Transcranial Electrical Stimulation in Stroke EaRly After Onset Clinical Trial
Phase: NA
Conditions: Stroke, Acute
Sponsor: University of California, Los Angeles

1 
Study Protocol 
Transcranial electrical Stimulation in Stroke EaRly After onset Clinical Trial 
(TESSERACT) 
Version 1.6 (Revised on 
1/12/21 and approved on 
1/22/21)
NCT03574038

6/7/23, 9:22 AM
webirb.research.ucla.edu/WEBIRB/Doc/0/8C9NI8BA5FA4RAJCKL5FDAOT90/fromString.html
https://webirb.research.ucla.edu/WEBIRB/Doc/0/8C9NI8BA5FA4RAJCKL5FDAOT90/fromString.html
1/3
 
 
University of California Los Angeles
10889 Wilshire Blvd, Suite 830
Los Angeles, CA 90095-1406
http://ora.research.ucla.edu/ohrpp
General Campus IRB: (310) 825-7122
Medical IRB: (310) 825-5344
 
 
 
APPROVAL NOTICE
 
 
Conducting Research During the COVID-19 Public Health Outbreak: Please review the information provided on
the UCLA Research Ramp Up website to determine whether any current Policy may affect this IRB approved or
exempt study. https://www3.research.ucla.edu/research-ramp-up Information includes (a) an overview of the ramp-
up process, (b) health and safety guidelines, and (c) appendices describing requirements for different types of
research.
 
DATE:
1/22/2021
TO:
MERSEDEH BAHR-HOSSEINI, MD 
NEUROLOGY 
FROM:
JAMES MC GOUGH, MD
Chair, MIRB3
RE:
IRB#18-000421-AM-00009  
Broadening the exclusion criteria, minor revisions of the protocol and informed
consent form
Transcranial Electrical Stimulation in Stroke EaRly After onset Clinical Trial
(TESSERACT)
Version: v1.5, 6/13/2019  
 
The UCLA Institutional Review Board (UCLA IRB) has approved the above-referenced study.  UCLA's Federalwide Assurance
(FWA) with Department of Health and Human Services is FWA00004642.
Submission and Review Information
Type of Submission
Amendment
Type of Review
IRB Review: Expedited 
Approval Date
1/22/2021
Expiration Date of the Study
3/25/2021
Funding Source(s)
1) AMERICAN HEART ASSOCIATION - NATIONAL
    Grant PI: MERSEDEH BAHR-HOSSEINI
    Grant Title: Developing transcranial direct current

6/7/23, 9:22 AM
webirb.research.ucla.edu/WEBIRB/Doc/0/8C9NI8BA5FA4RAJCKL5FDAOT90/fromString.html
https://webirb.research.ucla.edu/WEBIRB/Doc/0/8C9NI8BA5FA4RAJCKL5FDAOT90/fromString.html
2/3
stimulation as a novel neuroprotective method in acute
ischemic stroke
    Grant Number: 18CDA34110160
 
Initial IRB Approval Type
Full Board
Specific Conditions for Approval
 
-- Translations Needed - Please submit translated copies of your consent documents
as an amendment(s) before recruiting or consenting any subjects for whom these
translations are required. Be sure and provide subjects with the appropriately
translated Research Participant's Bill of Rights. Numerous translations are available
for download on the HRPP website at http://www.ohrpp.research.ucla.edu/pages/bill-
of-rights.
-- Research Participants Bill of Rights - By California law, a copy of the Research
Participants Bill of Rights in a language in which the participant is fluent must be given
to all research participants in this study as there is a real or foreseeable risk of
biomedical harm. Numerous translations are available for download on the HRPP
website at http://ora.research.ucla.edu/OHRPP/Pages/BillofRights.aspx .
Regulatory Determinations
-- Waiver of Informed Consent - The UCLA IRB waived the requirement for informed
consent under 45 CFR 46.116(d) for the no direct contact portion of the study (screen
failure data).
-- Waiver of Informed Consent - The UCLA IRB waived the requirement for informed
consent under 45 CFR 46.116(d) for medical record review to identify potential
subjects.
-- Surrogate Consent - The UCLA IRB approved the use of surrogate consent in an
emergency setting in accordance with CA Health & Safety Code 24178.
-- Medical Device - Significant Risk - The UCLA IRB determined that the medical
device being used in this study is a significant risk device [21CFR812.3(m)] and the
regulations at 21CFR812 must be followed.
-- Surrogate Consent - The UCLA IRB approved the use of surrogate consent in a
non-emergency situation in accordance with CA Health & Safety Code 24178.
-- HIPAA General Waiver - The UCLA IRB waived the requirement for HIPAA
Research Authorization for medical record review to identify potential subjects.
-- HIPAA General Waiver - The UCLA IRB waived the requirement for HIPAA
Research Authorization for the no direct contact portion of the study (screen failure
data).
Currently approved recruitment and/or consent documents:
 
Document Name
Document
Version #
18-000421- TESSERACT-Informed consent-Clean Version-
Jan2021 (1).pdf.pdf
0.01
Important Note:   Approval by the Institutional Review Board does not, in and of itself, constitute approval for the
implementation of this research.  Other UCLA clearances and approvals or other external agency or collaborating institutional
approvals may be required before study activities are initiated.  Research undertaken in conjunction with outside entities, such

6/7/23, 9:22 AM
webirb.research.ucla.edu/WEBIRB/Doc/0/8C9NI8BA5FA4RAJCKL5FDAOT90/fromString.html
https://webirb.research.ucla.edu/WEBIRB/Doc/0/8C9NI8BA5FA4RAJCKL5FDAOT90/fromString.html
3/3
as drug or device companies, are typically contractual in nature and require an agreement between the University and the
entity.
General Conditions of Approval
As indicated in the PI Assurances as part of the IRB requirements for approval, the PI has ultimate responsibility for the
conduct of the study, the ethical performance of the project, the protection of the rights and welfare of human subjects, and
strict adherence to any stipulations imposed by the IRB.
The PI and study team will comply with all UCLA policies and procedures, as well as with all applicable Federal, State, and
local laws regarding the protection of human subjects in research, including, but not limited to, the following:
Ensuring that the personnel performing the project are qualified, appropriately trained, and will adhere to the provisions
of the approved protocol,
Implementing no changes in the approved protocol or consent process or documents without prior IRB approval
(except in an emergency, if necessary to safeguard the well-being of human subjects and then notifying the IRB as
soon as possible afterwards),
Obtaining the legally effective informed consent from human subjects of their legally responsible representative, and
using only the currently approved consent process and stamped consent documents, as appropriate, with human
subjects,
Reporting serious or unexpected adverse events as well as protocol violations or other incidents related to the protocol
to the IRB according to the OHRPP reporting requirements.
Assuring that adequate resources to protect research participants (i.e., personnel, funding, time, equipment and space)
are in place before implementing the research project, and that the research will stop if adequate resources become
unavailable.
Arranging for a co-investigator to assume direct responsibility of the study if the PI will be unavailable to direct this
research personally, for example, when on sabbatical leave or vacation or other absences.  Either this person is
named as co-investigator in this application, or advising IRB via webIRB in advance of such arrangements.

2 
 
 
 
Investigational Plan:  
Protocol: Transcranial electrical Stimulation in Stroke EaRly After onset Clinical 
Trial (TESSERACT) 
 
 
Overview of Protocol of TESSERACT 
 
Title  
Transcranial electrical Stimulation in Stroke EaRly After 
onset Clinical Trial (TESSERACT) 
Objective 
To evaluate the safety, tolerability, and feasibility, and 
preliminarily explore the potential efficacy, of transcranial 
direct current stimulation (tDCS) as an innovative non- 
invasive neuroprotection technique in acute ischemic 
stroke. 
Study Design  
A single site, sham- controlled, dose escalation study 
Population 
Studied  
24-48 acute ischemic stroke patients from Ronal Regan 
Medical Center (RRMC) Emergency Department or RRMC 
Inpatient hospital with:  
1) New focal neurologic deficit consistent with acute 
ischemic stroke; 2) NIHSS >4; 3) Age >18; 4) Last known 
well time within 24 hours of randomization stimulation 
initiation; 5) ICA or M1 or M2 MCA occlusion on MRA; 6) 
substantial salvageable penumbra on multimodal MRI 
(tissue-at-risk perfusion lesion volume exceeds core 
volume by ≥ 20%); 7) Ineligible for intravenous 
thrombolysis; 8) Ineligible for endovascular thrombectomy; 
9) Signed informed consent obtained from the patient or 
patient’s legally authorized representative.  
Intervention 
3:1 randomization to active treatment vs sham control 
Device  
Transcranial Direct Current Stimulation (tDCS) 

3 
 
A. Specific aims 
   Transcranial direct current stimulation (tDCS) is a non-invasive neuromodulatory technique that 
applies a weak electrical current to the brain via scalp electrodes. tDCS has been investigated in 
a variety of chronic neurological and neuropsychiatric disorders such as depression, traumatic 
brain injury and stroke rehabilitation with promising benefits and excellent safety profile.  Notably, 
tDCS has been shown to carry a strong neuroprotective effect in animal models of acute ischemic 
stroke (AIS) due to large vessel occlusion (LVO).  
   Stroke is a leading cause of mortality and morbidity across the world. While endovascular 
therapy (ET) has fundamentally improved outcomes of AIS patients with LVO, patient outcomes 
even with ET remain suboptimal, with only 20-25% achieving a disability-free outcome. 
Complementary neuroprotective, vasoprotective, and collateral enhancement strategies can 
preserve cells and the neurovascular unit until orthograde reperfusion is achieved by ET, 
particularly in AIS patients in whom ET is delayed due to hospital-to-hospital transfer. 
Furthermore, these agents may protect against reperfusion injury, and attenuate secondary injury 
cascades that persist despite reperfusion. Importantly as well, even in the modern thrombectomy 
era, not all patients with LVO are treatable with ET. In some patients with LVOs, ET is not 
technically performable due to unfavorable angioarchitectural features or in other LVO patients, 
the risk of intervention is judged too great, due to the presence of early hemorrhagic 
transformation, temporally advanced or large core infarct, or severe cardiorespiratory 
comorbidities. Therefore, a great need for complementary or standalone therapies exist. While 
many past attempts at developing neuroprotective therapies have been disappointing, the great 
preponderance were pharmacologic agents that affected only one or two molecular ischemic 
pathways and were administered intravenously, reducing delivery to brain areas with low blood 
flow, and, even there, requiring passage through the blood-brain barrier. In contrast, in pre-clinical 
acute ischemic stroke models, tDCS has been shown to have widely pleiotropic neuroprotective 
molecular mechanisms of action and can be delivered to the salvageable ischemic tissue beyond 
the occlusive thrombus despite reduced blood flow. Given the promising results in acute stroke 
models, translational studies to the acute human ischemic stroke patients are needed, beginning 
with a dose-escalation feasibility and safety trial. 
   In this proposal, we will perform a single center, sham-controlled, dose escalation study. 
Cathodal tDCS (C-tDCS) will be delivered to penumbral tissue in patients with large and medium 
vessel occlusions who are not eligible for endovascular thrombectomy, yet harbor substantial 
salvageable penumbra. 
 
Specific Aim I: To establish the safety and tolerability of tDCS in AIS.  
   Hypothesis I-a: tDCS will be safe in AIS patients with no increased risk of symptomatic 
intracranial hemorrhage (SICH) within the 24-hour period after stimulation. Hypothesis I-b: tDCS 
will not increase the rates of asymptomatic intracranial hemorrhage, early neurological 
deterioration (NIHSS during the 24-hour period after stimulation), 90-day mortality, and all serious 
adverse events.  Hypothesis I-c: Majority of AIS patients (≥ 90%) will tolerate the tDCS by 
completing at least 75% of the stimulation period with no major stimulation related pain, discomfort 
and skin changes.  
 
Specific Aim II: To determine the feasibility of delivering tDCS in AIS.  
   Hypothesis II-a: tDCS will be started more rapidly over the course of the study and in the last 
10 patients median time from randomization to tDCS initiation will be ≤ 10 minutes.  
 
Specific Aim III: To explore the potential imaging and clinical efficacy of tDCS in AIS.  
This aim will be accomplished by measuring, in actively treated and sham patients:  
1) Early and late penumbral salvage, defined as proportion of penumbral tissue on baseline 
multimodal MRI that does not proceed to infarct on 2-hour and 24-hour MRI (PWI); 2) Early and 

4 
 
late collateral enhancement, evidenced by reduced perfusion lesion volume on 2-hour and 24-
hour perfusion-weighted MRI (PWI); 3) Early and late reduction in infarct growth from baseline to 
2-hour and 24-hour MRI; 4) Early improvement in neurologic deficit (NIHSS at 24h); 5) 
Improvement in final 3-month disability and quality of life (modified Rankin scale, AMC Linear 
Disability Scale, EQ-5D, and Barthel Index) 
 
Impact  
   This in-hospital safety trial, in non-thrombectomy candidates in a closely-observed, Emergency 
Department and hospital settings, will identify tDCS dose regimens that are feasible, well-
tolerated, and preliminarily safe in patients with acute ischemic stroke. Study finding will identify 
the most promising dose regimens to advance to phase 2b and pivotal phase 3 efficacy trials for 
two patient populations with pressing need for improved therapies: 1) thrombectomy ineligible 
patients (standalone neuroprotection), and 2) thrombectomy-eligible patients (bridging 
neuroprotection in prehospital and early ED-arriving patients).   
 
B. Background and Significance  
   Stroke is a devastating condition and continues to be a leading cause of adult death 
and disability.1 Current therapeutic strategies for AIS focus on timely restoration of blood 
flow by recanalization of the occluded artery to salvage penumbral tissue, using 
pharmacologic fibrinolysis and/or endovascular thrombectomy (ET).2,3 However, the 
reperfusion strategy has limitations that would be aided by a neuroprotective intervention. 
An important minority of early-arriving patients are ineligible for both IV tPA (due to lytic 
contraindications) and ET (due to difficult vascular access, large core, peripheral target 
occlusion beyond catheter reach in patients with medium vessel occlusion (MVO)). Other 
patients are non-responders: IV tPA only achieves reperfusion in only 15-40 percent of 
large vessel occlusions (LVOs); ET fails to achieve substantial reperfusion in 20-30%. 
Furthermore, even among reperfusing patients, rates of excellent outcome are low, only 
20-25% mRS 0-1, due to infarct growth prior to, and following reperfusion. 4-6 Therefore, 
even in the modern stent retriever era, the need to develop additional therapies exists. 
Neuroprotective therapies interrupt the cellular, biochemical and metabolic process that 
mediate hypoxic and reperfusion cellular injury. Neuroprotective therapies could serve as 
alternative treatments for patients who harbor salvageable penumbra in whom 
reperfusion therapies are contra-indicated or have failed, and as early bridging therapy in 
pre-reperfusion patients, preserving more viable penumbra to rescue intervention by 
reperfusion. While multiple candidate neuroprotective agents have failed in translation 
from animal to human studies, important lessons have been learned.7,8 Two intervention 
properties that offer greater prospect of success are: 1) pleiotropic effects, interdicting 
multiple pathways in the ischemic cascade, and 2) delivery by a direct transcranial, rather 
than intravascular, route, with fast and direct delivery to neural tissues regardless of 
cerebral perfusion. Transcranial direct current stimulation (tDCS) offers promise as just 
such an approach. Furthermore, few trials of neuroprotection in human have used 
penumbral imaging for patient selection 9 and importantly, the recent trials of 
thrombectomy in late-arriving patients have shown a significant benefit from 
recanalization therapy in patients with a salvageable penumbra despite their late 
presentation from last known well time. 10,11Therefore, the use of penumbral imaging to 
limit the patient selection to those for whom the intervention is most likely to be of benefit 
is crucial in studies of neuroprotection and our study utilizes such an approach.  

5 
 
   tDCS is a non-invasive neuromodulation method that delivers a weak electrical current 
to the brain via scalp electrodes.12 Rather than directly eliciting a neuronal response, 
tDCS modulates neuronal excitability in regions of the brain depending on the polarity of 
stimulation. By altering the resting membrane potential cathodal tDCS (C-tDCS) reduces 
neuronal excitability [in contract to anodal tDCS (A-tDCS) which increases excitability]. 
13,14 tDCS has been extensively investigated in humans for decades, as a 
neuromodulatory intervention to treat depression and diverse other neuropsychiatric 
disorders, as a neuroplasticity-enhancing intervention for chronic stroke patients, and as 
a tool to change cognition and behavior in healthy individuals. 15-18Thus far, tDCS has 
been found safe and tolerable with no reported serious adverse events across multiple 
clinical and preclinical studies. 19,20 In addition to these established applications of tDCS, 
tDCS is of substantial promise for acute cerebral ischemia, based on preclinical studies. 
In pre-clinical studies, multiple investigators in several independent labs worldwide have 
found evidence of a neuroprotective effect of tDCS in different animal models of acute 
cerebral ischemia (table 1):  
B.1. Proposed neuroprotective mechanisms of tDCS based on experimental pre-
clinical models of acute cerebral ischemia  
B.1.1. Inhibition of peri-infarct excitatory depolarizations 
   During the acute stages of cerebral ischemia, an excitotoxic cascade will be triggered 
by the excess glutamate and other excitotoxic amino acids that are released as the result 
of cellular necrosis.21 Experimental models of acute middle cerebral artery occlusion 
(MCAO) have shown that the excitotoxicity generates recurrent spontaneous waves of 
depolarization also known as peri-infarct depolarizations (PIDs).22,23 The PIDs occur soon 
after the MCA occlusion and spread across the penumbra to the normally perfused tissue. 
The infarct growth correlates with the number and duration of PIDs and the basis for this 
relationship has been related to: 1) An abnormal vasoconstriction in response to 
depolarization 2) An imbalance between increased metabolic overload, induced by the 
depolarization, and blood supply in acute ischemic stroke.24 Notturno et al. studied the 
effect of C-tDCS on PIDs in 3-vessel occlusion rat stroke model, with cumulative 
stimulation durations of 120 and 180 mins (15' on-15' off cycles).25 They found that C-
tDCS was applied to the ischemic MCA territory significantly reduced PIDs, and reduced  
infarct volume by 20-30%. They found no effect on brain edema between the stimulated 
and sham groups and no tDCS induced macroscopic or microscopic lesion or 
hemorrhagic transformation. 
B.1.2. Anti-inflammatory, Anti-apoptotic, and Angiogenic effect 
  Beyond the activation of the excitotoxic cascade, an inflammatory response and 
programmed cellular apoptosis will result in a secondary damage and expansion of the 
irreversibly damaged core (Figure1). 21 Therefore, suppression of the innate pro-
inflammatory cells and the cellular apoptotic cascade results in the reduction of the 
infarct size and cerebral edema. Peruzzotti et al. studied tDCS in acute stroke mice 
models with MCAO with cathodal hemispheric tDCS applied for 40 minutes (20'on-
20off-20’on). 26 Cathodal stimulation of the ischemic hemisphere reduced final infarct 
size, with lowering of cortical glutamate synthesis, downregulation of N-methyl-D- 
aspartate (NMDA) receptor (NR2B) expression, and reduction in peri-ischemic 
inflammatory response and apoptotic markers.   

6 
 
Furthermore, a significant functional amelioration and improvement of cerebral edema 
were observed even when stimulation was applied hours after the MCAO. No 
macroscopic or microscopic lesion or hemorrhagic transformation induced by tDCS was 
found.  
   Baba et al. showed in their study that a low-frequency (2 and 10 Hz) electrical cortical 
stimulation exerts neuroprotective effects reflecting by attenuation in both necrotic and 
apoptotic cell deaths, blockade of microglial/astrocytic activation and expression of 
trophic factors. They also demonstrated an increase in cerebral blood flow of the 
electrically stimulated animals. 27 No neuroprotective effect was observed at higher 
frequency (50Hz). 
 
 
Figure 1. This schematic shows the events leading to ischemic brain injury. 
 
B.1.4. Preservation of neuronal axons 
   Kim et al. studied the neuroprotective effect of cathodal and anodal tDCS on axons and 
myelin integrity. They delivered tDCS for 30 minutes two days after MCAO. They found 
significant amelioration of axonal damage and preservation of white matter axonal 
integrity in rat models of cerebral ischemia. They demonstrated such effect only after 
anodal stimulation. 28 
B.1.3. Direct vasodilatory effect 
   In addition to the direct neuroprotective effects, tDCS may confer benefit in AIS via 
direct vasodilation and collateral blood flow enhancement. In fact, Fox et al. found a direct 
vasodilatory effect of electrical stimulation when applied over the basilar artery. 29This 
effect was more pronounced with cathodal compared to anodal stimulation. 
 
 

7 
 
 
Study 
authors 
Type 
of 
subjects 
Onset of stim 
following  MC
AO 
Polarity 
and 
location 
of 
the 
center electrode 
Intensity (mA) 
Total Duration 
of stim  
Total N 
Notturno et al 
et. al 
2013 
Rat 
MCAO 
model 
45 min 
Cathode over cortical 
surface 
overlying 
ischemia 
0.2 
(density of 2.86 
mA/cm2)  
120 and 180min 
(alternating 
15’on-15’off) 
48 
Peruzzotti-
Jametti et. al  
2010 
Mice 
MCAO 
model  
30 min  
Cathode or anode 
over cortical surface 
overlying ischemia 
0.25 (density of 
5.5 mA/cm2) 
40min 
(alternating 
20’on-20’off)  
137 
Baba 
et 
al. 
2009 
Rat  MCAO  
Model  
60 min 
Electrode 
over 
cortical 
surface 
overlying ischemia 
0.1 and 0.2 with 
frequencies of 0, 
2, 10, 50 
3 Days or 1 
week  
107 
Kim 
et 
al. 
2010 
Rat 
MCAO 
model 
Day 2 
Cathode or anode 
over cortical surface 
overlying ischemia 
0.1  
30 min daily for 
2 weeks 
61 
Glickstein et. 
al 1999 
  
Rat 
MCAO 
model 
5 days prior to 
MCAO 
Stimulation 
of the 
fastigial nucleus of 
cerebellum 
0.01-0.02 
60min(alternati
ng 1 sec on-1 
sec off) 
98 
Reis et.al 
1997, 1991  
Rat 
MCAO 
model 
Immediately 
after, up to 10 
days prior to 
MCAO 
Cathode 
over 
the 
fastigial nucleus of 
cerebellum 
0.01-0.02 
60min 
99 
Zhang et.al 
1993 
Rat 
MCAO 
model 
3-5 min 
Cathode 
over 
the 
fastigial nucleus of 
cerebellum 
0.07-0.1 
60min 
(alternating 
1 
sec on-1 sec 
off) 
44 
Yamamoto 
et.al 
1993 
Rat 
MCAO 
model 
Immediately 
Cathode 
over 
the 
fastigial nucleus of 
cerebellum 
0.07-0.1  
60min 
(alternating 
1 
sec on-1 sec 
off) 
41 
Burger et. al 
1990 
Rat 
MCAO 
model 
Immediately 
Stimulation 
of the 
fastigial nucleus of 
cerebellum 
Unknown 
60min 
 
Table 1. shows the detailed description of the studies using tDCS as a neuroprotective method.  
 
C. Preliminary studies  
C.1. Experience with transcranial neuromodulation in human subjects 
   Our group at UCLA has extensive experience with transcranial neuromodulation using 
direct electrical and magnetically induced currents in human subjects. Over the past 10 
years, we have performed transcranial neuromodulation in over 500 subjects.30-35 This 
substantial experience provides a firm foundation for undertaking tDCS studies in patients 
with acute ischemic stroke. 
C.2. A meta-analysis of preclinical studies using tDCS as neuroprotection in acute 
cerebral ischemia 
To assess the neuroprotective effect of tDCS in AIS, we performed a systematic review 
of all preclinical acute cerebral ischemia studies using tDCS as a neuroprotective method. 
Our systematic search identified 21 controlled comparisons of tDCS in preclinical acute 
cerebral ischemia models, including a total of 256 animals, all with middle cerebral artery 
occlusion. 25,26,36-40 Hemispheric cathodal stimulation was used in 3 experiments (32 
animals), hemispheric anodal stimulation in 1 experiment (8 animals), Electrical 
stimulation in 4 experiments (--- animals) and fastigial nucleus stimulation in 13 
experiments (91 animals). Overall, tDCS reduced final infarct volume by 24.68 mm3 (95% 
CI 26.53-22.83, P<0.00001). Only mild heterogeneity of effect by stimulation type was 
noted (I2=90.5%), with the infarct reduction magnitudes relatively larger with cathodal 
hemispheric stimulation– 30.94 mm 3 (95% CI 34.35- 27.53, P< 0.00001), followed by 

8 
 
targeted fastigial nucleus stimulation – 26.4 mm 3 (95% CI 29.26-23.63, P< 0.00001), 
then hemispheric electrical stimulation – 18.16 (95% CI 23.85-12.48, P< 0.00001), and 
hemispheric anodal stimulation- 13 mm 3 (95% CI 17.56- 8.44, P< 0.00001) (Figure 2). 
 
 
Figure 2. Forest plot shows the neuroprotective effect of tDCS across 21 pre-clinical experiments* 
*includes all published studies except Kim et al 2009, which did not report infarct volume in assimilable units 
  
These findings demonstrate that tDCS significantly reduces final infarct volume across 
animal preclinical studies. The greatest neuroprotective effect is observed with the C-
tDCS directly applied to the ischemic hemisphere (hemispheric cathodal stimulation). 
Therefore, our proposed study of hemispheric C-tDCS in patients with acute ischemic 
stroke is warranted.  
C.3. Vascular response associated with tDCS 
   A preliminary study in human volunteers by Marom Bikson (Co-mentor of the current 
proposal) demonstrated that tDCS produces vasodilation of cerebral vessels (Figure 3). 
Furthermore, the vasodilatory response to tDCS is evident by its known mild dose-
dependent effect in causing skin erythema. The cerebral vasodilatation is likely partially 
due to non-specific polarization of vascular system. Bikson and colleagues also 
demonstrated that 10 minutes of tDCS resulted in up-regulation of endothelial nitric oxide 
synthase (eNOS) gene expression and increase production of nitric oxide (NO), a known 
vasodilator. 41 Samdani et al. have demonstrated in their study that the endothelial NO 
upregulation favorably affects outcomes by the accentuation of the cerebral blood flow 

9 
 
and attenuation of platelet aggregation, platelet adhesion, and NMDA current. 42 These 
findings support that tDCS could augment blood flow through the stimulated vasculature. 
Leptomeningeal collateral networks, peripherally located, are particularly accessible to 
the electric field. The potential vasoactive effects of tDCS also raise the possibility that 
stimulation will affect the blood-brain barrier. While no hemorrhagic transformation with 
C-tDCS was noted in preclinical models, this potential effect supports the approach of 
undertaking dose escalation safety trial as the first study in AIS patients, even though all 
studied dose tiers are within ranges safe in chronic stroke and other brain disease 
patients.12 20  
 
Figure 3. shows models of intra-cranial current flow 
during tDCS is concentrated by the vasculature 
 
 
 
 
C.4. Feasibility of neuroprotection therapies in acute ischemic stroke 
   Our group has extensive experience with the conduct of clinical trials of drug and device 
neuroprotective therapies for acute ischemic stroke, both as standalone interventions and 
as a complement to reperfusion treatment. We recently completed the NIH Field 
Administration of Stroke Therapy-Magnesium phase 3 trial, enrolling 1700 patients. 8 Of 
particular relevance to the current proposal, we have conducted trials of transcranial 
delivery of acute neuroprotective intervention using laser 43, and trials of collateral 
enhancement interventions 44 and trials and studies using MRI penumbral imaging and 
permeability imaging as technical efficacy and safety end points.  
C.5. Frequency and features of AIS LVO and MVO patients with substantial 
salvageable penumbra who do not undergo ET 
   Among the eventual target populations for tDCS as a neuroprotective intervention in 
acute LVO and MVO AIS, several are suboptimal for inclusion in an initial, dose escalation 
safety trial. Ambulance patients (prehospital neuroprotection) are in a chaotic 
environment unsuited for close safety observations; ED patients pre-ET (bridging 
neuroprotection) have intense time-pressure for usual care making safety-emphasis 
studies difficult; ET failure patients (rescue neuroprotection) have potential complications 
from their failed procedure confounding study interpretation. In contrast, ET-ineligible 
patients (pure neuroprotection) are an attractive cohort for a safety study, as they are 
under close observation, free of intense time-pressure for ET, and free of course outcome 
being strongly determined by ET outcome. To plan the current proposal, we, therefore, 
performed a study to delineate the frequency, clinical characteristics, and outcomes of 
patients with substantial salvageable penumbra who are ineligible for ET in the modern 
stent retriever era 45. Patients were recognized as having substantial salvageable 
penumbra when their perfusion lesion volume (tissue with a delay in contrast arrival to 
peak concentration (Tmax) of  6 sec on perfusion-weighted image (PWI)) was ≥ 1.2 
times larger than the ischemic core volume (tissue with a low mean water diffusivity or 
apparent-diffusion coefficient (ADC) ≤ 620 µm2/s on diffusion-weighted image (DWI)) 
(PWI-DWI Mismatch). 46-48 We then categorized the patients with substantial salvageable 
penumbra as having an LVO if MRA or CTA showed occlusion of the intracranial internal 
carotid (ICA), the M1 segment of the middle cerebral artery (MCA), the vertebral artery 

10 
 
(VA), or the basilar artery (BA). Patients were categorized as having an MVO if MRA or 
CTA showed occlusion of the M2 segment of the MCA, the A1 segment of the anterior 
cerebral artery (ACA), or the P1 segment of the posterior cerebral artery (PCA); or if 
perfusion imaging indicated occlusion an M3 segment of the middle cerebral artery by 
showing a perfusion lesion volume of at least 10 ml in an appropriate territorial distribution. 
Among 174 consecutive AIS patients, 29 (17%) were LVO and MVO patients with 
substantial salvageable penumbra who did not undergo ET. Mean age was 81 (±13), 45 
% were female, and median NIHSS was 11 (IQR 5-19).  The prevalence of LVO was 59 
% (19/29) and MVO 41% (12/29). Patients with ICA, M1 and M2 occlusions constituted 
most of the cases (78%).  The four most common reasons for not pursuing ET intervention 
were: distal occlusion (28%), large infarct core (16%), low NIHSS (16%), temporally 
advanced core injury evident from fluid attenuated recovery (FLAIR) changes on MRI or 
frank hypodensity on CT (13%). Other reasons included: chronic occlusion of the cervical 
internal carotid artery precluding intracranial access (9%); poor pre-stroke baseline 
function (9%); intracranial occlusion judged to be a chronic atherosclerotic occlusion 
(6%); extracranial vessel tortuosity precluding intracranial access (3%). Median time from 
LKN to imaging was 410 min (IQR 198-615). Mismatch ratio was median 5.6 (IQR 2- 
infinite), salvageable penumbra volume mean was 54 ml (±63), and ischemic core volume 
was mean 20ml (±31). Severe disability or death at discharge (mRS 4-6) occurred in 72%. 
These findings demonstrate that, even in the modern stent retriever era, one in six acute 
cerebral ischemia patients presents with substantial salvageable penumbra judged not 
appropriate for ET. This population is more than sufficiently common for the proposed 
study. Figure 4 demonstrates an exemplary patient with an LVO and substantial 
penumbra in whom endovascular thrombectomy was not pursued. 
 
 
 
Figure 4. 92 y/o woman with left intracranial internal carotid occlusion with ischemic core judged too large 
for favorable benefit-risk ratio. Perfusion lesion volume 195 ml, ischemic core volume 100.3 ml, mismatch 
ratio 1.9. The penumbral volume is calculated as 95 ml (195 ml-100ml).  
 
D. Trial Design and Methods 
D.1. Study overview 
This proposal is a prospective, single-center, dose-escalation safety, tolerability and 
feasibility study of tDCS in acute stroke patients with substantial salvageable penumbra 
due to a large or medium vessel occlusion who are ineligible for endovascular therapy. 
The primary safety endpoints will be symptomatic intracranial hemorrhage during the 24-
hour period after stimulation. Secondary measures of safety will include asymptomatic 
intracranial hemorrhage, early neurological deterioration, 3-month mortality and all 

11 
 
serious adverse events. Tolerability will be judged based on the percentage of the 
patients completing the protocol-assigned stimulation treatment and secondarily, the rate 
and severity of cutaneous, neurologic, nociceptive or other adverse effects will be 
assessed. Feasibility endpoints will analyze the speed with which tDCS will be 
implemented. Finally, we will explore signals of potential efficacy by examining the 
imaging biomarkers, including penumbral salvage, collateral enhancement, and infarct 
growth, and clinical outcomes of early neurologic deficit evolution, and 3-month global 
disability and health-related quality of life.  
D2. Technology 
D.2.1. tDCS Device and Stimulation Parameters  
The study will employ a Soterix™ high-definition DC-Stimulator, owned by the principal 
investigator. This tDCS unit consists of a stimulator, 4x1 HD interface and an adjustable 
cap with pre-maid openings that quickly and easily fits different head sizes. (Figure 5). 
The cap will be loaded with plastic electrode holders. These will be filled with conductance 
gel (Signa® gel), 1 cm2 electrodes will be placed in the holders, and the holder then 
locked. 
 
Figure 5.  Shows an example of electrode positioning in a 4 to 1-ring configuration in a patient with left M1 
occlusion. A) The reference electrodes (anode-blue) are positioned on F3, T3, Cz and P3 and the center 
electrode (cathode-red) is positioned over the C3 (central sulcus). B) shows the computational modeling of 
the electrical field, concentrated over the MCA territory. C) Shows the electrode positioning on the tDCS 
HD cap, the schematic of the tDCS stimulator connected to the HD interface, and the Soterix HD tDCS 
unit (stimulator + interface) that will be used in this study. This stimulator connects to the adjustable cap. 
D) Shows the penumbral region on the perfusion MRI of the patient with L MCA occlusion.   
 
D.2.2. Montage 
The electrode positioning montage will be a 4 to 1-ring configuration, with the center or 
active electrode connected to cathode and the 4 reference or return electrodes connected 

12 
 
to anode. The 4 to 1-ring configuration is chosen to focus the stimulation to the penumbral 
region.   
For electrodes positioning location, we use one of the 6 predefined positionings according 
to the location of the vascular occlusion: middle cerebral artery (MCA) M1 branch, MCA 
inferior branch (M2-I), MCA superior branch (M2-S), Anterior Cerebral artery (ACA), 
Posterior Cerebral Artery (PCA), Posterior Inferior Cerebellar Artery (PICA). These 
electrode positionings are based on computational modeling of 6 electrical fields 
concentrated over different parts of the aforementioned vascular territories: electrical field 
covering territory of MCA-M1 branch; electrical field covering territory of MCA-M2 superior 
branch; and electrical field covering territory of MCA-M2 inferior branch, electrical field 
covering territory of ACA; electrical field covering territory of PCA; electrical field covering 
territory of PICA. 
 
D.2.3. Sterility and Quality Assurance 
   Prior to stimulation, all the electrodes will be monitored for any sign of damage such as 
chipping. The electrodes will be discarded after being exposed to 5 cycles of stimulation. 
We will avoid any metal to contact the electrodes. The stimulation cap and the electrodes 
will be sanitized prior to each subject use.  
D.2.4. Device training  
  Device use will be performed by physician investigators, technologists, and research 
staff who have completed training and certification in safe tDCS use. Training will 
include instructions on different components of the device, installing and assembling the 
components, charging the device prior to the first use, recharging the device after each 
procedure, verifying the device is charged prior to each procedure, recognizing and 
addressing the different Warning/Error indications (e.g., battery light flashing blue, 
indicating that the battery is low but can still perform at least one procedure, battery light 
steady red, indicating battery low error – not enough battery power to run a complete 
procedure, etc.) and specific instructions for returning the device to the sponsor in the 
event of an error notification that cannot be addressed by the site personnel, or a failure 
of the device to charge after three hours. All device training will be documented in a 
training log that will be maintained in the site regulatory binder. 
D3. Subjects 
   Twenty-four to 48 acute ischemic stroke patients with substantial salvageable 
penumbra due to a large or medium vessel occlusion who are ineligible for endovascular 
therapy and meet study inclusion/exclusion criteria will be enrolled from Ronald Reagan 
Medical Center (RRMC) Emergency Department or RRMC inpatients.   
    Based upon acute stroke patient referral rates to UCLA over the past 3 years and our 
retrospective study looking at the thrombectomy-ineligible patients with substantial 
penumbra in an 8-month period (1 in 6 acute ischemic stroke patients), we anticipate 8-
16 enrollments per year. Therefore, we estimate that the study enrollment will take 3 
years to complete. Enrolled subjects will be randomized to active versus sham 
stimulation in 3:1 ratio.  
D.3.1 Entry Criteria 
Inclusion criteria:  
1) New focal neurologic deficit consistent with AIS 

13 
 
2) NIHSS≥4 or NIHSS< 4 in the presence of disabling deficit (a deficit that, if unchanged, 
would prevent the patient from performing basic activities of daily living such as bathing, 
ambulating, toileting, hygiene, and eating or returning to work);  
4) Age>18;  
5) Presence of any cortical vessel occlusion including ICA, branches of MCA, Anterior 
Cerebral artery (ACA), Posterior Cerebral artery (PCA), Posterior-Inferior cerebellar 
artery (PICA);  
6) Presence of salvageable penumbra with Tmax> 6 sec/ ischemic core volume (ADC < 
620 µm2/s or rCBF< 30%) ≥ 1.2  
7) Patient ineligible for IV tPA, per national AHA/ASA Guidelines  
8) Patient ineligible for ET per AHA/ASA national Guidelines – one or more of: poor 
prestroke functional status (mRS score >1), mild neurological symptoms (NIHSS <6), 
large ischemic core (ASPECTS <6), thrombectomy not technically performable due to 
severe vessel tortuosity, cervical artery chronic occlusion, or other unfavorable 
angioarchitectural features that preclude endovascular access to the target intracranial 
vessel.  
9) Subject is able to be treated with tDCS within 24 hours of last known well time;  
10) A signed informed consent is obtained from the patient or patient’s legally authorized 
representative  
Exclusion criteria  
1) Acute intracranial hemorrhage 
2) Evidence of a large Ischemic core volume (ADC < 620 µm2/s or rCBF< 30%) ≥ 100 
3) Presence of tDCS contraindications - electrically or magnetically activated intracranial metal 
and non-metal implants. 
4) Severe MR contrast allergy or renal dysfunction with eGFR<30ml/min, precluding MRI 
gadolinium or CT iodine contrast 
5) Pregnancy 
6) Signs or symptoms of acute myocardial infarction, including EKG findings, on 
admission 
7) History of seizure disorder or new seizures with presentation of current stroke 
8) Evidence of any other major life-threatening or serious medical condition that would 
prevent completion of the study protocol including attendance at the 3-month follow-up 
visit 
9) Concomitant experimental therapy 
10) Preexisting scalp lesion at the site of the stimulation or presence of skull defects (may 
alter current flow pattern) 
11) Preexisting coagulopathy, consist of platelet count of ≤ 100, INR ≥ 3, PTT ≥ 90. 
12) Patients suspected of having infective endocarditis and ischemic stroke related to 
septic emboli  
13) Patients suspected or known to be infected with coronavirus 2019 (CoVID-19) 
14) Patient with radiographic evidence or suspicion of chronic conditions that may 
predispose them to intracranial hemorrhage including brain arteriovenous malformations, 
cerebral 
cavernous 
malformations, 
cerebral 
telangiectasia, 
multiple 
previous 
intracerebral hemorrhages (amyloid angiopathy) 
15) Suspected cerebral vasculitis based on medical history and CTA/Magnetic 
Resonance Angiogram (MRA) 
16) Suspected cysticercosis 

14 
 
17) Suspected cranial dural arteriovenous fistula 
18) Cerebral venous thrombosis 
19) Head trauma causing loss of consciousness, concussion, confusion, or a headache 
within the past 30 days 
20) Patient has suffered a hemorrhagic or ischemic stroke within the last three (3) months 
21) History of a cancer known to cause hemorrhagic metastases, e.g., melanoma, renal 
cell carcinoma, choriocarcinoma, thyroid carcinoma, lung carcinoma, breast carcinoma, 
and hepatocellular carcinoma 
22) History of left atrial myxoma 
23) Evidence of dissection in the intracranial cerebral arteries 
24) Suspicion of aortic dissection  
25) Significant mass effect with midline shift 
26) The patient is in a coma 
Biological variables 
   The entry criteria have been designed to be broadly inclusive of biological variables that 
may modify disease course and treatment response, including enrollment of all adults of 
any age, both males and females (except pregnant females), and all weights compatible 
with MR-scanning. Pregnant women will be excluded as the safety of tDCS has not been 
established in pregnancy. A pregnancy test will be performed prior to enrollment in 
women of childbearing age. Children will be excluded because of the rarity of diagnosis 
in children in the acute time window, and greater brain plasticity and recovery in younger 
individuals. Given the uncommon availability for enrollment and very different course, 
including children in trial could differentially favor or unfavor one study arm, and make 
interpretation of findings challenging.  
   With regards to the time window, patients treatable within 24 hours of last known well 
are included, as the DAWN and DEFUSE 3 trials have shown that patients in the 6-24h 
window with imaging evidence of substantial salvageable penumbra are responsive to 
acute stroke therapies. 10,11 Sites of vessel occlusion will include any cortical vessel 
occlusion including distal branches of MCA (M3, M4), ACA, PCA, and PICA, in addition 
to LVO’s (ICA, M1, and M2 branches of MCA), and regarding the severity of deficits, we 
will include NIHSS < 4 in the presence of a disabling deficit, in addition to NIHSS ≥ 4. This 
patient population with more distal vessel occlusion and less severe deficits are the likely 
patients not proceeding to thrombectomy even in the current expanded treatment era, 
and who are also as informative regarding the main safety, tolerability, and feasibility 
endpoints of the study.  
D.3.2.Enrollment and Consent 
   All acute ischemic stroke patients within 24 hours of their symptoms onset who 
present to Roland Reagan Medical Center (Emergency Department or inpatient hospital 
if they are already admitted for a different indication) and meet the study 
inclusion/exclusion criteria will be identified by a study physician-investigator and 
subsequently offered enrollment in the trial. Prospective subjects will be provided with 
written and verbal information regarding the nature of the study, the procedures and 
evaluations involved, and the potential risks and benefits. All participating patients or 
their legally authorized representatives (LAR) will provide explicit written informed 
consent.  

15 
 
Not all adult subjects will have the capacity to give informed consent. The likely range of 
impairment includes stupor and aphasia. By interviewing the patient, the investigators 
will assess whether the affected individual understands the central elements of the 
study procedures and has the capacity for informed consent, using the recommended 
approach of the institution’s Institutional Review Board, such as the UCLA Office of 
Human Research Protection Decision-Making Capacity Assessment Tool.  
    Patients with capacity to consent will be invited to participate by the PI. In patients 
without the capacity to consent, the patient’s LAR will be asked to provide consent for 
participation. If the LAR is not physically available but reachable through the phone at 
the time of enrollment, the informed consent will be sent to the LAR via fax or email 
after discussing the details of the study via phone. Then the LAR returns the signed/e-
signed form to the PI, again either via tax or email.   
The investigator will inform the patient or legally authorized representative of the 
availability of the study as follows: “You (your relative) is having a stroke. We are doing 
a research study of a new treatment for stroke. Here is an informed consent form that 
describes the study. Please read it. After you are finished, I will answer any questions 
you may have.” Once subjects or their legally authorized representatives have read and 
understood the IRB-approved consent form, and had all their questions answered, 
written informed consent will be elicited. 
D.4. Dose Tiers and Randomization 
   We will implement a traditional 3+3 (rule-based, modified Fibonacci) dose escalation 
design, with 3:1 randomization to active treatment vs sham control. There will be 6 dose 
tiers, reflecting increasing intensity and duration of stimulation: Tier 1 – 1 mA, single 20 - 
min cycle; Tier 2– 2 mA, single 20 min cycle; Tier 3 – 1 mA, 2 cycles of 20 min/20 min off; 
Tier 4– 2 mA, 2 cycles of 20 min/20 min off; Tier 5 – 1 mA, 3 cycles of 20 min/20 min off; 
Tier 6 – 2 mA, 3 cycles of 20 min/20 min off (Figure 7). Patients in the sham stimulation 
arm at all the tiers will have the cap and electrodes in place, and switches moved but 
without any delivered electrical stimulation. While the highest dose tier in this study is 
expected to be fully safe, based on preclinical and clinical studies 12,19, since this is a first-
in-human study in acute stroke, a formal escalation to higher dose tiers is prudent.  
 
 
Figure 
7. 
This 
figure 
shows the 6 escalating 
tiers. Blue represents 1 
mA and purple shows 2 
mA of tDCS. Symptomatic 
ICH (SICH) in none of the 
three patients in a tier will 
result 
in 
escalation. 
However, SICH in one 
patient, 3 more patients 
and 1 sham will be enrolled 
at the same tier.  
 
 
D.4. Management during and post stimulation period  

16 
 
 
    
Figure 8. Shows the technician-filled tolerability form. The selected items are based on the most common 
reported adverse effects associated with tDCS. 
 
After randomization and during the stimulation, all patients will be monitored closely by a 
physician-investigator. NIHSS will be obtained at the end of each 20-minute stimulation 
cycle and a visual inspection of the skin and rate degree of any potential erythema under 
the electrode will be performed. Then, a tolerability form will be completed based on 
validated cutaneous, neurological, and pain items of the PRO-CTAE (Patient-Reported 
Outcomes version of the Common Terminology Criteria for Adverse Events) (Figure 8). 
49,50.  
After the stimulation, nursing neurologic assessments will be performed by 
Neurointensive Care Unit or Stroke Unit  nurses with extensive experience in monitoring 
acute stroke patients. Specifically, patients will be monitored for any signs of neurological 
worsening and will be queried on development of new or worsening neurological 
symptoms including headache, dizziness, numbness, or weakness, etc. If any sign or 
symptom of neurological worsening is suspected, the patient will be immediately 
assessed by the on-call neurologist and an immediate brain imaging (CT or MRI) will be 
obtained. Neuro-checks will be performed at 1h and 2h after stimulation and then every 
2 hours in patients requiring Neurointensive Care and every 4 hours in patients requiring 
Stroke Unit Care.  Subsequent care will be continued in these settings, including medical 
management per national guidelines for acute ischemic stroke management issued by 
the American Stroke Association.51 Patients will not receive NSAIDs as concomitant 
therapy for the first 7 days after enrollment. All patients will undergo a multimodal MRI or 
CT including standard parenchymal images, non-invasive angiography, and perfusion 
studies and formal NIHSS assessment at 2-hour and 24-hour following the end of the 
stimulation tier as part of the study protocol. 
 

17 
 
D.6. Study Visits and Data Acquisition  
D.6.1 Schedule of Events  
* Skin Inspection will be performed before each stimulation period  
D.6.2. Baseline Evaluation 
• Demographics (age, sex, race) 
• Last known well time 
• Past medical/surgical history including vascular diagnoses and risk factors (stroke, 
TIA, carotid stenosis, myocardial infarction, atrial fibrillation, peripheral arterial 
disease, hypertension, diabetes, dyslipidemia) 
• Medications, 
including 
antithrombotics, 
antihypertensives, 
statins, 
anti-
arrhythmics      Family history of vascular disease; 
• Tobacco (including timing, duration, amount), alcohol, and illicit drug use;  
• Vital signs (systolic blood pressure, diastolic blood pressure, pulse, respiratory 
rate, oxygen saturation); 
• Premorbid global disability (modified Rankin Scale);   
• Neurological deficits severity (NIHSS);  
• Laboratory results (CBC, platelet count, glucose, lytes, INR, PTT, LFTs.  
D.6.3. During tDCS Treatment  
• NIH Stroke Scale (NIHSS),  
• Tolerability/AE Form – Technologist, Tolerability Questionnaire – Patient  
D.6.4. Early (2 Hours) After tDCS  
• NIHSS,  
• Multimodal MRI/CT 
• Interval serious adverse events  
• Interval medications/procedures  
D.6.5. Late (24 Hours) After tDCS   
• NIHSS 
• Multimodal MRI/CT 
• Interval serious adverse events 
• Interval medications/procedures  
Baseline 
End of each 20-min 
stimulation cycle 
2-hr 24-hr Day 4 Day 30 Day 90 
 
1 
2 
3 
 
 
 
 
 
Consent 
 
 
 
 
 
 
 
 
 
History / Exam 
 
 
 
 
 
 
 
 
 
Routine Labs 
 
 
 
 
 
 
 
 
 
Vital Signs 
 
 
 
 
 
 
 
 
 
Patient tolerability form 
 
 
 
 
 
 
 
 
 
Technician tolerability form/Skin 
Inspection* 
 
 
 
 
 
 
 
 
 
Multimodal MRI or CT 
 
 
 
 
 
 
 
 
 
NIHSS 
 
 
 
 
 
 
 
 
 
Modified Rankin Scale (mRS) 
 
 
 
 
 
 
 
 
 
Barthel Index (BI) 
 
 
 
 
 
 
 
 
 
EuroQol (EQ-5D) 
 
 
 
 
 
 
 
 
 
AMC Linear Disability Scale 
 
 
 
 
 
 
 
 
 
Interval serious adverse events 
 
 
 
 
 
 
 
 
 
Concomitant/Interval 
medications/procedures  
 
 
 
 
 
 
 
 
 

18 
 
D.6.6. Day 4  
• Modified Rankin Scale (mRS) 
• Interval serious adverse events 
• Interval medications/procedures  
D.6.7. Day 30  
• mRS (phone),  
• Interval serious adverse events 
• Interval medications/procedures  
D.6.8. Day 90  
• NIHSS,  
• Modified Rankin Scale (mRS) 
• AMC Linear Disability Scale (granular disability)  
• Barthel Index (BI) (activities of daily living) 
• EuroQol (EQ-5D) (health-related quality of life) 
• Interval serious adverse events 
• Interval medications/procedures  
D.6.9. Imaging Assessments  
• Baseline 
Emergent multimodal MRI or CT is currently acquired as the routine initial imaging study 
in all acute stroke patients at UCLA without contraindications such as the presence of a 
pacemaker or metal implant. A 1.5 T or 3 T scanner equipped with echo-planar imaging 
capability is used for rapid acquisition of diffusion and perfusion scans. The standard 
clinical MRI protocol includes Gradient Recall- Echo (GRE), DWI, FLAIR (Fluid-
Attenuated Recovery Image), PWI and MR angiography. The ADC (apparent -diffusion 
coefficient) values derived from DWI acquisition (b=0, 1000 s/mm2 applied in each of 
three principal gradient directions) will be used to delineate the volume of ischemic core. 
The tissue with ADC values of ≤ 620 µm2/s will be considered ischemic core, indicative 
of tissue with advanced, irreversible bioenergetic compromise. FLAIR delineates early 
parenchymal signal abnormality associated with ischemia and slow retrograde flow in 
leptomeningeal collaterals appearing as FLAIR vascular hyperintensity (FVH). The GRE 
sequence is used to evaluate the presence of intracranial hemorrhage and deoxygenated 
leptomeningeal collaterals appearing as GRE vascular hypointensity (GVH). PWI is 
acquired with sequential T2*-weighted (gradient echo) EPI time sequence scanning. Early 
in the time series, a bolus (0.1 mmol/kg) of MRI contrast material is rapidly infused (5 
ml/sec through an 18 or larger gauge angiocatheter) using a power injector. The perfusion 
lesion volume (tissue at risk volume) will be the region with Tmax  6sec (Tmax = the 
time delay from the arrival of contrast to its peak concentration at the tissue vasculature). 
52,53 Intracranial CEMRA (Contrast-Enhanced MRA) will identify large and medium vessel 
occlusion.  
In patients receiving CT, the standard clinical CT protocol includes non-contrast CT (NCCT), 
multiphase CT angiography, CT perfusion (CTP) processed through RAPID software. NCCT is 
used to rule out acute intracranial hemorrhage appearing as hyperdensity. The tissue with rCBF 
< 30% on CTP will be considered ischemic core and the perfusion lesion volume (tissue at risk 
volume) will be the region with Tmax  6sec. CT angiography (CTA) will identify large and 
medium vessel occlusion.  
 

19 
 
• 2h and 24h Post-Stimulation 
Follow-up MR or CT imaging will be obtained 2h and 24h post-stimulation (supported by 
Radiology 
Dept. 
research 
funds). 
MRI 
Imaging 
sequences 
will 
include 
DWI/FLAIR/GRE/PWI/CEMRA and CT imaging sequences will consist of NCCT/CTA/CTP. 
RAPID image processing software will be applied to the above images to quantify, at the 
baseline, 2h, and 24h time-points: 1) Ischemic Core volume, 2) Perfusion lesion volume, 
and 3) Penumbra volume (perfusion volume - core volume). From these values, the 
following measures will be constructed: 1) Early penumbra preservation: Volume of 
baseline penumbra tissue not progressing to ischemic core at 2h; 2) Penumbral salvage: 
Volume of baseline penumbra tissue not progressing to ischemic core at 24h; 3) Early 
collateral flow enhancement: Perfusion lesion volume at baseline – Perfusion lesion 
volume at 2h; 4) Sustained collateral flow enhancement: Perfusion lesion volume at 
baseline – Perfusion lesion volume at 24h; 5) Early infarct growth: Ischemic core lesion 
volume at 2h – Ischemic core lesion volume at baseline; and 6) Final infarct growth: 
Ischemic core lesion volume at 24h – Ischemic core lesion volume at baseline. Additional 
location and extent of ischemic injury at baseline, 2h, and 24h will be rated using the MRI 
ASPECTS scoring system, with regions considered involved if diffusion restriction is 
present in more than 20% of the region or CT ASPCETS. 54,55 In patients receiving MRI, 
location and extent of FVH and GVH will be rated using the FVH-modified ASPECTS and 
GVH modified ASPECTS scales.56 
D.6.10  Adverse Events 
D.6.10.1 Serious Adverse Events (SAEs) 
   All serious adverse events occurring during the 90 days of study participation will be 
recorded. A serious adverse event is any adverse event that is fatal, is life-threatening, is 
permanently or substantially disabling, requires or prolongs hospitalization, or requires 
medical or surgical intervention to prevent one of the above outcomes.19  
D.6.10.2 Symptomatic intracranial hemorrhage 
   The lead safety endpoint adverse event is symptomatic intracranial hemorrhage (SICH), 
defined using the SWIFT PRIME trial criteria 55: an increase of 4 or more points on the 
NIHSS within 24 hours of stimulation associated with parenchymal hematoma type 1 
(PH1), parenchymal hematoma type 2 (PH2), remote intraparenchymal hemorrhage 
(RIH), subarachnoid hemorrhage (SAH), or intraventricular hemorrhage (IVH). In 
addition, all hemorrhages, both symptomatic and asymptomatic, will also be separately 
classified and analyzed by radiologic subtype, as hemorrhagic infarction type 1 (HI1), 
hemorrhagic infarction type 2 (HI2), PH1, PH2, RIH, SAH, or IVH.55 A central 
neuroimaging core lab, blinded to treatment assignment, will review all brain MRI scans 
obtained at 24h and rate presence and type of radiologic hemorrhagic transformation. In 
addition, in patients who experienced worsening by 4 or more NIHSS points in the first 24 
hours, they will review any and all additional brain MRI or CT scans obtained during the 
24h time period,   
   SICH is the primary safety endpoint of the current trial, but trial results will be assessed 
on a variety of additional safety, feasibility, and tolerability results as well. It is anticipated 
that, after completion of the current trial, the judgement of whether to proceed directly to 
a pivotal trial, to proceed to a larger safety and preliminary efficacy trial, or to not proceed 
with further development, will rest on a considered and informed assessment of all 
outcome measures. It is important therefore to collect data on a wide range of safety 

20 
 
endpoints and a wide range of measures of functional outcome, as is planned in this 
proposal. In making the selection of a primary safety endpoint, an emphasis was placed 
on ensuring patient safety throughout the course of the trial by choosing an endpoint with 
uncontestable clinical relevance (Symptomatic Intracranial Hemorrhage).  
D.6.10.3 Additional Adverse Events with Specific Interrogation 
    In addition to general screening for all serious adverse events and focused elicitation 
of symptomatic intracranial hemorrhage events, the following events will be specifically 
interrogated for and recorded in the case report forms: skin redness, scalp rash, hair loss, 
seizure, headache, sensitivity to light, new ischemic stroke, deep venous thrombosis, 
pulmonary embolism, pneumonia, acute MI.  
E. Safety Monitoring 
E.1. Data and Safety Monitoring Plan 
   The trial will be monitored by an Independent Data and Safety Monitoring Board 
(DSMB). Dr. Bruce Dobkins from department of neurorehabilitation will lead the DSMB. 
DSMB will assess for the causal relationship of the serious adverse event to the study 
treatment as definite, probable, possible, unlikely, or unrelated.  
DSMB will meet at the completion of each dose tier, review all safety data, and 
determine whether the study will proceed to the next dose tier. DSMB deliberations will 
be guided by: 1) a formal stopping/escalation rule, based on the occurrence of the lead 
safety endpoint, symptomatic intracranial hemorrhage (SICH), and 2) The DSMB 
members’ clinical judgement upon review of all other safety outcomes. In addition, 
DSMB will monitor separately the patients who enroll in the study with a stroke scale 0-3 
during the study as they are treated to determine if they have an increase in NIHSS of 2 
or more or which is disabling. 
Furthermore, Food and Drug Administration (FDA) will be notified if there is one 
occurrence of SICH prior to repeating the tier or escalating to a higher tier.  
E. 2. Statistical Design and Analyses Plan 
E.2.1. Sample size 
   The study sample size derives from the use of the 3+3, rule-based, modified Fibonacci, 
dose escalation design, with 3:1 randomization to active treatment vs sham control. There 
will be 6 dose tiers, reflecting increasing intensity and duration of stimulation (Figure 7). 
The 3+3 study design (3 patients and 1 sham) with 6 dose tiers yields a sample size of at 
least 24 and potentially up to 48. The 3+3 design is the classical approach to dose 
escalation in first-in-human studies. 57,58 While newer, adaptive designs for dose 
escalation trials have been developed, they are more complex and have limited 
advantages when major toxicities are not expected. 59 Therefore, the rule-based, 3+3 
design remains the dominantly employed approach in current dose-escalation studies.  
We will take every step to avoid missing data by scheduling of the follow-up visits early in 
visit time windows and readiness to travel to the patient’s location to perform needed 
assessments. Should any missing data occur, primary analyses will be performed using 
multiple imputation, with sensitivity analyses including complete case and worst possible 
outcome analyses. 60  
E.2.2. Baseline characteristics 
   The demographic and baseline clinical characteristics of the study population will be 
delineated with standard descriptive statistics. Categorical variables describing the 
clinical history, examination findings, and initial treatment will be summarized by 

21 
 
frequencies. Continuous variables such as vital signs, laboratory results, and time 
variables will be characterized by means, standard deviations, and 95% confidence 
intervals (CI). Ordinal and non-normally distributed variables (such as the NIHSS) will be 
characterized by medians and interquartile ranges. Baseline characteristics will be 
compared between the tDCS stimulation group with sham group to assess covariate 
balance. Wilcoxon Rank-Sum tests will be used for continuous or ordinal variables; 
Fisher’s exact tests and chi-square tests will be used for grouped or nominal categorical 
variables.   
E.2.3. Safety and Tolerability (Specific Aim 1) 
E.2.3.1 Dose Escalation 
   The study Data and Safety Monitoring Board (DSMB) will meet at the completion of 
each dose tier, review all safety data, and determine whether the study will proceed to 
the next dose tier. DSMB deliberations will be guided by: 1) a formal stopping/escalation 
rule, based on the occurrence of the lead safety endpoint, symptomatic intracranial 
hemorrhage (SICH), and 2) The DSMB members’ clinical judgement upon review of all 
other safety outcomes. The formal dose escalation rule uses SICH frequency to gate the 
occurrence and pace of escalation through the 6 dose tiers. If no SICH occurs in the 3 
active patients at a dose tier, enrollment may escalate to the next dose tier. If one SICH 
occurs, 3 more active (and 1 more control) patient will be enrolled at that dose tier before 
escalation. If 2 SICHs occur at a dose tier, further study enrollment is held until detailed 
review by the DSMB (Fig 6). In addition, whenever the formal SICH criteria for dose 
escalation has been met, the DSMB will formally meet, review the SICH data and all other 
safety data, and advice regarding proceeding to the next tier, continuing at the current 
tier, or placing the study on hold. 
E.2.3.2. Primary Safety Endpoint Analysis 
   For the final statistical analysis of the primary SICH safety endpoint, a chi-square test 
will be used to detect differences in the rate of SICH between the active treatment and 
sham patients and higher and lower dose tiers. The treatment will be considered to have 
exhibited adequate safety in the current trial to proceed to future, larger, pivotal efficacy 
trials if tDCS results in lower or equivalent rates of SICH compared to sham.  
E.2.3.3. Secondary Safety Endpoints Analysis 
   In secondary safety endpoint analyses, the following will be compared between the 
active treatment and sham patients, and between higher and lower dose tiers, using chi-
squared tests: 1) Asymptomatic ICH by 24h (intracranial hemorrhage not associated with 
NIHSS worsening ≥ 4); 2) Early neurologic deterioration (worsening ≥ 4 on NIHSS during 
the 24-hour period after stimulation, with or without intracranial hemorrhage); 3) All-cause 
mortality at day 90 (mRS); and 4) All serious adverse events.  
E.3.3. Tolerability Endpoint Analysis 
    The lead tolerability endpoint is completion of the protocol-assigned stimulation 
treatment without early cessation due to cutaneous, neurologic, nociceptive or other 
adverse effects. Experience with tDCS in post-stroke patients indicates only infrequent 
cutaneous (itching, tingling) adverse effects are likely to occur. Accordingly, for the current 
study, a patient will be considered to have tolerated the procedure if at least 75% of the 
stimulus period was completed. The treatment will be considered generally tolerable if, 
among all enrolled patients, tolerated procedures are achieved in ≥90% of patients, 
assessed with a one-sided p value of 0.025. Secondary tolerability endpoints will be the 

22 
 
rate and severity of cutaneous, neurological, and pain items of the technician-filled (Figure 
7) and patient-filled tolerability forms 49, descriptively compared between active treatment 
and sham patients, and between higher and lower dose tiers.   
E.3.4. Feasibility Endpoint Analysis (Specific Aim 2) 
   A time-motion analysis and mock run-throughs will be conducted prior to first 
enrollment. Nonetheless, it is anticipated that processes to optimize rapid placement of 
the cap and electrodes will continue to improve with experience gained from initially 
enrolled patients. The predefined success threshold for feasibility will be median time from 
randomization to tDCS initiation ≤ 10 minutes in the last 10 enrolled patients. 
E.3.5. Exploratory Efficacy Endpoints Analysis (Specific Aim 3) 
E.3.5.1. Exploratory Imaging Biomarker Efficacy Endpoints 
   This study is underpowered to definitively determine efficacy, so all imaging efficacy 
analyses will be purely exploratory and descriptive. Imaging biomarker efficacy endpoints 
will be characterized in the active and sham patients, and in higher and lower dose tiers, 
using means and 95% confidence intervals. The six imaging efficacy endpoints of 
greatest interest that will be explored are: early and late penumbral salvage, early and 
late collateral flow enhancement, and early and late infarct growth.  
E.3.5.2. Exploratory Clinical Efficacy Endpoints 
   This study is underpowered to definitively determine efficacy, so all clinical efficacy 
analyses will be purely exploratory and descriptive. Four clinical outcome measures were 
selected based on their reliability, familiarity to the neurologic community, and adaptability 
for use in patients who have had a stroke. These endpoints are: the modified Rankin 
Scale (mRS), a rating of global disability; the Barthel Index (BI), a measure of instrumental 
activities of daily living; the National Institutes of Health Stroke Scale (NIHSS), a measure 
of neurologic deficit severity; and the EuroQol (EQ-5D), an assessment of health-related 
quality of life; and AMC Linear Disability Scale, a granular degree of disability.  
Clinical efficacy endpoints will be characterized in the active and sham patients, and in 
higher and lower dose tiers. Early course clinical efficacy endpoints of greatest interest 
that will be explored are: 1) Normalized change in neurologic deficit from baseline to 24h 
(normalized delta NIHSS – linear variable, analyzed with means and 95% CIs; and 2) 
Degree of neurologic deficit at 24h (NIHSS – quasi-linear variable, analyzed with means 
and 95% CIs). Final outcome clinical efficacy endpoints of greatest interest that will be 
explored are: 1) Degree of disability at 90 days, assessed across all 7 levels of the 
modified Rankin Scale – ordinal variable, analyzed with medians (IQRs) and means (95% 
CIs); 2) Functional independence (mRS 0-2) at 90 days – binary variable, analyzed with 
rates and 95% CIs; 3) Granular degree of disability at 90 days (AMC Linear Disability 
Scale) – linear variable, analyzed with means and 95% CIs; and 4) Health-related quality 
of life (EQ-5D) – linear variable, analyzed with means and 95% CIs. 
 
 
 
 
 
 
 
 
 
 

23 
 
 
 
 
 
 
 
 
 
References: 
1. 
Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart Disease and Stroke Statistics-2017 Update: 
A Report From the American Heart Association. Circulation. 2017. 
2. 
Campbell BC, Donnan GA, Lees KR, et al. Endovascular stent thrombectomy: the new 
standard of care for large vessel ischaemic stroke. Lancet Neurol. 2015;14(8):846-854. 
3. 
Adeoye O, Hornung R, Khatri P, Kleindorfer D. Recombinant tissue-type plasminogen 
activator use for ischemic stroke in the United States: a doubling of treatment rates over 
the course of 5 years. Stroke. 2011;42(7):1952-1955. 
4. 
Saver JL, Goyal M, van der Lugt A, et al. Time to Treatment With Endovascular 
Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis. JAMA. 
2016;316(12):1279-1288. 
5. 
Haussen DC, Nogueira RG, Elhammady MS, et al. Infarct growth despite full reperfusion 
in endovascular therapy for acute ischemic stroke. J Neurointerv Surg. 2016;8(2):117-121. 
6. 
Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel 
ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. 
Lancet. 2016;387(10029):1723-1731. 
7. 
Tymianski M. Novel approaches to neuroprotection trials in acute ischemic stroke. Stroke. 
2013;44(10):2942-2950. 
8. 
Saver JL, Starkman S, Eckstein M, et al. Prehospital use of magnesium sulfate as 
neuroprotection in acute stroke. N Engl J Med. 2015;372(6):528-536. 
9. 
Warach S, Pettigrew LC, Dashe JF, et al. Effect of citicoline on ischemic lesions as 
measured by diffusion-weighted magnetic resonance imaging. Citicoline 010 
Investigators. Ann Neurol. 2000;48(5):713-722. 
10. 
Albers WG. Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 
(DEFUSE 3). https://clinicaltrialsgov/ct2/show/NCT02586415. 2017. 
11. 
Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke 
with a Mismatch between Deficit and Infarct. N Engl J Med. 2017. 
12. 
Woods AJ, Antal A, Bikson M, et al. A technical guide to tDCS, and related non-invasive 
brain stimulation tools. Clin Neurophysiol. 2016;127(2):1031-1048. 
13. 
Nitsche MA, Seeber A, Frommann K, et al. Modulating parameters of excitability during 
and after transcranial direct current stimulation of the human motor cortex. J Physiol. 
2005;568(Pt 1):291-303. 
14. 
Nitsche MA, Nitsche MS, Klein CC, Tergau F, Rothwell JC, Paulus W. Level of action of 
cathodal DC polarisation induced inhibition of the human motor cortex. Clin Neurophysiol. 
2003;114(4):600-604. 
15. 
Brunoni AR, Nitsche MA, Bolognini N, et al. Clinical research with transcranial direct 
current stimulation (tDCS): challenges and future directions. Brain Stimul. 2012;5(3):175-
195. 

24 
 
16. 
Dmochowski JP, Datta A, Huang Y, et al. Targeted transcranial direct current stimulation 
for rehabilitation after stroke. Neuroimage. 2013;75:12-19. 
17. 
Teichmann M, Lesoil C, Godard J, et al. Direct current stimulation over the anterior 
temporal areas boosts semantic processing in primary progressive aphasia. Ann Neurol. 
2016;80(5):693-707. 
18. 
Wessel MJ, Zimerman M, Hummel FC. Non-invasive brain stimulation: an interventional 
tool for enhancing behavioral training after stroke. Front Hum Neurosci. 2015;9:265. 
19. 
Bikson M, Grossman P, Thomas C, et al. Safety of Transcranial Direct Current Stimulation: 
Evidence Based Update 2016. Brain Stimul. 2016;9(5):641-661. 
20. 
Chhatbar PY, Chen R, Deardorff R, et al. Safety and tolerability of transcranial direct 
current stimulation to stroke patients - A phase I current escalation study. Brain Stimul. 
2017;10(3):553-559. 
21. 
Harukuni I, Bhardwaj A. Mechanisms of brain injury after global cerebral ischemia. Neurol 
Clin. 2006;24(1):1-21. 
22. 
Nakamura H, Strong AJ, Dohmen C, et al. Spreading depolarizations cycle around and 
enlarge focal ischaemic brain lesions. Brain. 2010;133(Pt 7):1994-2006. 
23. 
Hossmann KA. Periinfarct depolarizations. Cerebrovasc Brain Metab Rev. 1996;8(3):195-
208. 
24. 
Hartings JA, Rolli ML, Lu XC, Tortella FC. Delayed secondary phase of peri-infarct 
depolarizations after focal cerebral ischemia: relation to infarct growth and 
neuroprotection. J Neurosci. 2003;23(37):11602-11610. 
25. 
Notturno F, Pace M, Zappasodi F, Cam E, Bassetti CL, Uncini A. Neuroprotective effect of 
cathodal transcranial direct current stimulation in a rat stroke model. J Neurol Sci. 
2014;342(1-2):146-151. 
26. 
Peruzzotti-Jametti L, Cambiaghi M, Bacigaluppi M, et al. Safety and efficacy of transcranial 
direct 
current 
stimulation 
in 
acute 
experimental 
ischemic 
stroke. 
Stroke. 
2013;44(11):3166-3174. 
27. 
Baba T, Kameda M, Yasuhara T, et al. Electrical stimulation of the cerebral cortex exerts 
antiapoptotic, angiogenic, and anti-inflammatory effects in ischemic stroke rats through 
phosphoinositide 3-kinase/Akt signaling pathway. Stroke. 2009;40(11):e598-605. 
28. 
Kim SJ, Kim BK, Ko YJ, Bang MS, Kim MH, Han TR. Functional and histologic changes after 
repeated transcranial direct current stimulation in rat stroke model. J Korean Med Sci. 
2010;25(10):1499-1505. 
29. 
Fox JL, Yasargil MG. The experimental effect of direct electrical current on intracranial 
arteries and the blood-brain barrier. J Neurosurg. 1974;41(5):582-589. 
30. 
Iacoboni M. The role of premotor cortex in speech perception: evidence from fMRI and 
rTMS. J Physiol Paris. 2008;102(1-3):31-34. 
31. 
Aziz-Zadeh L, Iacoboni M, Zaidel E, Wilson S, Mazziotta J. Left hemisphere motor 
facilitation in response to manual action sounds. Eur J Neurosci. 2004;19(9):2609-2612. 
32. 
Iacoboni M. Visuo-motor integration and control in the human posterior parietal cortex: 
evidence from TMS and fMRI. Neuropsychologia. 2006;44(13):2691-2699. 
33. 
Dunn W, Rassovsky Y, Wynn JK, et al. Modulation of neurophysiological auditory 
processing measures by bilateral transcranial direct current stimulation in schizophrenia. 
Schizophr Res. 2016;174(1-3):189-191. 

25 
 
34. 
Rassovsky Y, Dunn W, Wynn J, et al. The effect of transcranial direct current stimulation 
on social cognition in schizophrenia: A preliminary study. Schizophr Res. 2015;165(2-
3):171-174. 
35. 
Dunn W, Rassovsky Y, Wynn J, et al. The effect of bilateral transcranial direct current 
stimulation on early auditory processing in schizophrenia: a preliminary study. J Neural 
Transm (Vienna). 2017. 
36. 
Reis DJ, Berger SB, Underwood MD, Khayata M. Electrical stimulation of cerebellar 
fastigial nucleus reduces ischemic infarction elicited by middle cerebral artery occlusion 
in rat. J Cereb Blood Flow Metab. 1991;11(5):810-818. 
37. 
Reis DJ, Kobylarz K, Yamamoto S, Golanov EV. Brief electrical stimulation of cerebellar 
fastigial nucleus conditions long-lasting salvage from focal cerebral ischemia: conditioned 
central neurogenic neuroprotection. Brain Res. 1998;780(1):161-165. 
38. 
Yamamoto S, Golanov EV, Reis DJ. Reductions in focal ischemic infarctions elicited from 
cerebellar fastigial nucleus do not result from elevations in cerebral blood flow. J Cereb 
Blood Flow Metab. 1993;13(6):1020-1024. 
39. 
Zhou P, Qian L, Glickstein SB, Golanov EV, Pickel VM, Reis DJ. Electrical stimulation of 
cerebellar fastigial nucleus protects rat brain, in vitro, from staurosporine-induced 
apoptosis. J Neurochem. 2001;79(2):328-338. 
40. 
Glickstein SB, Ilch CP, Reis DJ, Golanov EV. Stimulation of the subthalamic vasodilator area 
and fastigial nucleus independently protects the brain against focal ischemia. Brain Res. 
2001;912(1):47-59. 
41. 
Bikson M. The coupled vascular hypothesis for transcranial direct current stimulation 
(tDCS). In. Unpublished work.2017. 
42. 
Samdani AF, Dawson TM, Dawson VL. Nitric oxide synthase in models of focal ischemia. 
Stroke. 1997;28(6):1283-1288. 
43. 
Huisa BN, Stemer AB, Walker MG, et al. Transcranial laser therapy for acute ischemic 
stroke: a pooled analysis of NEST-1 and NEST-2. Int J Stroke. 2013;8(5):315-320. 
44. 
Shuaib A, Bornstein NM, Diener HC, et al. Partial aortic occlusion for cerebral perfusion 
augmentation: safety and efficacy of NeuroFlo in Acute Ischemic Stroke trial. Stroke. 
2011;42(6):1680-1690. 
45. 
Bahr Hosseini M WG, Hinman JD, Sharma LK, Rao NM, Starkman S, Yoo B, Scalzo F, 
Liebeskind DS, Saver JL,for the UCLA Penumbral Imaging Investigators. Prevalence of 
substantial salvageable penumbra in patients with large vessel occlusion who do not 
undergo endovascular therapy. In. European Stroke Organisation Conference (ESOC)2017. 
46. 
Butcher KS, Parsons M, MacGregor L, et al. Refining the perfusion-diffusion mismatch 
hypothesis. Stroke. 2005;36(6):1153-1159. 
47. 
Furlan AJ, Eyding D, Albers GW, et al. Dose Escalation of Desmoteplase for Acute Ischemic 
Stroke (DEDAS): evidence of safety and efficacy 3 to 9 hours after stroke onset. Stroke. 
2006;37(5):1227-1231. 
48. 
Hacke W, Albers G, Al-Rawi Y, et al. The Desmoteplase in Acute Ischemic Stroke Trial 
(DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with 
intravenous desmoteplase. Stroke. 2005;36(1):66-73. 

26 
 
49. 
Basch E, Reeve BB, Mitchell SA, et al. Development of the National Cancer Institute's 
patient-reported outcomes version of the common terminology criteria for adverse 
events (PRO-CTCAE). J Natl Cancer Inst. 2014;106(9). 
50. 
Dueck AC, Mendoza TR, Mitchell SA, et al. Validity and Reliability of the US National 
Cancer Institute's Patient-Reported Outcomes Version of the Common Terminology 
Criteria for Adverse Events (PRO-CTCAE). JAMA Oncol. 2015;1(8):1051-1059. 
51. 
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management 
of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From 
the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-
e110. 
52. 
Albers GW, Lansberg MG, Kemp S, et al. A multicenter randomized controlled trial of 
endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3). Int J 
Stroke. 2017;12(8):896-905. 
53. 
Bahr Hosseini M, Liebeskind DS. The role of neuroimaging in elucidating the 
pathophysiology of cerebral ischemia. Neuropharmacology. 2017. 
54. 
Demchuk AM, Coutts SB. Alberta Stroke Program Early CT Score in acute stroke triage. 
Neuroimaging Clin N Am. 2005;15(2):409-419, xii. 
55. 
Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA 
vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285-2295. 
56. 
Mahdjoub E, Turc G, Legrand L, et al. Do Fluid-Attenuated Inversion Recovery Vascular 
Hyperintensities Represent Good Collaterals before Reperfusion Therapy? AJNR Am J 
Neuroradiol. 2017. 
57. 
Hansen AR, Graham DM, Pond GR, Siu LL. Phase 1 trial design: is 3 + 3 the best? Cancer 
Control. 2014;21(3):200-208. 
58. 
Penel N, Isambert N, Leblond P, Ferte C, Duhamel A, Bonneterre J. "Classical 3 + 3 design" 
versus "accelerated titration designs": analysis of 270 phase 1 trials investigating anti-
cancer agents. Invest New Drugs. 2009;27(6):552-556. 
59. 
Le Tourneau C, Lee JJ, Siu LL. Dose escalation methods in phase I cancer clinical trials. J 
Natl Cancer Inst. 2009;101(10):708-720. 
60. 
Little RJ, D'Agostino R, Cohen ML, et al. The prevention and treatment of missing data in 
clinical trials. N Engl J Med. 2012;367(14):1355-1360.