Measures 
 
This is not an intervention study, and therefore it would not be appropriate to assess classical primary and 
secondary outcome measures such as death and disability for this study. However, we intend to evaluate 
the following relevant outcomes: 
a) The number of participants recruited 
b) The number of participants able to comply with the full measurement protocol 
c) The number of measurements rejected because of aspects related to data quality 
during the analysis protocol, with recorded reasons 
d) Overall, the number of recruited subjects in whom values for the following parameters 
can be derived: 
% change of cerebral blood flow velocity (CBFv) at baseline in response to 
performance of a squat-stand manoeuvre 
Autoregulation index 

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7. 
TRIAL PARTICIPANTS 
 
7.1 
 Overall Description of Trial Participants 
20 patients with acute TIA (within 7 days), and 20 healthy controls will be recruited from 
the specialist TIA clinic at University Hospitals of Leicester NHS Trust. 
TIA participants will be given a minimum of 1 hour, and a maximum of 48 hours to decide 
whether or not to take part in the study, but must undertake the study assessment within 7 
days of their TIA. 
Healthy control participants will be given a minimum of 1 hour, and a maximum of 7 days 
to decide whether or not to take part in the study.  There is no time restriction on when 
they undertake the study assessment. 
 

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7.2 
Inclusion Criteria  
  
HEALTHY CONTROLS: 
  
• 
Willing to participate 
  
• 
Capacity to consent to the study 
  
• 
Aged over 18 years 
  
• 
Able (in the Investigator’s opinion) and willing to comply with all study   
requirements  
  
• 
Good understanding of written and verbal English 
 
  
TIA PATIENTS: 
  
• 
Willing to participate 
  
• 
Capacity to consent to the study 
  
• 
Aged over 18 years 
  
• 
Able (in the Investigator’s opinion) and willing to comply with all study 
requirements  
  
• 
A diagnosis of acute (≤7 days) TIA, made by a specialist in the TIA clinic at University 
Hospitals of Leicester NHS Trust that fulfils the 2009 American Heart Association definition 
of TIA 
  
• 
Good understanding of written and verbal English 
 
7.3 
Exclusion Criteria 
  
ALL PARTICIPANTS (HEALTHY CONTROLS AND TIA PATIENTS) 
  
• 
Unwilling to take part 
  
• 
Unable to consent 
  
• 
Aged under 18 years 
  
• 
Unable (in the Investigator’s opinion) or unwilling to comply with any study 
requirements 
  
• 
Female participants who are pregnant, lactating or planning pregnancy during the 
course of the study 
  
• 
A diagnosis of atrial fibrillation 
  
• 
A diagnosis of severe heart failure (Ejection Fraction <30%) 
  
• 
Severe respiratory disease 
  
• 
Inadequate bilateral transcranial Doppler windows (see section 8.3) 
  
• 
Carotid stenosis ≥70% (unilateral or bilateral) 
  
• 
Participant enrolled in an interventional research study. 
  
• 
Poor understanding of written and verbal English 

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8. 
STUDY PROCEDURES 
8.1          Screening and Eligibility Assessment 
Patients attending the specialist TIA clinic at University Hospitals of Leicester NHS Trust will be 
eligible for recruitment into the study.    
Medical records will be reviewed by the direct care team to ensure participants meet the inclusion 
and exclusion criteria.  Eligibility screening will only be undertaken by the direct clinical care team 
for potential participants.  
Participants will be approached at their clinical consultation in the specialist TIA clinic by 
consultants, registrars or specialist nurses to determine study interest prior to referral to the 
researcher and provision of study specific information.  A poster advertising the study will be 
displayed in the TIA clinic waiting room.  Both participants with TIA, and healthy controls (those 
without a diagnosis of TIA) will be recruited from the clinic.  Healthy spouses, friends or partners of 
patients with TIA will be asked if they would like to participate in the study as a healthy control 
subject.   
TIA participants will be given a minimum of 1 hour, and a maximum of 48 hours to decide whether 
or not to take part in the study, but must undertake the study assessment within 7 days of their 
TIA. 
Healthy control participants will be given a minimum of 1 hour, and a maximum of 7 days to decide 
whether or not to take part study.  There is no time restriction on when they undertake the study 
assessment. 
 
 
8.2  
Informed Consent 
We will only invite participants who have capacity to give us consent in this research study.  The 
researcher will have primary responsibility for assessing the capacity of the individual to participate 
in research, according to the Mental Capacity Act 2005 and under the direct supervision of the 
Chief Investigator of the project.  
Informed consent will be undertaken by Mr Angus Batterham in the Cerebral Haemodynamics in 
Ageing and Stroke Medicine (CHIASM) laboratory located in the Windsor building, Leicester Royal 
Infirmary.   
The participant must personally sign and date the latest approved version of the informed consent 
form before any study specific procedures are performed.  Written and verbal versions of the 

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current approved Participant Information Leaflet (PIS) and Participant Consent Form will be 
presented detailing no less than: the exact nature of the study; the implication and constraints of 
the protocol; the known side effects and any risks involved in taking part. It will be clearly stated 
that the participant is free to withdraw from the study at any time for any reason without prejudice 
to future care and with no obligation to give the reason for withdrawal.  However, should this 
situation occur the research team would like to keep all the information and data that has been 
collected so far for the final analysis.  This will be clearly stated in both the PIS and Participant 
Consent Form. 
Participants with TIA will be allowed up to 48 hours (minimum of one hour) to consider the 
information, providing they will still be able to participate in the study within 7 days of their TIA.   
Healthy control participants will be given a minimum of 1 hour, and a maximum of 7 days to decide 
whether or not to take part in the study.  There is no time restriction on when they undertake the 
study assessment. 
Participants will be given the opportunity to question the Investigator, their GP or other 
independent parties to decide whether they will participate in the study.  Written Informed 
Consent will then be obtained by means of participant dated signature and dated signature of the 
person who presented and obtained the informed consent. 
Volunteers will also be allowed up to 48 hours (minimum of one hour) to consider the information, 
and the opportunity to question the Investigator or other independent parties to decide whether 
they wish to participate in the study.  Written informed consent will then be obtained by means of 
volunteer dated signature and dated signature of the person who presented and obtained the 
informed consent. 
The person who obtains the consent will be suitably qualified and experienced, and have been 
authorised to do so by the Chief/Principal Investigator as detailed on the Delegation of Authority 
and Signature log for the study. The original signed form will be retained at the study site within the 
Trial Master File (TMF) or Investigator Site File (ISF). A copy of the signed Informed Consent will be 
given to participants and a copy retained in the participant medical notes.   
 
 
 
8.3 
TCD window insonation check 
Once a consent form has been signed, and before collecting baseline information on demographics 
and handedness, or undertaking the SSM, participants will undergo a brief Transcranial Doppler 

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Ultrasound (TCD) check to ensure they have adequate acoustic temporal windows (inadequacy 
rates of 5-37% well documented in the literature) [Itoh et al 1993, Marinoni et al 1997]. 
If the participant is found to have inadequate acoustic windows, then they will be unable to 
participate in the study any further, and will be recorded as a screen failure. 
 
8.4 
Collection of demographic data 
To avoid repetition and undue burden to participants, consent will be obtained from participants 
to record the following data from their TIA clinic letter as detailed below: 
 
Date of birth 
 
Gender 
 
Height 
 
Weight and BMI 
 
Past Medical History 
 
Current Medications 
 
GP name and address  
 
Smoking status 
 
Capillary blood glucose 
 
Carotid ultrasound result 
 
Type and result of brain imaging 
 
Healthy controls will be asked the above information directly, although will be unable to 
provide capillary blood glucose, carotid ultrasound or brain imaging results. 
 
 
Participants will be asked to detail their ethnicity according to the 18 standardised ethnic 
categories outlined in the 2011 Office of National Statistics census (Appendix A) 
 
Handedness will be determined for all participants using the Edinburgh Handedness 
Inventory [Oldfield 1971] (Appendix B) 
 

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8.5 
TCD Assessment  
For all subjects, all assessments will be undertaken in a dedicated cardiovascular research 
laboratory at Leicester Royal Infirmary (LRI), which is at a controlled temperature (20-24⁰C) and is 
free from distraction. Participants will be asked to refrain from heavy meals, strenuous exercise, 
alcohol, smoking and caffeine if possible for four hours prior to attending the research laboratory.  
Baseline brachial casual BP will be measured using a validated UA767 BP monitor.  Beat-to-beat 
non-invasive BP will be recorded continuously using the Finometer cuff device (Finapres Medical 
Systems; Amsterdam, The Netherlands) attached to the middle finger of the right hand which will 
be supported in an arm sling.  R-R interval will be recorded using a 3-lead electrocardiogram 
(ECG). Respiratory rate will be recorded, and end-tidal partial pressure of carbon dioxide (EtCO2) 
will be monitored using small nasal cannulae placed at the base of the nose (Salter Labs, ref 4000) 
attached to a capnograph (Capnocheck Plus) to monitor the breathing. A tilt sensor will be 
attached to the thigh of the participant’s right leg by means of a Velcro strap to measure the 
efficiency and angle of the squatting motion.  Simultaneous bilateral insonation of the middle 
cerebral arteries (MCAs) will be performed using TCD with 2MHz probe using a DWL Doppler box, 
with the subject either sitting or lying supine on a couch (in the case of difficult to insonate 
windows). The vessels will be located via the temporal bone window, and identified as the MCAs 
by their waveform, depth, velocities, and direction of flow. All parameters will be simultaneously 
recorded onto a computer software system (PHYSIDAS), providing data for subsequent off-line 
analysis.  A head frame will be used to secure the ultrasound probes in position and to minimise 
their movement. Once satisfactory signals have been obtained, four recordings will be made: 
1) A 5 minute baseline recording during which the participant sits quietly with their 
eyes open 
2) A 6 minute recording during which the participant sits for 1 minute before 
standing and remaining standing quietly with their eyes open for 5 minutes 
3) A recording during which the participant is asked to stand for 10 seconds before 
squatting down and remaining in a squat position for 10 seconds before standing 
back up and then repeating this process for 5 minutes.  A computer program will 
provide visual cues to the participant to guide the timings of the squat-stand 
sequence.  As each squat manoeuvre (consisting of a squat down and stand back 
up) will last for 20 seconds, the participant will be required to perform a total of 
15 squats in the 5 minute period.  This recording will begin and end with a period 
of 90 seconds baseline recording where the participant stands quietly with their 
eyes open.  

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A period of instruction will precede recording 3 during which the SSM will be demonstrated.  
During squats, participants will be asked to breathe through their nose and to avoid straining if 
possible.  Participants will be instructed to squat down as low as they feel able.  They will be 
informed that they will need to perform a maximum 15 squats and to take this into account when 
choosing their depth.  Participants will be informed that they should try to complete all 15 squats if 
possible.  However, if they wish to stop the SSM before this, they should make the investigator 
aware during a standing period and ideally remaining standing for a further 90 seconds before 
being disconnected from the equipment. 
During the recordings the internal plethysmography servo-adjust of the Finometer will be switched 
off, but this will be switched back on in between each recording to allow for accurate calibration of 
BP.  A brachial BP will also be taken in between each recording using the same validated UA767 BP 
monitor as at the beginning of the baseline assessment. 
Participants will be allowed to rest for as long as needed before leaving the laboratory at the end of 
the study measurement.  Refreshments will be provided, and travel expenses will be refunded. 
There is a very small chance that the 3 lead ECG could detect a heart abnormality (arrhythmia) in 
either the healthy controls or the patient participants. Should this situation occur, we would 
explain our findings to the participant and notify their GP.  Formal written consent will be obtained 
to cover this circumstance.   
 
 8.6 
Definition of End of Trial 
The end of trial is the date of the last visit of the last participant.  
 
8.7 
Discontinuation/Withdrawal of Participants from Study Treatment  
As detailed in section 8.3, if the participant is found to have inadequate acoustic windows, then 
they will be unable to participate in the study any further.  They will therefore be recorded as a 
screen failure and withdrawn from the study.   
Furthermore, each participant has the right to withdraw from the study at any time and without 
giving a reason.  
In addition, the investigator may discontinue a participant from the study at any time if the 
investigator considers it necessary for any of the following reason: 
 
An inability to comply with study procedures 

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 
Significant protocol deviation 
 
Consent withdrawn 
All of the above will be recorded in the case report form (CRF). 
 
 
8.8  
Source Data 
Source documents are original documents, data, and records from which participants’ CRF data are 
obtained. These include, but are not limited to, hospital records (from which medical history and 
previous and concurrent medication may be summarised into the CRF), clinical and office charts, 
laboratory and pharmacy records, diaries, microfiches, radiographs, and correspondence. Medical 
records will be used as source documents for the TIA participants.  
CRF entries will be considered source data if the CRF is the site of the original recording (e.g. there 
is no other written or electronic record of data).  The CRF will therefore be considered the  source 
document for the healthy control participants. 
All documents will be stored within a locked filing cabinet, within a locked office in an access 
restricted University of Leicester site. On all study-specific documents, other than the signed 
consent, the participant will be referred by the study participant number/code, not by name.  
 

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9. 
TREATMENT OF TRIAL PARTICIPANTS 
9.1 
  
Storage of Study Equipment of Related Apparatus 
All study specific equipment is stored securely in the CHIASM laboratory and maintained 
annually by the Medical Physics department at University Hospitals of Leicester NHS Trust.   
9.2  
 
Clinical Care 
Throughout the study, TIA patients will continue to receive standard clinical care, which 
includes (but is not limited to): specialist multi-disciplinary assessment, further radiological 
investigations, and appropriate investigation and secondary prevention interventions 
(including antithrombotic/ anticoagulant, BP-lowering and cholesterol-lowering therapies).  
 
 
 

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10. 
SAFETY REPORTING  
10.1  Definitions 
Adverse Event (AE) 
An AE or adverse experience is: 
Any untoward medical occurrence in a patient or clinical investigation participant, which 
does not necessarily have to have a causal relationship with his/her treatment.  
An AE can therefore be any unfavourable and unintended sign (including an abnormal 
laboratory finding), symptom or disease temporally associated with the study, whether or 
not considered related to the study.  
 
Adverse Reaction (AR) 
All untoward and unintended responses related to the study.  
All cases judged by either the reporting medically qualified professional or the sponsor as 
having a reasonable suspected causal relationship to the study qualify as adverse reactions.  
 
Severe Adverse Events (SAE) 
To ensure no confusion or misunderstanding of the difference between the terms “serious” 
and “severe”, which are not synonymous, the following note of clarification is provided: 
The term “severe” is often used to describe the intensity (severity) of a specific event (as in 
mild, moderate, or severe myocardial infarction); the event itself, however, may be of 
relatively minor medical significance (such as severe headache). This is not the same as 
“serious”, which is based on patient/event outcome or action criteria usually associated 
with events that pose a threat to a participant’s life or functioning. Seriousness (not 
severity) serves as a guide for defining regulatory reporting obligations.  
 
Serious Adverse Event or Serious Adverse Reaction (SAR) 
A serious adverse event or reaction is any untoward medical occurrence that: 
 
Results in death 
 
Is life-threatening 

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NOTE: The term "life-threatening" in the definition of "serious" refers to an event in which the 
participant was at risk of death at the time of the event; it does not refer to an event which 
hypothetically might have caused death if it were more severe. 
 
Requires inpatient hospitalisation or prolongation of existing hospitalisation 
 
Results in persistent or significant disability/incapacity, or 
 
Is a congenital anomaly/birth defect 
 
Other important medical events* 
*Other events that may not result in death, are not life threatening, or do not require 
hospitalisation, may be considered a serious adverse event when, based upon appropriate medical 
judgement, the event may jeopardise the patient and may require medical or surgical intervention 
to prevent one of the outcomes listed above. 
 
 
Expected Serious Adverse Events/Reactions 
See Appendix D for a complete list of expected adverse events not subject to immediate reporting. 
 
Suspected Unexpected Serious Adverse Reactions (SUSAR) 
A serious adverse reaction, the nature or severity of which is not consistent with the applicable 
product information. 
 
10.2   Reporting procedures for All Adverse Events 
All AEs occurring during the study observed by the investigator or reported by the participants, 
whether or not attributed to study, will be recorded on the CRF. 
The following information will be recorded: description, date of onset and end date, severity, 
assessment of relatedness to study, other suspect device and action taken.  Follow-up information 
should be provided as necessary.  
AEs considered related to the study as judged by a medically qualified investigator or the sponsor 
will be followed until resolution or the event is considered stable.  All related AEs that result in a 
participant’s withdrawal from the study or are present at the end of the study, should be followed 
up until a satisfactory resolution occurs. 

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It will be left to the investigator’s clinical judgment whether or not an AE is of sufficient severity to 
require the participant’s removal from the study. A participant may also voluntarily withdraw from 
the study due to what he or she perceives as an intolerable AE.   
The severity of events will be assessed on the following scale:  1 = mild, 2 = moderate, 3 = severe.   
The relationship of AEs to the study will be assessed by a medically qualified investigator.  
 
10.3   Reporting Procedures for Serious Adverse Events 
 
 
 
All SAEs, except those expected ones defined in Appendix D that do not require immediate 
reporting (see Appendix D), must be reported to the Sponsor within 24 hours of discovery or 
notification of the event.  The Sponsor will perform an initial check of the information and ensure 
that it is reviewed at the next R&D Management meeting.  All SAE information must be recorded 
on an SAE form and sent to the Sponsor using the appropriate reporting form and the contact 
details on there. Additional information received for a case (follow-up or corrections to the 
original case) needs to be detailed on a new SAE form which must be sent to the Sponsor using 
the appropriate reporting form and the contact details on there.  
The Sponsor will report all SUSARs to the Research Ethics Committee concerned. Fatal or life-
threatening SUSARs must be reported within 7 days and all other SUSARs within 15 days. The CI 
will inform all investigators concerned of relevant information about SUSARs that could adversely 
affect the safety of participants. 
In addition to the expedited reporting above, the CI shall submit once a year throughout the study 
or on request an Annual Report to the Ethics Committee which lists all SAEs / SUSARs that have 
occurred during the preceding 12 months. 
 
 
 
 
 
 

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11. 
STATISTICS 
11. 1 Statistical analysis 
The null hypotheses being tested are: 
 cerebral haemodynamic parameters, including CBFv and ARI, do not differ between 
baseline recordings and during performance of squat-stand manoeuvres 
 cerebral haemodynamic parameters, including CBFv and ARI, do not differ between TIA 
patients and HC 
 
All data will be tested for normality prior to statistical testing using Shapiro-Wilks.  Categorical data 
will be reported as absolute number and percentages. Continuous data will be plotted and assessed 
for normality; normally distributed continuous variables will be described as mean (SD) and 
continuous variables with skewness as median (IQR).   Statistical testing for differences between HC 
and TIA groups will be by two-way ANOVA for continuous, parametric data, Friedman 2 way 
analysis of variance for continuous, non-parametric data, and Chi-Square for nominal data. 
Data will be recorded in Microsoft Excel. Statistical analyses will be performed using the latest 
versions of SPSS for Windows or Statistica, and graphs will be produced using the latest version of 
Statistica. 
 
11.2   Sample size calculation 
A formal sample size calculation was not possible for this study therefore a realistic number of 
participants has been selected based on previous experience of similar research studies by Dr 
Haunton, Professor Robinson and Professor Panerai.  
Brodie FG et al reported in 2009 that a sample of 11 patients per group will allow the detection of a 
difference in ARI of 2 units between groups, with 80% power at the 5% significance level.   
 
11.3 The Level of Statistical Significance 
 
Statistical significance will be set at p<0.05 
 

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11.4 Procedure for Accounting for Missing and Unused Data 
Unused data will be reported, with reasons in the final report after study completion, and in any 
publication. Spurious and missing data will be reported, but not included in final analyses. 
 
 

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12. 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS  
Direct access will be granted to authorised representatives from the Sponsor, host institution and 
the regulatory authorities to permit trial-related monitoring, audits and inspections. 

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13. 
QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES 
  
The study will be conducted in accordance with the current approved protocol, ICH GCP, relevant 
regulations and standard operating procedures. 
The University of Leicester operate a risk based monitoring and audit programme to which this 
study will be subject. 

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14. 
CODES OF PRACTICE AND REGULATIONS  
14.1     Ethics 
All informed consent taken from TIA patients and HC subjects will be taken following GCP 
guidelines.   
 
14.2  Sponsor Standard Operating Procedures 
All relevant Sponsor SOPs will be followed to ensure that this study complies with all relevant 
legislation and guidelines. 
 
14.3    Declaration of Helsinki 
The Investigator will ensure that this study is conducted in full conformity with the current revision 
of the Declaration of Helsinki (last amended October 2000, with additional footnotes added 2002 
and 2004). 
 
14.4  ICH Guidelines for Good Clinical Practice 
The Investigator will ensure that this study is conducted in full conformity with relevant regulations 
and with the ICH Guidelines for Good Clinical Practice (CPMP/ICH/135/95) July 1996. 
 
14.5 Approvals 
Once Sponsor authorisation has been confirmed, the protocol, informed consent form, participant 
information sheet and any proposed advertising material will be submitted to an appropriate 
Research Ethics Committee (REC), Health Research Authority (HRA),  and host institution(s) for 
written approval.   
 
Once Sponsor authorisation has been confirmed, the Investigator will submit and, where necessary, 
obtain approval from the above parties for all substantial and non-substantial amendments to the 
original approved documents.    
 
 
14.6  Participant Confidentiality 
The trial staff will ensure that the participants’ anonymity is maintained.  The participants will be 
identified only by initials and a participants ID number on the CRF and any electronic database.  All 
documents will be stored securely and only accessible by trial staff and authorised personnel. The 

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study will comply with the Data Protection Act which requires data to be anonymised as soon as it 
is practical to do so.   

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15. 
DATA HANDLING AND RECORD KEEPING 
 15.1   Data Extraction 
As supportive evidence of the diagnosis of TIA in TIA participants, results and significant findings 
from Computerised Tomography (CT) head/Brain Magnetic Resonance Imaging (MRI) and Carotid 
Ultrasound, if undertaken, will be recorded on the CRF. 
Other information which will be extracted from the medical notes of TIA participants and recorded 
on the CRF include smoking status, capillary blood glucose, medications, past medical history, 
height, weight and BMI. 
The medical notes of healthy control participants will not be reviewed, and participants will instead 
be asked their smoking status, medications, past medical history, height and weight directly.  
Answers to these questions will be recorded on the CRF. 
Data regarding participants’ age, date of birth, ethnicity and handedness will also be recorded onto 
the CRF.  All other parameters, including CBFv, squat angle, heart rate (HR), BP, and ETCO2, will be 
recorded onto a computer system (PHYSIDAS), providing data for subsequent analyses. 
 
 15.2 Data Analysis 
Off-line analyses will be undertaken using software designed by the University of Leicester’s 
Medical Physics Group.  
 
 
15.3 Data Management 
Baseline and demographic data will be recorded on the CRF, which will be retained in the study site 
file. This will be stored within a locked filing cabinet, within a locked office in a building which 
requires swipe card or security review for access at the University of Leicester.  CRF data will be 
anonymised for storage on a secure drive on encrypted, password protected, university desktop 
computers.   
Personal data that cannot be anonymised (e.g. contact details and enrolment logs) will be stored 
within a locked filing cabinet, within a locked office in a building which requires swipe card or 
security review for access at the University of Leicester and/or within a password protected file, on 
an encrypted, password protected, desktop computer which is kept within a locked office.  No 
personal data will be accessed or stored on personal laptops. 
 

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All physiological parameters (signals) that are collected during the measurement will be saved using 
a coded filename. The participant name and other identifying detail will NOT be included in any 
study data electronic file. All study data will be entered into Microsoft Excel for Windows on an 
encrypted, password protected, desktop computer which is kept within a locked office. . 
Anonymised outcome data will be held on an encrypted, password protected desktop computer 
which is kept within a locked office.  Anonymised outcome data may also be held on an encrypted, 
password protected personal laptop belonging to researchers named on the authorisation log.  
Participants will be identified by a study specific participants number and/or code in any database.  
Names and any other identifying detail will NOT be included in any study data electronic file. 
Anonymised research data may be shared with researchers from other Departments or Universities 
conducting similar research.  Information regarding this will be detailed in the PIS, and explicit 
written consent for the sharing of such data will be obtained from participants. 

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16. 
STUDY GOVERNANCE 
The trial management group, which consists of the CI, co-investigators, and other research 
staff, will meet monthly to monitor study progress, and recruitment targets. As this is a 
prospective case control study, and not a therapeutic study, a data safety monitoring 
committee is not required.  
 
 
 

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17. 
FINANCING AND INSURANCE 
In this study Dr Haunton and Professor Robinson will supervise the researcher who is responsible 
for participant recruitment, data collection and analysis. Dr Haunton will take a lead role in 
preparing the experimental procedures and then guiding participant recruitment.  Professor 
Panerai will supervise data analysis and will also have a key role in the interpretation of results. 
In this study, the assessments on participants will be carried out by the researcher, and all the 
equipment to be used is provided, serviced and maintained by the Department of Medical Physics, 
University of Leicester.  
 
There are no NHS treatment or support costs. 

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18. 
PUBLICATION POLICY 
On all publications, the host institution will be acknowledged, and each author will be required to disclose 
details of their own involvement/contribution in the study (specific publication).  
 
 

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19. 
REFERENCES 
 
Aaslid R, Markwalder TM, Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity 
in basal cerebral arteries. J.Neurosurg. 1982;57:769-74 
 
Aaslid R, Lindegaard KF, Sorteberg W et al. Cerebral autoregulation dynamics in humans. Stroke 1989; 20: 
45-52 
 
Aries MJ, Elting JW, De Keyser J, et al.  Cerebral autoregulation in stroke: a review of transcranial Doppler 
studies.  Stroke 2010; 41(11):2697-704.  
 
Atkins ER, Brodie FG, Rafelt SE et al. Dynamic Cerebral Autoregulation Is Compromised Acutely following 
Mild Ischaemic Stroke but Not Transient Ischaemic Attack Cerebrovasc Dis 2010; 29: 228–235 
 
Barnes SC, Ball N, Panerai RB et al.  Random squat/stand maneuvers: a novel approach for assessment of 
dynamic cerebral autoregulation?  J Appl Physiol 2017; 123(3): 558-566.  
 
Barnes SC, Ball N, Haunton VJ et al.  How many squat-stand manoeuvres to assess dynamic cerebral 
autoregulation?  Eur J Appl Physiol. 2018 [Epub ahead of print] doi: 10.1007/s00421-018-3964-2.  
 
Brodie FG, Atkins ER, Robinson TG et al.  Reliability of dynamic cerebral autoregulation measurement using 
spontaneous fluctuations in blood pressure.  Clin Sci (Lond). 2009; 116(6): 513-20  
 
Chiu C, Yeh S, Liau B. Assessment of CA dynamics in diabetics using time-domain cross-correlation analysis. 
J Med Biol Eng 2005; 25: 53–59 
 
Claassen JAHR, Levin BD, Zhang R.  Dynamic cerebral autoregulation during repeated squat-stand 
maneuvers.  J Appl Physiol 2009a; 106: 153-160 
 
Claassen JA, Diaz-Arrastria R, Martin-Cook K et al. Altered cerebral hemodynamics in early Alzheimer 
disease: a pilot study using transcranial Doppler. J Alzheimer’s Dis 2009b; 17(3): 621–629 
 
Claassen JAHR, Zhang R. Cerebral autoregulation in Alzheimer's disease. J Cereb Blood Flow Metab 2011;   
31(7): 1572-1577 
 
Claassen JA, Meel-van den Abeelen AS, Simpson DM et al. Transfer function analysis of dynamic cerebral 
autoregulation: A white paper from the International Cerebral Autoregulation Research Network.  J Cereb 
Blood Flow Metab 2016; 36(4): 665-80 
 
Coull AJ, Lovett JK, Rothwell PM.  Population based study of early risk of stroke after transient ischaemic 
attack or minor stroke: implications for public education and organisation of services. BMJ 2004; 328: 326 
 
Czosnyka M, Smielewski P, Kirkpatrick P et al. Monitoring of cerebral autoregulation in head-injured 
patients. Stroke 1996; 27: 1829-1834 
 

CONFIDENTIAL 
Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
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Eames PJ, Blake MJ, Dawson SL et al. Dynamic cerebral autoregulation and beat to beat blood pressure 
control are impaired in acute ischaemic stroke. J Neurol Neurosurg Psych 2002; 72: 467-472 
 
Easton JD, Saver JL, Albers GW et al.Definition and evaluation of transient ischemic attack: a scientific 
statement for healthcare professionals from the American Heart Association/American Stroke Association 
Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and 
Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular 
Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for 
neurologists.  Stroke 2009; 40(6): 2276-93.  
 
Giller CA. The frequency-dependent behavior of cerebral autoregulation. Neurosurgery 1990; 27: 362-368 
 
Haunton, VJ. (2013). Cerebral autoregulation in idiopathic Parkinson's disease.  MD Thesis.  University of 
Leicester, UK.  Available at http://hdl.handle.net/2381/28752 
 
Itoh T, Matsumoto M, Handa N et al.  Rate of successful recording of blood flow signals in the middle 
cerebral artery using transcranial Doppler sonography. Stroke 1993; 24: 1192–1195 
 
Itoh Y, Suzuki N. Control of brain capillary blood flow.  J Cereb Blood Flow Metab  2012; 32: 1167 – 76 
 
Kontos HA, Wei EP, Navari RM et al. Responses of cerebral arteries and arterioles to acute hypotension and 
hypertension. Am J Physiol 1978; 234: H371-H383. 
 
Kuga N, Hirata T, Sakai I et al. Rapid and local autoregulation of cerebrovascular blood flow: a deep-brain 
imaging study in the mouse. J Physiol 2009; 587(4): 745–752 
 
Lassen NA. Cerebral blood flow and oxygen consumption in man. Physiol Rev 1959; 39: 183-238 
 
Llwyd O, Salinet ASM, Panerai RB et al.  Cerebral Haemodynamics following Acute Ischaemic Stroke: Effects 
of Stroke Severity and Stroke Subtype.  Cerebrovasc Dis Extra. 2018; 8(2): 80-89.  
 
Marinoni M, Ginanneschi A, Forleo P et al.  Technical limits in transcranial Doppler recording: Inadequate 
acoustic windows.  Ultrasound Med Biol 1997; 23: 1275–1277 
 
Musthak A, Dimassi D, Akhtar N et al.  Cerebral blood flow and auto-regulation in acute TIA patients from a 
general hospital in Qatar. Neurology  2017; 88 (16S) 
 
Oldfield, R. C. The assessment and analysis of handedness: The Edinburgh inventory. Neuropsychololgia 
1971; 9: 97-113. 
 
Office of National Statistics Final recommended questions for the 2011 Census in England and Wales 
https://www.ethnicity-facts-figures.service.gov.uk/ethnicity-in-the-uk/ethnic-groups-and-data-collected 
 
Oudegeest-Sander MH1, van Beek AH, Abbink K et al.  Assessment of dynamic cerebral autoregulation and 
cerebrovascular CO2 reactivity in ageing by measurements of cerebral blood flow and cortical oxygenation. 
Exp Physiol 2014; 99(3): 586-98 
 

CONFIDENTIAL 
Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
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Reinhard M, Roth M, Muller T et al. Effect of carotid endarterectomy or stenting on impairment of dynamic 
cerebral autoregulation. Stroke 2004; 35: 1381-1387 
 
Rothwell, P, Coull AJ, Silver LE et al.  Population-based study of event-rate, incidence, case fatality, and 
mortality for all acute vascular events in all arterial territories (Oxford Vascular Study). Lancet 2005; 366: 
1773-1783  
 
Rothwell PM, Giles MF, Chandratheva A et al. Effect of urgent treatment of transient ischaemic attack and 
minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential 
comparison. Lancet 2007; 370(9596): 1432-1442.  
 
Smirl JD, Haykowsky MJ, Nelson MD et al. Relationship between cerebral blood flow and blood pressure in 
long-term heart transplant recipients.  Hypertension 2014; 64(6): 1314-20 
 
Smirl JD, Hoffman K, Yu-Chieh Tzeng et al.  Methodological comparison of active- and passive-driven 
oscillations in blood pressure; implications for the assessment of cerebral pressure-flow relationships.  J 
Appl Physiol 2015; 119: 487–501 
 
Tiecks FP, Lam AM, Aaslid R et al. Comparison of static and dynamic cerebral autoregulation 
measurements. Stroke 1995; 26: 1014-1019 
 
Van Beek A, Claasen J, Rikkert M et al. Cerebral autoregulation: an overview of current concepts and 
methodology with special focus on the elderly. J Cereb Blood Flow Metab 2008; 28: 1071-1085 
 
van Veen TR, Panerai RB, Haeri S et al.  Cerebral autoregulation in normal pregnancy and preeclampsia.  
Obstet Gynecol 2013; 122(5): 1064-9 

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Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
Study Protocol V1.0_20/02/2019 
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20. 
APPENDIX A: CATEGORISATION OF ETHNICITY 
 
White 
1. English / Welsh / Scottish / Northern Irish / British 
2. Irish 
3. Gypsy or Irish Traveller 
4. Any other White background, please describe 
 
Mixed / Multiple ethnic groups 
5. White and Black Caribbean  
6. White and Black African 
7. White and Asian  
8. Any other Mixed / Multiple ethnic background, please describe  
 
Asian / Asian British 
9. Indian 
10. Pakistani 
11. Bangladeshi 
12. Chinese 
13. Any other Asian background, please describe 
 
Black / African / Caribbean / Black British 
14. African  
15. Caribbean 
16. Any other Black / African / Caribbean background, please describe 
 
Other ethnic group  
17. Arab  
18. Any other ethnic group, please describe 

CONFIDENTIAL 
Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
Study Protocol V1.0_20/02/2019 
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21. 
APPENDIX B: EDINBURGH HANDEDNESS INVENTORY 
Please indicate with a check () your preference in using your left or right hand in the following tasks. 
Where the preference is so strong you would never use the other hand, unless absolutely forced to, put 
two checks ().  
If you are indifferent, put one check in each column (   |  ). 
Some of the activities require both hands. In these cases, the part of the task or object for which hand 
preference is wanted is indicated in parentheses. 
Task / Object 
Left Hand 
Right Hand 
1. Writing 
 
 
2. Drawing 
 
 
3. Throwing 
 
 
4. Scissors 
 
 
5. Toothbrush 
 
 
6. Knife (without fork) 
 
 
7. Spoon 
 
 
8. Broom (upper hand) 
 
 
9. Striking a Match (match) 
 
 
10.  Opening a Box (lid) 
 
 
Total checks: 
LH =  
RH =  
Cumulative Total 
CT = LH + RH =  
Difference 
D = RH – LH =  
Result 
R = (D / CT)  100 =  
Interpretation: 
(Left Handed: R < -40) 
(Ambidextrous: -40  R  +40) 
(Right Handed: R > +40) 
 
 

CONFIDENTIAL 
Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
Study Protocol V1.0_20/02/2019 
Page 42 of 43 
 
22. 
APPENDIX C: SCHEDULE OF PROCEDURES 
 
 
 
PROCEDURES 
VISIT 
Screening 
 
Baseline 
Informed consent 
0 
1 
Demographics 
1 
1 
Medical history 
1 
1 
Concomitant medications 
1 
1 
Eligibility assessment 
1 
0 
Ethnicity categorisation 
0 
1 
Handedness 
0 
1 
Cerebral Haemodynamic 
Assessment (TCD, blood 
pressure, ECG, ETCO2) 
0 
1 
 

CONFIDENTIAL 
Cerebral Haemodynamics in Transient Ischaemic Attack, IRAS no: 222960 
Study Protocol V1.0_20/02/2019 
Page 43 of 43 
 
23. 
APPENDIX D: EXPECTED EVENTS NOT SUBJECT TO EXPEDITED REPORTING 
 
 
Acute Coronary Syndromes 
Malignancy 
Agitation 
Myocardial infarction 
Angina 
Nausea 
Anorexia 
Personality change 
Anxiety 
Peripheral Vascular Disease 
Cognitive decline 
Pressure sores 
Constipation 
Renal impairment 
Delirium 
Sedation 
Depression 
Seizure 
Disease progression 
Sexual dysfunction 
Dysphagia 
Sleep disturbance 
Electrolyte disturbance 
Stroke 
Fall 
Syncope 
Fatigue 
Transient ischemic attack 
Fracture 
Urinary retention/catheterisation 
Gastrointestinal disturbance 
Urinary tract infection 
Hallucinations 
Ulceration 
Heart failure 
Violent behaviour 
Incontinence, faecal 
Visual loss 
Incontinence, urinary 
Vomiting 
Infections 
Wandering 
Institutionalisation / Admission to care home 
Weakness 
Intracerebral Haemorrhage 
Weight loss 
Loss of ability to function or care for self