Preventing Epilepsy Using Vigabatrin In Infants With Tuberous Sclerosis Complex (PREVeNT Trial) A Randomized, Double-blind, Placebo-controlled Seizure Prevention Clinical Trial for Infants With TSC
Phase: PHASE2
Conditions: Tuberous Sclerosis Complex
Sponsor: Martina Bebin

PREVENTING EPILEPSY USING VIGABATRIN IN INFANTS WITH TUBEROUS 
SCLEROSIS COMPLEX (PREVeNT TRIAL)-NCT02849457 
Protocol version 6.0 _ 7/2/2020 

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PREVENTING EPILEPSY USING VIGABATRIN IN INFANTS WITH TUBEROUS 
SCLEROSIS COMPLEX (PREVeNT TRIAL) 
A randomized, double-blind, placebo-controlled seizure prevention clinical trial for infants with TSC 
 Study PI:  
 
 
 
 
E. Martina Bebin, MD, MPA
University of Alabama – Birmingham 
Director, Pharmacy Core: 
Darcy A. Krueger, MD, PhD 
Cincinnati Children’s Hospital Medical Center 
Director, EEG Analysis Core: 
Joyce Y. Wu, MD 
University of California – Los Angeles 
Brian Litt, MD 
University of Pennsylvania- IEEG.org Portal 
Director, Data Coordinating Center: 
Gary Cutter, PhD 
University of Alabama – Birmingham 
Genetic Research Laboratory:  
Bruce Korf, MD, PhD and Ludwine Messiaen, PhD 
University of Alabama – Birmingham (UAB) Medical 
Genomics Laboratory  
Participating Clinical Sites: 
E. Martina Bebin, MD, MPA
Stephanie Randle, MD 
University of Alabama – Birmingham
Seattle Children’s Hospital 
Darcy A. Krueger, MD, PhD  
Danielle Nolan, MD 
Cincinnati Children’s Hospital Medical Center 
Beaumont Children’s Hospital 
Joyce Y. Wu, MD 
Michael Wong, MD, PhD 
University of California – Los Angeles 
Washington University in St. Louis 
Mustafa Sahin, MD, PhD 
William McClintock, MD 
Boston Children’s Hospital 
Children’s National Medical Center 
Mary Kay Koenig, MD 
Katherine Taub, MD 
University of Texas – Houston 
The Children’s Hospital of Philadelphia 
Michael Frost, MD 
 
Klaus Werner, MD, PhD 
Minnesota Epilepsy Group 
Duke University Health Center 
Brenda Porter, MD, PhD 
Stanford University 
 
KEYWORDS: Tuberous Sclerosis Complex, epilepsy, prevention, vigabatrin, electroencephalography

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Table of Contents 
Study Objectives: .............................................................................................................................................. 4 
Primary Study Objective: ......................................................................................................................... 4 
Secondary Study Objectives: ............................................................................................................... 4 
Study/Background/ Rationale: .................................................................................................................. 4 
Protocol description: ................................................................................................................................. 7 
INCLUSION CRITERIA: .......................................................................................................................... 8 
EXCLUSION CRITERIA: ........................................................................................................................ 8 
EEG Acquisition and Data Transfer: ............................................................................................. 11 
Vigabatrin and Placebo: ........................................................................................................................ 12 
Developmental Assessments: ........................................................................................................... 13 
Ophthalmologic Assessments: ........................................................................................................ 14 
PREVeNT Trial Background for Vision Testing and Creation of eCRFs ...................... 15 
Background .................................................................................................................................................. 15 
Optical Coherence Tomography ...................................................................................................... 17 
Examination .................................................................................................................................................. 17 
Biomarker Blood Samples, Genetic testing and Bio-specimen Sharing: .................... 18 
Biomarker blood samples: .................................................................................................................. 18 
Genetic testing: .......................................................................................................................................... 19 
Study Organization and Data Management: (Appendix 1:Figure 2- PREVeNT Trial 
Organization) .................................................................................................................................................... 21 
Estimate of Key timelines: ................................................................................................................... 22 
Statistical Methods, Sample Size and Analysis Plan: ............................................................. 22 
Monitoring Recruitment ........................................................................................................................ 22 
Primary Study Objective: .......................................................................................................................... 23 
Drug resistant epilepsy: ............................................................................................................................ 29 
Additional developmental measures and ASD Risk: .................................................................. 29 
EEG biomarker feasibility: ....................................................................................................................... 29 
Additional measures and analyses considerations: .................................................................... 30 
Adverse Event Reporting .......................................................................................................................... 30 
Data and Monitoring Plan .......................................................................................................................... 31 
Human Subject Protection ....................................................................................................................... 33 

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Privacy and Confidentiality ...................................................................................................................... 34 
Appendix 1: Figure 1: PREVeNT STUDY DESIGN ...................................................................... 35 
Appendix1: Figure 2- Organizational Chart ................................................................................... 36 
Protocol Version 6.0 Summary of Changes ................................................................................... 42 
Bibliography & References Cited ......................................................................................................... 43 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Study Objectives: 
 
Primary Study Objective:  
 
The primary endpoint is the developmental impact of early versus delayed treatment with 
vigabatrin. To this endpoint we propose to demonstrate the effect of the intervening 
variable (early versus delayed treatment) on the developmental outcome at 24 months. 
The primary outcome measure for this objective will be the cognitive assessment score 
of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) at 24 
months of age. 
 
Secondary Study Objectives: 
 
1) Determine the effectiveness of early versus delayed treatment with vigabatrin in 
clinical seizure prevention. The outcome measure will be time to first clinical seizure 
following randomization. The prevalence of drug-resistant epilepsy will be assessed 
at 24 months for each group (vigabatrin early treatment vs. vigabatrin delayed 
treatment). 
2) Determine the impact of early versus late treatment on the other components of the 
Bayley-III (receptive communication, expressive communication, fine and gross motor 
skills) and risk of autism spectrum disorders (ASD). The primary outcome measures 
for this objective will be subdomain scores of the Bayley-III, Vineland-II (Survey 
Interview Form), Beery Visual Motor Integration (VMI), and ADOS2 at 24 months. 
Additional exploratory analysis will be completed at 36 months to access changes 
observed at 24 months are consistent with those seen at 36 months and indicative of 
long-term outcome. At 36 months of age subjects will also complete the Peabody 
Picture Vocabulary Test (PPVT). During the COVID-19 Pandemic in order to minimize 
the risk of infection to observer and infant until the completion of the study the Brief 
Observation of Symptoms of Autism (BOSA) will be administered at 24- and 36-month 
visits. Additionally, the ADI-R will be administered at the 36-month visit. 
3) Confirm vigabatrin safety as a preventative treatment for clinical seizures in infants 
with TSC. The outcome measure will be percentage of patients in each group 
(vigabatrin early treatment vs. vigabatrin delayed treatment) with treatment associated 
adverse events (AEs), serious adverse events (SAEs), and risk evaluation and 
mitigation strategy (REMS) measures. 
4) Confirm of the feasibility of using EEG biomarkers to identify TSC infants at risk for 
developing epilepsy. The outcome measure will be the sensitivity and specificity of 
EEG epileptiform activity in predicting epilepsy outcomes at 24 months within 
treatment groups. 
Study/Background/ Rationale: 
 
TSC is a multisystem genetic disorder, in which 90-95% of the affected individuals have 
CNS involvement consisting of subependymal nodules, subependymal giant cell 

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astrocytomas (SEGA), multifocal areas of cortical dysplasia consisting of tubers and 
migration defects, and abnormalities of white matter organization.  Clinically, epilepsy is 
manifest in 80-90%, of which half or more are drug-resistant1.  In addition, intellectual 
disability, autism spectrum disorder, developmental delays, and psychiatric disorders are 
highly prevalent and demonstrate a strong association with early-onset epilepsy and 
severity in this population2,3.  The molecular basis of TSC is known, arising from 
deficiency in proteins encoded by the TSC1 and TSC2 genes that form a protein complex 
that plays a critical role in the regulation of the serine-threonine kinase mammalian target 
of rapamycin (mTOR)4,5.  Pharmacological inhibitors of mTOR have been demonstrated 
to reduce various tumor types and hamartomas characteristic of TSC6-8.  Early studies 
have also suggested these drugs may have favorable impact on other TSC disease 
manifestations, including seizures and neurocognition9-12, but definitive studies are still 
forthcoming.  
  
As a rare disease, there is limited data regarding efficacy of current anticonvulsants for 
the treatment of epilepsy specifically in TSC. A clear exception is vigabatrin, in which 
multiple published studies have repeatedly demonstrated the efficacy of vigabatrin for the 
treatment of infantile spasms and partial-onset seizures in TSC.1,13-18  Other FDA-
approved treatments for infantile spasms in patients with TSC, such as 
adrenocorticotrophic hormone (ACTH), are less effective when compared to vigabatrin.  
Relatively few studies have compared both treatments directly to one another, and the 
large United Kingdom Infantile Spasms Study (UKISS) specifically excluded patients with 
TSC.19 A smaller prospective treatment trial by Vigevano and Cilio for infants with new-
onset infantile spasms found that vigabatrin was superior for patients with cerebral 
malformations and TSC, whereas ACTH was more effective for patients with hypoxic-
ischemic injury.20 This is consistent with the more recent retrospective study by 
Camposano et al., in which spasms cessation occurred in 55% of those treated initially 
with vigabatrin but 13% of those initially treated with ACTH.14  These and similar studies 
were the basis of the International League of Epilepsy Infantile Spasms US Working 
Group to recommend the use of vigabatrin as effective first-line therapy for infantile 
spasms, particularly in patients with infantile spasms and TSC.21  
 
First developed in 1975, vigabatrin potentiates the action of an important, protective 
neurotransmitter in the brain called γ-aminobutyric acid (GABA). Human clinical trials 
began in 1979 and first regulatory approval occurred in the United Kingdom in 1989, 
followed by Australia (1993) and Canada (1994).  Potential side effect concerns and 
industry decisions delayed FDA approval in the United States until 2009.  The main side 
effect cited of concern with vigabatrin treatment is potential treatment-associated 
peripheral vision loss (vigabatrin-associated visual field loss, or VAVFL), estimated to 
occur in 10-15% of children by some measures, but clinically meaningful vision effects 
are estimated to be less than <1%.18  Given the highly favorable benefit to risk ratio of 
vigabatrin in this population, vigabatrin is now the recommended first-line treatment for 
infantile spasms for patients with TSC by the International TSC Consensus Group and 
the European TSC Consensus for SEGA and Epilepsy Management.22,23 However, 
current standard of care applies only to patients after clinical spasms are manifest.  

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Presently, there is no indication for pre-symptomatic treatment or treatment initiated on 
the basis of EEG findings alone. 
 
The scientific basis for the use of vigabatrin as a potential treatment intervention that will 
slow the progression of epileptogenesis versus its efficacy for seizure control is based on 
the recent publication by Zhang et al. from the Michael Wong laboratory.24   In the 
TSC1GFAPCKO mouse model characterized by early seizures that are progressive and 
eventually lethal,25 vigabatrin treatment increased GABA concentration, resulting in 
decreased seizures and increased survival.24 These changes were associated with 
decreased activation of the mTOR pathway in both the cortex and hippocampal brain 
regions that were dose-dependent. Also, Russo et al reported that early treatment with 
vigabatrin had “antiepileptogenic” effects in a genetic rat model of absence epilepsy.26 
The exact mechanism of action in TSC is unclear, but together with its already established 
clinical efficacy in treating seizures, these data are the starting point for our proposal to 
investigate vigabatrin as an anti-epileptogenesis treatment for TSC.  
 
Due to the high frequency of epilepsy in TSC that is often drug-resistant and associated 
with significant CNS-related comorbidities, interest in early, presymptomatic treatment 
has existed for decades. However, lack of supporting evidence and selection of a suitable 
agent has limited efforts that would justify initiating treatment with medication that has 
potential side effects in otherwise asymptomatic infants. Clinical characteristics of TSC 
and recent clinical developments now make such a treatment strategy rational and 
feasible: 
(1) Many TSC patients are diagnosed before birth or at the time of birth due the presence 
of rhabdomyomas in the heart. A fetus or a newborn with multiple cardiac tumors has 
a 95% chance of having TSC.27 Increased use of prenatal ultrasounds has significantly 
increased the detection of TSC in the fetus such that cardiac manifestations have 
become the most common presenting sign of TSC. 28 Therefore, there is essentially a 
newborn imaging screen available to detect individuals with TSC very early in life.  
(2) More than 80-90% of individuals with TSC will experience seizures in their lifetime, 
with majority onset within the first 2 years of life.1 Drug-resistant epilepsy is extremely 
common, estimated to occur in more than 50%.  Epileptic encephalopathy and 
treatment-related side effects are also common, as are high likelihood of additional 
CNS comorbidities that have long-term implications on independence, quality of life, 
and overall health. Thus the majority of newborns and infants identified with TSC have 
an extremely high risk of significant negative outcomes as a result of their epilepsy for 
which current treatment strategies and standard of care are inadequate. 
(3) Vigabatrin is already FDA-approved for use in TSC and therefore its use in infants is 
well-established. Medication-related safety risks and side effect profiles are known, 
and a risk evaluation and mitigation strategy (REMS) program with the FDA is in place 
to monitor and address potential vision-related concerns that might arise in treated 
individuals. Vigabatrin has a unique position in TSC because it is more efficacious for 
IS than other therapeutic options. Developmental outcomes are closely related to the 
presence of IS and suppression of IS, so based on the efficacy of vigabatrin in patients 
with TSC and IS, vigabatrin has the potential of being a disease modifying agent for 
neurodevelopmental outcomes in TSC. Vigabatrin mechanism of action is a GABA 

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potentiator, but is has superior efficacy to other GABA drugs such as phenobarbital 
and benzodiazepines suggesting another potential mechanism of action of vigabatrin 
in controlling IS in TSC. The TSC mouse model data has shown modest effect of 
vigabatrin as a mTOR inhibitor. However, the preclinical data of mTOR inhibitors as 
antiepileptogenic drugs in multiple mouse models for TSC are very convincing, 
suggesting that even a small effect of vigabatrin on mTOR is a significant candidate 
for antiepileptogenic therapy24,25.  
(4) Two recent publications: the first by Jozwiak et al. (2011), in which 14 TSC infants 
were treated with vigabatrin based on EEG abnormalities rather than waiting until 
onset of clinical seizures, demonstrated improved rates of seizure-freedom and 
intellectual ability compared to 31 historical controls treated only after onset of clinical 
seizures.29 Although this study has significant limitations, it does support the potential 
for early treatment to positively change subsequent outcome trajectories of these at-
risk infants. The second by Bombardieri et al. published a series of 10 children who 
received vigabatrin within one week of the onset of focal seizures or infantile spasms 
and had at least 30 months of neurodevelopmental follow up. They concluded that 
early control of seizures plays a pivotal role in preventing subsequent epileptic 
encephalopathy and reducing the impact of persistent seizures on developmental 
outcomes30. 
(5) Preliminary results of video EEG biomarker analysis from the NIH P20 grant-Potential 
EEG Biomarkers and Antiepileptogenic Strategies for Epilepsy in TSC (P20-
NS080199) are compelling and support the use of the presence of epileptiform activity 
as an EEG biomarker for the PREVeNT Trial. The conventional EEG data analysis 
was focused on infants 6 to 24 months of age, when clinical seizures were more likely 
to emerge in the TSC population. The presence of inter-ictal EEG epileptiform activity 
and developing seizures had a sensitivity of 73.7% and specificity of 100%.  The 
corresponding positive predictive value (PPV) for inter-ictal EEG epileptiform activity 
is 100% (that the subject with epileptiform discharges on EEG would develop 
seizures) and negative predictive value (NPV) is 64% (that the subject without 
epileptiform discharges on EEG would not develop seizures).  
 
The central hypothesis of this Phase IIb trial is that early identification of 
electroencephalography (EEG) biomarkers and early treatment versus delayed treatment 
with vigabatrin in infants with TSC will have a positive impact on developmental outcomes 
at 24 months of age.  It would also prevent or lower the risk of developing infantile spasms 
and refractory seizures.  This preventative approach would be expected to result in more 
favorable long-term cognitive, behavioral, developmental and psychiatric outcomes and 
significantly improve overall quality of life. It is a randomized, double-blind, placebo-
controlled clinical trial design. Successful completion of this trial will also advance the field 
by demonstrating the value of systematic surveillance with EEG in asymptomatic infants 
with TSC.  
 
 Protocol description: 
 
Study design is a Phase IIb prospective multi-center, randomized, placebo-controlled, 
double-blind clinical trial.  The goal will be to enroll 80 infants with TSC who are less than 

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6 months of age prior to the onset of their first seizure (Appendix1: Figure 1-PREVeNT 
Trial Study Design).   
INCLUSION CRITERIA: 
1) < 6months of age  
2) No history of seizures or infantile spasms, or evidence of subclinical electrographic 
seizures on a previous video EEG  
3) Meet genetic or clinical diagnostic criteria for TSC, the latter based on current 
recommendations for diagnostic evaluation, such as physical exam, neuroimaging, 
echocardiogram28.    
EXCLUSION CRITERIA:  
1)  Is greater than 6 months of age 
2)  Has not been diagnosed with TSC 
3)  History of seizures or infantile spasms, or evidence of subclinical electrographic 
seizures on a previous video EEG 
4) Has received any anticonvulsant medication including vigabatrin, other anti-seizure 
therapeutic agent including cannabidiol 
5) Has received an oral mTOR inhibitor such as everolimus or sirolimus 
6) Has taken an investigational drug, including but not limited to cannabidiol, as part of 
a research study 30 days prior to enrollment, or plans on taking an investigational drug 
at any time during the duration of the study 
7) Is currently enrolled, or plans on enrolling at any time during the duration of the 
study, in an experimental behavioral early intervention study 
8) Has a history of being born prematurely (born less than <30 weeks gestation at the 
time of delivery) 
 
Subjects who have consented and at the time of their baseline study visit and show 
evidence of electrographic seizures on their initial video EEG will exit from the PREVeNT 
study and proceed with initiation of management of their clinical condition. All other 
enrolled subjects will be followed until the age of 36 months with physical and neurologic 
exams, serial 1-hour awake and sleep video-EEGs, and ophthalmologic evaluation at 
baseline and defined intervals, every 6-12 weeks based on subjects chronological age. 
 
Study visits and procedures are based on subjects’ chronological age in months (±1 week 
if under 12 months of age and ±2 weeks if 12 months and older).  Once enrolled, subjects 
enter a ‘watchful waiting’ protocol which includes baseline EEG at 1.5 month (~6 week) 
intervals until 12 months of age, then every 3 month (~12 week) intervals until 24 months 
of age. Subjects will continue in this protocol phase until treatment is justified.   
 
Randomization will be stratified into two groups, according to age at time of emergence 
of EEG biomarkers: 1) <= 7 months; 2) >7 months of age.  This is to account for natural 
history studies and data from our P20-NS080199 study that indicates mean age of clinical 
seizure onset less than 7 months of age, with a significant portion of TSC infants 
developing seizures between 6-12 months and still others after 12 months of age1.  
Accordingly, this randomization strategy will ensure we are able to evaluate age 
independently of timing of EEG change and treatment randomization.   

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For the accurate identification of clinical seizures, parents and caregivers will review a 
seizure recognition video at the time of study enrollment and retain it as a reference 
throughout the study. They will also be encouraged to video any suspicious events during 
the study period for review by clinicians of the investigation team.  If at any point during 
the study the subject is suspected of having a clinical seizure, the parents/caregiver will 
be instructed to contact their site’s study coordinator. The subject will be seen as soon as 
possible for a study visit and a video EEG will be completed for confirmation of clinical or 
electrographic seizure onset. Those subjects with either a documented clinical seizure on 
video or evidence of an electrographic seizure on video EEG will be transitioned to the 
Open-Label treatment phase.  
 
At the emergence of abnormal epileptiform activity (i.e. sharp waves, spikes or polyspikes, 
spike and wave discharges, classic or modified hypsarrhythmia) prior to the onset of the 
first clinical or electrographic seizure, subjects will enter the protocol blinded-treatment 
phase (Arm A). Emergence of these specific, predetermined EEG biomarkers detected 
by video EEG will lead to a 1:1 randomization with vigabatrin or placebo. The vigabatrin 
and placebo will be dispensed as a sachet and those subjects randomized to vigabatrin 
will be titrated up to 100mg/kg/day by 50mg/kg/day every 3 days during the blinded phase 
of the study. The research pharmacist at each site will be unblinded during this phase of 
the study and the vigabatrin and placebo sachets doses will be identical in order to 
maintain the blind. 
 
To further maintain the treatment blind, subjects who experience their first seizure after 
randomization to either vigabatrin or placebo will follow the same blinded 2 week 
transition to open label vigabatrin (dose increased to 150mg/kg/day in the open label 
phase), so that all patients regardless of randomization group will exit the blinded 
treatment phase in identical fashion.  This way, neither the treating physician nor the 
parent/guardian would know which treatment group the child had been assigned.  Only 
the PREVeNT trial independent medical monitor and research pharmacists at each site 
would have access to randomization assignments throughout the study.  The blinded 2 
week transition phase will also occur if the subjects in Arm A are seizure free at the time 
of their 24 month of age study visit. They will be tapered off the study drug (vigabatrin or 
placebo) without breaking the treatment blind and continue to be followed for the duration 
of the study (36 months) under best medical care (i.e. if seizures develop, vigabatrin may 
be initiated).  
 
Both vigabatrin and placebo will be repackaged into identical aluminum foil sachets so as 
to maintain treatment blinding and distribute as appropriate to the investigational 
pharmacies at local participating sites for individual patient distribution and administration. 
For administration, the entire content of one sachet (500 mg active drug) is dissolved in 
10 ml water for oral administration that is dosed according to body weight 50-150 
mg/kg/day divided BID. Dosing will follow established recommended guidelines (50 
mg/kg/day and increased as needed by 50 mg/kg/day every 3 days up to 100mg/kg/day 
during the blinded phase of the study, divided BID).  
 

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Only those subjects who have clinical seizures or electrographic seizures in the blinded 
treatment phase of the study will transition to open label vigabatrin to a dose of 
150mg/kg/day. 
Note** Subjects who have consented and at the time of their baseline study visit and 
show evidence of electrographic and/or clinical seizure(s) on their initial video EEG will 
exit from the PREVeNT study and proceed with initiation of management of their clinical 
condition. 
 
If an enrolled subject has an electrographic or clinical seizure(s) prior to randomization 
and the previous EEG(s) have been normal they will move into the Open label phase of 
the study (Arm B). If the seizures are not controlled in the Open label phase at the 
vigabatrin maximum dose of 150mg/kg/day, the investigator may change the antiepileptic 
medication as clinically warranted to improve seizure control (including tapering off 
vigabatrin). These subjects will remain in the open arm of the study for the duration of the 
protocol (36 months). 
 
Patients enrolled without prior clinical seizures but found on first baseline EEG to have 
electrographic or clinical seizures of which the parent and clinician were previously 
unaware will exit the PREVeNT trial and begin medical treatment by the site PI based on 
clinically accepted management guidelines for seizures in TSC infants. Based on the P20-
NS080199 study, this group is estimated to be very small (<5%) and will not affect the 
total number of enrolled patients (N=80) eligible to be randomized to either placebo or 
vigabatrin treatment.  
 
Enrolled subjects who never develop EEG abnormalities or clinical seizures (ARM C) will 
remain in the study and continue with regular clinical evaluations, EEG testing, and 
developmental assessments as scheduled (Table 2). Without EEG change or developing 
seizures, they will have neither been randomized nor treated with vigabatrin.  These 
patients will serve as a negative control and be key for validating the sensitivity and 
specificity of EEG biomarkers as predictors of seizure risk and baseline disease 
characteristics attributable to TSC that are independent of epilepsy and AED treatment 
(TREATMENT ARM A).     
 
All patients on placebo or vigabatrin will exit the blinded treatment phase (TREATMENT 
ARM A) at the onset of electrographic and/or clinical seizures or 24 months of age 
whichever comes first. Subjects experiencing clinical seizures will undergo a 2 week 
blinded transition to open label vigabatrin to a target dose of 150mg/kg/day, thus 
maintaining the blind. The treating clinician at that time may further optimize treatment 
with vigabatrin as tolerated, add adjunctive treatment, or transition to alternative AED 
according to best clinical judgment and established standard of care.  All seizure 
treatments and dosing will be recorded and analyzed for synergistic effects, efficacy for 
specific seizure types, impact on long-term epilepsy and developmental outcome 
measures, and safety. Vigabatrin safety data will include the ophthalmologic examination 
data elements as outlined in the protocol and any potentially vigabatrin related changes 

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noted on routine clinical brain MRI that are obtained as part of clinical care during the 
subjects PREVeNT participation. 
 
EEG Acquisition and Data Transfer: 
 
Subjects will receive serial 1-hour video-EEG studies to monitor for the development and 
evolution of EEG abnormalities.  All video EEG studies will be recorded for one hour, 
incorporating both sleep and wakefulness, at a sampling rate of 2000 Hz. A standard EEG 
acquisition protocol has been designed for all 15 sites to ensure uniform recording 
parameters as well as data collection with standard 23 electrodes placed according to the 
10-20 international placement system. All subjects will receive the first EEG study within 
a 2 week window after study enrollment. Those subjects with evidence of epileptiform 
activity on their EEG will have repeated EEGs every 6 weeks until 12 months of age, then 
every three months until 24 months year of age, and a final EEG at 36 months. (Table 1).   
 
Those subjects with no evidence of epileptiform activity on their EEG and remain seizure 
free will have repeated EEGs every 6 weeks until 12 months of age, then every three 
months until 24 months year of age, and a final EEG at 36 months. (Table 2). 
 
In addition to the PREVeNT central EEG readers there should be a designated on-site 
EEG reader who will review the EEG and generate a clinical EEG report for the medical 
record at every study visit.  
 
Prior to the subject being randomized into the blinded phase of the protocol the EEG 
report generated by the PREVeNT readers (Drs. Peters, Porter and Wu) will determine 
the subject’s course in the study.  
 
Once the subject enters the blinded phase of the study the study visit EEG should be 
read by the designated EEG reader at each site before the subject completes the 
designated requirements for the study visit.  The EEG will continue to be read by the 
PREVeNT EEG readers but they will have up to 14 days to complete the study CRF.  If 
the clinical EEG during the blinded phase of the study shows evidence of electrographic 
and/or clinical seizures the site clinical EEG reader should notify the site PI, site study 
coordinator. The site study coordinator will then notify the Prevent study coordinator 
(Jessica Krefting RN) and Dr. Bebin.  Dr. Bebin will then notify the PREVeNT EEG reader 
on call to request an EEG review and confirmation of the EEG findings the subject 
completes the study visit. If there is a difference in interpretation between the site clinical 
EEG reader and the PREVeNT EEG reader the final determination will be made based 
on the PREVeNT EEG reader interpretation. This will determine if the subject will 
transition to the open-label phase of the protocol or not at this study visit. 
 
If a subject develops clinical seizures during the blinded phase of the study their 
parent/LAR should contact the site study coordinator as soon as possible. It is strongly 
encouraged that the parent/LAR video any suspicious events that raise concern for 
seizures so they can be reviewed by the site PI.  If it is determined by the site PI that the 
subject is having clinical seizures every effort should made to see the subject back in 

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clinic within 24-72 hours of receiving the call from the parent/LAR. The subject will return 
for an “Unscheduled Study Visit” which will include: physical examination, EEG, 
medication reconciliation, seizure classification, and determination if the subject is to 
transition into the Open Label phase of the protocol. If there are any questions regarding 
the subject’s transition to the Open Label Phase of the protocol Dr. Bebin should be 
contacted to discuss the subject course in the study. 
 
The deidentified EEG data, without video, will be transferred to IEEG.org managed by the 
University of Pennsylvania for same day analysis by the blinded primary central EEG 
reviewer. There will be an assigned back up EEG reader to the primary central EEG 
reviewer in the rare instance that primary central EEG reviewer is not available. There will 
be 2 EEG readers (Dr. Brenda Porter and Dr. Peters) throughout the study. Prior to the 
subject randomization, the EEGs will be read the same day as the EEG is completed 
by either EEG reader, which will be pre-determined the week prior for any given 
week, and a CRF report will be generated.  Once the subject has been randomized the 
EEGs will be read by both readers within 14 days of the EEG being completed. The 
primary central EEG reviewer’s interpretation of the EEG and identification of epileptiform 
activity will determine if the subject will be placed in Arm A for treatment randomization to 
vigabatrin or placebo.  
 
The Central EEG reviewer’s interpretation will be communicated back to each site. The 
primary central EEG reviewer will be available to each site as needed for clarification or 
any discrepancy of the individual site readers EEG interpretation. Should either the 
primary central EEG reviewer or the backup EEG reader be uncertain of epileptiform 
discharges in rare cases, these two readers will consult each other and reach a 
consensus.  
 
Video EEG will be viewed digitally in the standard time scale of 30 mm/sec and standard 
filter settings of 1 Hz low frequency filter (high pass) and 70 Hz high frequency filter (low 
pass), along with a 60 Hz notched filter. Each video-EEG study will be scored, based on 
age-appropriate norms, as either: normal or abnormal. Abnormalities will be further 
characterized in terms of specific background abnormalities (e.g. generalized or focal 
slowing), epileptiform abnormalities (e.g. focal, multifocal, or generalized spike 
discharges, electrographic seizures), and presence of hypsarrhythmia. EEG data will be 
collected using a modified NINDS Common Data Element Epilepsy Tools.  
 
Vigabatrin and Placebo: 
 
The investigational drug product to be used in this study is vigabatrin, marketed in the US 
under the trade name Sabril by Lundbeck Pharmaceuticals.  Lundbeck will supply 
vigabatrin for this study directly to the Investigational Pharmacy at Cincinnati Children’s 
Hospital (CCHMC).  It is supplied as a white granular powder enclosed in 50x60 mm child-
resistant aluminum foil packets (sachet).  It is non-hygroscopic, freely soluble in water, 
and thermodynamically stable with an established shelf life of more than 36 months at 
room temperature. Povidone is the primary inactive excipient. The investigational 
pharmacy at CCHMC will produce identical white granular powder with indistinguishable 

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physical appearance, color, solubility, and taste to the vigabatrin powder supplied by 
Lundbeck.  Both vigabatrin and placebo will be repackaged into identical aluminum foil 
sachets so as to maintain treatment blinding and distribute as appropriate to the 
investigational pharmacies at local participating sites for individual patient distribution and 
administration. For administration, the entire content of one sachet (500 mg active drug) 
is dissolved in 10 ml water for oral administration that is dosed according to body weight 
50-150 mg/kg/day divided BID. Dosing will follow established recommended guidelines 
(50 mg/kg/day and increased as needed by 50 mg/kg/day every 3 days up to a maximum 
dose of 100 mg/kg/day, divided BID in the blinded phase and 150mg/kg/day in the Open 
Label Phase).  
 
Subjects randomized to vigabatrin in Arm A (Figure 1) will be treated with vigabatrin 
100mg/kg/day or placebo until 24 months of age or until they show evidence of clinical 
seizures or electrographic seizures on video EEG. Based on the published EEG 
biomarker data for infants with TSC, the subjects randomized to our primary randomized 
trial population, Arm A (who have evidence of epileptiform activity in their EEG) will be at 
high risk for developing epilepsy (approaching 100%). 
 
If the subjects in Arm A are seizure free at 24 months of age, they will be tapered off the 
study drug (vigabatrin or placebo) without breaking the treatment blind and continue to 
be followed for the duration of the study (36 months).  
 
If electrographic or clinical seizures occur while on study drug, they will transition into the 
Open label phase of the study (Arm B) and continue to be followed until 36 months of age 
as per the PREVeNT protocol schedule. If the seizures are not controlled in the Open 
label phase at the vigabatrin maximum dose of 150mg/kg/day, the investigator may 
change the antiepileptic medication as clinically warranted to improve seizure control 
(including tapering off vigabatrin). These subjects will remain in the open arm of the study 
for the duration of the protocol (36 months). 
 
Based on the TSC-EBS data, it is estimated that 30% of subjects (24 subjects) in Arm C 
will not be treated but continue in the study until the age of 36 months (Table 2).  
 
See Pharmacy Manual for details of packaging and labeling, product tracking and 
accountability, and product disposal and destruction. 
 
Developmental Assessments: 
 
The developmental leadership team will oversee the implementation of the developmental 
assessments and monitor the quality and consistency across all  sites.  
 
All enrolled subjects, regardless of which arm of the PREVeNT protocol, will complete the 
Bayley-III assessment scale and Vineland -II (Survey Interview Form), at 6 months, 12 
months, 24 months and 36 months of age. The Bayley Social Emotional Adaptive 
Behavior Assessment will be completed at the 6 month study visit. The Bayley Scales of 
Infant and Toddler Development, Third Edition (Bayley-III) which will be completed at 12, 

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24 and 36 months of age. The blind will be maintained for the clinical psychologist 
performing the developmental assessments throughout the study. They will be blind to 
treatment arm, subject’s seizure control and concomitant medications. In addition to the 
primary outcome analysis to determine the impact of early vs. delayed treatment with 
vigabatrin on neurodevelopmental outcome at 24 months, the inclusion of the 12-month 
time-point allows additional exploratory analysis to determine if problematic areas of 
cognitive function and/or developmental domains are evident before 24 months of age. 
Additional developmental assessments will be completed which include the subdomain 
scores of the Bayley-III, Vineland (Survey Interview Form), Beery Visual Motor Integration 
(VMI), Child Behavior Check List (CBCL) and ADOS2, and/or Brief Observation of 
Symptoms of Autism (BOSA)* and DSM-5 checklist at 24 months. At 36 months of age 
subjects will complete the same assessments as 24 months with the addition of the 
BOSA* and ADI-R if the ADOS is not administered, as an exploratory analysis to access 
whether changes observed at 24 months are consistent with those seen at 36 months 
and indicative of long-term outcome and those subjects at risk for autism or ASD. At 36 
months of age subjects will also complete the Peabody Picture Vocabulary Test (PPVT). 
When appropriate instruments are available, measures can be administered to Spanish 
speaking individuals. 
 
*During the COVID-19 Pandemic and for the remainder of the study the BOSA and DSM5-
checklist was added to the 24 and 36 month study visit. This would enable the study to 
complete the Autism assessments at the 24 and 36 month visit using a valid assessment 
tool while complying with the COVID-19 safety measures. Because of the requirement to 
wear a facemask during the subject’s study visit would invalidate the ADOS-2 result. In 
its place the BOSA will be administered over a 15-20 min session by trained ADOS-2 
research reliable psychologists, since it requires the same clinical skill and judgement 
required for the ADOS-2 administration and scoring. The ADI-R will be completed at the 
36 month study visit if the ADOS is not administered to aid the Autism diagnostic accuracy 
with the BOSA. (See Appendix 3 page 36) 
 
A summary of the neurodevelopmental assessment will be provided to the site 
investigators after each assessment. If the subject shows evidence of developmental 
delays they will be referred for early intervention services, including physical, occupational 
and speech therapy. The investigators are aware that this could potentially bias the 
results but it is ethically imperative that referrals to early intervention services be initiated 
when warranted. The proportion referred and the early intervention services implemented 
will be tracked over the duration of the study 
 
Ophthalmologic Assessments: 
 
Since approval of vigabatrin for the treatment of infantile spasms in 2009, the FDA has 
required a risk evaluation and mitigation strategy (REMS) that includes recommended 
ophthalmologic evaluations every 3 months.  For the current study, this recommended 
safety guidelines of the REMS program will be followed, but we recognize that this creates 
some unique challenges within a double-blinded, placebo-controlled randomized study. 
All subjects enrolled in the PREVeNT Trial will follow a standard ophthalmologic protocol. 

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At each site, the ophthalmologic examination will be completed by a pediatric 
ophthalmologist or neuro-ophthalmologist who has experience in TSC infant 
ophthalmologic examinations. 
 
The protocol will include a baseline eye exam within 4 weeks of initial enrollment in study. 
This will include: visual acuity, pupillary reaction and dilated funduscopic examination with 
fundus photography. Electroretinography (ERGs) will not be obtained as part of the 
ophthalmologic examination at any of the participating sites.  It should be noted that the 
FDA risk evaluation and mitigation strategy (REMS) program does not require ERGs.   
 
Subjects randomized to the Blinded Treatment phase (Arm A) will be treated with 
vigabatrin 100mg/kg/day or placebo until 24 months of age, or have a clinical seizure or 
electrographic seizure on EEG as determined by the Central EEG Reader.  During this 
phase of the study, the established FDA REMS guidelines will be followed.  Eye 
examinations will be completed within 4 weeks after randomization (Arm A) and then 
every three months while the subject is in the double blind phase of the study.  The eye 
exams will include: visual acuity, pupillary reaction and dilated funduscopic examination.  
A final eye exam will be completed after the subject has been off study drug for 3-6 
months. The final exam will include: visual acuity, pupillary reaction and dilated 
funduscopic examination. 
 
If the subject continues into the Open-label phase (Arm B) of the study and remains on 
vigabatrin, the REMS guidelines will be followed as long as they are treated with 
vigabatrin. A final eye exam will be completed once they have been off vigabatrin 3-6 
months in the Open label phase of the study. The final exam will include: visual acuity, 
pupillary reaction and dilated funduscopic examination with fundus photography. 
 
If the subject remains in Arm C (seizure free and Normal EEG) they will have a baseline 
eye exam within 4 weeks of the initial enrollment in the study. A repeat eye exam will be 
done at 12 months of age, 24 months of age and 36 months of age. 
 
If at any time during the study the ophthalmologist detects visual changes in the subject, 
they will contact the site PI directly. At that point, the site PI and ophthalmologist will 
discuss and recommend further ophthalmologic assessments such as Pediatric optical 
coherence tomography (OCT) under anesthesia and fundus photography. The 
parents/LAR, examining ophthalmologist, site PI, and NIH DSMB will review the 
ophthalmologic examination results and consider all options including the decision to 
withdraw from the study at that point. 
PREVeNT Trial Background for Vision Testing and Creation of eCRFs 
 
Background 
 
The PREVeNT trial will require evaluation of the visual function of patients enrolled in the 
study because of previous reports of adverse effects of vigabatrin upon the anterior 
afferent visual system.  However, more recent work from the FDA/Lundbeck Risk 

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Evaluation Mitigation Strategy [REMS] program and the prospective “Lundbeck Vision 
Study” has disclosed a much lower incidence of visual defects than previously reported 
in the literature. 
 
The discrepancy between the past studies and the more recent work is explained by 
obtaining baseline evaluations of the patients eligible for vigabatrin compared to the prior 
case reports that were cross-sectional in nature and failed to evaluate the patients’ 
baseline visual status and also failed to account for the now well-recognized high 
variability of automated visual field testing.  Studies by Gonzalez et al; Sergott et al, the 
REMS reports over the past 6 years since FDA approval and the Lundbeck vision study 
have consistently demonstrated that 20-40% of patients considered appropriate for 
vigabatrin therapy have abnormalities of the afferent visual system at baseline as 
measured by visual acuity, visual fields, funduscopic examination and optical coherence 
tomography [OCT].   
 
Based upon these new data, the REMs program and the product label are now being 
considered for revisions by the FDA.  Although it is premature to assume that vigabatrin 
is without any risk to the visual system, the current data suggest that it may be safer than 
originally thought at least over a 24 month cumulative exposure. 
 
The following protocol is being proposed to protect the vision of the subjects participating 
in the PREVeNT trial.  The protocol will then be converted to a standard operating 
procedures [SOP] format and electronic clinical research forms [eCRFs] to insure that the 
subjects are evaluated in a standardized manner at all the clinical sites and that the data 
can be analyzed throughout and at the conclusion of the trial. 
 
Age Appropriate Methods for Evaluation of Visual Function [Based upon the 
recommendations of the American Academy of Ophthalmology] 
 
Method 
Abnormalities 
Recommended 
Age 
 
 
 
 
 
 
Newborn 
 to 6 months 
6 months until 
Able to cooperate 
With testing 
Red Reflex & 
Bruckner test 
Absent, white, dull 
opacified, 
asymmetric 
X 
  X 
External Exam 
Structural 
abnormality such 
as ptosis, proptosis 
X 
X 

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Pupils  
Irregular shape, 
anisocoria, afferent 
defect 
X 
X 
Visual acuity 
Fix and follow 
Failure to fix and 
follow, failure to 
maintain central 
fixation 
X 
Cooperative infant 
3 months or older 
X 
Corneal reflex 
Asymmetric or 
displaced 
X 
X 
Retinoscopy 
& Strabismus 
Significant Myopia, 
hyperopia 
Anisometropia 
Glasses & 
amblyopia therapy 
at discretion of the 
pediatric 
ophthalmologists 
X 
Dilated funduscopic  
examination 
Retinal 
hamartomas Optic 
atrophy Photos if 
possible 
X 
X 
 
Optical Coherence Tomography 
 
To be performed if high index of suspicion for decreased visual function.  Will require 
general anesthesia. 
Examination 
 
1. Documentation of the child’s level of cooperation with the examination required to 
interpret the results 
 
2. Testing of sensory function should be performed before any dissociating 
techniques such as covering an eye to check monocular visual acuity or cover 
testing to test ocular alignment.  Testing for alignment should be done before 
dilating drops are instilled. 
 
3. Binocular Red Reflex [Bruckner] Test 
 
a. In a darkened room, the direct ophthalmoscope light is directed towards 
both eyes from approximately 18-30 inches. 
b. A symmetric red reflex in each eye is normal 

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c. Opacities of the reflex are always abnormal 
d. The reflex will vary upon retinal pigmentation so variation will be present by 
race/ethnicity 
e. Significant hyperopia demonstrates an inferiorly placed brighter crescent in 
the reflex 
f. Significant myopia presents as superiorly displaced reflex 
g. Also used to assess for ocular misalignment—esotropia, exotropia, and 
hypertropia. 
 
4. Fixation 
 
a. Visual acuity testing in this age group requires a qualitative assessment of 
fixation and tracking movements of the eyes.  The child’s attention is drawn 
to the examiner’s or caregiver’s face [infants < 3 months] to a hand-held 
light, toy, or other fixation target. 
b. Fixation behavior is recorded for each eye as “fixes and follows” or “central, 
steady, and maintained”. 
Fixation preference graded by the energy the child objects to occlusion of one eye relative 
to the other eye. 
Biomarker Blood Samples, Genetic testing and Bio-specimen 
Sharing: 
 
Biomarker blood samples: 
 
Serial Blood sample collection will be optional and collected at each subject’s enrollment 
in the study, at the time of the subject’s randomization to vigabatrin or placebo (Arm A), 
at clinical seizures onset, and a final sample after 3 months of seizure control or 3 months 
of uncontrolled seizures in the open label phase of the study (Arm B). For this group of 
subjects it will be a total of 4 blood samples over the course of the study. For subjects 
randomized but remain seizure free on study drug will have three blood samples (at 
enrollment, randomization and at 24 months of age). 
 
Those subjects who remain seizure free and have a normal EEG will have a second 
biomarker sample collected at 12 months of age and a final sample at 24 months of age 
(Arm C). Samples will be stored in the TS Alliance Biosample Repository (a research 
resource supported by the National Institutes of Health/National Institute of Neurological 
Disorders and Stroke), for a future research initiative that will test whether we can detect 
increased mTOR activity and protein synthesis in peripheral lymphocytes from individuals 
with TSC. 
 

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Genetic testing: 
 
Blood samples from the patient and parents if available will be collected after the subjects’ 
enrollment, and stored at the TS Alliance Central Biobank Repository. DNA will be 
extracted from these samples and will be used in genetic studies to identify tuberous 
sclerosis complex disease phenotype modifiers in the future Network collaborative grant 
proposals. Proposals for sample use will be reviewed by a committee including site PIs 
and PREVeNT Biorepository Committee which includes a representative from NIH and 
the TS Alliance. This is optional for subjects and their parents participating in the study 
and will not impact their enrollment eligibility. 
 
TSC genetic testing will be obtained as part of the clinical diagnostic evaluation of each 
subject, if it has not already been completed. If the patient’s insurance will cover genetic 
testing of the TSC1 and TSC2 genes, this will be done as part of the routine clinical care 
and will be billed through insurance. If this is not possible DNA samples for those subjects 
needing testing of TSC1/TSC2 will be sent to UAB Medical Genomics Laboratory which 
is a CLIA certified laboratory to undergo genetic testing of TSC1/TSC2 using next 
generation sequencing. The DNA will have been extracted and stored at the TS Alliance 
Central Biobank Repository. The results will be given to the site PI, subject’s 
parent(s)/LAR and entered into the DCC’s database.  
 
We will collect the necessary demographic and clinical data information from the human 
participants for genotype-phenotype analyses and this information will be maintained in 
the Data Coordinating Center (DCC). We plan to deposit de-identified genotyping data in 
NIH designated databases (e.g. dbGaP). We will share research data in accordance with 
NIH and NDAR data sharing policy. Identifiers will be removed from the final data set to 
fully protect the human participants. We will evaluate each data request to ensure that 
special circumstances do not exist that would permit anyone to deduce the identification 
of individuals from the remaining data. If such case exists, we will make the data available 
under a data-sharing agreement that provides for (1) a commitment to using the data only 
for research purposes and not to identify any individual participant; (2) a commitment to 
securing the data using appropriate technology; and (3) a commitment to destroying or 
returning the data after analyses are completed. 
 
After central extraction/processing, biorepository specimens will be securely labeled, 
cataloged, and stored according to standard operating procedures appropriate for the 
specific biosample type and intended future investigations thereof. The TSC PREVeNT 
Biorepository will utilize liquid nitrogen and/or -80ºF freezer cryostorage equipment with 
automatic emergency electrical backup and a remote notification temperature alarm for 
long-term storage. Depending on local procedures and capability, permanent 
preservation of fixed tissues and their storage may be performed locally or shipped for 
central catalog and storage, as detailed in the study manual of operations. Processing 
may include receipt and storage of frozen biosamples, centrifugation, separation, 
aliquoting, labeling and storage, histology/molecular processing, microtomy, and tissue 
staining for analysis and quality control analysis. Procedures may also include the 
isolation and quality management of RNA, DNA or proteins, digital imaging of stained 

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tissue sections, also for quality assessment and/or measurable analysis of small 
molecules or labeled analytes. In some cases immunohistochemistry or protein profiles 
may performed to assess the quality of the fluids or tissues. During all procedures, the 
biosample identification is managed using barcode labels to reduce transcription error. 
Biosample identification numbers are unique for each aliquot and are de-identified from 
any subject PHI.  
 
For access and analysis to repository tissues and associated de-identified clinical data, 
there will be a repository use committee, comprised of the Lead PI (Bebin), PREVeNT  
PIs (Sahin, Krueger, Wu, Porter, Koenig, Frost), and Dr. Bruce Korf, Dr. Hope Northrup 
and TS Alliance Representative (Roberds), and NIH Representative (Laura 
Mamounas).  The Repository Use Committee will be responsible for approving release  
of PREVeNT study blood samples or, genetic material, and clinical data to both PREVeNT 
and external investigators. The TSC Project Leader (Bebin) will serve as chair of the 
committee. A specimen request form will be required that includes among other data, the 
name of the principal investigator making the request, funding source for the proposed 
analysis, a research synopsis, IRB approval of the research project, and justification for 
the required samples. At the time a de-identified sample is requested, the requesting 
investigator may also request de-identified clinical data, if needed. Completion of the 
specimen request form and majority approval by the Repository Use Committee is 
required before samples will be distributed. The request form specifies that the 
investigator must not try to re-identify the subjects from whom the samples are derived. 
Under no circumstance may an investigator provide these samples for use to additional 
investigators unless specified otherwise in an approved sample request. Repository 
committee members will excuse themselves during discussions in any case that they 
themselves have requested samples. The chair of the committee, with agreement from 
at least one other member of the committee, will have the authority to approve minor 
changes to requests (i.e. addition of a small number of samples to an already approved 
study). Once the Repository Use Committee approves the scientific/technical merit of a 
specimen request, the samples will be released to the requesting investigator and/or 
institution.  
  
Acquired specimens of the TS Alliance Central Biobank Repository may continue to be 
used in accordance with the study protocol and the signed informed consent active at the 
time the specimens were obtained, even if the subject withdraws consent or fails to 
complete the entire study.   Subjects withdrawing consent from the study and wishing that 
previously collected specimens be removed from the biorepository must provide written 
request for specimen removal to the study principal investigator (Dr. Bebin).  The written 
request for specimen removal should include the subject’s name and date of birth, the 
name of the person submitting the request and relationship to the subject, and the 
specimen(s) requested to be removed from the TSC Alliance Central Biobank 
Repository.  Upon receipt and verification, we will do our best to remove the requested 
specimens and associated clinical data from the biorepository and destroy them.  

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Study Organization and Data Management: (Appendix 1:Figure 2- PREVeNT Trial 
Organization)  
 
The PREVeNT Principal Investigator and Clinical Coordinating Center (CCC) Director, 
Martina Bebin, MD, will maintain responsibility for the overall conduct of the study and 
communications with the NINDS. The CCC will be responsible for coordinating the 
activities of the Steering Committee (SC), Data Coordinating Center (DCC), the EEG 
Analysis Core, the Pharmacy Core and the Genetic Research Laboratory Core.  The 
Research Pharmacy core will be led by Dr. Darcy Krueger, EEG Analysis core led by Dr. 
Joyce Wu and Dr. Brenda Porter and Dr. Jurriaan Peters will assist in EEG analysis, 
Developmental Assessment Leadership Team will coordinate all the developmental 
assessments throughout the study and ensure consistency in the assessments across all 
15 sites. The Data Coordinating Center led by Dr. Gary Cutter, the TSC Genetic Research 
Laboratory by Drs. Korf and Messiaen. Dr. Robert Sergott will serve as a consultant 
regarding the ophthalmologic assessments throughout the PREVeNT Trial. 
 
The CCC will provide site management oversight, including the following duties: site 
evaluation; subcontract development and execution; providing the protocol and study 
documents to the site investigators for submission to the IRB; obtaining documentation 
of IRB approval prior to shipping study materials; ensuring patient informed consent is 
properly obtained; and ensuring proper clinical site monitoring.  
 
The EEG data will be stored and analyzed using the University of Pennsylvania IEEG.org 
Portal. They will provide technical support for each of the 15 sites for data processing, 
conversion and upload to the IEEG.org platform via Amazon’s Elastic Computing Cloud 
(EC2). The software engineer will ensure that IEEG.org will support upload of the data 
from each study site within 1-2 hours of data collection. Data will be stored and accessible 
to the study investigators on IEEG.org for the length of the study. The University of 
Pennsylvania IEEG.org group, which includes a software engineer, will develop tools and 
features on IEEG.org portal that is specific for the needs and goals of this project. 
 
The Data Coordinating Center (DCC) will provide full service electronic data capture 
(EDC), data management, and reporting services as it currently does for the current TSC-
EBS study (P20-NS080199). The extent of these data management services include: 
database specification, development and testing; validation rules programming; data 
management plan development and maintenance; ongoing manual data review; and data 
cleaning and locking. The DCC will implement a quality assurance plan to provide 
feedback to the clinical sites in order to maintain and improve the quality of the study 
database.  In addition, the DCC will provide statistical analysis and DSMB reports. The 
PREVeNT Trial Steering Committee will consist of Dr. Bebin as Study PI, Dr. Robert 
Flamini-Medical Safety Monitor (MSM), Dr. Wu, Dr. Krueger and Dr. Cutter.  The Data 
Quality Committee will routinely review the monthly data summaries from the trial and 
monitor the quality and identify any related study issues that warrant a protocol 
amendment or further analysis or review. NIH will select the PREVeNT Trial DSMB which 
will review the quarterly DCC reports and communicate with Study PI and MSM. 
 

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Estimate of Key timelines: 
Year 1, Q1/2: Study initiation, implementation of Data Coordinating Center, IEEG.org for 
EEG data transfer/   storage, and enrollment of subjects 1-4 
Year 1, Q3/4: Subjects 5-28 will be enrolled=Total enrollment 28 subjects at the end of 
Year 1 
Year 2, Q1/2: Subjects 29-52 enrolled=total 56 enrolled, Subjects 1-4 complete the 12 
month visit 
Year 2, Q3/4: Subjects 53-76 enrolled=total 80 subjects, Subjects 5-28- complete 12 
month time point 
Year 3, Q1/2: Subjects 1-4 reach the 24 month time point and Subjects 29-52 reach the 
12 month time point. 
Year 3, Q3/4: Subjects 5-28 complete the 24 month time point, Subjects 53-76 reach the 
12 month time point 
Year 4, Q1/2: Subjects 1-4 reach 36 month time point; Subjects 29-52 reach 24 month 
time point 
Year 4, Q3/4: Subjects 5-28 reach 36 month time point, Subjects 53-76 reach 24 month 
time point;  
 
*Analysis begins for the PREVeNT trial using the baseline, 12 and 24 month data 
set. 
Year 5, Q1/2: Subjects 29-52 reach 36 month time point, 
Year 5, Q3/4: Subjects 53-76 reach 36 month time point, 
           *Analysis will begin for the 36 month developmental assessments and primary and 
secondary outcome measures. 
Statistical Methods, Sample Size and Analysis Plan:  
 
Monitoring Recruitment 
The table below shows the number screened and the lower limit of a 95% confidence 
interval for the number randomized.  For example, if we screen 10 patients, we expect 
6.3 to be biomarker positive (62.5% of the cohort based on the pilot).  If the expected is 
6.25 (6.3), then if we observe 0 or 1 of the 10 biomarker positive screened who are 
eligible, we can conclude that the rate of biomarker positivity is statistically likely to be 
less than 62.5% and we may not reach our target numbers for randomization.  The Study 
and DSMB will monitor recruitment in this manner to enlist early monitoring concerns and 
discussions of potential solutions, including adding clinical sites or extending recruitment. 
An analysis of the EEG biomarker data will be done after the first 28 subjects have 
reached 12 months of age (toward the end of year 2) to estimate whether additional 
subjects would be needed for  Arm A (randomization arm). 
 
Number Screened 
Epileptiform Activity 
Using Poisson and Normal Approx 
 
Expected (62.5% screened) 
Lower Limit of 95% CI 
10 
6.3 
1.4 

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Primary Study Objective: 
 
The primary endpoint of this Phase IIb feasibility trial will be the demonstration of the 
prevention of seizures and the subsequent cognitive assessment component of the 
Bayley-III.  The other components of the Bayley (receptive communication, expressive 
communication, fine and gross motor subscores) will be used as secondary and 
supportive endpoints.  The primary goal of this Phase IIb trial will be to provide the 
evidence needed for a Phase III pivotal trial.  Thus, the study will need to demonstrate 
the purported mechanism by which an improved clinical outcome is achieved, prevention 
of seizures, leading to a difference in cognitive outcomes.  The rationale for not using a 
composite outcome at this stage of evaluation is that it will be simpler to focus on a single 
most promising outcome measure of early treatment and one that is clinically meaningful.  
The other components of the Bayley-III will be evaluated in a multivariate composite as 
part of the secondary outcomes and exploratory outcome. 
 
The sample size for this feasibility trial is derived from the resources available to support 
the trial as per this NINDS mechanism, the primary goal of demonstrating a reduction in 
seizures and the power to assess the differences in cognitive scores on the Bayley-III. To 
assess the plausibility of recruitment, we looked at the pilot data from our ongoing TSC 
15 
9.4 
3.4 
20 
12.5 
5.6 
25 
15.6 
7.9 
30 
18.8 
10.3 
35 
21.9 
12.7 
40 
25.0 
15.2 
45 
28.1 
17.7 
50 
31.3 
20.3 
55 
34.4 
22.9 
60 
37.5 
25.5 
65 
40.6 
28.1 
70 
43.8 
30.8 
75 
46.9 
33.5 
80 
50.0 
36.1 

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Project.  To date, we have enrolled 40 patients, 1 patient dropped out; 15 continue without 
seizures to date; 19 developed well controlled seizures, and 5 have developed refractory 
seizures.  Thus, 25 of the 40 or almost two thirds of the enrolled patients have developed 
seizures to date.  Reducing this number with earlier intervention would seem consistent 
with achieving a positive effect on the cognitive outcomes as assessed by the Bayley-III. 
 
We expect to be able to recruit between 75 and 80 participants over the course of the 
recruitment period.  Based on these numbers we expect 37.5% (based on our P20 data 
where15/40 remained seizure free) to be biomarker free and never randomized.  Thus, 
we expect to lose to randomization between 28 to 30 participants yielding approximately 
48 patients to be randomized (75-28 = 47 and 80-30=50) or 24 to 25 participants per 
group.   
 
To estimate sample size needed, we first assess the ability to demonstrate the feasibility 
that the intervening variable, seizures, can be prevented with early treatment.  In the 
placebo arm, we expect that all patients will develop seizures, but to be conservative we 
assume that 2/24 in the placebo arm do not develop a seizure within the time frame, 
making the proportion of seizure occurrence 0.917.  In the vigabatrin arm, we assume it 
mirrors the proportion well controlled in our ongoing TSC project, thus our seizure rate 
will be estimated at 5/24 (19 remain seizure free to date) or 0.208.  A Fisher's exact test 
with a 0.05 two-sided significance level will have 99% power to detect the difference 
between a Group 1 proportion, p1, of 0.917 and a Group 2 proportion, p2, of 0.208 when 
the sample size in each group is 24. 
 
The percent difference for seizures used in the power calculation is based on data 
collected during our current TSC project.  We note that this is a large difference.  However, 
it is conservatively estimated through discounting our expected 100% seizure rate in the 
control arm to 91.7% and using our observed data for the treatment arm, which under a 
strict protocol could be higher. Even if the vigabatrin treatment is less effective than 
expected and 10/24 (0.417) in the treatment arm experience seizures, we still have 
greater than 90% power to detect this treatment effect. 
 
We proposed the percent difference in cognitive scores also based on our ongoing work. 
We have found that the distribution of Mullen Scales of early development show that by 
two years there is a substantial downward shift in scores (bottom right figure (red graph) 
below for the 24 month results).  The mean at 6 months was 89.9 (sd=18.1) and mean at 
24 months 75.7 (sd=22.1). The estimated standard deviation of the change is 4 points 
(assuming a correlation of 0.60 between the two time points as is consistent with the 
correlations of Bayley’s over time).  With the mean decline of over 14 points from 6 months 
to 24 months on average, with a standard deviation of 4 points, there is a great deal of 
potential for an intervention to achieve an effect size of 0.889 (our proposed effect size 
based on differences amongst disease groups on the Bayley’s).  This effect size would 
be approximately 3.5 points on the Mullen Scale.  This would amount to a percent 
reduction in the decline of 3.5/14.2 or about 25% of the natural decline, which seems 
reasonable for a drug intervention.  Thus, our pilot data once again provide reasonable 
evidence that our intervention effects are achievable.   

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In addition, for the cognitive outcomes, using a t-test on the final Bayley-III Cognitive 
Scores shows that when the sample size is 24 participants per arm there is 85% power 
to detect an effect size on the cognitive component of the Bayley III of 0.885 when the 
Type I error is 0.05, two tailed.  The plausibility of achieving this effect size was assessed 
using published data from the Bayley III manual.  In children with Pervasive 
Developmental Disorders, the average cognitive score is 5.7 (sd 2.9) compared to 
matched controls with a mean of 11.0 (sd 3.0)31. The effect size for the difference between 
this disorder and the matched controls is 1.77 [(11.0-5.7)/3.0], a difference double the 
effect size detectable with the sample size available for this Phase IIb trial.   While it is 
unlikely that early treatment would return these patients to normal levels, we are 
hypothesizing as the alternative that we will achieve an effect size of approximately 50% 
of the difference compared to normal scores. That is, we will use a sample size necessary 
to detect an effect size of 0.885.  
 
To further examine the ability of the sample size to achieve the goals of the study, we first 
examined the sensitivity of the design to our assumption of the standard deviation by 
examining the standard deviation against other groups of special interest. 
 
 

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The Bayley-III cognitive test battery shows that the standard deviations vary from a low 
of 1.9 at an assessment in Downs Syndrome Children to 3.5 amongst SGA infants.  The 
table below shows the standard deviations for various special groups. 
 
PDD 
CP 
DD 
Language 
impaired 
Perf At 
Risk 
Asphyx 
Fetal 
Alcohol 
SGA 
Premie 
2.9 
3.1 
1.9 
2.4 
3.2 
3.1 
2.7 
3.5 
3.1 
 
The average standard deviation is 2.9, the median is 3.1, so again, using 3.0 in our 
calculations seemed reasonable. 
 
We next estimated the sensitivity of the trial in terms of the power for testing the time-
averaged difference (TAD) between two means in a repeated measures design.  In the 
TAD model, we assumed the mean difference starts to become evident at 3 months and 
is continuing or enlarging at 12, 24 and 36 months.  The correlation amongst Bayley-III 
Cognitive assessments within person was varied from 0.10 to 0.80.  
 
The power for this study is actually slightly higher than 85% because the analysis 
approach planned will make use of repeated measures analyses enabling more 
information to be gleaned from the data.  Information and thus power is gained because 
partial data are used from the annual cognitive assessment measurement on those 
completing the trial.  Thus, the sample size provides further protection against minor 
deviations from the assumptions used to calculate the feasibility based on the sample 
size.  
 
BOSA PRELIMINARY DATA Based on the ADOS (Reference BOSA Manual version 
6-25-20) 
 
 As of 7/1/2020 no BOSA data has yet been collected or analyzed.  Preliminary data 
analyses were conducted by MAKING BETTER MEASURES Group at UCLA led by Dr. 
Cathy Lord. 
 
They used binary ADOS algorithm codes scored from full standardized ADOS 
administrations. Based on the findings with the ADOS, it was determined that a cut-off 
estimate of 5 for Modules T,1 and 2 yielded the best pairing of sensitivity and specificity. 
It is important to note that these cut-offs are only estimates and were determined using 
ADOS data (not BOSA data). They may also not reflect scores from much briefer and 
less nuanced BOSA administration. Thus the information should only be used to inform 
clinical decisions when using the BOSA in combination with other sources of information. 
These estimates are intended to give the physicians a sense of what may come and may 
change as data is collected on BOSA administration.  
 
 
 
 
 

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Given the age of the participants, the PREVeNT study will be using two BOSA versions:  
 
1) BOSA-MV which is appropriate for individuals of any age who are minimally verbal 
(i.e., nonverbal or use only single words/rote phrases) and includes sets of free 
play toys and bubbles. 
2) BOSA-PSYF which is appropriate for individuals of any age who use flexible 
phrase speech or verbally fluent children under the age of 6-8 and includes sets of 
free play toys, a dollhouse with figurines and bubbles. 
 
The sensitivities at a cut-off of 4 or 5 ranged from 0.80 to 0.93 (Module T: 0.84, Module 
1: 0.93, Module 2: 0.86, Module 3: 0.84, Module 4: 0.80). Thus, clinicians should take 
note that similar to the ADOS-2, there will be individuals who have autism who will have 
scores lower than the cut-offs, particularly those who do not display repetitive behaviors 
during the BOSA. For this reason, it is very important to supplement the BOSA with the 
ADI-R caregiver interview. 
 
The specificity at a cut-off of 4 or 5 also ranged widely (Module T: 0.76, Module1: 0.84, 
Module 2: 0.80, Module 3: 0.76, Module 4: 0.65), though the AUC’s consistently exceeded 
0.80. These low specificities mean that false positives will be common when comparing 
the BOSA scores to these estimated cut-offs and should be cross checked with other 
sources of information. 
 
 Analyses 
 
The primary analyses for this Phase IIb trial consists of two testing hypotheses: time to 
onset of a first clinical seizure, documenting that the intervening variable (i.e. vigabatrin 
treatment) does indeed reduce or delay clinical seizures and comparison of the 
developmental outcomes at 24 months.  While vigabatrin is used to control seizures and 
thus suppress them once seizure onset has been identified, it is presumed that if given 
prior to occurrence of clinical seizures occurring such a delay will be observed, but this is 
untested.  Thus, the study endpoint of time to first clinical seizure is an essential step in 
determining the impact on developmental ability. The first step in the analyses will include 
demonstrating a difference between the proportion seizure free in the treatment arm 
versus placebo.  This will be assessed at two years of follow-up using a chi square test 
and an intention to treat analysis.  Supportive analyses will use a time to first seizure 
analysis using Cox regression methods to evaluate the treatment effects.  Kaplan Meier 
analyses will provide graphical and overall test of the incidence of seizures.  Cox models 
with age, gender, baseline number of epileptiform discharges included with treatment 
group will be attempted keeping in mind the relatively small sample size.  Tests will use 
2 sided Type I errors of 0.05. 
 
The next key analysis to move to a go decision for Phase III will focus on the Bayley-III.  
While ideally the primary assessment would be made at age 5 or 6, there will be 
insufficient follow-up to make such an assessment in this grant period.   We will perform 
assessment of the Bayley-III using the standardized cognitive scores over time using the 
constrained longitudinal data analysis (cLDA) method proposed by Liang and Zeger32 

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which assumes a common mean across treatment groups at Baseline and a different 
mean for each treatment at each of the post-Baseline time points (12, 24, and 36 months 
for those who have them). In this model, we use a response vector that includes the time 
0 or the baseline measure and assessments at each post-baseline observation time point.   
Each time point is considered a categorical variable so that no overall linear restrictions 
are imposed on the means over time. 
 
The unanticipated pandemic which has interrupted almost all studies has caused us to 
develop an alternative assessment during the pandemic for safety of the participants as 
well as providing some information on our primary endpoint if a key time point visit occurs 
during this time period.  Conversion to approximate ADOS-2 scores will be attempted 
using internal and data external to PREVeNT.  If such linkage is not adequate for mapping 
between the two methods of assessment, imputation will be done using this information 
as a covariate to aid in the imputation.   Since it is unknown at this time, how many visits 
will be impacted by this study interruptions, a formal plan has not been put into place.  If 
an exam is not one of the endpoint exams, the impact will be far less than if it is a final 
visit for the participant.  This will be assessed and the final plan decided before breaking 
the blind. Before the final analysis begins, we will contact Making Better Measures and 
Dr. Cathy Lord regarding additional data on the BOSA measure for accessing autism. 
 
Additional analyses will focus assessing whether the treatment effect is symptomatic or 
potentially a disease modifying effect assessed by a comparison of the early differences 
(12 months minus baseline) compared to late differences (24 month minus 12 month or 
36 minus 12). Corresponding 95% confidence intervals (CIs), and nominal (unadjusted) 
P-values will be estimated using the cLDA model.  If the contrast between the early and 
late differences is significant, this is consistent with a disease modifying effect. 
 
A second consideration is the observation time during the trial.  Since the patients will be 
put on active therapy following an event, a second consideration is the duration of seizure 
suppression, that is, the time after an event has occurred up until two years. This is 
effectively, the medication possession ratio (MPR =total time on vigabatrin treatment/total 
follow-up time).  We expect the delayed treatment group on average to have Vigabatrin 
treatment for slightly less than 1-2 years and effectively 2-3 years for early treatment 
group. This is based on assuming a uniform distribution of occurrence of the clinical 
seizures. Clearly, if there were no significant differences between the early and late 
treatment in this parameter, we would expect a negative outcome.  However, this 
parameter may be useful in understanding the extent of the differences observed.  The 
MPR, if there is a relationship to the primary outcome, may be useful for imputation of 
missing data (which we expect to be quite low). This variable can be entered into the 
cLDA model and assessed using the procedures of MacKinnon for testing mediation.33-
37The mediation model would say that the effect of the treatment on the outcome of the 
cognitive scores is mediated through the MPR and not the earlier intervention.  The 
sample size may not allow a clear answer to this question, but if earlier intervention before 
the onset of a clinical seizure is key in preservation of cognitive function, then the 
mediation will not be demonstrated. 
 

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Drug resistant epilepsy: For the current study, drug resistant epilepsy is defined as the 
“failure of adequate trials of two tolerated appropriately chosen and used antiepileptic 
drug schedules (whether as monotherapy or in combination) to achieve sustained seizure 
freedom as put forth by the International League Against Epilepsy31. This will be compared 
between the early and delayed treatment groups using Fisher’s exact test. 
Additional developmental measures and ASD Risk: The sub-scores on the Bayley-III and 
the composite score estimated using Hotelling’s T2. The power for this endpoint will vary, 
but is expected to be similar to the primary.  In the children with Pervasive Developmental 
Disorders, the effect sizes versus normal matched controls were 1.77, 1.67, 1.17 and 
1.33 for the Receptive communication, Expressive Communication, Fine and gross motor 
sub-scores respectively.  The ADOS2 will be completed at 24 and 36 months of age as a 
neurodevelopmental assessment for symptoms of ASD. The results from Study Arm A 
(seizure free, no treatment), Arm B (VGB versus. Placebo), and subjects with 
electrographic seizures at baseline EEG who move directly into Open Label treatment will 
be compared increasing our power to assess differences (Figure1). 
 
Determination of vigabatrin safety as a preventative treatment for clinical seizures in 
infants with TSC will be assessed using comparison between the treatment groups and 
as a summary of exposure time on the drug. The outcome measure will be percentage of 
patients in each group (vigabatrin early treatment vs. vigabatrin delayed treatment) with 
treatment associated adverse events (AEs), serious adverse events (SAEs), and risk 
evaluation and mitigation strategy (REMS) measures.  Treatment related AEs and SAEs 
will be monitored and tabulated.  Given the expectation that the delayed group will cross-
over to active treatment sooner than the early treatment group, adverse events will be 
characterized using life table approaches to ensure adjustment for exposure time.  Thus, 
counts of individuals with AEs, total number of specific AEs and rate per months of follow-
up will all be provided and assessed for any differences and for the safety population 
(early plus late on person years of exposure basis).  Events of specific interest and risk 
evaluation and mitigation strategy (REMS) measures will be compared, including any and 
all ophthalmologic problems that may arise. Data from the negative control group 
(estimated to be approximately 15-20 patients) will also be used to compare the 
occurrence of AEs and SAEs. 
 
EEG biomarker feasibility: The outcome measure will be the sensitivity and specificity 
of EEG epileptiform activity in predicting outcomes at 24 months for each treatment group.  
To confirm the feasibility of using EEG biomarkers to identify TSC infants at risk for 
developing epilepsy, sensitivity and specificity of EEG epileptiform activity at each time-
point for predicting subsequent development of epilepsy by 24 months of age will be 
conducted within each treatment arm.  Successful treatment in the vigabatrin arm should 
produce significantly poorer specificity and lower positive predictive value (PPV) by 
mitigating the predictive power of the EEG epileptiform activity.  Exploratory analysis will 
further evaluate the timing of EEG change with time to seizure onset and type of EEG 
change with epilepsy type and treatment response as a covariate in the Cox proportional 
hazards assessment of time to clinical seizure. Additional analysis will evaluate the 
separate impact of TSC clinical features and concurrent AEDs. Our estimate is that 75% 
will develop the EEG biomarker prior to clinical seizures, some of the enrolled infants will 

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develop neither EEG biomarker nor seizures and some will develop seizures prior to 
being identified with the EEG biomarker or never develop the EEG biomarker despite the 
onset of clinical seizures. If the incidence of developing the EEG biomarker relative to the 
incidence of seizures without the EEG biomarker is very low, then the efficacy of treatment 
would have to be great to warrant the cost of monitoring. Thus, evaluation of this aim will 
be a tradeoff between biomarker incidences versus the treatment benefit.  Descriptive 
statistics and numbers needed to treat (NNT) will be used to evaluate this endpoint. 
  
Additional measures and analyses considerations: We will use descriptive statistics to 
quantify the percentage of patients requiring unblinded treatment after randomization and 
the duration of blinded treatment within the study period.  We will also determine the 
percentage of randomized patients at 24 and 36 months of age with drug-resistant 
epilepsy as a clinically meaningful and significant correlate to the time to first seizure 
measure. As noted above, Cox regression models will be attempted with the pre-
treatment covariates from the baseline and index EEG (that is, the biomarker findings that 
initiated the randomization) to examine if there are gradients in the predictors and levels 
of risk/time to events that can be predicted.  These analyses will be done both within the 
treatment group and with the interaction of treatment and biomarkers included in the 
model. Since subject randomization is based on EEG findings, not seizure onset and the 
most common age of seizure onset is 3-7 months based on published natural history 
studies and the data from our P20-NS080199 study.1 The subjects will be stratified into 
two groups for the analysis: 1) subjects randomized based on EEG biomarkers 
<12months, 2) subjects randomized based on EEG biomarker >12 months of age. There 
will be 2 additional groups in the analysis: subjects with normal EEGs, seizure free and 
never randomized and subjects with electrographic seizures at baseline, never 
randomized but treated with vigabatrin (the 28-30 children not randomized). Additional 
analysis will be done to measure the impact of concomitant AEDs used during the study. 
Adverse Event Reporting 
 
Baseline conditions at study entry will be noted and documented during 
screening/baseline medical history. Changes in health status and disease progression 
will be collected as part of interval history and will not be evaluated as adverse events. 
Clinical data such as medication use, seizure history, and EEG activity will be collected 
as part of interval medical history and recorded for the determination of disease 
development. 
 
Adverse events will be defined as those relating to study procedures including 
neurodevelopment and EEG will be tracked on an Adverse Event log. Adverse Events 
will be categorized using the Common Terminology Criteria for Adverse Events 
(CTCAE) CTCAE version 4.0. 
 
Each procedure related adverse event (AE) will also be graded for severity as follows: 
 
Mild-Discomfort noticed, but no disruption of normal daily activity. 
Moderate-Discomfort sufficient to reduce or affect normal daily activity.  

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Severe-Incapacitating, with inability to work or to perform normal activity. 
 
Adverse Events (AEs) will also be determined to be expected or unexpected events. 
An unexpected adverse event is any adverse event occurring in subjects participating 
in the study, for which the nature, severity, or frequency of the event is not consistent 
with the foreseeable risks associated with the procedures involved in the research, as 
described in the study-related documents or literature regarding the procedures, or the 
expected natural progression of any underlying disease, disorder, or condition of the 
subject experiencing the adverse event. 
 
Adverse events that require capture are to be reported per local IRB requirements and 
reported on a regular basis as outlined in the Manual of Procedures. 
 
For this study, a Serious Adverse Event (SAE) is defined as any untoward medical 
occurrence that results in death; is life threatening; requires inpatient hospitalization or 
prolongation of an existing hospitalization; results in persistent or significant 
disability/incapacity; is any other untoward significant medical event, which may not be 
immediately life threatening or result in death or hospitalization but may jeopardize the 
patient or may require interventions to prevent one of the outcomes listed above. Also 
included are untoward behavioral, psychosocial or legal events which may jeopardize 
the subject, as determined by the investigator. SAEs at least possibly related to study 
participation, should be reported within 1-2 business days of the site’s knowledge of the 
event. Each site should report related SAEs to their institution as per local and 
institutional requirements. 
 
The SAEs will also be reviewed by the medical safety monitor (Dr. J. Robert Flamini) for 
relatedness to the study. All SAEs that are at least “possibly, probably, or definitely” 
related to the study will be reported to the site IRB (if applicable) and lead PIs as soon as 
possible. The lead PI, Dr. E. Martina Bebin, will be asked to review these related SAE 
reports within 72 hours of receipt of report. 
Data and Monitoring Plan 
 
Data management system features for project management and clinical site end users 
A distributed data management system, where the clinical sites are responsible for the 
entry and management of data from their own center, is both cost-effective (as it removes 
a majority of the query process) and results in higher quality data, with continual re-
education of staff. At the site level, participant data will likely be recorded first on paper 
forms  and a web-based integrated system will be used to implement such a distributed 
data management system, where the system: 
• Establishes eligibility: As the local coordinator enters critical components of the 
eligibility criteria, each is confirmed to ensure that participants with protocol violations 
are not permitted to be randomized without specific approvals that can be automated 
to allow for real time decision making so that participants are only minimally 
inconvenienced and the short time-window of eligibility is not missed. A participant ID, 
in the form ccc-pppp (center-participant), is automatically assigned with this initial 

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encounter and is used to track the participant throughout their interactions with the 
system. As these data (and all subsequent data) are entered, range and validity 
checks (including cross-form checks) to identify invalid data are performed and the 
coordinator is queried for correct values – thereby providing immediate 
communication to the clinical center to resolve inconsistencies within the data.  
• Randomizes the participant: Participants who are candidates for this trial will be 
recruited using well established protocols to identify these participants. Inclusion and 
exclusion criteria forms will be completed prior to randomization to ensure eligibility. 
Informed consent and/or assent for participation will be carried out by the participant 
or legally authorized representative in circumstances where the potential participant 
is not competent to do so. Participants will be randomized using the web-based 
integrated data management system. Usually a permuted block randomization 
scheme will be employed, with stratification by clinical site and block sizes of 2, 4, and 
6 (assuming 2 groups). Nevertheless, the coordinator will enter critical elements of 
eligibility to ensure the identification of the participant and the eligibility of the 
participant. After the entry of these data, the coordinator will be asked to confirm that 
the participant is to be irrevocably randomized, and, after confirmation, the treatment 
PID2 will be provided.  
• Assists in the management of participant flow in the center: After randomization, the 
system updates the schedule for treatment, tests and assessments for the rest of the 
hospital stay or clinic visit, and future follow up contacts. The scheduling portion of the 
system provides real-time reports of expected treatments to be delivered and visits 
and participant encounters for the clinic or on the telephone. In addition, the system 
prints participant-specific forms for each encounter, ensuring that the correct forms 
(and only the correct forms) are completed. 
• Tracks drug supplies: The system records the use of the drug in the inventory system 
that is jointly maintained by the DCC, trial Central Pharmacy, and the site pharmacies. 
The Central Pharmacy will also have access to portions of the web-based system to 
review and monitor the drug inventory at each site, and regular reports are produced, 
showing drug inventory levels and identifying sites requiring resupply. 
• Provides a platform for data entry: Following a participant encounter, the case report 
forms (CRFs) are brought to any computer connecting to the internet, and are entered 
in a web-based system that transmits data to the database (that resides at the DCC 
at UAB) in real-time with immediate transfer to prevent lost data. The system tracks 
each CRF through its life-cycle where it is first due to be printed, partially completed, 
completed and “confirmed” (i.e., all data fields are completed and all pass data range 
and validity checks), and finally locked. The system will be built upon an existing 
platform in place at UAB, where a matrix of rows for data items or forms and columns 
for participant contacts is created and is color coded, allowing the coordinator to 
instantly know of forms pending or overdue for specific participants. Once a form is 
locked, the site can review, but not change, data on the form. In order to change data, 
a request has to be made to the DCC to unlock the specific variables on the form. This 
is one place in the system where, in order to reinforce the importance of accurate form 
completion and locking, it has been made intentionally burdensome to the clinic. 
• Assists in ensuring data quality: Not only does the system assist in ensuring data 
quality through enforcing the participant schedule with visits entered within windows, 

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but it also monitors and tracks other components of data quality, including missed 
visits and missed forms and data lag for entry (i.e., overdue forms). In addition, the 
system generates reports on the status of data quality to the local site (at both a 
summary and a participant-level report), which can then be forwarded to other trial 
and Network committees as needed.  
• Supports the clinical center sites in the transfer of data to central reading centers (as 
required or needed): Triggered when responses on the CRFs are entered into the 
system, the web-based system can identify, manage and track large digital files and 
also track these data through the reading process to ensure that the central facility 
provides results for all participants submitting information. 
• Supports transfers of participants from one site to another: Based on our experience 
in trials, we have been able to plan our system to seamlessly allow for movement of 
participants from one location to another either due to participant relocation or a site 
closure (both have occurred in our trials). Our estimated rates of participant moves 
are about 5 percent, and when not planned for in advance, often cause ad hoc 
solutions and confusion; however, in the PREVeNT Trial the procedures will already 
be in place. 
• Assists in ensuring participant safety: With each AE/SAE in the trial, a tracking system 
of the event is generated. When SAE CRFs are entered, the safety monitor is notified 
of the event through an automatically generated email as are pre-specified key 
individuals (the Chair or members of the DSMB, NINDS representative, appropriate 
DCC, etc.). Reminders are sent until the email is opened and the alert acknowledged 
online in the DCC web-based system. The safety monitor has access to the details of 
the SAE through a separate interface to the system, and as he/she codes the SAE 
(determining likelihood of association with trial drug, severity of the SAE, the 
expected/unexpected nature of the event, and the resolution of the event), the event 
can be closed and locked in the system. If appropriate, tracking of the event over time 
is also monitored to determine its resolution or continued severity, and also the 
duration of the process. 
 
Each site will use trained personnel from their institution who are independent of this 
trial to conduct monitoring visits twice a year. The UAB Center for Clinical and 
Translational Science (CCTS) group will serve as UAB site monitor. This includes both 
regulatory and clinical. Each site will be monitored at the site level and summary 
monitoring report will be emailed to UAB addressing any action items. All monitoring 
reports will be sent to UAB IRB. 
Human Subject Protection 
 
Compliance with Good Clinical Practice (GCP) guidelines for the conduct and 
monitoring of this observational study will occur through the performance of the ethical 
and regulatory requirements presented in ICH E6, Good Clinical Practice: 
Consolidated Guideline. The study (protocol, informed consent, advertisements, and 
subject information sheets) should be reviewed and approved by the Institutional 
Review Board (IRB). Any changes to the protocol will be approved by the IRB. 
Subjects must sign written informed consent prior to being screened, before 

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undergoing any study procedures. 
 
The investigators and institutions affiliated with this study will permit trial-related 
monitoring, audits, IRB review, and regulatory inspection(s) by providing direct access 
to source documents. 
Privacy and Confidentiality 
 
Subject confidentiality will be maintained by the investigator, the investigator’s 
associates and co-workers, and by all administrators who are part of the project. 
Confidentiality will be maintained according to ICH E6; 4.8.10, part O: “Records 
identifying the subject will be kept confidential and, to the extent permitted by the 
applicable laws and/or regulations, will not be made publicly available. If the results of 
the trial are published, the subject’s identity will remain confidential.” 
 
The investigator, his or her staff and associates, and the appropriate regulatory 
agencies may use the information included in this protocol as necessary for the 
conduct of the trial and the safety of subjects. The parent/legal guardian may obtain 
the results of clinical and procedures obtained for this research study if (1) results are 
available and (2) disclosure does not have the potential to impact the accuracy of 
future assessments of the subject during the course of the study. 
 
Data file records that are to be shared between sites will be encrypted before sharing 
so that they will be undecipherable if intercepted in transit. All subject data entered 
into the study database will be identified only by a unique identifier for research 
records. Any publications will reflect only unique identifiers. Data on paper will be kept 
locked. Any data on computer will be accessible only by password access. Only 
members of the research team will have access to these files. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Appendix 1: Figure 1: PREVeNT STUDY DESIGN 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
80 subjects 
enrolled 
Subjects with 
normal EEG and 
seizure free 
Subjects with abnormal 
EEG and randomized 
to treatment 
No treatment 
Open-label 
treatment (VBG) 
Blinded 
Treatment 
VGB 
Placebo 
SEIZURES 
SEIZURES 
NO 
SEIZURES 
ARM A 
ARM B 
ARM C 

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Appendix1: Figure 2- Organizational Chart 
PREVeNT Trial Organizational Chart 
 
 

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Appendix 2: Table 1-Study Visit Schedule Enrollment and Randomization to vigabatrin or placebo 
 
 
Study Visits 
Screening/Baseline 
(1st visit) 
Study Visits 
(Study Follow-up Period) 
 
~6wks 
(1.5m) 
~12wks 
(3m) 
~18wks 
(4.5m) 
~24wks 
(6m) 
~12wks 
(3m) 
~18wks 
(4.5m) 
~24wks 
(6m) 
~30wks 
(7.5m) 
~36wks 
(9m) 
~45wks 
(10.5m) 
~52wks 
(12m) 
~65wks 
(15m) 
~78wks 
(18m) 
~91wks 
(21m) 
~104wks 
(24m) 
~156wks 
(36m) 
 
If 6wks is BSL, then 12wks is the second visit (FU). 
If 12wks is BSL, then 18wks is the second visit (FU).  
If 18wks is BSL, then 24wks is the second visit (FU). 
If 24wks is BSL, then 30wks is the second visit (FU). 
Informed consent 
 
 
 
  
Eligibility Assessment 
 
 
 
  
TSC Genotype Information 
 
 
 
  
Parent’s Genetic Blood Sample 
 
 
 
  
Biomarker blood collection2 
 
 
 
  
Family History & Demographics 
 
 
 
  
Medical History 
 
 
 
  
 
 
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 
 
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 
  
  
Physical exam 
 
 
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  
 
 
 
 
 
  
 
 
 
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  
  
VEEG 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
  
  
Concomitant Medications 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
  
  
Eye Exam1 
 
 
 
  
Bayley Scales of Infant and 
Toddler Development (3rd 
edition)3 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
  
Beery-Buktenica Developmental 
Test of Visual-Motor Integration 
(6th edition) 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
Autism Diagnostic Observation 
Schedule (2nd edition)  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  

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1. Follow up eye exams will be completed within 4 weeks after randomized to vigabatrin or placebo and then every 3 months. A final eye exam will be completed after subject has been off study 
drug for 3-6 month as per the REMS recommendations. For those patients who come off Vigabatrin at 24 months they will have to have final eye exam between 27-30 months of age. 
2. Biomarker samples will be collected at each subject’s enrollment, subject randomization to vigabatrin or placebo, clinical seizures onset, and a final sample after 3 months of seizure control 
after randomization in Arm B or 3 months of uncontrolled seizures in the open label phase of the study.  
3. Bayley III (Social-Emotional and Adaptive Behavior Questionnaire) will be completed at 6 month visit and the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) will 
be completed at 12, 24 and 36 months of age. 
  
 
 
 
 
 
 
 
 
 
 
 
Peabody Picture Vocabulary 
Test 94th edition) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Child Behavioral Checklist 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
Vineland Adaptive Behavior 
Scale (2nd edition) 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
Study Visits 
Screening/Baseline 
(1st visit) 
Study Visits 
(Study Follow-up Period) 
 
~6wks 
(1.5m) 
~12wks 
(3m) 
~18wks 
(4.5m) 
~24wks 
(6m) 
~12wks 
(3m) 
~18wks 
(4.5m) 
~24wks 
(6m) 
~30wks 
(7.5m) 
~36wks 
(9m) 
~45wks 
(10.5m) 
~52wks 
(12m) 
~65wks 
(15m) 
~78wks 
(18m) 
~91wks 
(21m) 
~104wks 
(24m) 
~156wks 
(36m) 
 
If 6wks is BSL, then 12wks is the second visit (FU). 
If 12wks is BSL, then 18wks is the second visit (FU).  
If 18wks is BSL, then 24wks is the second visit (FU). 
If 24wks is BSL, then 30wks is the second visit (FU). 

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Appendix 2: Table 2- Study Visit Schedule for Subjects with Normal EEG and Seizure Free 
 
 
 
Study Visits 
Screening/Baseline 
(1st visit) 
Study Visits 
(Study Follow-up Period) 
 
~6wks 
(1.5m) 
~12wks 
(3m) 
~18wks 
(4.5m) 
~24wks 
(6m) 
~12wks 
(3m) 
~18wks 
(4.5m) 
~24wks 
(6m) 
~30wks 
(7.5m) 
~36wks 
(9m) 
~45wks 
(10.5m) 
~52wks 
(12m) 
~65wks 
(15m) 
~78wks 
(18m) 
~91wks 
(21m) 
~104wks 
(24m) 
~156wks 
(36m) 
 
If 6wks is BSL, then 12wks is the second visit (FU). 
If 12wks is BSL, then 18wks is the second visit (FU).  
If 18wks is BSL, then 24wks is the second visit (FU). 
If 24wks is BSL, then 30wks is the second visit (FU). 
Informed consent 
 
 
 
  
Eligibility Assessment 
 
 
 
  
TSC Genotype Information 
 
 
 
  
Parent’s Genetic Blood Sample 
 
 
 
  
Biomarker blood collection2 
 
 
 
  
Family History & Demographics 
 
 
 
  
Medical History 
 
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 
 
 
 
 
  
 
 
 
 
  
  
Physical exam 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
  
  
VEEG 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
  
  
Concomitant Medications 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
  
  
Eye Exam1 
 
 
 
  
 
 
 
 
  
  
Bayley Scales of Infant and 
Toddler Development (3rd 
edition)4  
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
  
Beery-Buktenica Developmental 
Test of Visual-Motor Integration 
(6th edition) 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
Autism Diagnostic Observation 
Schedule (2nd edition)  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  

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1. Follow up eye exams will be completed within 4 weeks of the initial enrollment in the study. A repeat eye exam will be done at 12 months of age, 24 months of age and 36 months of age. 
2. Biomarker samples will be collected at each subject’s enrollment. Those subjects who remain seizure free and have a normal EEG will have a second biomarker sample collected at 12 
months of age and a final sample at 24 months of age. 
3. Telephone Contact – will be done every 3 months after the 1 month of age visit until the final visit at 36 months. 
4. Bayley III (Social-Emotional and Adaptive Behavior Questionnaire) will be completed at 6 month visit and the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) 
will be completed at 12, 24 and 36 months of age. 
 
 
  
 
 
 
 
 
 
 
 
 
Peabody Picture Vocabulary 
Test 94th edition) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Child Behavioral Checklist 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
Vineland Adaptive Behavior 
Scale (2nd edition) 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
Study Visits 
Screening/Baseline 
(1st visit) 
Study Visits 
(Study Follow-up Period) 
 
~6wks 
(1.5m) 
~12wks 
(3m) 
~18wks 
(4.5m) 
~24wks 
(6m) 
~12wks 
(3m) 
~18wks 
(4.5m) 
~24wks 
(6m) 
~30wks 
(7.5m) 
~36wks 
(9m) 
~45wks 
(10.5m) 
~52wks 
(12m) 
~65wks 
(15m) 
~78wks 
(18m) 
~91wks 
(21m) 
~104wks 
(24m) 
~156wks 
(36m) 
 
If 6wks is BSL, then 12wks is the second visit (FU). 
If 12wks is BSL, then 18wks is the second visit (FU).  
If 18wks is BSL, then 24wks is the second visit (FU). 
If 24wks is BSL, then 30wks is the second visit (FU). 

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APPENDIX 2: Table 3- COVID-related modifications for PREVeNT ASD-focused assessments beginning 7/1/2020 and 
going forward: 
 
Visit 
BOSA & 
DSM5 
Checklist 
ADOS 
ADI-R 
Clinical 
Certainty 
Rating 
24 months 
(ADOS 
permitted) 
 
X 
 
X 
 
 
X 
24 months 
(ADOS not 
permitted) 
 
X 
 
 
 
X 
36 months 
(ADOS 
permitted) 
 
X 
 
X 
 
 
X 
36 months 
(ADOS not 
permitted) 
 
X 
 
X 
 
X 
 
X 
 
• The BOSA and DSM5 checklist should be administered at every 24- and 36-month visit moving forward, even once the 
ADOS-2 is re-instated.  
• The ADI-R is being added at the 36-month visit to aid diagnostic accuracy with the BOSA when the ADOS is not being 
administered. 
• If no ADI research-reliable evaluator available at your site, this can be done via zoom or phone by Sarah O’Kelley (UAB) or 
another ADI evaluator within the PREVeNT network.  
• When administering both the BOSA and the ADOS-2, the BOSA should be administered/coded by someone who is BOSA-
trained but not the same person who does the ADOS-2 for that child 
o Video of the BOSA could be uploaded for an independent rater to score 
o All BOSA assessments will be video recorded to evaluate test reliability as part of the PREVeNT data analysis.  
• After 7/1/2020 the BOSA and ADOS can be done at the 24 month study visit only if permitted by each individual 
PREVeNT site  

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Protocol Version 6.0 Summary of Changes 
Before Amendment 
After Amendment 
 
Sites Children’s Hospital of Orange County 
and Icahn School of Medicine at Mount Sinai 
were participating sites.  
 
 
 
 
Removed from page 1 and Organizational 
Chart on page 37 Children’s Hospital of 
Orange County and Icahn School of Medicine 
at Mount Sinai as participating sites – no 
subjects were enrolled at these sites.  
 
Page 4 - Modified Secondary Objectives under 
#2 to add During the COVID-19 Pandemic in 
order to minimize the risk of infection to 
observer and infant until the completion of the 
study the Brief Observation of Symptoms of 
Autism (BOSA) will be administered at 24- and 
36-month visits. Additionally, the ADI-R will be 
administered at the 36-month visit. See also 
page 14 under Development Assessments, 
pages 26-27, BOSA Preliminary Data Based 
on the ADOS, page 28 Analyses, and 
Appendix 2: Table 3.  
 
Page 45, Added Reference #38 relating to 
Brief Observation of Symptoms of Autism 
(BOSA) Version: 6-25-20. 

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