The Effect of Remote Ischemic Conditioning on Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Prospective, Randomized, Patient-assessor Blinded, Sham-controlled Pilot Study Investigating Effect on Clinical Outcome.
Phase: NA
Conditions: Subarachnoid Hemorrhage, Aneurysmal, Delayed Cerebral Ischemia
Sponsor: Aarhus University Hospital

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Clinical Investigation Plan
RESCUE-SAH trial
The effect of Remote Ischemic Conditioning on Delayed Cerebral
Ischemia in patients with ruptured Aneurysmal Subarachnoid
Hemorrhage: a randomized, patient-assessor blinded, sham-controlled
study.
A prospective, randomized, patient-assessor blinded, sham controlled pilot study investigating whether
remote ischemic conditioning (RIC) can improve clinical outcome in aneurysmal subarachnoid hemorrhage.
Project acronym
RESCUE-SAH trial
The effect of Remote Ischemic Conditioning on Delayed
Cerebral Ischemia in patients with ruptured Aneurysmal
Subarachnoid Hemorrhage: a randomized, patient-assessor
blinded, sham controlled study examining the effect on long-term
clinical outcome
Clinical investigation plan
Version 1.0, 5th of February 2023
Principal investigator, sponsor
Investigator
Postdoc & study Coordinator
Investigator
Grethe Andersen, Senior Consultant, MD, DMSc, Professor of
Neurology, Department of Neurology, Aarhus University Hospital,
DK-8200, Denmark. Phone:+4578463294, e-mail: greander@rm.dk
Jens Christian H Sørensen, Senior Consultant MD, PhD, DMSc,
Professor of Neurosurgery, Aarhus University, Dk-8200, Denmark.
Phone: 78463461, e-mail: jenssore@rm.dk
Arzu Bilgin-Freiert, MD, PhD, Associate Professor, Department of
Neurosurgery, Aarhus University, DK-8200, Denmark. Phone:
+23882221, e-mail: arzbil@rm.dk
Kim Morgenstjerne Ørskov, MD, PhD Student, Department of
Neurosurgery, Aarhus University Hospital, DK-8200, Denmark.
Phone: +4542791933, e-mail: kimoer@rm.dk
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Contents
1.
Synopsis
3
Abbreviations
8
2.
Introduction
9
3.
Hypothesis
10
4.
Trial design
11
5.
Selection and withdrawal of subjects
12
6.
Study procedure and assessment
14
7.
Endpoints
18
8.
Benefit of the study
24
9.
Assessment of safety
24
10.
Project timetable and recruitment feasibility
25
11.
Ethical considerations
26
12.
Data handling and record keeping
26
13.
Publications policy
27
14.
Statistics
27
15.
Source data access and monitoring
28
16.
Economy
28
Supplement A - Neuroimaging protocol
29
Supplement B – Baseline data
30
Supplement C – Study Design
31
Supplement D – Roles and Responsibilities
32
References
33
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1. Synopsis
Name of the principal investigator
Grethe Andersen, Senior Consultant, MD, DMSc, Professor of Neurology, Department of Neurology, Aarhus
University Hospital, DK-8200, Denmark.
Title of study: RESCUE-SAH
The effect of Remote Ischemic Conditioning on delayed cerebral ischemia in patients with ruptured
aneurysmal subarachnoid hemorrhage.
Trial Management Groups (TMG):
Principal investigator/Sponsor (Aarhus University Hospital):
Grethe Andersen, Senior Consultant, MD, DMSc, Professor of Neurology, Department of
Neurology, Aarhus University Hospital, DK-8200, Denmark.
Postdoc- and Study Coordinator (Aarhus University Hospital):
Arzu Bilgin-Freiert, MD, PhD, Associate Professor, Department of Neurosurgery, Aarhus University
Hospital, Palle Juul-Jensens Blvd. Indgang J, 8200 Aarhus N, Denmark
Trial Steering Committee (TMC):
Arzu Bilgin-Freiert (Aarhus University Hospital), Grethe Andersen (Aarhus University Hospital),
Jens Christan H Sørensen (Aarhus University Hospital), Stig Dyrskog (Aarhus University Hospital),
Ronni Mikkelsen (Aarhus University Hospital), Mahmoud Albarazzi (Aarhus University Hospital).
Data Monitoring Committee (and Trial Safety Committee):
The DMSC comprises of:
Independent neurosurgeon: Carsten Reidies Bjarkam, Senior Consultant, MD, PhD, DMSc,
Professor of Neurosurgery, Aalborg University Hospital
Independent Neurologist: To be determined
Independent statistician: To be determined
Trial Endpoints Validation Committee:
EVC comprises of Independent senior consultants in Neurosurgery and Neurology
Trial monitoring:
During the entire study period quality assurance control will be performed.
Study centers:
Department of Neurosurgery, Aarhus University Hospital, DK-8200 Aarhus, Denmark
Planned study period: 2023-2033.
Phase of development:
Improve routine care of patients with aneurysmal subarachnoid hemorrhage and its secondary
complications.
Objectives:
●
To determine whether combined remote ischemic pre-, per- and postconditioning can improve
clinical outcome in aneurysmal subarachnoid patients as an adjunct to standard treatment.
Diagnosis:
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Aneurysmal Subarachnoid Hemorrhage (aSAH).
Methodology:
An investigator-driven, prospective, randomized, pilot, parallel assignment, patient-assessor
blinded, sham-controlled efficacy trial.
Randomization:
●
Eligible patients will be randomized upon arrival at the hospital (via a secure web site).
●
The patients and the clinical outcome assessor will be blinded to the treatment allocation.
Number and subjects (planned):
●
100 patients with full data sets
Inclusion criteria:
●
Male and female patients (≥18 years)
●
Aneurysmal subarachnoid hemorrhage confirmed by computed tomography (CT) with
aneurysm origin confirmed by computed tomography angiography (CTA) or digital
subtraction angiography (DSA)
●
Aneurysmal subarachnoid hemorrhage symptom-onset ≤3 days
●
Aneurysm protected by clipping or coiling
●
Independent in daily living before symptom onset (mRS ≤2)
Exclusion criteria:
●
Subarachnoid hemorrhage caused by a lesion other than cerebral aneurysm
●
History of severe peripheral vascular disease or signs of severe peripheral vascular disease
on physical examination
●
History of deep vein thrombosis or signs of deep vein thrombosis on physical examination
●
Pregnancy
●
Concomitant other acute life-threatening medical or surgical condition
Criteria for evaluation:
Primary endpoints
●
Clinical outcome after 6 months in patients with aSAH. Clinical outcome will be measured by
modified Rankin Scale score.
Secondary endpoints
●
Difference in infarct volume in patient with aneurysmal subarachnoid hemorrhage (aSAH)
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●
Difference in occurrence of delayed cerebral ischemia in aSAH patients
●
Early signs of microscopic vasospasm detectable by perfusion-ct scan, time-to-drain
sequences.
●
Occurrence of radiological signs of vasospasm at CT-cerebral angiography 7-8 days from ictus.
●
Clinical outcome (mRS) after 3 and 12 months in patients with aSAH.
●
Difference in TCD measures
●
To determine continuous cerebrovascular autoregulation represent a predictive marker of
secondary ischemia
●
Proportion of RIC treated aSAH patients with cerebral vasospasm receiving inta-arterial drug
infusion/therapy
●
Three-month and one-year mortality aSAH and overall
●
Early and very early neurological improvement in aSAH patients
●
Overall Bed-day, and neurointensive care bed-day, use at 3 and 12 months and quality of life
measures at 3 months
●
To determine whether prestroke physical activity level (PASE) is a predictor for early and
long-term recovery
Biochemical, blood and cerebrospinal fluid samples (tertiary and exploratory endpoints)
●
Coagulation profile of aSAH patients in daily hospital obtained blood samples
●
To determine whether RIC modulates coagulation in aSAH patients, and explore links between
coagulation and infarct growth in aSAH and occurrence of DCI in aSAH
●
Obtain a biobank of CSF from aSAH patients with an aim to explore potential prognostic CSF
biomarkers with regards til DCI
●
Obtain a biobank of blood samples from aSAH patients with an aim to explore potential
prognostic CSF biomarkers with regards til DCI
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Study flowchart
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Abbreviations
aSAH aneurysmal Subarachnoid Hemorrhage
CT
Computed tomography
CTA
Computed tomography angiography
DCI
Delayed Cerebral Ischemia
DWI
Diffusion-weighted imaging
DMC
Data Monitoring Committee and Endpoints Validation Committee
FLAIR Fluid attenuated inversion recovery
END
Early neurological deterioration
EVT
Endovascular treatment
ICP
Intracranial Pressure
MRI
Magnetic resonance imaging
NPR
Danish National Patient Register
PA
Physical Activity
PreSS Prehospital Stroke Score
RIC
Remote Ischemic Conditioning
RIPerC
Remote Ischemic Perconditioning
RIPreC
Remote Ischemic Preconditioning
RIPostC
Remote Ischemic Postconditioning
TCD
Transcranial Doppler
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2. Introduction
Aneurysmal subarachnoid hemorrhage (aSAH) is one of the most devastating types of stroke. Half
of the patients die during the acute ictus, and those who survive have a poor prognosis as 20-30%
of them are disabled or eventually die from the disease.1,2 In the acute phase after aSAH, the most
devastating complication is rebleeding, whereas in the late phase, delayed cerebral ischemia (DCI)
is another feared complication, associated with high morbidity and mortality3–7. Symptoms of DCI
occur in 30 % of patients and 15-20 % of patients will develop a disabling stroke due to DCI. DCI
typically occurs between days 4 and 14 after the initial bleeding. The cause of DCI is not fully
understood. Cerebral vasospasms (CVS) are commonly seen on angiography in the first 4-14 days
after initial bleeding, and have been linked to late onset of symptoms of focal ischaemia since the
60s. Modern research suggests that the pathophysiology is multifactorial, but CVS is still thought to
be a major contributor.8–10 Other contributing factors are thought to be microthrombosis,
microvascular spasm, oxidative stress, cortically spreading depolarizations, cell death, breakdown
of blood-brain barrier, among others11,12. Treatment with nimodipine is standard-of-care and is the
only pharmacological intervention that has been shown to improve outcome in aSAH patients,
although it has no impact on large-vessel CVS.13 The need for developing effective methods for
prevention or treatment of DCI persists, and an effective prophylactic treatment may have a large
impact on the general outcome of aSAH.14
Ischemic conditioning is a potent activator of endogenous protection against ischemic injury. RIC
can be applied as repeated short-lasting ischemia in a distant tissue that results in protection
against subsequent long-lasting ischemic injury in the target organ.15 This protection can be
applied prior to or during a prolonged ischemic event as remote ischemic preconditioning (RIPreC)
and perconditioning (RIPerC), respectively.16 RIC is commonly achieved by inflation of a blood
pressure cuff to induce 5-minute cycles of limb ischemia alternating with 5 minutes of reperfusion.
RIC activates several protective mechanisms, through humoral and neural pathways and shows
promise in the setting of acute stroke.17,18
Inflammation initiated by cerebral ischemia can contribute to secondary brain injury and is
correlated with poor outcome. Following ischemia there is a harmful excess leukocyte infiltration in
the brain parenchyma, and in experimental studies on aSAH, pharmacological inhibition of
cytokines has been associated with improved outcome.19,20 RIC has been demonstrated to reduce
inflammation and downregulate inflammatory markers. In addition, RIC has protective effects on
cerebral endothelial function and induces vasodilation, increasing cerebral blood flow (CBF).21–32
Angiogenesis, erythropoietin and nitric oxide (NO) are suggested to induce neuroprotection and
stimulation of these strategies by conditioning including inhibition of inflammation has the potential
to play an important part in treatment of patients after aSAH.33–36
The effect of RIC on blood and cerebrospinal fluid biomarkers has never been explored in the
setting of aSAH.
To-date, no serious adverse events have been documented in RIC. The procedure has been
applied in numerous cardiovascular ischemic patients and in patients suffering from ischemic
stroke and cerebral hemorrhage (ICH/SAH).37–41 A recent smaller randomized trials of RIPreC after
aSAH showed promising results with regards to functional outcomes and incidence of cerebral
oxygen desaturation, likewise without adverse effects of RIC.42–44
RIC is a non-pharmacologic and non-invasive treatment without noticeable discomfort that has
neuroprotective potential worldwide.45
Aneurysmal SAH and subsequent DCI represents a unique clinical opportunity to test RIC as DCI
typically manifests within the first 14 days after ictus and is often a significant contributor to
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neurological injury. The treatment is feasible, safe, and rooted in well-explored physiological
concepts. There is a clear scientific gap and opportunity to explore RIC in the setting of aSAH and
DCI in larger randomized trials.
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3. Hypothesis
RIC may improve clinical outcome after 6 months in patients with aneurysmal
subarachnoid
hemorrhage,
as
measured
by
modified
Rankin
scale.
We
hypothesize that the patient group treated with RIC will have a lower incidence of
radiologically verified vasospasm, DCI AND/OR less disabling lesions as a
consequence of DCI, as compared to the group treated by sham-RIC.
Objectives
Primary endpoints
●
Clinical outcome after 6 months in patients with aSAH. Clinical outcome will be measured by
modified Rankin Scale score (mRS).
Secondary endpoints
●
Difference in infarct volume in patient with aneurysmal subarachnoid hemorrhage (aSAH)
●
Difference in occurrence of delayed cerebral ischemia in aSAH patients
●
Early signs of microscopic vasospasm detectable by perfusion-ct scan, time-to-drain
sequences.
●
Occurrence of radiological signs of vasospasm at CT-cerebral angiography 7-8 days from ictus.
●
Clinical outcome (mRS) after 3 and 12 months in patients with aSAH
●
Difference in TCD measures between treatment arms
●
Difference in measures of cerebrovascular autoregulation between treatment arms
●
Proportion of RIC treated aSAH patients with cerebral vasospasm receiving inta-arterial drug
infusion/therapy as compared to controls
●
Three-month and one-year mortality aSAH and overall
●
Early and very early neurological improvement in aSAH patients (Improvement from baseline
GCS)
●
Overall Bed-day, and neurointensive care bed-day, use at 3 and 12 months and quality of life
measures at 3 months (WHO-5)
●
To determine whether prestroke physical activity level (PASE) is a predictor for early and
long-term recovery
Biochemical and cerebrospinal fluid (tertiary and exploratory endpoints)
●
Coagulation profile of aSAH patients in daily hospital obtained blood samples
●
To determine whether RIC modulates coagulation in aSAH patients, and explore links between
coagulation and infarct growth in aSAH and occurrence of DCI in aSAH
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●
To explore potential CSF biomarkers for prognostication of DCI i aSAH.
●
Obtain a biobank of CSF from aSAH patients with an aim to explore potential prognostic CSF
biomarkers with regards til DCI
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4. Trial design
​
Trial design
This is a prospective, randomized, patient-assessor blinded, sham-controlled pilot trial investigating
whether RIC improves clinical outcome after 6 months in patients with aneurysmal subarachnoid
hemorrhage.
Number of centers
Patients with aSAH from Aarhus University Hospital in Denmark will be recruited.
Number of subjects
We estimate that a sample size of 100 aSAH patients(full data sets) will be required to achieve
sufficient data for evaluation of primary endpoint.
Sample size determination
Primary clinical endpoint
The treatment effect of RIC on long-term functional outcome and infarct size is unknown. The
sample size calculation is based on the article from Van Donkelaar et al. (2019) describing the
distribution of functional outcome according to modified Rankin Scale after 2 months32. Therefore
we anticipate an effect size of a factor 0.6 on the long-term functional outcome with RIC compared
to sham intervention.
The sample size is estimated with the formula:
N=2 x  (Z1-α/2 + Zβ)2 x (SD/MIREDIF) x (SD/MIREDIF)
And with power at a alfa-level (significance) of 5% and power at a beta-level significance of 80 %,
N=2 x 16 x (1/0.6) x (1/0.6) = 90.
The sample size calculation was based on a simulation-based approach to the analysis of
statistical power when logistic linear regression analysis is performed (significance level of 5%). To
account for withdrawal and loss to follow-up we therefore plan to include 100 patients with full data
sets. Lost to follow-up rate is estimated to be less than 5%. There is no planned replacement of
patients lost to follow-up.
Randomization
Randomization procedure
The patient will be randomized to standard treatment with RIC or sham-RIC by the study
coordinator at the receiving center. The randomization is based on a secure web site providing
blocked randomization lists generated by a blinded, independent datamanager, stratified by the
center. The investigator will make an assessment based on all available information whether the
patient is eligible to participate in the study. Randomization is performed in- hospital.
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Randomization will be stratified between Fisher grade 1-2 and Fisher Grade 3-4. Registered
nurses or clinical assistants participating in the study will receive unique access and will have no
influence on the randomization process.
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5. Selection and withdrawal of subjects
​
Selection of patients
All patients with aSAH admitted to Aarhus University Hospital will be screened, and all who meet
the study criteria will be included barring non-consent to participation.
●
Depending on the randomization (RIC versus sham-RIC), patients with aSAH will continue
RIC or sham-RIC treatment for an extended period after the aneurysm is secured.
​
​
Informed consent for enrollment
​
The inclusion:
In relation to enrollment, the patient’s record will be reviewed to identify if the patient fulfills any
exclusion criteria (listed below). Information on any patients excluded due to fulfillment of one or
more exclusion criteria will be included for use in patient inclusion/exclusion flowchart (only the
exclusion criterion will be registered).
The on-duty neurosurgeon/research physician will have examined the patient both physically and
cognitively and will have assessed whether the patient is competent or not. The competent
patient will be presented with a consent form with information about the study. The competent
patient will receive oral information by the research physician based on the written patient
information. The written patient information will be handed out (deltager information). We will ask
for the patient’s acceptance to be included in the study. The patient can withdraw consent at any
time. In addition, the patient will have the usual requirements concerning a 24-hour time period for
consideration and discussion with a lay representative. In-hospital inclusion and assessment of
cognitive impairment will be undertaken during the admission at the neurosurgery center. Patients
and next of kin will be given detailed information regarding the standard-of-care, and are informed that in
the event of non-consent to inclusion, the patient will still receive standard-of-care treatment. Every effort
will be made to inform the patients and relatives in quiet and undisturbed settings, this will be at the
hospital bedroom or the designated room for conversations. We will prioritize the presence of
nearest relatives at time of study information and inclusion.
The incidence of SAH is estimated at 9.1 per 100.000 per year. About 43 % of patients die from the
initial bleeding and one third of those who survive the initial bleeding will die within 6 months if left
untreated. In the acute phase, 20 % of aSAH patients may develop hydrocephalus. Patients with
aSAH often because of the bleeding and development of hydrocephalus, experience an increase
in the intracranial pressure causing confusion, cognitive impairment and/or loss of consciousness.
The location and/or size of the aSAH, may also cause an altered mental status and some degree
of cognitive impairment, rendering the patient incompetent33. Due to the nature of aSAH, we expect
that a high percentage (around 80%) of patients will be incompetent at the time of inclusion, and
the study detailed in this protocol cannot realistically reflect the patient population without inclusion
of incompetent patients. The study entails minimal risk for included patients, but has the potential
to greatly improve outcome for the individual patient. We submit that points 2a, 2b and 2c-iii of the
NVKs checklist for inclusion of incompetent patients are fulfilled.
For the incompetent patients, informed consent will be obtained from next of kin and an
independent physician. The consenters will be provided information (based on the summary of the
protocol for the independent physicians and study participant information for the relatives) on the
trial to be able to make an informed decision about the patient’s participation in this trial. The
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independent physician will be the on-duty physician at the local department of neurosurgery,
neurology, neuroanesthesiology, intensive care, or the on duty physician from another specialty
with aSAH patient experience. On-duty physicians at these departments will receive detailed study
information.
A patient who during the initial phase was legally incompetent and included as such, but during the
follow-up period is assessed competent will receive oral and written information and we will ask for
his/her informed consent.
Patients who fulfill the inclusion criteria will, according to randomization, receive RIC/sham-RIC
treatment after the aneurysm is secured.
Once consent to participation is given, the investigators, sponsor and representatives of the
sponsor, as well as any monitoring bodies, will have direct access to any information available in
the patient’s electronic journal. Access may be used to assess any details on the patient’s prior
health necessary for completion of the trial as well as for control purposes (including
self-monitoring, quality control and monitoring of the study, all of which the TMG are obliged to
perform).
Inclusion criteria
●
Male and female patients (≥18 years)
●
Aneurysmal subarachnoid hemorrhage confirmed by computed tomography (CT) with
aneurysm origin confirmed by computed tomography angiography (CTA) or digital
subtraction angiography (DSA)
●
Aneurysmal subarachnoid hemorrhage symptom-onset ≤3 days
●
Aneurysm protected by clipping or coiling
●
Independent in daily living before symptom onset (mRS ≤2)
Exclusion criteria
●
Subarachnoid hemorrhage caused by a lesion other than cerebral aneurysm
●
Symptomatic vasospasm at the time of enrollment
●
Previous cerebral lesion e.g. symptomatic cerebral infarction (>2cm), multiple sclerosis,
symptomatic intracerebral hemorrhage, tumour, prior neurosurgery (excluding prior clipping
or coiling of cold aneurysms without complications).
●
History of severe peripheral vascular disease or signs of severe peripheral vascular disease
on physical examination
●
History of deep vein thrombosis or signs of deep vein thrombosis on physical examination
●
Kidney involvement or prior kidney disease with an eGFR below safe levels for contrast
infusion in relation to CT-perfusion.
●
Pregnancy*
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●
Concomitant other acute life-threatening medical or surgical condition
*Women of child-bearing age should be asked about their use of safe birth control methods (contraceptive pill,
intrauterine devices both hormonal and non-hormonal, hormonal implants, hormonal depot injection and transdermal
hormonal patch). Women of child-bearing age will have s-HCG taken prior to final inclusion. If pregnancy cannot be ruled
out,the patient can’t be included. Women with a safe birth control method will be encouraged to use this method during
the entire period of active RIC treatment.
Method of blinding
Outcome assessment is blinded to the treatment leg and obtained by a clinical measure of the
level of dependency and need for help in daily activities (modified Rankin Scale).
No information regarding randomization status will be recorded in the patient record.
Patients and the assessors of endpoints are blinded.
Discontinuation of study participation
A patient can withdraw from the study at any time. Patients can be withdrawn from the study at the
principal investigator’s discretion. In case the patient cannot be reached via telephone, every effort
will be made to contact the patient or to document the outcome regarding new vascular events via
registries/electronic health records. If the patient withdraws from the study, the date and the reason
for the patient’s withdrawal will be recorded. The patient is encouraged to provide information
about his or her reason(s) for withdrawal and any experienced adverse effects (AE) during the
study. Any patient who withdraws from the study will continue to receive standard in-hospital
treatment and standard follow-up.
6. Study procedure and assessment
Identification of patient with aSAH
All patients with verified SAH on CT in the central Denmark region will be admitted to the
neurosurgery center at Aarhus University Hospital and all patients with an aneurysmal SAH are
identified by the on-duty neurosurgeon/vascular neurosurgeon, which is standard operating
procedure. The aneurysm is then treated either by surgical clipping or endovascular coiling as
standard operating procedure. All patients will be examined for neurological symptoms/findings
and will have a structured assessment of Glascow coma score (GCS) before randomization.
Baseline data
Baseline data and process indicators are collected from the Danish Stroke Registry (DSR) and
electronic health records. Additional information about medical history and medication and clinical
and physiological data are collected at baseline. Data are recorded in an electronic case report
form (e-CRF) at discharge from the Neurosurgery Center and on follow-up. For a complete list of
registered data, see Supplement B
Brain autoregulation estimates:
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The autoregulation impairment can be estimated by bedside computation of the correlation
coefficient between ICP and mean arterial blood pressure (MAP). This produces a live estimate of
how ICP reacts to changes in blood pressure. If the coefficient is zero or negative, it means that
auto regulation is spared, and if positive, impaired.
This is an important difference distinguishing healthy brain tissue from tissue at risk of DCI due to
aSAH, and hence autoregulation has been proposed to be a surrogate of brain tissue vitality, and
could in turn represent a predictive marker of secondary ischemia after aSAH.
Magnetic Resonance Imaging (MRI) / Computed Tomography (CT)
Patients with aSAH diagnosis will have a CT perfusion with arterial angiography performed at
Aarhus University Hospital Neurosurgery Center, 24 (16-32) hours after randomization as a
baseline imaging. To differentiate the early and late infarction, the imaging will be performed again
at 8 days after the initial bleeding. If issues should arise that present a contraindication to CT with
intravenous contrast, an MRI will be performed in its stead wherever possible. If not, the patient will
remain included for follow-up but will be excluded from the subcohort which had all planned
radiography performed.
In case a patient develops clinical signs of DCI before the 8th day post-hemorrhage, the perfusion
protocol will be added to the standard-of-care CT-STEALTH with angiography. This series of
images will replace the day 8 imaging.
In case a patient develops clinical signs of DCI after the 8th day post-haemorrhage, standard of
care is to perform a CTC-STEALTH with angiography and perfusion. These imaging data will be
included in the project.
Patients will have an MRI performed and in cases where MRI is contraindicated a CT will be
performed, 4-6 weeks after randomization as a baseline imaging for the purpose of differentiating
early and late infarction. The images will be analyzed by automatic or manual segmentation.
Ionizing radiation:
A CT-perfusion protocol has been set up at the department of Neuroradiology at Aarhus University
Hospital We intend to supplement the standard-of-care protocol, which includes CT-STEALTH and
a CT Cerebral angiography performed after surgery to ensure sufficient closure of aneurysm.
The perfusion protocol has been tested on anthropomorphic phantoms intended for estimating
CT-dose indices (CTDIvol). CTDIvol multiplied by scan length in cm produces the Dose-Length
Product (DLP), which may be expressed in mSv by multiplying by a set conversion factor, for CTC,
the factor is 0.0018.
The CT-perfusion protocol has a DLP of 1569.8, the STEALTH-protocol has a DLP of 776.5, and
the angiography has a DLP of 229.0.
Thus, the total estimated DLP of the protocols intended for use in this study is
DLPstudy = (DLPCTperfusion x 2) + DLPangiograpy + DLPSTEALTH = (1569.9 x 2) + 776.5 + 229 = 4145.3 mGy x
cm
Or, expressed in mSv
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4145.3 mGy x cm / 0.0018 mSv/mGy x cm = 7.46 mSv
Therefore, with 1 planned CT-perfusion protocol added to the post-operative standard of care
CT+CTA-protocols, and another scan (CT STEALTH, angiography and perfusion) at the 8th day
after initial bleeding the total dose of study-related radiation should remain below 10 mSv during
the course of the study.
It is important to note that patients with aSAH will have CT-STEALTH and CT-angiography
performed as standard-of-care (2 at minimum, baseline and control after aneurysm has been
secured).
The total exposure to radiation in this protocol falls under category IIb of NVKs appendix 2, as the
category covers 0-10 mSv of exposure. It should be noted that the experimental treatment has the
potential to prevent an often devastating complication of aSAH, and that CT protocols including
perfusion and angiography imaging is the gold standard for monitoring development of DCI in
patients during intensive care, which in turn provides invaluable information about efficacy of
treatment in the present study.
Most patients diagnosed with aSAH in Denmark are around 50 yrs of age.
Blood samples
Patients with aSAH diagnosis will have baseline blood-samples drawn 24 (16-32) hours after
randomization. Blood samples will be drawn again before and after RIC on day 2, 4, 7 and 10.
These samples will supplement the standard operating procedure. 40mL in total will be drawn at
the time of each sampling. If the patient develops signs of DCI, further samples are drawn on the
day the patient develops these, and the following day, regardless of timeframe. No more than 80
mL in total will be drawn in a day.
Blood samples will be stored until completion of the trial in a research biobank.
A research biobank will be established, and all blood samples obtained during the study are stored
here. During the entire study and analysis period, the material will be stored at Aarhus University
Hospital. The last patient will be included in 31. May 2027. Analysis of blood samples, according to
secondary endpoints, will be performed during the study and until 6 years after inclusion of the last
patient (no later than 31. May 2033). Hereafter the remaining material will be transferred to a
biobank for future unspecified research purposes. The study will be registered in the internal
registry of scientific projects in the central Denmark Region, for this additional 20-year storage
period of the blood samples (until 31 May 2053), after that, the samples will be destroyed. All
analysis will be performed in Denmark.
Cerebrospinal Fluid samples
There are many potential neurological and medical complications following aSAH. Acute temporary
unconsciousness after aSAH is very common due to high intracranial pressure caused by either
the initial hemorrhage, hydrocephalus or both, even in patients with minor aSAH. Increases in ICP
from hydrocephalus are associated with secondary brain ischemia, therefore prompt recognition
and aggressive treatment is necessary34. Patients with aSAH developing hydrocephalus will be
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treated surgically by placing an intraventricular catheter for external drainage of cerebrospinal fluid
as a standard operating procedure. The CSF production is approximately 500 mL pr. day and there
is normally equilibrium between its production and absorption. Disruption of the equilibrium may
cause buildup of fluid and cause intracranial hypertension. The insertion of external drainage as
standard of care reduces risk of symptomatic intracranial hypertension by draining excess
cerebrospinalfluid35.
Patients with aSAH diagnosis who have an external drainage of cerebrospinal fluid as a standard
operating procedure will have cerebrospinal-samples taken from the external drainage pre-and
post RIC after randomization. This will be repeated on day 2, 4, 7 and 10. 20 mL will be drawn
daily until 14 days after surgery. This is not standard operating procedure, but poses no risk to the
patient since there is need for drainage because of excess fluid. Even in patients without raised
ICP, 20 mL is an inconsequential amount due to the daily production, which normally exceeds 500
mL. As the samples are taken from the external drainage, the 20 mL are taken from what is
already excess fluid, drained as standard operating procedure.
Cerebrospinal fluid samples will be stored in a research biobank until completion of the trial.
A research biobank will be established, and all cerebrospinal fluid samples obtained during the
study are stored here. During the entire study and analysis period, the material will be stored at
Aarhus University Hospital. The last patient will be included by May 31 2027. Analysis of
cerebrospinal fluid samples, according to secondary endpoints, will be performed during the study
and until 6 years after inclusion of the last patient (no later than 31 May 2033). Hereafter the
remaining material will be transferred to a biobank for future unspecified research purposes. The
study will be registered in the internal registry of scientific projects in the central Denmark Region,
for this additional 20-year storage period of the cerebrospinal fluid samples (until 31 May 2053),
after that, the samples will be destroyed. All analysis will be performed in Denmark.
ICP and blood pressure monitoring
Patients with intraventricular drainage or ICP monitoring, used as a clinical tool at Aarhus
University Hospital Neurosurgery Center, will be monitored for ICP changes before, during and
after each RIPC session after randomization. ICP changes in the event of DCI will also be
recorded.
Patients with an Arterial cannula will be monitored for changes in blood pressure in relation to
RIPC as well as in relation to developing DCI.
ICP and blood pressure are continuously monitored using ICBM+ Software (Cambridge Enterprise
Ltd, University of Cambridge, Cambridge, UK).
Transcranial Doppler Monitoring
Transcranial Doppler (TCD) non-invasively measures CBF velocities and cerebrovascular
hemodynamics within the basal arteries of the brain. During TCD, ultrasound is transmitted through
thin areas of the skull, e.g. windows. These sound waves reflect off blood cells moving within the
blood vessels, allowing for the calculation of their speed based on the Doppler effect36. As a
standard operating procedure at Aarhus University Hospital Neurosurgery Center, TCD recordings
will be performed daily in all patients with aSAH from the day of admission until day of discharge.
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TCD monitoring will be performed in patients with aSAH before, and after each RIC session after
randomization.
Brain Microdialysis/Brain Tissue Oxygen Monitoring
In patients with aSAH, cerebral microdialysis or Raumedic Neurovent-PTO can be used as a
clinical tool to monitor brain metabolism and/or brain tissue oxygen monitoring during
neurointensive care as a standard operating procedure. After randomization the brain metabolic
changes and brain tissue oxygen monitoring will be monitored before, during and after the RIC
sessions. After RIC sessions microdialysis samples will be collected continuously every hour as a
clinical tool to monitor brain metabolism as standard operating procedure. Glucose, lactate,
Lactate/pyruvate ratio, glycerol and pyruvate will be measured immediately.
The Raumedic Neurovent-PTO system has the advantage of brain tissue oxygen monitoring
(PbtO). In patients with heightened risk of cerebral ischemia such as patients with aSAH the
Raumedic Neurovent-PTO system can detect hypoxia when it occurs. The normal value for PbtO in
the brain ranges from 25 to 50 mmHg. Values below 15 mmHg indicate cerebral ischemia, and
values below 5 mmHg indicate cell death. After randomization, the Raumedic Neurovent-PTO
values will be registered before, during and after the RIPC session in patients with a Raumedic
Neurovent-PTO inserted as a standard operating procedure.
Remote ischemic conditioning protocols
Device
RIC will be performed using an Automatic Tourniquet System 2200 (A.T.S. 2200), produced by
Zimmer Biomet. The A.T.S. 2200 is an automated pneumatic tourniquet device, developed for
safely regulating the interruption of blood flow during operations. It regulates the pressure of a
tourniquet cuff, which temporarily occludes blood flow to a patient's upper or lower extremity to
maintain an anemic field. The device is designed to safely maintain interruption of blood flow to an
extremity for up to 120 minutes, and has built-in alarms that serve to ensure that time thresholds
are respected.
The device is classified as class I according to annex VIII of the MDR under EU law, produced by
the US-based company Zimmer Biomet, Warsaw, Indiana, USA. In Denmark, the Device is
imported, sold and serviced under , and marketed in Denmark and maintained by Zimmer Biomet
Denmark ApS, Herstedlund 12, 2620 Albertslund, Denmark. Both companies are CE, QM, MDSAP
and ISO 13485 certified.
Using the Zimmer A.T.S. 2200 for RIC falls under the intended functions covered by the
CE-marking of the device. The device has previously been approved for use in Danish randomized
trials, regarding interventions in orthopedic surgery.
Remote Ischemic Conditioning (RIC)
After randomization a large thigh blood pressure cuff will be placed on the lower limb. The cuff will
be inflated to a pressure 30 mm Hg greater than the systolic arterial blood pressure measured by
the patient's arterial line or upper limb blood pressure cuff. The adequate level of inflation will be
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confirmed by the absence of pulse in the ipsilateral pedal artery detected by palpation. If the pulse
signal is still present, the cuff will be inflated further until it disappears. The cuff will remain inflated
for 5 minutes. Then the cuff will be deflated and the limb allowed to re-perfuse for 5 minutes. The
procedure will be repeated five times followed by reperfusion. The first session will be performed
24-72 hours after the initial hemorrhage, within the first 24 hours after treatment of aneurysm, and
repeated every 24 hours, between 8-10 am, until post hemorrhagic day 14.
Sham – remote ischemic conditioning (Sham-RIC)
After randomization a large leg blood pressure cuff will be placed on the lower limb. The cuff will be
inflated to a pressure 20 mm Hg. The cuff will remain inflated for 5 minutes, then the cuff will be
deflated for 5 minutes. The procedure will be repeated for five cycles. The first session will be
performed 48-72 hours after the initial hemorrhage, at least 24 hours after treatment of aneurysm
and repeated every 24 hours, between 8-10 am, until post hemorrhagic day 14.
RIC/sham-RIC treatment will continue for a total of 14 days. If patients are discharged from the
hospital, treatment will be halted upon discharge.
RIC/sham-RIC protocol
Accepted time frame
First RIC
Within 24 hours after aneurysm secured
Second RIC
23 hours from last cuff of the initial RIC
RIC daily until post hemorrhagic day 14
23 hours from last cuff of the last RIC until day
14
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Table 2: Schedule and Activities
Days after
treatment
(First RIC the
morning after
surgery)
ICTUS/
0
1
2
3
4
5-6
7
8
9
10
11-14
Discharge
Wk
4-6
90
days
180
days
Informed
Consent
x
Medical history
x
Medication
x
Weight
x
Physical
examination
x
Baseline imaging
x
Surgical
intervention
x
Clinical
evaluation,
standard-of-care
x
x
x
x
x
x
x
x
x
x
x
RIC/ sham-RIC
x
x
x
x
x
x
x
x
x
x
Blood sample
before and 1-2
hours after RIC*
x
x
x
x
CSF sample
Before and after
RIC*
x
x
x
x
TCD
x
x
x
x
x
x
x
x
x
x
CTC, perfusion,
angiography*
x
x
MRI-c
x
Follow-up
interview
x
x
mRS-score
x
x
x
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7. Endpoints
An independent end-point committee will adjudicate clinical events.
Primary endpoints
Criteria for evaluation
Clinical outcome at 6 months in patients with aSAH
The level of dependency and need for help in daily activities will be determined by either
face-to-face assessment or based on structured telephone interviews performed by assessors who
are blinded to the intervention at 3 and 6 months after the index aSAH.
The assessment will be performed by two independent blinded assessors, which can be either
face-to-face or telephone based assessment (not same day), and the patient will be contacted by a
third assessor (face-to-face or telephone) who is blinded to the intervention who will assess the
level of dependency.
●
If disagreement occurs between two telephone assessments – a third, and final,
telephone or face-to-face assessment will be made.
●
If disagreement occurs between one face-to-face assessment and one telephone
assessment – the face-to-face will be considered the final assessment
●
If disagreement occurs between two face-to-face assessments – a third, and final,
telephone or face-to-face assessment will be made.
Every possible effort will be made to assess the outcome in patients who are unable to participate
in the interview (this could be due to post-stroke neurological impairment (for example aphasia
and/or dysarthria), or that the patient cannot be reached by telephone). The outcome will then be
assessed by contact to a named relative or the general practitioner. Several attempts to contact the
patient by telephone will be made before contacting the named relative or general practitioner.
Death in the follow-up period will be obtained from the Danish Civil Registration System (CPR).
The structured telephone interview will be based upon a validated Danish translation of the “slightly
revised simplified, modified Rankin Scale questionnaire”37. The translation and its validation will be
performed according to the AAOS guideline37,38.
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Bruno et al. 2011. Stroke.
Furthermore, modified Rankin Scale assessors are required to have received specific mRS
training, which could be an online mRS certification:
https://secure.trainingcampus.net/uas/modules/trees/windex.aspx?rx=rankin-english.trainingcampu
s.net
Outcome
Accepted time frame (from symptom onset)
3, 6 and 12-month follow-up – 1st and 2nd
assessment
3, 6 and 12 months +/- 2 weeks
3, 6 and 12 month follow-up – 3rd assessment
3, 6 and 12 months and 2 weeks +/- 2 weeks
Secondary endpoints
Clinical outcome attributed to secondary cerebral ischemia in aSAH
Early neurological improvement in aSAH patients
Neurological deficits and daily neurological assessment are documented with the GCS.
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●
Early neurological improvement is defined as:
Increase in GCS from baseline or resolution of symptoms at discharge.
●
Increase in GCS ≥2 points or resolution of symptoms after 24 hours in subgroups:
endovascular treated aSAH.
Diagnosis of aSAH and the clinical outcome is documented in the electronic case report form. The
daily difference in neurological impairment during the hospital stay will be documented in all
randomized patients. Neurological deficits are documented using Glasgow Coma score (GCS).
The GCS score is obtained and registered by the on-call neurosurgeon before randomization.
Glasgow Coma Score is assessed at 24-hour by a certified and trained general neurosurgery
nurse/neurosurgery research nurse/physician/neurosurgeon. Only information regarding time and
place of assessment, patient name, age and social security number will be available. The GCS
score of patients with aSAH and non-aSAH diagnoses, are performed by the on-call
physician/neurosurgeon or a research nurse/general neurosurgery nurse. mRS is documented at
discharge. The outcome assessor will be alerted in advance of the assessment. The mRS is
recorded in the electronic CRF.
Secondary infarct attributed to secondary cerebral ischemia in aSAH
Secondary infarct growth is defined as the difference in infarct volume between baseline and 14
days on CT. In all aSAH patients, the baseline imaging modality is CT. In cases of initial CT, a
baseline with CT perfusion is performed 24-hours after the aneurysm is secured. To estimate the
infarct volume the imaging will be performed at day 8 after the initial hemorrhage and 24 (16-32)
hours after the last RIC/sham-RIC session or before discharge. Patients will have an MRI
performed 4-6 weeks after randomization to differentiate the late infarction.
Imaging protocol
Accepted time frame
CT perfusion baseline – aSAH
24 hours after aneurysm secured
CT perfusion (8 days)
8 days from initial bleeding
MRI (4-6 weeks)
4-6 weeks from initial bleeding
Information about imaging protocols, see Supplement A
Ischemic vascular events at 3 and 12 months in aSAH patients
Ischemic vascular events defined as:
▪
Acute ischemic stroke
▪
Transient ischemic attack
▪
Myocardial infarction, ST-elevation myocardial infarction (STEMI), and Non-STEMI
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Three-month and one-year mortality
Information about mortality is collected using the CPR and LPR, at two time points (6 and 15
months after the inclusion of the last patient). All-cause mortality is assessed and subdivided into
vascular mortality versus non-vascular mortality39.
Analyses are performed on all randomized patients and according to subgroups.
Endovascular treatment in RIC treated aSAH patients with cerebral vasospasm
There is a rapid advance in the endovascular treatment of cerebral vasospasm following aSAH and
the primary goal is to increase CBF to prevent infarction. The common modalities of endovascular
vasodilatation are an intra-arterial drug infusion and/or balloon angioplasty40.
Difference in proportion of RIC treated aSAH patients with cerebral vasospasm receiving
intra-arterial drug infusion/therapy.
Quality of life measures at 3, 6 and 12 months in aSAH patients
▪
Quality of life and bed-day use measures in aSAH patients
Quality-of-life measurements are assessed by telephone interview at 3, 6 and 12 months after
inclusion. The modified Rankin scale and WHO-5 questionnaire are used. Reliability to determine
the patient’s mRS category score is satisfactory both when assessed by telephone interview and
by consultation46, and the WHO-5 is validated for use in telephone interviews47. Baseline WHO-5 is
obtained at Aarhus University Hospital.
Link to: Danish National Board of Health - WHO-5.
Information about bed-day use via the LPR and the local stroke registry.
Biochemical profile of aSAH subtypes and of RIC-induced neuroprotection
Biochemical substudies
●
Coagulation, fibrinolysis, endothelial and inflammatory marker profile in obtained blood
samples to differentiate between baseline infarct, secondary infarct, and non-infarct.
●
Microvesicular changes in relation to aSAH
●
MicroRNA changes in relation to aSAH
●
Modulation of the mentioned biomarkers by RIC in aSAH.
Handling of blood samples:
Blood samples will be collected from patients with aSAH. After randomization the blood samples
will be obtained through arterial cannula from patients in the ICU, or via standard peripheral
venous blood sampling where not possible. The local biochemical department or study personnel
will centrifuge the blood and divide the plasma into cryotubes that will be kept at 80 °C for
long-term storage.
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Patients with aSAH diagnosis will have baseline blood-samples drawn 24 (16-32) hours after
randomization. Blood samples will be drawn again before and after RIC on day 2, 4, 7 and 10. This
is not standard operating procedure. 40mL in total will be drawn at the time of each sampling. If the
patient develops signs of DCI, further samples are drawn on the day the patient develops these,
and the following day. No more than 80 mL in total will be drawn in a day.
All blood samples obtained during the study will be stored in a research biobank
Blood-samples, in the research biobank, will be stored until completion of the trial (no later than 31.
May 2033). Hereafter the remaining material will be transferred to a biobank for future unspecified
research purposes (see section “Blood Samples” under “study procedure and assessment”).
Planned biochemical analysis
Coagulation assays:
Functional and immunologic plasma assays will be employed to analyze proteins and pathways in
coagulation, fibrinolysis, endothelium and inflammation. The analyses will be performed in the
accredited clinical laboratory and the thrombosis and hemostasis research unit at the Department
of Clinical Biochemistry, Aarhus University Hospital. Plasma samples will be stored in cryotubes at
-80 °C until analysis is undertaken in large batches.
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Overview, blood samples:
Analyses
Vials
Volume
(ml)
Handling
Place of analysis
Routine coagulation analysis
aPTT, INR, fibrinogen,
fibrin d-dimer,
antithrombin
Blue Na-citrat,
1 x 1,8 ml
1,8
Delivery in the
24-7 lab within 1
hour of sampling
24-7 lab, dept of
clinical biochemistry
Biobank
Secondary hemostasis:
TG, F1+2, TAT
Fibrinolysis:
clot-lysis, PAI-1
Endothelium:
sTM, VWF, P-selectin
Biobank for future
research
Blue
Na-citrat,
2 x 9 ml
18
Centrifugation and
aliquoting, storage
at -80°C until
analysis
Research lab, dept
of clinical
biochemistry
Neurofilament light
chain and other
neurological
biomarkers
Biobank for future
research
Serum 1 x 9 ml
9
-
-
Markers of complement
activation
Proinflammatory
cytokines
Biobank for future
research
Purple K-EDTA
1 x 9 ml
9
-
-
Total (max)
37,8 ml
aPTT: activated partial thromboplastin time; INR, international normalized ratio; TG: ex vivo
tissue factor induced thrombin generation; F1+2: prothrombin fragment 1+2; TAT:
thrombin-antithrombin Complex; clot-lysis: ex vivo tissue factor induced fibrin generation
or -lysis; PAI-1, plasminogen activator-inhibitor 1; sTM, soluble thrombomodulin; VWF, von
Willebrand-factor
Handling of Cerebrospinal samples:
Patients with aSAH diagnosis who have an external drainage of cerebrospinal fluid as a standard
operating procedure will have cerebrospinal-samples drawn pre- and post RIC on day 2, 4, 7 and
10 after randomization. Samples will be taken from the external drainage. This is not standard
operating procedure. 10mL will be drawn at all times.
Brain microdialysis:
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In select aSAH patients where cerebral microdialysis (CMA 70, microdialysis AB, Stockholm,
Sweden) is being used as a standard operating procedure to monitor brain metabolism during
neurointensive care, the brain metabolic changes will be monitored before, during and after the
RIC sessions with a standard flow rate of 0.3 μL/min, which leads to a higher recovery. After
randomization we will collect the baseline (pre-session) vial measures the hour before the start of
the RIC and the second vial will be collected during RIC sessions (the inflation–deflation rounds),
which represents the average ischemic effect of the five inflations. After RIC sessions samples will
be collected continuously as a clinical tool to monitor brain metabolism. Glucose, lactate, L/P ratio,
glycerol and pyruvate will be measured immediately (CMA 600 microdialysis AB, Solna, Sweden).
Brain Tissue Oxygen Monitoring
In select patients with aSAH, Raumedic Neurovent-PTO can be used as a standard operating
procedure to monitor brain tissue oxygen monitoring during neurointensive care. The Raumedic
Neurovent-PTO system can give an early warning of a significant difference between the cerebral
tissue oxygen supply and oxygen demand. After randomization the brain tissue oxygen monitoring
will be recorded. All values will be registered including before, during and after the RIC sessions.
Physical activity (PA) measures in aSAH patients
Patients and their relatives will be asked to complete the physical activity in the elderly (PASE)
questionnaire during the acute hospital admission. In patients who are unable to complete it
themselves an structured interview based on the PASE questionnaire will be performed41,42.
The PASE is a 12-item questionnaire, which quantifies the amount of PA over a 7-day period. The
PASE questionnaire was developed with the purpose of assessing the level of PA in middle-aged
and elderly individuals. The PASE score is calculated by taking the average number of hours spent
on an activity (sports, occupational activity, household activities, and leisure time activities) per day
over a 7-day period multiplied by an activity coefficient. Item scores are added to reveal the PASE
score. The PASE score may range from zero to more than 400.
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8. Benefits of the study
Potential benefits:
Participating patients with aSAH may experience an improvement of clinical outcome and
reduction in secondary cerebral ischemia.
Disadvantages:
Mild-to-moderate pain and petechiae in the RIC-treated leg may occur during the inflation of the
blood pressure cuff. It should be noted that all patients are on a standard-of-care regime of
analgesics following aSAH and surgical intervention, which should mediate any pain. Otherwise,
the RIC treatment has been tested in large populations of patients with ischemic stroke,
intracerebral hemorrhage as well as in large populations of patients with cardiac ischemia, and has
so far proven safe and without serious side effects. Recent smaller trials have tested RIC in
patients with aSAH, also without any serious adverse events.
Sham-RIC will only be associated with a slight sensation of pressure on the lower extremity.
Baseline CT and CT angiography are obtained for primary assessment (according to hospital
SOP). An additional (compared to standard operating procedure) head CT-perfusion will be
performed. The CT scan will be repeated during the patients hospital stay (according to hospital
SOP) in aSAH patients and an additional (compared to standard operating procedure) head
CT-perfusion protocol will be performed at day 8 if the patient’s clinical status allows. CT-scans are
associated with a dose of radiation. The CT-protocols associated with the study will not exceed 10
mSv (see “Ionizing Radiation” above). This corresponds to about 3 years of background radiation
in Denmark.
An additional head MRI will be performed 4-6 weeks after the initial aSAH bleeding. In cases
where MRI is contraindicated we will perform a head CT perfusion. The MRI scan is harmless and
not associated with radiation risk. The scan may be associated with discomfort due to noise and
claustrophobia.
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9. Assessment of safety
Emergency unblinding procedure
In cases where emergency unblinding is necessary the on-call neurosurgeon will log-on to
electronic CRF at redcap.dk and enter the civil registration number (CPR) of the patient. The
treatment can now be unblinded. All changes will leave an audit-trail.
Adverse events
Patients are monitored in the neurosurgery unit with GCS scoring at close intervals, and
neurological examination when indicated, and adverse events are treated according to clinical
guidelines.
The Data Monitoring Committee will assess safety according to primary study endpoints,
rebleeding, recurrent stroke, myocardial infarction and mortality.
Interim analysis of safety parameters in aSAH will be performed regularly during the study.
During the hospital stay the patients will be asked if they have experienced any deterioration of
health or new symptoms during or after RIC. Furthermore all patients will have a 24/7 contact
number to the neurosurgery center and a contact to study research physician and will be instructed
to report any deterioration of health, development of new symptoms or other adverse events.
All possible serious adverse events (SAEs) will be registered in the e-CRF and stratified by
seriousness (benign, serious, serious unexpected). All cases of re-bleeding from a secured
aneurysm will be reported as possible adverse events for evaluation. All possible adverse events
will be examined for causality by an independent evaluator. Petechiae in the treated extremity as
well as moderate pain are expected and mild adverse events, and will not be reported.
Suspected unexpected serious adverse reactions /events (SUSARs) will be unblinded and
reported directly to the committee of research ethics. SUSARs deemed lethal or life-threatening will
be reported to the sponsor immediately upon discovery. The sponsor will inform the committee of
research ethics within seven days of the SUSAR.
All discharged patients (and relatives) will be given contact details to study personnel and be
instructed to report any deterioration of health or new symptoms. The patients with aneurysmal
subarachnoid hemorrhage will once again be asked for adverse events at the 3- month telephone
interview. In this group, end-of-study visit is the last telephone interview, whereas end-of-study visit
for participants without a vascular diagnosis is at the time of discharge from the neurosurgery
center.
All patients who have consented are followed (through Danish Health Registries, LPR and DSR)
for new vascular events and mortality for up to 12 months.
Event report and causality assessment
All events will be registered in the electronic CRF and reported to the authorities at the interim
analysis. A yearly safety report, containing a list of all SAEs will be submitted to the Independent
Ethics Committee by the Sponsor as required by Danish law.
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10.
Project timetable and recruitment feasibility
Study preparation: January 2022 to May 2023
Study start date: June 2023
Month 0-3: Patient recruitment
Expected inclusion end date: 31. May 2027
Month 2-5: Study analysis
Expected end date for last analysis and follow-up: 31. May 2033
Annual admissions of aSAH patients at the neurosurgery department at Aarhus University Hospital
is approximately 70 patients. Approximately 40% of those patients die due to acute ictus or
rebleeding before surgery can be initiated. It is estimated that we will include about 30-35 patients
annually.
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11.
Ethical considerations
The study will await approval from the Regional Ethical Committee. The study will comply with the
Data Protection Act and data protection regulation. Enrollment of additional Danish stroke centers
will require a new application to the regional ethics committee (amendment).
Any discomfort and stressing of the patients can potentially put patients at risk of rebleeding and
therefore we will randomize the patients after the aneurysm is secured. Improvement of standard
care in patients suffering from aSAH is of paramount importance. Inclusion of all aSAH patients is
necessary in order to translate any positive research results into a benefit for all aSAH patients.
The intervention is without any known risk apart from moderate pain in the lower extremity when
the cuff is inflated, and has been explored in the setting of intracerebral hemorrhage, ischemic
stroke and cardiac ischemia previously without reported serious adverse events18,45 (REF).
There is a risk of infection during cerebrospinal sample draw, but to minimize this risk samples will
be drawn by experienced personnel under sterile, secure conditions. Patients frequently have CSF
drawn daily for analysis, and samples can be taken concurrently to minimize any additional risk.
Study participants are covered in accordance with the Danish Patient Insurance Act.
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12.
Data handling and record keeping
All study data are recorded in an electronic CRF with blinded data and identification via a study
identification number. The study will apply to the specifications of the act on processing of personal
data. The study will also comply with the Data Protection Act and data protection regulation.
Baseline data and process indicators are collected from the Danish Stroke Registry (DSR) and
electronic health records. Additional information about medical history and medication and clinical,
paraclinical and physiological data are collected by the examining physician at baseline, and taken
from the electronic health records upon inclusion. Data are recorded in an electronic case report
form (eCRF) during the admission period, at discharge from the Neurosurgery Center and at
follow-up. For a list of registered data, see Supplement B.
Study data were collected and managed using REDCap electronic data capture tools hosted at
Aarhus University Hospital.48,49 REDCap (Research Electronic Data Capture) is a secure,
web-based software platform designed to support data capture for research studies, providing 1)
an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and
export procedures; 3) automated export procedures for seamless data downloads to common
statistical packages; and 4) procedures for data integration and interoperability with external
sources.
Patient participation will be recorded in the medical record. Data will be stored at the Department of
Neurosurgery, Aarhus University Hospital, for 15 years, after which the documents will be
shredded.
A notification to The Danish Data Protection agency will be submitted.
The investigator permits direct access to all source data/documents (including electronic patient
record) at monitoring visits, audits and/or inspections by the regional ethics committee.
The informed consent permits the investigators, sponsors and its representative and the control
authority direct access to all source data/documents from patient records and electronic records to
keep information about the study participant’s health information that can necessitate completion of
the project, control purposes such as self-control, quality control and monitoring which are required
to perform.
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13.
Publications policy
The results of the study negative, inconclusive and positive will be disseminated as widely as
possible - through publication in an international peer-reviewed journal, as conference
presentations and on www.clinicaltrials.gov.
The trial will be registered on www.clinicaltrials.gov and www.strokecenter.org/trials.
After the trial period, a report on the device efficacy as a mediator of RIC, as well as a shorter
resumé will be published online and referred to in the various publications as well as on
clinicaltrials.gov.
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14.
Statistics
Primary study endpoint:
Difference in clinical outcome (mRS) at 6 months in aneurysmal SAH (General ordinal
logistic
regression analysis. Significance level of 5%)
Ordinal logistic regression analysis, expressed as a common odds-ratio50. This method is
encouraged by the European Stroke Organization’s Outcomes Working Group, both for calculating
sample sizes and analyzing results of clinical trials.
Secondary study endpoints (selected):
●
Difference in infarct growth after 4-6 weeks (Binomial regression analysis, significance level
of 5%)
●
Difference in modified Rankin scale during the first 14 days: (general ordinal logistic
regression analysis, Significance level of 5%)
●
Difference in early neurological improvement in aSAH (general ordinal logistic regression
analysis. Significance level of 5%)
●
Difference in occurrence of delayed cerebral ischemia in aSAH patients (ordinal logistic
regression analysis, significance level of 5%)
●
Three-month and one-year mortality (Two sample test of proportion (Chi-square test),
significance level of 5%)
●
Difference in the coagulation profile (general ordinal logistic regression analysis,
Significance level of 5%)
●
Difference in presence of vasospasm at cerebral angiography baseline vs 8-day scan
(two-sample test of proportion (chi-square test), significance level of 5%)
Interim analysis
We will perform an interim analysis for evaluation of the actual event rate after inclusion of 50% of
the patients. If this shows a lower infarct size than expected, a new sample size calculation will be
performed.
The trial can be stopped at interim analyses for futility, efficacy and safety reasons.
Missing data:
Missing data will be handled using multiple imputation (predictive mean matching imputation).
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15.
Source data access and monitoring
Trial-related audits and/or monitoring will be provided by direct access to source data/documents.
The sponsor will conduct a yearly audit and compile a report of any adverse events.
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16.
Economy
Study initiators are Grethe Andersen, Senior Consultant, MD, DMSc, Professor of Neurology at
Department of Neurology, Aarhus University Hospital and Jens Christian H Sørensen, Senior
Consultant MD, PhD, DMSc, Professor of Neurosurgery, Aarhus University Hospital.
The Danish foundation TrygFonden has supported the study with 3.695.172 dkk (research
personnel
salaries, running costs and imaging).
The Danish Foundation Region Midtjyllands Sundhedsvidenskabelige Forskningsfond has
supported the study with 898.396 dkr (study investigator/coordinator salary).
The full amount of granted funds flows through the Department of FAS (Regnskab, Forskning og
Eksterne midler), Aarhus University Hospital which will then approve and manage dispersal
including all project-related expenses and remuneration, in accordance with the project budget.
The funders have no role in study design, data collection, analysis or interpretation, nor the
decision to
publish or the preparation, review and approval of any part of the manuscript.
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Supplements
Supplement A - Neuroimaging protocol
On admission CT is performed according to hospital SOP.
All aSAH patients can be included in RIC/sham-RIC based on a baseline native CT. However, after
the aneurysm is secured there is a risk of infarct either complications to the procedure or from the
initial hemorrhage and therefore patients with aSAH after randomization require a CT perfusion at
baseline demonstrating acute ischemic lesion in order to evaluate infarct growth. Baseline head CT
perfusion in aSAH patients is performed within 24 hours after the aneurysm is secured and before
the first RIC series.
Non aSAH diagnosis (only evaluated with CT) will not be included in the RIC study and no further
neuroimaging outside the standard care will be performed.
Imaging protocol
Accepted time frame
CT perfusion baseline
24 hours after aneurysm secured
CT baseline
24 hours after aneurysm secured
Control CT perfusion
8 days from baseline CT
MRI
4-6 weeks from baseline CT
Computed tomography (CT) protocol
Baseline CT and CT angiography are obtained in centers using CT for primary assessment
(according to hospital SOP).
CT analysis
Infarct volume assessment at baseline (24 hours after aneurysm is secured), and at 8 days will be
performed by an experienced neuroradiologist. Any visible vasospasm at angiography will also be
registered. The assessment will be assisted using an automated CT Neuro perfusion workflow
software for stroke volume assessment (e.g. Siemens, SyngoVia, Aarhus University Hospital,
Denmark)43.
Magnetic resonance imaging (MRI) protocol
Diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC), T2* gradient-recalled echo
(T2*GRE), and T2 fluid-attenuated inversion recovery (T2-FLAIR).
The protocol for 4-6 weeks MRI includes: DWI, T2*, T2 and T2-FLAIR.
The total acquisition time for this protocol is approximately 10-20 mins (MRI), depending on the
MRI equipment.
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MRI analysis
Follow-up MRI, 4 -6 weeks after the initial bleeding, the DWI and FLAIR lesion will be outlined,
representing irreversibly damaged tissue.
Infarct volume assessment at 4-6 weeks is performed by an experienced neuroradiologist. The
assessment may be assisted using an automated stroke volume assessment software.
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Supplement B – Baseline data
Age
Prior or active long-course immunosuppressive
treatment
Male/female
Prior or current chemo or radiation therapy in
relation to head/neck areas.
Medical History
Prior or current phosphodiesterase-5-inhibitor
treatment
Hypertension
Prior or current stimulant drug use (amphetamine,
ephedrine, cocaine)
Smoking
Alcohol
Clinical and physiological data
Hyperlipidemia
Symptoms on admission and worsening of
symptoms, if any.
Diabetes
Modified Rankin Scale prior to aSAH
Previous myocardial infarction
Yes: within 3 months, yes: more than 3 months, no, unknown
Symptom onset (time)
Angina pectoris
Time of admission
Atrial fibrillation
Completed prehospital RIC/sham cycles
Previous ischemic stroke or TIA
= 5, 4, 3, 1-2, 0
Peripheral artery disease
Time (start/stop) for each RIC/sham cycle
Physical activity (PASE interview)
Substudy at Aarhus University Hospital
Admission blood pressure
Medication on admission
DCI onset
Statins
Stroke onset
Calcium channel blockers
Modified Rankin Scale (t = 14 days)
ACE inhibitors/angiotensin receptor blockers
Endovascular spasmolysis therapy
Beta-blockers
Treatment initiation (time)
Platelet inhibitor treatment
Paraclinical data
Anticoagulation therapy
Diagnostic CT-scan /MRI made on admission for
assessing severity of aSAH (Fisher scale)
Direct oral anticoagulation treatment (DOAC)
Mode of securing aneurysm
Opioid treatment
Coiling or Clipping
SSRI treatment
Baseline data obtained from treating physicians, database of Danish stroke centers (ddsc.dk), Danish
stroke registry and electronic health records.
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Supplement C – Study Design
All patients with verified SAH on CT will be admitted to the neurosurgery department at Aarhus
University Hospital. All patients with an aneurysmal SAH are identified by the on-duty
neurosurgeon/vascular neurosurgeon, which is standard operating procedure in Denmark. After
the aneurysm is secured, the research physician will make an assessment based on all available
information whether the patient is eligible to participate in the study. If the patient is eligible, the
patient or family members will be informed by the study coordinator/registered nurse, on-duty
neurosurgeon/vascular neurosurgeon or a neurocritical care physician and signed consent will be
obtained. The patient will be randomized to standard treatment with RIC or sham-RIC by the study
coordinator at the receiving center. Registered nurses participating in the study will receive unique
access and will have no influence on the randomization process.
Prior to the first round of RIC, the aneurysm has to be secured by clipping or coiling. Patients will
have a CT perfusion performed 24 (16-32) hours after the aneurysm is secured as a baseline
imaging to confirm the early infarction that can occur due to the initial aneurysm rupture or as a
result after the treatment from clipping or coiling of the aneurysm.
The neurocritical and neurosurgery team decides if there is an indication to place a brain
microdialysis catheter, Raumedic Neurovent-PTO catheter, external drainage or ICP monitor. Once
it is indicated the same team will place it. The hemodynamic and ICP changes will be monitored
during the RIC procedure. Once all monitoring is in place the study team will perform the RIC
procedure.
As a standard procedure TCD measurements will be obtained from the day of admission to the
patient's hospital discharge and once the patient gives consent for the study, TCD will also be
measured during and after the RIC procedure. Similarly blood and CSF samples will be taken
during and after the RIC procedure.
RIC will be induced by inducing Ischemia in the lower extremity. In the neurointensive care unit, the
arms often have numerous monitoring devices and catheters inserted, which make their use for
conditioning problematic. The RIC sessions will consist of 5-minute cycles of lower limb ischemia
followed by 5-minute periods of reperfusion. The procedure will be repeated five times followed by
reperfusion. The aim is to start the RIC procedure at post hemorrhage day 2 and perform RIC
sessions every 24 hours between 8-10 am until post hemorrhage day 14. The RIC procedure will
be performed via an adult large lower extremity blood pressure cuff wrapped around the thigh. The
cuff will be inflated to a pressure 30 mm Hg greater than the systolic arterial blood pressure as
measured by the patient's arterial line or upper limb blood pressure cuff. The adequate level of
inflation will be confirmed by the absence of pulse in the ipsilateral pedal artery .The cuff will
remain inflated for 5 minutes. The cuff will then be deflated and the limb will re-perfuse for 5
minutes, after which the procedure will be repeated. In sham-RIC, the cuff will be inflated to a
pressure 20 mm Hg. The cuff will remain inflated for 5 minutes then the cuff will be deflated for 5
minutes. The procedure will be repeated for five cycles daily.
The device used for inflating the cuff is the Zimmer A.T.S. 2200, a CE-marked device intended for
creating a bloodless working environment during surgeries of a duration up to 2 hrs.
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Head CT perfusion imaging will be performed 24 hours after securing the aneurysm and on day 8
post-hemorrhage. To differentiate late infarction, an MRI will be performed 4-6 weeks after the
initial hemorrhage.
Patients with aSAH diagnosis who have an external drainage of cerebrospinal fluid as a standard
operating procedure will have cerebrospinal-samples drawn pre- and post RIC on day 2, 4, 7 and
10 after randomization. This is not standard operating procedure. 10mL will be drawn at all times.
Patients with aSAH diagnosis will have baseline blood-samples drawn 24 (16-32) hours after
randomization. Blood samples will be drawn again before and after RIC on day 2, 4, 7 and 10. This
is not standard operating procedure. 40mL in total will be drawn at the time of each sampling. If the
patient develops signs of DCI, further samples are drawn on the day the patient develops these,
and the following day. No more than 80 mL in total will be drawn in a day.
The primary end point is patient modified Rankin Scale score at 6 months. MRS will be evaluated
at admission (prior mRS), discharge, at 3 months, 6 months and 12 months.
Supplement D – Roles and Responsibilities
Name
Role
Responsibility
Grethe Andersen, MD, DMSc,
Professor of Neurology
Sponsor, Principal
investigator
Principal investigator
Jens Christian Sørensen MD, DMSc,
Professor of Neurosurgery
Professor, department of
Neurosurgery
Coordination,
inter-department logistics
Arzu Bilgin-Freiert, MD, PhD,
Associate Professor
Study Coordinator
Investigator
Stig Dyrskog, MD
Neuro ICU
Coordinator
TCD measures
Mads Rasmussen, MD
Neuroanesthesiologist
Patient transport to Imaging
Leif Østergaard MD, Professor
Ronni Mikkelsen MD
Neuroradiologist
Image description and
measurements
Søren Paaske Johnsen,
Professor
Statistician
Data analysis
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Claus Vinter Bødker Hviid
Department of clinical
biochemistry, Research
division
Coordination of (exploratory)
biomarker studies, CSF
Julie Brogaard Larsen
Department of clinical
biochemistry, Thrombosis
and Hemostasis,
Research division
Coordination of (exploratory)
biomarker studies,
coagulation
Kim Morgenstjerne Ørskov
PhD Student, investigator
Investigator, Coordinator
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