Remote Ischemic Conditioning in Patients With Acute Stroke: a Multicenter Randomized, Patient-assessor Blinded, Sham-controlled Study
Phase: NA
Conditions: Stroke, Acute, Ischemic Stroke, Hemorrhagic Stroke, Intracerebral Hemorrhage, Cerebrovascular Disorders, Central Nervous System Diseases
Sponsor: Grethe Andersen

Page 1 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Clinical Investigation Plan 
 
Remote ischemic conditioning in patients with acute stroke: a multicenter 
randomized, patient-assessor blinded, sham-controlled study. 
A multicenter, prospective, randomized, patient-assessor blinded, sham controlled study investigating whether remote 
ischemic conditioning (RIC) can improve recovery. 
 
Project acronym 
RESIST stroke trial 
REmote iSchemic conditioning In patients with acute STroke: a multicenter 
randomized, patient-assessor blinded, sham controlled study examining the 
effect on recovery 
Clinical investigation plan 
Version 8.0, 29th of November 2018 
Sponsor/Principal investigator 
(Aarhus) 
 
 
Study Coordinator & investigator 
 
 
Principle Investigator (Holstebro) 
 
 
Grethe Andersen, Senior Consultant, MD, DMSc, Professor of Neurology. 
Department of Neurology, Aarhus University Hospital, DK-8000, Denmark. 
Phone:+4578463294, e-mail: greander@rm.dk 
 
Rolf Blauenfeldt, MD, PhD Student. Department of Neurology, Aarhus 
University Hospital, DK-8000, Denmark. 
Phone: +4520774053, e-mail: rolfblau@rm.dk  
 
Birgitte Forsom Sandal, Senior Consultant, MD. Department of Neurology, 
Regional Hospital West Jutland (Holstebro), DK-7500, Denmark. Phone: +45 
78437280, e-mail: Birgitte.Forsom.Sandal@vest.rm.dk  
 
Principle Investigator (Odense) 
 
 
Principle Investigator (Aalborg) 
 
 
Principle Investigator (Roskilde) 
Anne-Mette Homburg, Senior Consultant, MD. Department of Neurology. 
Odense University Hospital, DK-5000, Denmark. Phone: +45 65414691, e-
mail: anne-mette.homburg@rsyd.dk 
 
Boris Modrau, Senior Consultant, PhD-student, MD. Department of 
Neurology. Aalborg University Hospital, DK-9000, Aalborg. Phone: +45 
97662239, e-mail: boris.modrau@rn.dk 
 
Troels Wienecke, Senior Consultant, Associate professor, PhD, MD. 
Department of Neurology, Zealand University Hospital, DK-4000 Roskilde, 
Phone: +45 47322800, e-mail: trw@regionsjaelland.dk  
 
 

Page 2 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
 
RESIST trial is conducted according to the clinical investigation plan and current Danish legislation  
The Clinical Investigation Plan will be approved and signed by all investigators before study start.   
Contents 
1. 
Synopsis ..................................................................................................................................................... 3 
2. 
Abbreviations ............................................................................................................................................. 7 
3. 
Introduction ............................................................................................................................................... 9 
4. 
Hypothesis ............................................................................................................................................... 10 
5. 
Objectives ................................................................................................................................................ 10 
6. 
Trial design ............................................................................................................................................... 11 
7. 
Selection and withdrawal of subjects ...................................................................................................... 13 
8. 
Study procedure and assessment............................................................................................................ 16 
9. 
Endpoints ................................................................................................................................................. 20 
10. 
Benefit of the study ............................................................................................................................. 29 
11. 
Assessment of safety ........................................................................................................................... 30 
12. 
Project timetable and recruitment feasibility ..................................................................................... 34 
13. 
Ethical considerations .......................................................................................................................... 35 
14. 
Data handling and record keeping ...................................................................................................... 35 
15. 
Publications policy ............................................................................................................................... 36 
16. 
Statistics ............................................................................................................................................... 36 
17. 
Source data access and monitoring ..................................................................................................... 40 
18. 
Economy .............................................................................................................................................. 40 
References ....................................................................................................................................................... 44 
 
 
 
 
 
 

Page 3 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
1. Synopsis 
 
Name of the Sponsor/principal investigator  
Grethe Andersen, Senior Consultant, MD, DMSc, Professor of Neurology, Department of Neurology, 
Aarhus University Hospital, DK-8000, Denmark  
Name of investigational medical device: “Stroke RIC” & “Sham RIC” 
The investigational devices is developed in collaboration with the Faculty of Biomedical Engineering, 
Aarhus University, 8200-DK, Aarhus N, Denmark; Seagull Aps, 4160-DK, Herlufmagle, Denmark, and the 
Department of Neurology, Aarhus University Hospital, 8000-DK, Aarhus C, Denmark. 
Title of study: RESIST 
Remote ischemic conditioning in patients with acute stroke: a multicenter randomized, patient-assessor 
blinded, sham-controlled study, examining the effect on recovery. 
Trial Management Groups (TMG):  
Principal investigator/Sponsor (Aarhus University Hospital): 
Grethe Andersen, Senior Consultant, MD, DMSc, Professor of Neurology, Department of Neurology, 
Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark 
 
Study Coordinator/Investigator  
Rolf Ankerlund Blauenfeldt, MD, PhD student. Department of Neurology, Aarhus University Hospital, 
Nørrebrogade 44, 8000 Aarhus C, Denmark 
 
Trial Steering Committee (TMC):  
Grethe Andersen (Aarhus University Hospital), Rolf Ankerlund Blauenfeldt (Aarhus University Hospital), 
Niels Hjort (Aarhus University Hospital), Hans Erik Bøtker (Aarhus University Hospital), David C. Hess 
(Medical College of Georgia, USA), Hans Kirkegaard (Aarhus University Hospital). Rikke Bay Thomsen 
(Aarhus University Hospital), Birgitte Forsom Sandal (Regional Hospital West Jutland, Holstebro) and 
Marc Fisher (Beth Israel Deaconess Medical Center, Harvard Medical School, USA). 
 
Data Monitoring Committee (and Trial Safety Committee):  
The DMSC comprises of: 
Jesper Petersson (Skåne University Hospital, Sweden) – chair.  
Jan Brink Valentin (Aalborg University Hospital, Denmark) 
Thomas Christensen (Nordsjællands Hospital, Denmark) 
 
Trial Endpoints Validation Committee:  
EVC comprises of Independent senior consultants in Neurology and Cardiology 
Trial monitoring: 
During the entire study period and at all participating centres the regional GCP unit will perform quality 
assurance control including source data verification (GCP Unit Aarhus/Aalborg, ID 2017-718)  
Study centers:  
Department of Neurology, Aarhus University Hospital, DK-8000 Aarhus C, Denmark 
Department of Neurology, Holstebro Hospital, DK-7500 Holstebro, Denmark 

Page 4 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Department of Neurology, Odense University Hospital, DK-5000 Odense, Denmark  
(Future study center, 2019 or 2020) 
Department of Neurology. Aalborg University Hospital, DK-9000, Aalborg, Denmark  
(Future study center, 2019 or 2020) 
Department of Neurology, Zealand University Hospital, DK-4000 Roskilde, Denmark  
(Future study center, in 2019 or 2020) 
 
All Danish stroke centers will be invited to participate. 
Planned study period: 2018-2022. 
Phase of development:  
Improve routine care of patients with acute stroke and transitory ischemic attack (TIA). 
Objectives:  
To determine whether combined remote ischemic per- and postconditioning can improve long-term 
recovery in acute stroke patients as an adjunct to standard treatment. 
Diagnosis:  
Acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). 
Methodology:  
A multicenter, investigator-driven, prospective, randomized, parallel assignment, patient-assessor 
blinded, sham-controlled clinical efficacy trial. 
Randomization:  
• 
Eligible patients will be randomized prior to the arrival at the hospital (via a secure web site). 
• 
The patients and the clinical outcome assessor will be blinded to the treatment allocation. 
Number and subjects (planned):  
• 
1,500 patients 
Inclusion criteria (prehospital):  
The initial treatment regime will be applied in the acute prehospital phase in setting of an acute research 
study  
• 
Male and female patients (≥ 18 years) 
• 
Prehospital putative stroke 
• 
Onset of stroke symptoms < 4 hours before remote ischemic conditioning (RIC)  
• 
Independent in daily living before symptom onset (mRS ≤ 2) 
Final in-hospital inclusion criteria 
• 
acute ischemic stroke including documented TIA     
or     
• 
ICH 
 

Page 5 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
TIA without documented ischemic lesion and non-vascular diagnosis will only have register-based long 
term follow-up only.  
Exclusion criteria (pre-hospital) 
Exclusion criteria, to be established during the teleconference between ambulance and on call 
neurologist 
• 
Intracranial aneurisms, arteriovenous (AV) malformation, cerebral neoplasm, or abscess  
• 
Pregnancy  
• 
Severe peripheral arterial disease in the upper extremities 
• 
AV shunt in the arm selected for RIC 
• 
Concomitant acute life-threatening medical or surgical condition 
Criteria for evaluation  
Primary endpoints 
• 
Clinical outcome (mRS) at 3 months in acute stroke (AIS and ICH) 
Secondary endpoints  
• 
Difference in prehospital stroke score (PreSS) during 24 hours in all randomized patients 
• 
Clinical outcome (mRS) at 3 months in subgroups: AIS, IV tPA/EVT treated AIS and ICH 
• 
Difference in prehospital stroke score (PreSS) during 24 hours in subgroups: IV tPA/EVT treated AIS 
and ICH. 
• 
Difference in proportion of patients with complete remission of symptoms within 24 hours (TIA) 
• 
Major Adverse Cardiac and Cerebral Events (MACCE) and recurrent ischemic events based on 
registry data at 3 and 12 months in ICH, AIS patients, TIA and non-vascular diagnosis 
• 
Three-month and one-year mortality in AIS, ICH, and overall 
• 
Early and very early neurological improvement in AIS and ICH patients 
• 
Bed-day use at 3 and 12 months and quality of life measures at 3 months 
Sub-studies at Aarhus University Hospital (secondary endpoints) 
• 
Clinical outcome (mRS) at 3 months in patients with AIS and ICH and extended remote ischemic 
postconditioning protocol (substudy at Aarhus University Hospital) 
• 
Proportion of RIC/Sham-RIC treated AIS patients with large vessel occlusion (LVO) eligible to EVT 
treatment (substudy at Aarhus University Hospital) 
• 
Difference in acute (24-hour) hematoma expansion in patients with ICH 
• 
Difference in hematoma reabsorption rate (7 days) in patients with ICH 

Page 6 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
• 
Infarct growth in AIS patients and hematoma growth in ICH patients 
• 
Predictive abilities of Glial Fibrillary Acidic Protein (GFAP) in prehospital obtained blood samples 
combined with prehospital stroke severity to differentiate hemorrhagic from ischemic stroke and to 
grade ischemic stroke severity (substudy at Aarhus University Hospital) 
• 
Diagnostic abilities of a prehospital microRNA and extracellular vesicles blood samples profile 
combined with prehospital stroke severity on the differentiation of hemorrhagic from ischemic 
stroke and to grade ischemic stroke severity (substudy at Aarhus University Hospital) 
• 
microRNA and extracellular vesicle profile of RIC-induced neuroprotection at baseline (substudy at 
Aarhus University Hospital) 
• 
Coagulation profile of putative stroke patients in prehospital obtained blood samples (substudy at 
Aarhus University Hospital) 
• 
Modulation of coagulation by RIC (substudy at Aarhus University Hospital) 
• 
Characterization of rheoerythrocrine dysfunction (RBC deformability, eryNOS3 and plasma nitrite) in 
RIC vs Sham-RIC treated stroke patients and its possible association to improved short term (24 
hour) or long term (90 day mRS) clinical outcome or imaging biomarkers (DWI infarct growth) 
(substudy at Aarhus University Hospital) 
• 
Prestroke physical activity level (PASE) as a predictor for early and long-term recovery. (substudy at 
Aarhus University Hospital) 

Page 7 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Study flow chart 
 
 

Page 8 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Abbreviations 
AE 
Adverse event 
AIS 
Acute ischemic stroke 
AR 
Adverse reaction 
CT 
Computed tomography 
CPSS 
Cincinnati Prehospital Stroke Scale 
DWI 
Diffusion-weighted imaging  
DMC 
Data Monitoring Committee and Endpoints Validation Committee 
ICH 
Intracerebral hemorrhage 
END 
Early neurological deterioration  
EVT 
Endovascular treatment 
LVO 
Large Vessel Occlusion 
miRNA 
Micro ribonucleic acid 
mPTP 
Mitochondrial permeability transition pore 
MRI 
Magnetic resonance imaging 
NPR 
Danish National Patient Register 
PreSS 
Prehospital Stroke Score 
PWI 
Perfusion-weighted imaging 
RIC 
Remote ischemic Conditioning 
RIPerC 
Remote Ischemic perconditioning 
RIPreC 
Remote ischemic preconditioning 
RIPostC 
Remote ischemic postconditioning 
IV tPA 
Intravenous thrombolysis/recombinant tissue-type plasminogen activator 
SAE 
Serious adverse event 
SAR 
Serious adverse reaction 
TIA 
Transient ischemic attack 
TIA (DWI+) 
Transient ischemic attack with a DWI-positive lesion on MRI 
TMG 
Trial Management Group 
TSC 
Trial Steering Group 
 
 
 
 
 
 
 
 
 
 
 

Page 9 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
2. Introduction 
 
Our primary aim is to investigate whether remote ischemic conditioning (RIC) as an adjunctive treatment 
can improve long-term recovery in acute stroke patients as an adjunct to standard treatment. 
 
Stroke is the second-leading cause of death worldwide and a leading cause of serious, long-term disability. 
The most common type is AIS which occurs in 85% of cases. Acute cerebral thromboembolism leads to an 
area of permanent damage (infarct core) in the most severely hypoperfused area and a surrounding area of 
impaired, yet salvageable tissue known as the “ischemic penumbra”1. Intravenous alteplase (IV tPA) and 
endovascular treatment (EVT) are approved acute reperfusion treatments of AIS to be started within the 
first 4½-6 hours and as soon as possible after symptom onset to prevent the evolution of the infarct 
core2,3,4,5. The prognosis has improved overall for ischemic stroke and the one-month mortality rate has 
declined to an approx. 10% 6. However, reperfusion itself may paradoxically result in tissue damage 
(reperfusion injury) and may contribute to infarct growth7,8,9. Infarct progression can continue for days 
following a stroke, and failure of the collateral flow is a critical factor determining infarct growth10. The pre-
eminent therapeutic aim is to restore blood flow, improve collateral perfusion, and prevent reperfusion 
injury11. In transient ischemic attack (TIA), the ischemia and stroke symptoms are only temporary, but these 
patients possess a high risk of re-stroke – especially patients with evidence of infarction on neuroimaging12. 
TIA patients with a documented ischemic lesion are, per definition, handled as ischemic stroke in this study. 
On the other hand, in ICH the culprit is an eruption of blood into the brain parenchyma causing tissue 
destruction with a massive effect on adjacent brain tissues. Hematoma expansion as well as inflammatory 
pathways that are activated lead to further tissue damage, edema, and penumbral hypoperfusion13. The 
prognosis after ICH is poor with a one-month mortality of 40%. Acute blood pressure lowering is 
recommended to prevent further hematoma growth, but the mechanisms behind this effect are not 
understood14. 
Novel therapeutics and neuroprotective strategies that can be started ultra-early after symptom onset are 
urgently needed to reduce disability in both AIS and ICH.  
Ischemic conditioning is one of the most potent activators of endogenous protection against ischemia-
reperfusion injury15. RIC can be applied as repeated short-lasting ischemia in a distant tissue that results in 
protection against subsequent long-lasting ischemic injury in the target organ16. This protection can be 
applied prior to or during a prolonged ischemic event as remote ischemic preconditioning (RIPreC) and 
perconditioning (RIPerC), respectively, or immediate after reperfusion as remote ischemic postconditioning 
(RIPostC)17. RIC is commonly achieved by inflation of a blood pressure cuff to induce 5-minute cycles of limb 
ischemia alternating with 5 minutes of reperfusion. RIC activates several protective mechanisms, through 
humoral and neuronal pathways18. Circulating microRNA appears to be intimately involved in the RIC 
stimulus and might act as possible effector molecules19,20. 
Preclinical studies show that RIC induces a promising infarct reduction in an experimental stroke model21,22. 
It has been demonstrated that RIC protects against ischemia-reperfusion injury in the heart, lung, kidney, 
and the brain22. Results from a recent proof-of-concept study at our institution indicate that RIPerC applied 
during ambulance transportation as an adjunctive to in-hospital IV tPA increases brain tissue survival after 
one month23. Furthermore, RIPerC patients had less severe neurological symptoms at admission and 
tended to have decreased perfusion deficits23. Another study using RIPreC found a decreased stroke 
recurrence and shorter time to recovery in patients with intracranial arterial stenosis24, 25. Furthermore, 

Page 10 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
emerging preclinical data indicate a significant acceleration of hematoma size reduction increased 
hematoma reabsorption rate and an improved functional outcome after RIC-treated ICH26. 
To-date, no serious adverse events have been documented in RIC. The procedure has been applied in 
numerous cardiovascular ischemic patients and in patients suffering from cerebral hemorrhage 
(ICH/SAH)23,27,28,29,30. 
RIC is a non-pharmacologic and non-invasive treatment without noticeable discomfort that has first-aid 
potential worldwide31. However, whether combined remote ischemic per- and postconditioning can 
improve long-term recovery in AIS and ICH has never been investigated in a randomized controlled trial.  
3. Hypothesis 
RIC as an adjunctive treatment improves long-term functional recovery in AIS and ICH patients. 
 
4. Objectives 
Primary objectives 
• 
To determine whether RIC improves the clinical outcome (mRS) at 3 months in AIS and ICH 
Secondary objectives 
• 
To determine whether RIC reduces neurological impairment (PreSS) in all randomized patients  
• 
To determine whether RIC improves the clinical outcome (mRS) at 3 months in subgroups of AIS, IV 
tPA/EVT-treated AIS patients and ICH patients  
• 
To determine whether RIC reduces neurological impairment (PreSS) at 24 hours in subgroups of IV 
tPA/EVT treated AIS and ICH. 
• 
To determine whether RIC increases the proportion of patients with complete remission of symptoms 
within 24 hours (TIA; both with and without DWI lesion) 
• 
To determine whether RIC reduces major adverse cardiac and cerebral events (MACCE) and reduces 
recurrent ischemic events at 3 and 12 months  
• 
To determine whether RIC reduces the 3-month and 1-year mortality in patients with AIS, ICH, and 
overall 
• 
To determine whether RIC reduces bed-day use at 3 and 12 months and affects quality of life at 3 
months 
• 
To determine whether RIC increases the occurrence of early and very early neurological improvement 
in AIS and ICH patients 
Secondary endpoints (only Aarhus University Hospital) 
• 
To determine whether an extended RIC protocol (one week) improves clinical outcome (mRS) at 3 
months in patients with AIS and ICH (substudy at Aarhus University Hospital) 
• 
To determine whether RIC Increased the proportion of AIS patients with large vessel occlusion (LVO) 
eligible to EVT treatment (substudy at Aarhus University Hospital) 

Page 11 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
• 
To determine whether RIC reduces infarct growth in AIS patients and hematoma growth in ICH patients 
(substudy at Aarhus University Hospital) 
• 
To determine whether RIC increases the hematoma reabsorption rate (7 days) in patients with ICH 
(substudy at Aarhus University Hospital) 
• 
To determine whether prehospital obtained Glial Fibrillary Acidic Protein (GFAP) in blood samples 
combined with prehospital stroke severity can differentiate hemorrhagic from ischemic stroke and 
grade ischemic stroke severity (substudy at Aarhus University Hospital) 
• 
To determine whether prehospital obtained microRNA and extracellular vesicles blood samples 
combined with prehospital stroke severity can differentiate hemorrhagic from ischemic stroke and 
grade ischemic stroke severity (substudy at Aarhus University Hospital) 
• 
To determine whether a circulating microRNA and/or extracellular vesicle profile of RIC-induced 
neuroprotection can be established (substudy at Aarhus University Hospital) 
• 
To determine whether the prehospital determined coagulation profile from putative stroke patients 
differs between hemorrhagic, ischemic stroke and non-stroke (substudy at Aarhus University Hospital) 
• 
To determine whether RIC modulates coagulation in hemorrhagic and ischemic stroke, and explore 
links between coagulation and infarct growth in AIS, hematoma expansion in ICH, and MACCE and 
recurrent ischemic events at 3 and 12 months in both AIS and ICH (substudy at Aarhus University 
Hospital) 
• 
To characterize the rheoerythrocrine dysfunction (RBC deformability, eryNOS3 and plasma nitrite) in 
RIC vs Sham-RIC treated stroke patients and its possible association to improved short term (24 hour) 
or long term (90 day mRS) clinical outcome or imaging biomarkers (DWI infarct growth) (substudy at 
Aarhus University Hospital) 
• 
To determine whether prestroke physical activity level (PASE) is a predictor for early and long-term 
recovery (substudy at Aarhus University Hospital) 
 
5. Trial design 
 
Trial design 
This is a multicenter, prospective, randomized, patient-assessor blinded, sham-controlled trial investigating 
whether RIC improve long-term recovery in acute stroke. 
Number of centers 
Patients with putative stroke from participating stroke centers in Denmark will be recruited.  
Number of subjects 
We estimate that a sample size of 1500 prehospital putative stroke patients will be required to achieve 
1000 eligible AIS and ICH patients (primary study endpoint). 
Sample size determination 
Primary clinical endpoint 

Page 12 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
The treatment effect of RIC on long-term functional outcome is unknown. We have assumed a small but 
clinical significant neuroprotective effect corresponding to a 6-7% increased odds for a beneficial shift on 
the modified Rankin Scale. The sample size calculation was based on a simulation-based approach to the 
analysis of statistical power when ordinal logistic regression analysis is performed (significans level of 5% )  
The statistical power was simulated at different hypothetical sample sizes (on the target population) 
(ranging from 200 to 1900) with 2000 simulation-runs performed at each step.  Unpublished data on IV-tPA 
and/or EVT treated AIS patients and ICH patients from our institution were used:  
3 months modified Rankin Scale distribution (proportions) in 2017 for patients with ICH or IV tPA/EVT 
treated AIS at Aarhus University Hospital.  
Modfied Rankin 
Scale score 
mRS 0 
mRS 1 
mRS 2 
mRS 3 
mRS 4 
mRS 5 
mRS 6 
Proportion 
0.139 
0.273 
0.141 
0.110 
0.145 
0.07 
0.126 
 
Based on our previous trial experience with prehospital remote ischemic conditioning we estimate that a 
sample of 1000 subjects with target diagnosis (AIS and ICH) will be feasible to include during the study 
period. 
Including 1000 patients with target diagnosis provide sufficient power at a alfa-level (significans) of 5% to 
detect RIC treatment effects of the estimated 6-7 % (see table below) 
Treatment effect  
(assumed neuroprective) 
5% 
6% 
7% 
Sample (target diagnosis), n 
1000 
1000 
1000 
Power 
66% 
80% 
90% 
Alpha level (significans level) 
5% 
5% 
5% 
 
The estimated prehospital, randomized, sample:  
Sample size, prehospital 
Proportion of randomized 
n = 
Target diagnosis (AIS and ICH), n 
67% 
1000 
Non-vascular diagnosis 
27% 
403 
TIA without DWI lesion 
4% 
60 
Lost to follow-up 
2% 
30 
Total 
 
1492 
Plan to include 
 
1500 
 
We therefor plan to include 1500 patients with a prehospital putative stroke in order to get 1000 patients 
with the target diagnosis of acute ischemic stroke and intracerebral hemorrhage. There is no planned 
replacement of patients lost to follow-up.  

Page 13 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
 
Randomization 
 
Randomization procedure 
The patient will be randomized to standard treatment with RIC or sham-RIC by the on call 
neurologist/vascular neurologist at the receiving stroke center. The ambulance will contact the on call 
neurologist by telephone and describe the patient (standard operating procedure (SOP) in Denmark). The 
randomization is based on a secure web site providing computer-generated blocked randomization lists 
stratified by the center. The online randomization is stratified by age, strokecenter and the Prehospital 
Stroke Score (PreSS). The PreSS score consists of the Cincinnati Prehospital Stroke Scale (CPSS) with an 
additional opportunity to report other neurological symptoms (e.g. ataxia, sensory disturbances and visual 
field loss),  and PASS (Prehospital Acute Stroke Severity Scale)32,33. Prehospital personnel participating in 
RESIST are trained in identifying stroke symptoms included in PreSS. The on call neurologist will make an 
assessment based on all available information whether the patient is eligible to participate in RESIST. 
Randomization is performed in the prehospital setting. Each on call neurologist participating in the study 
will receive unique access and will have no influence on the randomization process. All neurologists on call 
will be educated and trained in performing evaluation of potential eligible study candidates and to perform 
the online randomization during the telephone call with the ambulance personnel. There is always one 
neurologist on call in participating centers (hospital SOP). 
Treatment allocation 
1:1 Allocation 
 
6. Selection and withdrawal of subjects 
 
Selection of patients 
All patients with a putative stroke who meet the study criteria will be included.  
• 
Depending on the prehospital randomization (RIC versus sham-RIC), patients with AIS will continue 
RIC or sham-RIC treatment for an extended period. This group includes TIA with a documented DWI 
lesion on magnetic resonance imaging (MRI). 
• 
Patients with ICH will continue in-hospital RIC or sham-RIC (according to randomization). 
Informed consent for prehospital enrollment 
Background: 
Acute temporary cognitive impairment after stroke is very common, even in patients with minor stroke or 
remission of symptoms (TIA) (54%) 34. Widespread cognitive deficits have been identified in an acute stroke 
patient population35. This finding is in line with the clinical experience in acute stroke care. Whether the 
putative stroke patients have major cognitive impairment in the prehospital setting can only be tested 
under calm and quiet in-hospital circumstances. Delivering acute neuroprotective care, it is of utmost 
importance that treatment is started as soon as possible, i.e. without delay. RIC is without any known 
serious adverse events.  

Page 14 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
According to the Danish research ethics committees, a patient who is a candidate for inclusion in an acute 
research study is considered incompetent if that person is not able to care for his or her own affairs due to 
physical or mental impairment. We believe that the vast majority of stroke patients fulfil these criteria, and 
it is not possible to select the few who are, indeed, competent in the acute phase without formal cognitive 
testing and thus missing the purpose of acute neuroprotection intervention. The intervention is associated 
only with mild to moderate discomfort and minimal risk for adverse events.  
Acute Prehospital phase:  
The initial RIC/sham-RIC treatment regime will be applied in the acute prehospital phase in setting of an 
acute research study approved by the regional research ethics committees. 
Whether further treatment, according to randomization, will be offered depends on the in-hospital 
examination. 
In-hospital inclusion: 
After the initial RIC/sham-RIC treatment, in-hospital diagnostic evaluation, and acute treatment, the 
competent patient will be presented with a consent form with information about the study. Before this, 
the on-duty neurologist/research physician will have examined the patient both physically and cognitively 
and will have assessed whether the patient is competent or not. The competent patient will receive oral 
information by the on-duty neurologist/research physician based on the written patient information. The 
written patient information will be handed out (deltager information). We will ask for the patient’s 
acceptance to be included in the study. The patient can withdraw consent at any time. In addition, the 
acute nature of the disease necessitates circumvention of the usual requirements concerning a 24-hour 
time period for consideration and discussion with a lay representative. This has been done in recent 
comparable acute studies. This approach is acceptable as the intervention is without any known risk and 
associated with a potential benefit for the patient. In-hospital inclusion and assessment of cognitive 
impairment will be undertaken during the admission at the stroke center. Every effort will be made to 
inform the patients and relatives in quiet and undisturbed settings, this will be at the hospital bedroom or 
the designated room for conversations.  We will prioritize the presence of nearest relatives at time of study 
information and inclusion.  
For the incompetent patients, informed consent will be obtained from next of kin and an independent 
physician. The consenters will be provided information (based on the summary of the protocol for the 
independent physicians and study participant information for the relatives) on the trial to be able to make 
an informed decision about the patient’s participation in this trial. The independent physician will be the 
on-duty physician at the local department of neurosurgery, neuroanesthesiology, intensive care, 
neurophysiology, (neuro)radiology or the on duty physician from another specialty with stroke patient 
experience. On-duty physicians at these departments will receive detailed study information. 
A patient who during the acute phase was legal incompetent and included as such, but during the follow-up 
period is assessed competent will receive oral and written information and we will ask for his/her’s 
informed consent.  
Patients who fulfill both prehospital and in-hospital inclusion criteria will, according to randomization, 
receive RIC/sham-RIC treatment again after +6 hours (all centres). 
Participation in the extended remote ischemic conditioning(RIC) or sham-RIC (for a total of 7 days) study 
will take place only at Aarhus University Hospital. The device will follow the patient when he/she is 
discharged from the stroke center.  

Page 15 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
TIA patients (without DWI lesion) and non-stroke diagnosis patients will be asked for consent to do registry 
follow-up until one year after discharge. For these patients end-of-study visit is registered at stroke center 
discharge. 
Inclusion criteria (prehospital) 
• 
Male and female patients (≥ 18 years) 
• 
Prehospital putative stroke  
• 
Onset of stroke symptoms < 4 hours before RIC  
• 
Independent in daily living before symptom onset (mRS ≤ 2) 
Exclusion criteria (prehospital) 
• 
Intracranial aneurisms, AV malformation, cerebral neoplasm or abscess  
• 
Pregnancy* 
• 
Severe peripheral arterial disease in the upper extremities 
• 
Concomitant acute life-threatening medical or surgical condition 
• 
AV shunt in the arm selected for RIC 
*Women of child-bearing age should be asked about their use of safe birth control methods (contraceptive pill, intrauterine devices 
both hormonal and non-hormonal, hormonal implants, hormonal depot injection and transdermal hormonal patch). If pregnancy 
cannot be ruled out in the prehospital phase the patient can’t be included. Women with a safe birth control method should be 
encouraged to use this method during the entire period of active RIC treatment.  
 
Final in-hospital inclusion criteria 
o AIS (including DWI-positive TIA patients) 
or 
o ICH 
 
TIA and non-stroke diagnose will only have long-term register based follow-up. 
Method of blinding 
Outcome assessment is blinded to the treatment arm and obtained by a clinical or telephone assessment of 
the level of dependency and need for help in daily activities (modified Rankin Scale) (Primary study 
endpoint).  
No information regarding randomization status will be recorded in the patient record.  
Patients and the assessors of endpoints are blinded.  
 
Discontinuation of study participation 
A patient can withdraw from the study at any time. Patients can be withdrawn from the study at the 
principal investigator’s discretion. In case the patient cannot be reached by telephone, every effort will be 
made to contact the patient or to document the outcome regarding new vascular events via 

Page 16 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
registries/electronic health records. If the patient withdraws from the study, the date and the reason for 
the patient’s withdrawal will be recorded. The patient is encouraged to provide information about his or 
her reason(s) for withdrawal and any experienced adverse effects (AE) during the study.   
 
7. Study procedure and assessment  
 
Prehospital stroke identification 
Prehospital putative stroke patients are identified in collaboration with the ambulance personnel and the 
on-duty neurologist/vascular neurologist at the nearest stroke center (by telephone), which is standard 
operating procedure in Denmark. All Danish ambulance personnel are trained in identifying putative stroke 
in the prehospital setting. In the present study protocol, all patients have a prehospital structured 
assessment of neurological symptoms/findings (based on items contained in PreSS) before randomization – 
which will further increase stroke symptom awareness. 
Baseline data 
Baseline data and process indicators are collected from the Danish Stroke Registry (DSR). Additional 
information about medical history and medication and clinical and physiological data are collected at 
baseline. Data are recorded in an electronic case report form (CRF) at discharge from the stroke unit. For a 
complete list of registered data, see Supplement B 
Acute treatment:  
 Patients are treated according to the national clinical guidelines on stroke treatment, intravenous  
thrombolysis and endovascular therapy. All patients are treated with state-of-the-art multidisciplinary care 
in the setting of a stroke unit monitored by the DSR.  
Blood samples  
Patients with putative stroke admitted to the Aarhus University Hospital will have blood samples 
withdrawn, in the ambulance, from peripheral venous catheter (placed as standard operating procedure, 
SOP). A total of 19mL (9mL + 10mL) will be drawn in the prehospital phase.  
Blood samples will also be drawn upon admission to the Aarhus University Hospital Stroke Center as a part 
of SOP. Additional 19mL (9mL + 10mL) of blood will be drawn at this time.  
Patients with AIS and ICH diagnosis will have blood-samples drawn, at Aarhus University Hospital Stroke 
Center, again 24 (16-32) hours after randomization. This is not standard operating procedure. 19mL (9mL + 
10mL) will be drawn at this time.  
Only patients received at the Stroke Center at Aarhus University Hospital will have blood samples drawn. 
(Prehospital and in-hospital blood samples) 
Not all ambulances will be equipped with for blood sample withdrawal, thus an estimated 500 patients will 
have blood samples drawn in the prehospital phase and in hospital at Aarhus University Hospital. 
Blood samples will be stored until completion of the trial in a research biobank.  

Page 17 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Patients not admitted at Aarhus University Hospital will have no additional blood samples drawn (neither 
prehospital or in-hospital) 
MicroRNA, extracellular vesicles, Glial Fibrillary Acidic Protein (GFAP), RBC deformability, NOS3, plasma 
nitrite and coagulation analysis will be performed on the obtained blood. A research bio bank will be 
established, and all blood samples obtained during the study are stored here. During the entire study and 
analysis period, the material will be stored at Aarhus University Hospital. The last patient will be included in 
December 2022. Analysis of blood samples, according to secondary endpoints, will be performed during the 
study and until 2 years after inclusion of the last patient (no later than 31. December 2024). Hereafter the 
remaining material will be transferred to a biobank for future unspecified research purposes. We will 
submit an application to the Danish Data Protection agency for this additional 20-year storage period of the 
blood samples (until 31 December 2044), after that, the samples will be destroyed.  All analysis will be 
performed in Denmark.  
 
Investigational devices and Remote ischemic conditioning protocols 
Automatic remote ischemic conditioning devices  
Both the RIC and sham-RIC device are developed in collaboration with Aarhus University, Faculty of 
Biomedical Engineering, 8200-DK, Aarhus N, Denmark; Seagull Aps, 4200-DK, Slagelse, Denmark and the 
Department of Neurology, Aarhus University Hospital, 8000-DK, Aarhus C, Denmark. 
The devices are manufactured by Shenzhen Raycome Health Technology Co., Ltd, 3F, 51 Building, No.5 
Qiong Yu Road, Hi-Tech Industrial Park, Nanshan District, Shenzhen, China 518057. 
The Investigator’s Brochure (IB) contains a detailed description of the investigational devices including risk 
analysis assessment. 
A brief user’s manual is found in each device bag. No preexisting experience is necessary in order to operate 
the device. Written and oral information combined (Healthcare professional at participating hospitals) with 
RESIST trial e-learning material (prehospital personnel) will be offered to familiarize the clinical personnel in 
using the investigational devices. Patients and relatives will be instructed using written and oral 
information.  
 
Remote Ischemic Conditioning device (RIC device) 
The device is programmed to five cycles (50 minutes), each consisting of five minutes of cuff inflation 
followed by five minutes with a deflated cuff. The cuff pressure will be 200mmHg; but if initial systolic 
blood pressure is above 175 mmHg, the cuff is automatically inflated to 35 mmHg above the systolic blood 
pressure. This is done to account for a maximum cuff air leakage of 6mmHg per minute and maximum 
deviation in bloodpressure measurement of 10mmHg. The maximum cuff pressure is 285 mmHg.  
Sham – remote ischemic conditioning device (Sham-RIC device) 
The device is programmed to five cycles (50 minutes), each consisting of five minutes of cuff inflation 
followed by five minutes with a deflated cuff. The cuff pressure during inflation will be 20mmHg. 
Timestamps, blood pressure before RIC/sham-RIC and total RIC/sham-RIC cycles are recorded and stored 
on the device (accessible by universal serial bus, USB). The RIC and sham-RIC is pre-programmed before 

Page 18 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
being delivered to collaborating centers/ambulances. No data on conditioning cuff pressure will be 
displayed on device screen.  
In cases of short transport time, the RIC/sham-RIC protocol continues during the initial assessment at the 
stroke center. RIC/sham-RIC stimulation is discontinued just prior to the MRI and continues afterwards if 
the protocol was incomplete (< 5 cycles). In centers using CT, the RIC/sham-RIC protocol is continued during 
the scan until a total of 5 cycles are reached. The device automatically stops treatment when the 5 cycles 
are completed. Except for RIC/sham-RIC, the prehospital observation and treatment are according to 
standard procedures in the ambulance. 
Stroke RIC/Sham-RIC will be used, only if approved by the Danish Medicines Agency 
The blood pressure and heartrate measurement, by RIC and Sham-RIC, will only be used for research 
purposes.   
 
Initial remote ischemic conditioning  
(all patients) 
RIC/sham-RIC cuff will be placed on the non-paretic upper arm. The cuff is placed on the upper extremity 
on the same side of the suspected side of cerebral stroke, e.g. in right hemiparesis the cuff on the left arm, 
and in monosymptomatic aphasia the cuff is placed on the left arm.  
Remote ischemic conditioning at +6 hours  
(All patients with AIS, ICH – all centers) 
At 6 hours after the first RIC/sham-RIC protocol (6 hours from the last cuff-off, respectively), another series 
of RIC/sham-RIC is performed; five cycles each consisting of 5 minutes of ischemia are followed by 5 
minutes of reperfusion.  
Remote ischemic postconditioning (twice daily for 7 days)  
(AIS and ICH – only at Aarhus university Hospital) 
 
The post-conditioning stimulus will be applied twice daily in the first week. This occurs at pre-specified 
times: 08.00 PM and AM. However, RIC/sham-RIC can be applied no sooner than 10 hours and not later 
than 21 hours after the initial perconditioning stimulus (last cuff).  
Aarhus University Hospital: RIC/sham-RIC treatment will continue for a total of 7 days. If patients are 
discharged to their home or to another department, they will continue treatment according to written 
instructions, including application of the device for 7 days. After RIC/sham-RIC on day 7, the device is then 
returned to the Stroke Center. 
RIC/sham-RIC protocol 
Accepted time frame 
Prehospital RIC 
< 4 hours from symptom onset 
RIC at +6 h 
4 to 8h from last cuff of the initial RIC 
RIC twice daily for 7 days – 08.00 PM and AM* 
 
06.00 to 10.00 PM and 06.00 to 10.00 AM 
*RIC/sham-RIC can be applied no sooner than 10 hours and no later than 21 hours after the initial perconditioning stimulus. 

Page 19 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Device Accountability log 
All devices are registered in a device accountability log. When the prehospital personnel arrives at the 
stroke center, with a patient included in RESIST trial, a new device (of the same color) will be handed out. 
Device ID, ambulance ID, contact details to the ambulance and date of device hand-out will be registered. It 
will be recorded on a paper-log in the stroke department. These data are transferred to an electronic log 
keeping track of device location and time to service/battery charge (1 year). Further details see 
Investigators Brochure. 
 
Study procedures table 
 
Acute prehospital and in-hospital phase 
+ 6 hour 
+ 24 hour 
+ 7days 
+3 
months 
12 months 
 
Prehosp. 
stroke 
score 
(PreSS)1 
Prehosp 
Blood- 
samples1 
RIC/Sham-
RIC 
In-hospital 
assessment2 
CT/MRI 
baseline 
+6 hour 
RIC/sham-
RIC 4 
PreSS 
24h 2 
CT/MRI 
24h3 
24-hour 
Blood-
samples 
Extended 
(7 days) 
RIC/sham-
RIC 5 
CT- 7 
days3 
mRS 3- 
months7 
Clinical 
events 
during 
follow-up6 
TIA 
(DWI-) -
all 
X  
(X)* 
X  
X 
X  
 
X 
 
 
 
 
 
X  
Non-
stroke -
all 
X  
(X)* 
X  
X  
X 
 
X 
 
 
 
 
 
X  
AIS incl. 
TIA 
(DWI+) 
– 
Other¥ 
X  
 
X  
X 
X  
X 
X 
X  
 
 
 
X  
X  
ICH - 
Other¥ 
X  
 
X  
X 
X (CT) 
X 
X 
 
 
 
 
X  
X  
AIS incl. 
TIA 
(DWI+) 
– AUH* 
X  
(X) 
X  
X 
X(MRI) 
X 
X 
X (MRI) 
(X)  
X  
 
X  
X  
ICH – 
AUH* 
X 
(X) 
X 
X 
X 
X 
X 
X (CT) 
(X) 
X 
X 
(CT) 
X 
X 
*AUH = Aarhus University Hospital , ¥ Other= Other participating stroke centers 
1 Prehospital stroke score (PreSS) and bloodsamples. Prehospital blood samples (19mL 2 x 5.5mL): only patients transported to 
Aarhus University Hospital) 
2 Acute assessment at the Stroke Center. NIHSS, blood samples (19mL blood) (2 x 5.5mL blood) and ECG (standard). Assessment of 
neurological symptoms at 24-hour: NIHSS. Patients with non stroke diagnosis and TIA without a DWI-MRI lesion, who are 
discharged before 24 hours will be scored using PreSS at discharge (performed by the on call neurologist). Patients with vascular 
diagnosis, who had blood samples taken in the ambulance and upon stroke center arrival will have additional samples withdrawn at 
24 hour (additional 19mL blood). In-hospital RESIST blood samples only at Aarhus University Hospital 
3 Baseline CT is preferable for ICH patients (hospital SOP). ICH patients, at Aarhus University Hospital, will receive a 24 hour control 
CT (hospital SOP). If possible, a 24-hour MRI is performed in all included AIS patients with an MRI baseline scan. Furthermore, a 24-
hour control CT will be provided for IV tPA-treated AIS patients, unless MRI can be performed and was the primary investigation. 
One week control CT will be performed, if possible, on ICH patients included at Aarhus University Hospital. End of study visit for 
non-vascular diagnosis and TIA (without DWI lesion) at stroke center discharge. 
4 RIC/sham-RIC at +6 hours from last RIC cuff 
5 RIC/sham-RIC twice daily for 7 days (Only at Aarhus University Hospital) 

Page 20 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
6 Mortality, MACCE, and recurrent ischemic events are recorded using the Danish National Patient Register (LPR) and DSR at 6 and 
15 months after the inclusion of the last patient. 
7 Assessments at 3 months by telephone or face-to-face (mRS and WHO-5). End-of-study (telephone or face-to-face) for AIS and ICH 
patients. WHO-5 will only be assessed by one assessor. 
8. Endpoints 
An independent end-point committee will adjudicate clinical events.  
Primary endpoints 
Criteria for evaluation 
Clinical outcome (mRS) at 3 months in acute stroke  
 
 
 
 
 
The level of dependency and need for help in daily activities will be determined by either face-to-face 
assessment or based on a structured telephone interviews performed by assessors who are blinded to the 
intervention at 3 months after the index stroke.  
 
The assessment will be performed by two independent blinded assessors, which can be either face-to-face 
or telephone based assessment (not same day). The electronic CRF database will alert if disagreement 
occurs, and the patient will be contacted by a third assessor (face-to-face or telephone) who is blinded to 
the intervention who will assess the level of dependency.  
 
• 
If disagreement occurs between two telephone assessments – a third, and final, telephone or face-
to-face assessment will be made. 
• 
If disagreement occurs between one face-to-face assessment and one telephone assessment – the 
face-to-face will be considered the final assessment 
• 
If disagreement occurs between two face-to-face assessments  – a third, and final, telephone or 
face-to-face assessment will be made. 
 
Every possible effort will be made to assess the outcome in patients who are unable to participate in the 
interview (this could be due to post stroke neurological impairment (for example aphasia and/or 
dysarthria), or that the patient cannot be reached by telephone). The outcome will then be assessed by 
contact to a named relative or the general practitioner. Several attempts to contact the patient by 
telephone will be made before contacting the named relative or general practitioner.  
Death in the follow-up period will be obtained from Danish Civil Registration System (CPR). 
 
The structured telephone interview will be based upon a validated Danish translation of the “slightly 
revised simplified, modified Rankin Scale questionnaire”36. The translation and its validation will be 
performed according to the AAOS guideline36, 37 
 
 
Primary study endpoint: Clinical outcome (modified Rankin Scale) at 3 months in acute 
stroke patients (generalized ordinal logistic regression) 

Page 21 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Bruno et al. 2011. Stroke.  
Furthermore, modified Rankin Scale assessors are required to have received specific mRS training, which 
could be an online mRS certification https://secure.trainingcampus.net/uas/modules/trees/windex.aspx?rx=rankin-
english.trainingcampus.net 
For a detailed statistical analysis plan, see statistics 
 
 
Outcome 
Accepted time frame (from symptom onset) 
3-month follow-up – 1st and 2nd assessment 
3 months +/- 2 weeks 
3 month follow-up – 3rd assessment 
3 months and 2 weeks +/- 2 weeks 
 
 
 
 
Secondary endpoints 
Difference neurological impairment during the first 24 hours in all randomized 
patients 
Neurological deficits are documented using PreSS (prehospital and in-hospital). The PreSS score is obtained 
by the prehospital personnel and registered by the on-call neurologist before randomization. Prehospital 
Stroke Score is assessed at 24-hour by a certified, trained and blinded general neurology nurse/neurology 
research nurse/physician/neurologist who is blinded to the treatment intervention and who is not a part of 
the daily stroke ward routine. Only information regarding time and place of assessment, patient name, age 

Page 22 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
and social security number will be available. The PreSS score of patients with TIA (without DWI lesion) and 
non stroke diagnoses, are performed by the on-call physician/neurologist or a research nurse/general 
neurology nurse, and will be documented as PreSS at discharge, if discharge occurs before 24 hours. The 
outcome assessor will be alerted in advance of the assessment. The PreSS is recorded in the electronic CRF. 
Clinical assessors are required to complete an online PreSS certification or face-to-face training. 
https://ekurser.rm.dk/test_projekter/anhesr/red-hjernen/scorm/Scorm2004%204th%20Edition/index.html 
 
For a detailed statistical analysis plan, see statistics 
Indicator 
Accepted timeframe (from symptom onset) 
PreSS 
Close to symptom onset 
PreSS24h (+ 24h) 
+ 16 to 32h 
 
Difference in proportion of patients with complete remission of symptoms 
within 24 hours (TIA; both with and without DWI) 
Diagnosis of TIA is documented in the electronic case report form 
Endpoint assessment 
Difference in proportion of patients with complete remission of symptoms within 24 hours (TIA; both with 
and without DWI) 
 
Major adverse cardiac and cerebral events (MACCE) and recurrent ischemic 
events at 3 and 12 months in AIS and all patients 
MACCE is defined as: 
Cardiovascular events (cardiovascular death, myocardial infarction, acute ischemic or hemorrhagic 
stroke) 
Cardiovascular death: Death from known cardiovascular cause or sudden death from unknown 
cause (no identified cause of death in medical history and/or autopsy) 
Acute myocardial infarction: Admission with a discharge diagnosis of ST-elevation myocardial 
infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) and unstable angina 
pectoris (UAP) 
 
Stroke: Admission with a discharge diagnosis of acute ischemic or hemorrhagic stroke.  
Evaluation is performed using the Danish National Patient Register (LPR) and the DSR at two time 
points (6 and 15 months after the inclusion of the last patient). 
  
Diagnosis of AIS/TIA, ICH and MI (STEMI, NSTEMI, and UAP) are made according to national clinical practice 
guidelines.  

Page 23 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
(http://neuro.dk/wordpress/nnbv/om-iskaemisk-apopleksi/ and http://nbv.cardio.dk/aks) 
Recurrent ischemic vascular events at 3 and 12 months in AIS patients 
Recurrent ischemic vascular events defined as:  
▪ 
AIS 
▪ 
TIA 
▪ 
MI, STEMI, and NSTEMI  
Three-month and one-year mortality 
Information about mortality is collected using the CPR and LPR, at two time points (6 and 15 months after 
the inclusion of the last patient). All-cause mortality is assessed and subdivided into cardiovascular 
mortality versus non-cardiovascular mortality40. 
Analysis are performed on all randomized patients and according to subgroups.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
According to “2014ACC/AHA Key Data Elements and Definitions for Cardiovascular Endpoint Events in Clinical 
Trial”. Circulation 2015;132:302-361. 
 
 
Cardiovascular mortality 
Non - cardiovascular mortality 
▪ 
Acute MI 
▪ 
Sudden cardiac death 
▪ 
Heart failure 
▪ 
Stroke: death as a direct consequence or 
complication of stroke 
▪ 
Cardiovascular procedure or procedure 
▪ 
Cardiovascular-related hemorrhage: non-stroke 
intracranial hemorrhage (subdural hematoma), 
non-traumatic vascular rupture (e.g. aortic 
aneurysm), or hemorrhage causing cardiac 
tamponade 
▪ 
Pulmonary, renal, gastrointestinal, 
hepatobiliary and pancreatic 
▪ 
Infection and inflammatory/immune (including 
autoimmune) 
▪ 
Hemorrhage (non-cardiovascular (CV)/non-
stroke-related bleeding) 
▪ 
Non-CV procedure or surgery, trauma, suicide, 
drug reaction, or overdose 
▪ 
 Neurological, malignancy, other non-CV 
Mortality (all-cause) 

Page 24 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
 
EVT-eligibility (MRI assessed) in RIC treated AIS patients with large vessel 
occlusion(LVO) 
EVT eligibility is assessed upon arrival at the Aarhus University Hospital in AIS patients with: 
• 
Severe Stroke (NIHSS ≥ 10) 
• 
Groin puncture feasible within 6 hours from stroke onset 
• 
MRI-TOF (time-of-flight) documented internal carotid artery (ICA), Intracranial ICA (ICA-T) and first 
and second stem of the middle cerebral artery (M1 and M2, respectively) 
• 
No contraindications to MRI (pacemaker, vomiting, respiratory insufficiency, obesity) 
• 
MRI-DWI lesion volume ≤ 70mL 
 
 
Endpoint assessment 
Proportion of RIC treated AIS patients with LVO eligible to EVT treatment compared to standard treatment, 
adjusted for prehospital stroke severity (PreSS) and symptom duration 
Difference in MRI-DWI lesion volume in RIC/sham-RIC treated LVO AIS patients eligible to EVT treatment 
 
Quality of life measures at 3 months in AIS and ICH patients 
▪ 
Quality of life and bed-day use measures in AIS and ICH patients 
Quality-of-life measurements are assessed by telephone interview at 3 months after inclusion. The WHO-5 
is used. Baseline WHO-5 is only obtained at Aarhus University Hospital. 
 
Link to: Danish National Board of Health - WHO-5.  
Information about bed-day use via the LPR and the DSR.  
 
Early neurological improvement in AIS and ICH patients  
Neurological deficits are documented with the PreSS and the National Institute of Health Stroke Scale 
(NIHSS), prehospital and in-hospital, respectively. 
▪ 
Very early neurological improvement is defined as:  
Reduction in prehospital stroke score (PreSS) ≥ 1 points or resolution of symptoms at admission: Items on 
PreSS related to NIHSS baseline ΔPreSS = PreSSprehospital – same items on NIHSS baseline 
▪ 
Early neurological improvement is defined as: 
Reduction in NIHSS ≥ 4 (baseline versus 24-Hour NIHSS): ΔNIHSS = NIHSSbaseline–NIHSS24 
• 
Reduction in prehospital stroke score (PreSS) ≥ 1 points or resolution of symptoms after 24 hours in 
subgroups: IV tPA/EVT treated AIS and ICH. 

Page 25 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Clinical assessors are required to complete an online PreSS certification  
PreSS certification: https://ekurser.rm.dk/test_projekter/anhesr/red-hjernen/scorm/Scorm2004%204th%20Edition/index.html 
 
 
Indicator 
Accepted timeframe (from symptom onset) 
PreSS 
Close to symptom onset 
NIHSS baseline 
0 to 6 hours from admission 
NIHSS (+ 24h) – standard operating procedure 
+ 16 to 32h 
PreSS (+ 24h) 
+ 16 to 32h 
 
Secondary endpoints (Only Aarhus University Hospital) 
Difference in acute hematoma expansion in patients with ICH  
(Substudy only at Aarhus University Hospital) 
• 
Hematoma expansion is defined as the difference in volume between the baseline and the 24-hour CT 
hematoma volume. Significant hematoma growth is defined as an absolute growth exceeding 6 mL or a 
relative growth of more than 33% from the initial CT39.  
In all ICH patients, the baseline imaging modality is CT. In cases of initial MRI, a CT is performed afterwards 
(no later than < 3 hours from last RIC cuff) 
 
Imaging protocol 
Accepted time frame 
CT baseline – ICH 
< 3 hours from last RIC/sham-RIC cuff 
MRI baseline – ICH 
Perform CT as soon as possible and < 3 hours after 
the last RIC/sham-RIC cuff 
Control CT (24-hour) – ICH 
18-30 hours from baseline CT 
 
Information about imaging protocols, see Supplement A – Neuroimaging protocols 
Difference in 7 days hematoma reabsorption rate in patients with ICH  
(Substudy only at Aarhus University Hospital) 
• 
Hematoma reabsorption rate is defined as the difference in hematoma volume between the baseline 
and the 7-day CT hematoma volume.  
In all ICH patients, the baseline imaging modality is CT. In cases of initial MRI, a CT is performed afterwards 
(no later than < 3 hours from last RIC cuff) 

Page 26 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
 
Imaging protocol 
Accepted time frame 
CT baseline – ICH 
< 3 hours from last RIC/sham-RIC cuff 
MRI baseline – ICH 
Perform CT as soon as possible and < 3 hours after 
the last RIC/sham-RIC cuff 
Control CT (7-day) – ICH 
5-9 days from baseline CT 
 
Information about imaging protocols, see Supplement A – Neuroimaging protocols 
 
 
Infarct growth in AIS patients  
(Substudy only at Aarhus University Hospital) 
Acute infarct growth is defined as the difference in infarct volume between baseline and 24 hours on DWI-
MRI. All patients with IV-tPA and/or EVT treated ischemic stroke and a baseline MRI will have an additional 
24-hour MRI performed.  
 
Imaging protocol 
Accepted time frame 
MRI baseline – AIS IV tPA eligible 
On admission 
MRI baseline – AIS not IV tPA eligible 
< 6 hours from last RIC/sham-RIC cuff 
MRI (24-hour) – AIS IV-tPA/EVT treated 
 
18-30 hours from baseline MRI 
 
Information about imaging protocols, see Supplement A 
 
Biochemical profile of stroke subtypes and of RIC-induced neuroprotection 
(Substudy only at Aarhus University Hospital) 
Prehospital biochemical substudies (Aarhus University Hospital) 
• 
Diagnostic abilities of a prehospital microRNA and extracellular vesicles blood samples profile 
combined with prehospital stroke severity to differentiate hemorrhagic from ischemic stroke and to 
grade ischemic stroke severity 
• 
Predictive abilities of Glial Fibrillary Acidic Protein (GFAP) in prehospital obtained blood samples 
combined with prehospital stroke severity to differentiate hemorrhagic from ischemic stroke and to 
grade ischemic stroke severity 

Page 27 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
• 
Coagulation profile in prehospital obtained blood samples to differentiate between hemorrhagic 
stroke, ischemic stroke, and non-stroke 
• 
Red blood cell rheo-erythrocrine dysfunction in acute stroke and its possible association to 
improved early (24 hour) or long term (90 day mRS) clinical outcome or imaging biomarkers (DWI 
infarct growth) (substudy at Aarhus University Hospital) 
 
In-hospital biochemical substudies  
• 
Characterization of a possible microRNA and extracellular vesicle profile in stroke subtypes 
• 
MicroRNA and extracellular vesicle characterization of a possible RIC treatment profile 
• 
Modulation of coagulation by RIC in hemorrhagic and ischemic stroke 
• 
Characterization of rheoerythrocrine dysfunction (RBC deformability, eryNOS3 and plasma nitrite) 
in RIC vs Sham-RIC treated in acute stroke patients  
 
Prehospital and in-hospital handling of blood samples:  
Blood samples will be collected from patients with a prehospital putative stroke. Thus, blood samples will 
be drawn in the ambulance and upon arrival at the stroke center (only Aarhus University Hospital). In the 
ambulance, the blood sample will be obtained through a peripheral venous catheter (placed as standard 
operating procedure) into a 9mL and 10mL Sarstedt Monovette® tubes and transported to hospital at 
ambient temperature (Tubes of 9 and 10mL will be drawn). The local biochemical department or study 
personnel will centrifuge the blood and divide the plasma into cryotubes that will be kept at 80 °C for long-
term storage. Cryotubes not used to measure GFAP within 5 to 7 days will be stored in a research biobank. 
Blood samples will be drawn upon admission to the Aarhus University Hospital Stroke Center as a part of 
local stroke center SOP. Additional 19mL (9+10mL) of blood will be drawn at this time.  
Patients with AIS and ICH diagnosis will have blood-samples drawn, at Aarhus University Hospital Stroke 
Center, again 24 (16-32) hours after randomization (19mL (9+10mL)) will be drawn at this time).  
All blood samples obtained during the study will be stored in a research biobank 
Blood-samples, in the research biobank, will be stored until completion of the trial (no later than 31. 
December 2024). Hereafter the remaining material will be transferred to a biobank for future unspecified 
research purposes (see section “Blood Samples” under “study procedure and assessment”) 
Planned biochemical analysis  
Glial Acidic Fibrillary Protein (GFAP): 
All plasma samples for GFAP measures will be analyzed with ELISA essay kits from the same batch at Clinical 
Biochemical Department, Regional Hospital Herning. Transport and shipment of samples will be done on 
dry ice to assure stability of the specimens. The samples will be marked with the unique research 
identification number. Cryotubes not used to measure GFAP will be stored as part of a biobank. 
MicroRNA analysis:  
MicroRNAs will be identified with Illumina next-generation sequencing using the TruSeq Small RNA Sample 
Preparation kit (Illumina) which allows for the addition of unique barcode sequences to each sample. Such 
barcoding allows pooling and simultaneous sequencing of multiple samples in a single-sequencing run on 

Page 28 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
the Illumina NextSeq500 sequencer thereby significantly reducing the cost of sequencing. Pooling of 
multiple samples will generate adequate data amounts for detailed miRNA profiling, yet at limited costs. 
Data generated from the NextSeq500 sequencer will be filtered based on sequence quality as part of our 
established bioinformatics pipeline. This will also include matching the filtered data to annotated RNA 
databases such as miRNA sequences from miRBase (mirbase.org). 
The output from our bioinformatic pipeline will be quantitative miRNA expression levels for each sample, 
which will form the basis for an miRNA differential analysis where miRNAs with statistically significant 
expression changes will be found.  
The microRNA (and extraceullar vesicles) analysis is not a mapping of the genome. The microRNA profile is 
a snapshot of microRNA activity at the specific time of the blood sampling. Levels of microRNA are changing 
constantly and with the current knowledge on the topic it is impossible to predict a risk of developing 
specific diseases in the future. Cryotubes not used to microRNA/exosome analysis will be stored as part of a 
biobank. 
Extracellular vesicle analysis:  
Extracellular vesicles (EVs, also known as exosomes) will be isolated from plasma samples before 
characterization of surface markers and content. EVs are isolated by a number of different techniques, ultra 
centrifugation, precipitation, size exclusion chromatography among others. While protein characterization 
will be done using classical molecular biological techniques such as ELISA and Western blots in addition to 
array techniques, EVarray that utilises a panel of antibodies directed against known EV surface markers. 
These analyses might be supported by proteomic analysis of all proteins as well as post-translational 
modifications such as phosphorylations and glycosylations. 
In addition, the nucleic acid (DNA and RNA including miRNA) content of EVs will be analysed using next 
generation sequencing (NGS), qRT-PCR, and other nucleic acid detection techniques. Both the protein data 
and the nucleic acid data will be subjected to bioinformatic analysis using different pipelines and analysis 
tools depending on the dataset and the purpose of the analysis. A number of validated published databases 
will be used for annotation and comparison. EVs do not contain genomic DNA and the analysis are 
therefore not a mapping of the subjects genome. As EV secretion and nucleic acid content in these are 
though to change rapidly in the body due to external and internal signals and are considered a snapshot at 
the specific time of blood sampling. With the current knowledge on the topic it is impossible to predict a 
risk of developing specific diseases in the future.  
 
Coagulation assays: 
Functional and immunologic plasma assays will be employed to analyze proteins and pathways in 
coagulation and fibrinolysis. The analyses will be performed in the accredited clinical laboratory and the 
thrombosis and hemostasis research unit at the Department of Clinical Biochemistry, Aarhus University 
Hospital. Plasma samples will be stored in cryotubes at -80 °C until they will be analyzed in large batches.  
 
Ektacytometry for Erythrocytic Deformability:  
The rheological properties of RBCs are quantified using a Deformability or Elongation Index (DI or EI). A 
higher EI at the optimum viscosity (300 Osmolality) indicates highly deformable RBCs indicative of better 
microcirculation, while a lower EI indicates rigid and fragile RBCs resulting into impaired microcirculation 
and tissue hypoxia. Briefly, 6-uL of heparinized fresh blood is mixed with 600-uL of PVP solution (300 Osm) 

Page 29 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
and transferred to a disposable kit (K01 Deformability Test Kit; RheoMeditech, South Korea). The kit is 
placed inside the laser-assisted ektacytometer (RheoScan AnD300, RheoMeditech, Seoul, S. Korea) for 
automated read out, data and image collection as per the vendor’s instructions.  
 
Analytical Flow Cytometry (FC) for eryNOS3 phosphorylation (pNOS3Ser1177) and s-nitrosylation (–SNO) 
in RBCs:  
Red blood cells are separated from 50-uL of freshly fixed blood samples, using a cocktail of monoclonal 
antibodies (mAb) to RBC-specific markers (Glycophorin A, GPA; and Hemoglobin, Hb; Bioss Biotech, USA). 
To assess the functional features, after fixation and permeabilization, RBCs are incubated with antibodies 
conjugated to fluorochrome either directly or through secondary antibodies to s-nitrosocysteine (–SNO; 
Abcam), and pNOS3Ser1177 (Bioss). Next, RBC samples are run through a flow cytometer (FACS Calibur, BD 
Biosciences, San Diego, CA), and data is collected using CellQuest software to process for FC analysis. 
 
 
Prestroke physical activity measures in AIS and ICH patients 
(Substudy only at Aarhus University Hospital) 
 
Patient and their relatives will be asked to complete the physical activity in the elderly (PASE) questionnaire 
during the acute hospital admission. In patients who are unable to complete it themselves an structured 
interview based on the PASE questionnaire will be performed41,42 
The PASE is a 12-item questionnaire, which quantifies the amount of PA over a 7-day period. The PASE 
questionnaire was developed with the purpose of assessing the level of PA in middle-aged and elderly 
individuals. The PASE score is calculated by taking the average number of hours spent on an activity (sports, 
occupational activity, household activities, and leisure time activities) per day over a 7-day period 
multiplied by an activity coefficient. Item scores are added to reveal the PASE score. The PASE score may 
range from zero to more than 400.  
 
9. Benefit of the study 
Potential benefits:  
Participating patients with AIS and ICH may experience an immediate reduction of their neurological 
symptoms and a persistent reduction of disability at long-term follow-up. 
Disadvantage:  
Mild-to-moderate pain and petechiae in the RIC-treated arm may occur during the inflation of the blood 
pressure cuff. Otherwise, the RIC treatment has been proven safe and without side effects.  
Sham-RIC will only be associated with a slight sensation of pressure on the upper extremity. 
Blood samples (only patients transported to and admitted at Aarhus University Hospital) of approximately 
22 57mL (19mL prehospital and 2x19 11 mL in-hospital) will be drawn.  
An additional (compared to standard operating procedure) head CT will be performed at 7 days in ICH 
patients included at Aarhus University Hospital (If possible, the scan will be performed at the hospital were 
the patient is admitted at day 7). The estimated added whole-body radiation dose of the 7 days CT-scan is 

Page 30 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
on average 1,5 mSv (range 1,05 to 1,95) corresponding to 6 months of accumulated background radiation 
in Denmark (Danish Health Authority). This corresponds to an estimated increased life-time cancer risk of 
0.005%. 
 
 
 
10. Assessment of safety  
 
Emergency unblinding procedure 
All on call neurologists will have access to electronic case report form using a personal and password 
protected login to perform randomization of study participants. In cases where emergency unblinding is 
necessary the on call neurologist will logon to electronic CRF at ddsc.dk and enter the civil registration 
number (CPR) of the patient. The treatment can now be unblinded. All changes will leave an audit-trail.  
Adverse events 
Patients are monitored in the stroke unit with NIHSS scoring and Scandinavian Stroke Scale (SSS) at close 
intervals, and adverse events are treated according to clinical guidelines.  
The Data Monitoring Committee will assess safety according to primary study endpoints, recurrent stroke, 
myocardial infarction and mortality.  
Interim analysis of safety parameters (hematoma expansion at 24 hours and mortality) in ICH will be 
performed regularly during the study.  
During the acute in-hospital phase the patients will be asked if they have experienced any deterioration of 
health or new symptoms during or after treatment with the investigational device. Furthermore all patients 
will have a 24/7 contact number to the stroke center and a contact to study research physician and will be 
instructed to report any deterioration of health or new symptoms. All discharged patients (and relatives) 
will be given contact details to study personnel and be instructed to report any deterioration of health or 
new symptoms. The patients with acute ischemic stroke and intracerebral hemorrhage will once again be 
asked for adverse events at the 3 month telephone interview. In this group, end-of-study visit is the last 
telephone interview, whereas end-of-study visit for participants without a vascular diagnosis or TIA(without 
DWI lesion) is at the time of discharge from the stroke center.  
All patients, who have consented, are followed (through Danish Health Registries, LPR and DSR) for new 
vascular events and mortality for up to 12 months. 
Adverse events and adverse device events are defined according to ISO 14155:2011 and European 
Commission guideline on medical devices (MEDDEV 2.7/3 revision 3). 
Adverse event (AE):  
Any untoward medical occurrence, unintended disease or injury or any untoward clinical signs (including an 
abnormal laboratory finding) in subjects, users or other persons whether or not related to the 
investigational medical device. 

Page 31 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Serious Adverse Event (SAE)  
Adverse event that: 
a) led to a death, injury or permanent impairment to a body structure or a body function.  
b) led to a serious deterioration in health of the subject, that either resulted in: - a life-threatening illness or 
injury, or - a permanent impairment of a body structure or a body function, or - in-patient hospitalization or 
prolongation of existing hospitalization, or - in medical or surgical intervention to prevent life threatening 
illness 
Device Deficiency 
Inadequacy of an investigational medical device related to its identity, quality, durability, reliability, safety 
or performance. This could be malfunctions, use error, or inadequacy in the information supplied by the 
manufacturer. 
Adverse Device Effect 
Adverse event related to the use of an investigational medical device.  
This includes any adverse event resulting from insufficiencies or inadequacies in the instructions for use, 
the deployment, the implantation, the installation, the operation, or any malfunction of the investigational 
medical device.  
This includes any event that is a result of a use error or intentional abnormal use of the investigational 
medical device. 
Serious Adverse Device Effect (SADE) 
Adverse device effect that has resulted in any of the consequences characteristic of a serious adverse 
event. 
Unanticipated Serious Adverse Device Effect (USADE)  
Serious adverse device effect which by its nature, incidence, severity or outcome has not been identified in 
the current version of the risk analysis report.  
Anticipated SADE (ASADE): an effect which by its nature, incidence, severity or outcome has been 
previously identified in the risk analysis report 
Event report and causality assessment 
The relationship between the use of the medical device and the occurrence of each adverse event will be 
assessed and categorized. All events will be registered in the electronic CRF and reported to the authorities 
at the interim analysis. A yearly safety report, containing a list of all SAEs/SADEs and near-miss incidents, 
thorough evaluation of individual events, risk/benefit analysis of the investigational medical device and 
safety conclusions, will be submitted to the Danish Health and Medicines Authority and the Independent 
Ethics Committee by the Sponsor as required by Danish law.  
Exceptions to and special considerations about reporting procedures are stated below: 
Acute stroke is an acute life threatening disease with a high risk of neurological deterioration and mortality. 
The natural history of stroke is associated with a high risk of complications (stroke in progression, 
hemorrhagic transformation, dysphagia, cardiac arrhythmia, pneumonia, and other serious infections). 
These complications all relates to the index stroke (occurring before randomization) and is foreseeable. If 
an event occurs that based on the assessment by the investigator is a result of the natural history of the 

Page 32 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
disease it will not be reported by the sponsor to the Danish medicines agency and regional ethics 
committee within 7 days/2 days (see list of foreseeable events/complications below). 
All expected serious adverse events will be reported to the Danish Medicines Agency (and regional ethics 
committee) every 3 months. 
All new serious events (Serious Adverse Events), complications that are not foreseeable or device near 
incidents or malpractice will be reported by the sponsor to the authorities (within 7 days, or 2 days if there 
is a risk of event reoccurrence) according to ISO 14155:2011 and European Commission guideline on 
medical devices (MEDDEV 2.7/3 revision 3). Investigators will report the event to sponsor (within 24 hours). 
Sponsor will as fast as possible and no later than 7 days, or 2 days if there is a risk of event reoccurrence, 
report the event to the Danish Medicines Agency and regional ethics committee.  
All Serious Adverse Device Effect (SADE) will be reported to the Danish Medicines Agency (and regional 
ethics committee) within 7 days, or 2 days if there is a risk of event reoccurrence 
List of foreseeable adverse events/complications 
Foreseeable events/complications that will not be reported by the sponsor to the Danish medicines agency 
and regional ethics committee within 7 days/2days. 
 
Patient 
Population 
Event 
Frequency  
Mitigation/treatment 
TIA and AIS 
Recurrent stroke. 
10% at 90 
days a 
Standard medical treatment, 
intravenous 
thrombolysis/mechanical 
thrombectomy according to 
patient characteristics 
AIS 
Symptomatic intracerebral 
hemorrhage (related to IV 
tPA or EVT) 
7% b 
Antithrombotic/anticoagulation 
therapy cessation. 
Antifibrinolytic agent. 
Bloodpressure control.  
AIS, ICH 
Early (<24hours) and late 
(>24hours) neurological 
deterioration 
(∆NIHSS ≥2 or death) 
7-22% c 
 
According to etiology  
AIS, ICH 
Aspiration pneumonia 
5-20% d 
Antibiotic treatment according 
to hospital SOP 
AIS, ICH 
Urinary tract infections 
12% e 
Antibiotic treatment according 
to local hospital SOP 
AIS, ICH 
Severe infections (sepsis) 
13% f 
Antibiotic treatment according 
to local hospital SOP 
AIS, ICH 
Cardiac arrhythmia 
29% g 
Depending on arrhythmia type. 
Treatment according to 
cardio.dk 

Page 33 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
AIS, ICH 
Acute myocardial infarction 
6% h 
Treatment according to 
cardio.dk and conference call 
with cardiologist 
AIS, ICH 
Deep venous 
Thrombosis(DVT)/pulmonary 
embolism(PE) 
DVT: 8% i 
PE:1% j 
Treatment according to 
cardio.dk 
AIS, ICH 
Falls (in-hospital phase) 
14-65% k, l 
Treatment according to type of 
injury 
AIS, ICH 
Seizure 
AIS:3-10% m 
ICH:8% n 
Treatment according to local 
SOP 
AIS/ICH 
Mortality 30 days 
AIS:10-20% m 
ICH:30% n 
 
a)  Wang Y et al. Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. NEJM. 2013; 369:11-19 
b) Berkhemer OA. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. NEJM. 2015; 372:11-20 
c) Kwan J et al. Early neurological deterioration in acute stroke: clinical characteristics and impact on outcome Journal of the 
Association of Physicians, 2006, Sept; 99:9: 625-633 
d) Hannawi Y et al. Stroke-Associated Pneumonia: Major Advances and Obstacles. Cerebrovasc Dis. 2013;35:430-443 
e) Bogason E. Urinary Tract Infections in Hospitalized Ischemic Stroke Patients: Source and Impact on Outcome. 2017;9(2):e1014. 
doi:10.7759/cureus.1014. 
f) BergerB. Epidemiologic features, risk factors, and outcome of sepsis in stroke patients treated on a neurologic intensive care unit. Journal of 
Critical care. 2013;29(2)  
g)Daniele O et al. Stroke and cardiac arrhythmias. J Stroke Cerebrovasc Dis. 2002 jan-feb;11(1):28-33 
h) Johnston KC et al. Medical and neurological complications of ischemic stroke: experience from the RANTTAS trial. RANTTAS Investigators. Stroke. 
1998;29(2):447 
i) Bembenek J. Early stroke-related deep venous thrombosis: risk factors and influence on outcome. J thromb Thrombolysis. 2011 Jul; 32(1):96-102 
j) Pongmoragot J. et al. Pulmonary Embolism in Ischemic Stroke: Clinical Presentation, Risk Factors, and Outcome. J Am Heart Ass. 2013 Dec;2(6) 
k) Davenport RJ, Dennis MS, Wellwood I, Warlow CP. Complications after acute stroke. Stroke. 1996; 27: 415–420. 
l Teasell R, McRae M, Foley N, Bhardwaj A. The incidence and consequences of falls in stroke patients during inpatient rehabilitation: Factors 
associated with high risk. Arch Phys Med Rehabil. 2002; 83: 329–333. 
m) Bladin C, Alexandrov AV, Bellavance A et al:  Seizures After Stroke: A Prospective Multicenter Study.Arch Neurol. 2000;57(11):1617-1622.  
n) Woo K-M, Yan S-Y, Cho K-T. Seizures after Spontaneous Intracerebral Hemorrhage. J. Korean Neurosurg Soc. 2012 Oct;52(4)312-319 
O)Schwartz J et al. Incorporating Stroke Severity Into Hospital Measures of 30-Day Mortality After Ischemic Stroke Hospitalization. Stroke. 2017. 
Ahead of print: https://doi.org/10.1161/STROKEAHA.117.017960 
p) Lichtman JH et al. 30-Day Mortality and Readmission after Hemorrhagic Stroke among Medicare 
List of anticipated adverse device effects 
RIC device 
Frequency 
Mitigation/treatment 
Local petechiae 
4-5% a 
none 
Discomfort/pain 
20-30%  
Treatment stopped if the non-competent patient 
verbally or non-verbally demonstrates intolerable 
discomfort or if the competent patient verbally 
want to discontinue the treatment 

Page 34 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Near events (device related) 
None known in 
the literature 
 
Acute limb ischemia (upper 
extremity) – theoretical 
complication. 
None known in 
the literature 
Treatment stopped. Treatment according local 
hospital SOP’s for acute limb ischemia.  
Known atherosclerotic stenosis in upper 
extremities are an exclusion criteria. 
See Investigators Brochure for further details. 
Sham RIC device 
 
 
None known 
 
 
 
a) Hausenloy D et al. Remote Ischemic Preconditioning and Outcomes of Cardiac Surgery. New England J. Medicine. 2015 Oct;373(15):1408-17 
Treatment and mitigation of any adverse events will be according regional guidelines.  
Adverse events as a result of standard treatment will be handled according to local guidelines. Adverse 
events may also occur as a suspected reaction to RIC/Sham RIC – in these cases, the conditioning stimulus 
will be stopped immediately and appropriate treatment will be initiated.  
In cases of SAE and device related near events all patients will be followed until resolution of 
symptoms/signs and/or all clinical relevant treatment have been performed and/or until the 
symptoms/signs are in a stable phase.  
 
11. Project timetable and recruitment feasibility 
Study preparation: January to February 2017 
Study start date: March 2018 
Month 0-60: Patient recruitment 
Expected inclusion end date: 31. December 2022 
Month 60-66: Study analysis 
Expected end date for last analysis and follow-up: 31. December 2024 
 
 
Patient inclusion per center: 
Aarhus University Hospital: 50% 
Regional Hospital West Jutland (Holstebro): 12,5% 
Odense University Hospital:  12,5% 
Aalborg University Hospital: 12,5% 

Page 35 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Zealand University Hospital (Roskilde): 12,5% 
 
12. Ethical considerations 
The study will await approval from the Regional Ethical Committee, the Danish Health Authority, and the 
Danish Data Protection Agency. Enrollment of additional Danish stroke centers will require a new 
application to the Danish Medicines Agency and the regional ethics committee (amendment).  
A large acute stroke results in immediate, major neurological deficits (+/-aphasia) and a substantially 
increased risk of a long-term reduction of functional capability. This group is assessed as legally 
incompetent. Even in patients suffering from minor stroke, acute cognitive impairment are common, 
making individual preference on acute treatment options impossible. In order to preserve brain tissue, the 
intervention must be applied without delay. Improvement of standard care in patients suffering from acute 
stroke is of paramount importance. Inclusion of all stroke patients is necessary in order to translate any 
positive research results into a benefit for all stroke patients. The intervention is without any known risk 
apart from moderate pain in the upper extremity when the cuff is inflated. We find that the conditions for 
an acute study are satisfied since the majority of the patients are incapacitated at stroke onset and the 
treatment has to be initiated as soon as possible and there are no reported serious side effects from RIC. 
 
Study participants are covered in accordance with the Danish Patient Insurance Act. 
13. Data handling and record keeping 
All study data are recorded in an electronic CRF with blinded data and identification via a study 
identification number. The study will apply to the specifications of act on processing of personal data.  
The database(e-CRF) is handled by OPUS consult Aps, Egaa, Denmark, who already handles the Danish 
Stroke Center Database in Aarhus (ddsc.dk) 
Remote Ischemic Conditioning in Stroke (RISC) is a predefined collaboration in which three large RIC trials 
have agreed to share anonymized patient data for a large metaanalysis once the individual trials have 
ended (Principle Investigators of the individual trials are: Grethe Andersen (DK), Philip Bath (UK) and 
Fernando Pico (France). 
Patient participation will be recorded in the medical record. Data will be stored at the Department of 
Neurology, Aarhus University Hospital, for 15 years, after which the documents will be shredded.  
A notification to The Danish Data Protection agency will be submitted. 
During the entire study period and at all participating centers the local GCP unit will perform quality 
assurance control including source data verification.  
A complete list of all source data will be made and approved by the local GCP unit before study initiation.  
The investigator permits direct access to all source data/documents (including electronic patient record) at 
monitoring visits, audits and/or inspections by the regional ethics committee and Danish Medicines Agency. 
 
 

Page 36 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
14. Publications policy 
The results of the study, both negative, inconclusive and positive, will be disseminated as widely as possible 
- through publication in an international peer-reviewed journal, as conference presentations and on 
www.clinicaltrials.gov.  
The trial is registered on ClinicalTrials.gov with Identifier: NCT03481777 
 
15. Statistics 
Primary study endpoint: 
Difference in clinical outcome (mRS) at 3 months in acute ischemic stroke (General ordinal logistic 
regression analysis. Significance level of 5%) 
 
The main analysis of the primary study endpoint will be performed using the entire range of the 
modified Rankin Scale (General ordinal logistic regression, unadjusted) on the population fulfilling the 
in-hospital inclusion criteria (target population). The trial success analysis is performed on the target 
population which consists of prehospital randomized patients with an in-hospital diagnosis of acute 
ischemic stroke (including TIA with a DWI lesion) and intracerebral hemorrhage (ICH) regardless of 
adherence to investigational treatment (modified Intention-To-Treat analysis).  
 
Supplementary safety analysis: 
All patients randomized in RESIST had pre-randomization a focal neurological deficit (documented on 
the prehospital stroke score). The presence or absence of specific focal neurological symptoms are 
assessed again after 24 hours using the same score as pre-randomization (PreSS) in all randomized 
patients (PreSS 24 hour/ at discharge).  The primary safety analysis will be made on the 
entire randomized population using the difference in prehospital stroke score (PreSS) to document 
change in neurological deficits between pre-randomization and 24 hour/discharge (General ordinal 
logistic regression, unadjusted). There has been no safety concern over RIC treatment in patients with 
non-vascular diagnosis23,27,28,29,30 
 
 

Page 37 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
 
 
If remote ischemic preconditioning is associated with ultra-early treatment effect and reduced 
symptom severity (in the ambulances), this could affect the in-hospital indication for IV-tPA and/or EVT 
(in the case of rapid improvement of symptoms or mild symptoms) 
Because of this, a supplementary analyses using general ordinal logistic regression, adjusted for a 
possible imbalances in reperfusion treatments (IV-tPA and EVT) between treatment arms will be made. 
 
Secondary study endpoints (selected): 
• 
Difference in prehospital stroke score (PreSS) (Supplementary safety endpoint, see above) (All 
randomized patients, general ordinal logistic regression, significans level 5%) 
• 
Difference in prehospital stroke score (PreSS) during the first 24 hours: (general ordinal logistic 
regression analysis in the stroke subtypes, Significance level of 5%) 
• 
Difference in early neurological improvement in AIS and ICH (general ordinal logistic regression 
analysis. Significance level of 5%) 
• 
Difference in prehospital stroke score (PreSS) after 24 hours in subgroups: IV tPA/EVT treated AIS and 
ICH. (ordinal logistic regression analysis, significance level of 5%) 
• 
Difference in acute hematoma expansion in patients with ICH (Binomial regression analysis, significance 
level of 5%) 
• 
Difference in acute infarct growth in patients with AIS treated with IV-tPA and/or EVT (Binomial 
regression analysis, significance level of 5%)  
• 
Major adverse cardiac and cerebral events (MACCE) and recurrent ischemic events at 3 and 12 months 
in AIS patients (Cox regression analysis, significance level of 5%) 
• 
Three-month and one-year mortality (Two sample test of proportion (Chi-square test), significance level 
of 5%) 

Page 38 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
• 
EVT-eligibility (MRI assessed) in RIC treated AIS patients with large vessel occlusion (LVO) (Binomial 
regression analysis. Significance level of 5%) 
 
 
Sample Size 
The treatment effect of RIC on long-term functional outcome is unknown. We have assumed a small but 
clinical significant neuroprotective effect corresponding to a 6-7% increased odds for a beneficial shift on 
the modified Rankin Scale. The sample size calculation was based on a simulation-based approach to the 
analysis of statistical power when ordinal logistic regression analysis is performed (significans level of 5% )  
The statistical power was simulated at different hypothetical sample sizes (on the target population)  
(ranging from 200 to 1900) with 2000 simulation-runs performed at each step.  Unpublished data on IV-tPA 
and/or EVT treated AIS patients and ICH patients from our institution were used:  
3 months modified Rankin Scale distribution (proportions) in 2017 for patients with ICH or IV tPA/EVT 
treated AIS at Aarhus University Hospital.  
Modfied Rankin 
Scale 
mRS 0 
mRS 1 
mRS 2 
mRS 3 
mRS 4 
mRS 5 
mRS 6 
Proportion 
0.139 
0.273 
0.141 
0.110 
0.145 
0.07 
0.126 
 
Based on our previous trial experience with prehospital remote ischemic conditioning we estimate that a 
sample of 1000 subjects with target diagnosis (AIS and ICH) will be feasible to include during the study 
period. 
Thus, including 1000 patients with target diagnosis provide sufficient power at a alfa-level (significans) of 
5% to detect RIC treatment effects of the estimated 6-7 % (see table below) 
Treatment effect  
(assumed neuroprective) 
5% 
6% 
7% 
Sample (target diagnosis), n 
1000 
1000 
1000 
Power 
66% 
80% 
90% 
Alfa level (significans level) 
5% 
5% 
5% 
 
The estimated prehospital, randomized, sample:  
Sample size, prehospital 
Proportion of randomized 
n = 
Target diagnosis (AIS and ICH), n 
67% 
1000 
Non-vascular diagnosis 
27% 
403 
TIA without DWI lesion 
4% 
60 
Lost to follow-up 
2% 
30 
Total 
 
1492 

Page 39 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Plan to include 
 
1500 
 
We therefor plan to include 1500 patients with a prehospital putative stroke in order to get 1000 patients 
with the target diagnosis of acute ischemic stroke and intracerebral hemorrhage. There is no planned 
replacement of patients lost to follow-up.  
 
               Interim analysis 
We will perform an interim analysis for evaluation of the actual event rate after inclusion of 50% of the 
patients. If this shows a lower good outcome rate than expected, a new sample size calculation will be 
performed. Furthermore, the Data monitoring committee (DMC) will perform an independent safety 
analysis and will review the overall safety and efficacy according to the DMC charter (planned in the early 
phase of the trial, at 12 month and hereafter at least every 18. months) An additional safety interim 
analysis of mortality and hematoma expansion in ICH patients will be performed. Interim analysis are 
assessed using a level of significance of 1%. 
The trial can be stopped at interim analyses for both futility, efficacy and safety reasons. 
Detailed description is found in the DMC charter. 
Missing data:  
Missing data with be handled using multiple imputation (predictive mean matching imputation). 
Deviations from the statistical plan: 
All deviations from the statistical plan will first be applied when approved by the regional ethics committee 
and the Danish Medicines Agency.  
Trial decision making and stopping rules 
A Data Monitoring Committee (DMC) will be appointed before trial start and include a signed DMC charter. 
The DMC will review the accumulated data during RESIST trial and provide advice on the conduct of the 
trial to the Steering Committee.  
 
The DMC should inform the Steering Committee  
if, in their view:  
 
1. 
the results are likely to provide convincing evidence that one trial arm is clearly indicated or 
contraindicated, and there is a reasonable expectation that this new evidence would materially 
influence patient management 
or  
 
2. 
it is beyond doubt that no clear outcome would be obtained (futility) 
 
It is not expected that RESIST trial will be stopped for reasons of efficacy or futility based on observed 
treatment differences. A predefined pooling of individual patient data (Remote Ischemic conditioning in 
Stroke Collaboration, RISC) is planned. To dispel scepticism, a robust demonstration of efficacy of this 
simple intervention is required. The primary reason to recommend stopping the trial will be for safety 
reasons. 
For Acute Ischemic Stroke and Intracerebral Hemorrhage: 

Page 40 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
• 
For the primary endpoint the DMC will consider stopping if there is a robust improvement in 
functional outcome after 3 months (modified Rankin Scale) for Acute Ischemic Stroke and 
Intracerebral haemorrhage in the sham (control) group compared to the intervention (RIC) group, 
achieving p<0.01. 
• 
A substantial number of patients experience serious adverse events (p<0.01) 
• 
DMC will consider stopping if there is an increase in mortality or stroke recurrence for Acute 
Ischemic Stroke and Intracerebral Hemorrhage patients in the intervention (RIC) group compared 
to the control (sham) group, achieving p<0.01. 
• 
For ICH the DMC will consider stopping/modification if there is a clear evidence of hematoma 
growth during the first 24-hour in the intervention group, achieving p<0.01 
 
The DMC will make recommendations, which could include: 
• 
No action needed, trial continues as planned  
• 
Early stopping due, for example, to clear benefit or harm of a treatment, futility, or external 
evidence  
• 
Stopping recruitment within a subgroup  
• 
Extending recruitment (based on actual control arm response rates being different to predicted 
other than on emerging differences) or extending follow-up  
• 
Approving and/or proposing protocol changes  
 
 
16. Source data access and monitoring 
Trial-related audits and/or monitoring will be provided by direct access to source data/documents. Local 
monitors from the Unit for Good Clinical Practice, Aarhus University, will perform the audit and monitoring. 
Audit and monitoring will, likewise, be perfomed by qualified local GCP-monitors when enrollment at other 
stroke centers in Denmark is starting. Before enrollment can start a trial monitoring plan must be available.  
The audit and monitoring process will involve a 100% monitoring of signed consent forms 
(“samtykkeerklæringer og fuldmagtserklæringer”) and serious adverse events.  
 
17. Economy 
Study initiator is Grethe Andersen, Senior Consultant, MD, DMSc, Professor of Neurology at Department of 
Neurology, Aarhus University Hospital. 
 
The Danish foundation Vilhelm Petersens mindelegat has supported the study with 1.240.000 dkr (research 
nurse salary and “stroke RIC” devices).  
The Danish foundation TrygFonden has supported the study with 4.000.000 dkr (research personnel 
salaries, running costs, micro RNA analysis and investigational devices).  
Aarhus University has supported the study with 550.000 dkr (study investigator/coordinator salary) 
The funders have no role in study design, data collection, analysis or interpretation, nor the decision to 
publish or the preparation, review and approval of the manuscript.  

Page 41 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Stroke RIC/Sham-RIC device is developed in collaboration with Aarhus University, Faculty of Biomedical 
Engineering, 8200-DK, Aarhus N, Denmark; Seagull Aps, 4160-DK, Herlufmagle, Denmark and the 
Department of Neurology, Aarhus University Hospital, 8000-DK, Aarhus C, Denmark. Seagull Aps has no role 
in study design, data collection, analysis or interpretation, nor the decision to publish or the preparation, 
review and approval of the manuscript. 
The research grants are transferred directly to a research account administered by the financial department 
of Aarhus University Hospital. None of the involved doctors or research nurses has any conflict of interest 
or economic advantages in regards to the study. There is no economic compensation or reimbursement for 
patients participating in the study. 
   
Supplements 
 
Supplement A - Neuroimaging protocol 
On admission, either CT or MRI is performed according to hospital SOP.  
All AIS and ICH patients can be included in the in-hospital RIC/sham-RIC based on a baseline native CT. 
However, patients with complete remission of symptoms after randomization (TIA) require an MRI at 
baseline demonstrating acute ischemic lesion on DWI in order to continue the randomized treatment. TIA 
patients with a documented ischemic lesion are, per definition, handled as ischemic stroke in this study. 
Baseline MRI in TIA patients is performed before the next RIC series (MRI <6 hours from RIC/sham-RIC last 
cuff). Patients with AIS who are not eligible for IV tPA due to contraindications will have CT/MRI before 
their next RIC/sham-RIC series (< 6 hours from RIPerC last cuff) according to hospital SOP. All ICH patients 
will have a baseline and 24-hour CT (hospital SOP) 
Non-stroke diagnosis and TIA (only evaluated with CT or TIA without DWI lesion on MRI) will not be 
included in the in-hospital RIC study and will receive no further RIC treatment or neuroimaging.   
 
Imaging protocol 
Accepted time frame 
MRI baseline – AIS IV tPA eligible 
Acute on admission 
CT baseline – AIS IV tPA eligible 
Acute on admission 
MRI/CT baseline – AIS non IV tPA eligible  
< 6 hours from last RIC cuff 
MRI (24-hour) - tPA/EVT treated AIS patients* 
18-30 hour from baseline MRI 
MRI baseline – ICH 
Perform CT as soon as possible and < 3 hours from last RIC cuff  
CT baseline – ICH 
< 6 hours from last RIC cuff 
Control CT (24-hour) – ICH* 
18-30 hour from baseline CT 
Control CT (7-day)* 
5-9 days from baseline CT 
*Substudy at Aarhus University Hospital 
Computed tomography (CT) protocol 
Baseline CT and CT angiography are obtained in centers using CT for primary assessment (according to 
hospital SOP). 

Page 42 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
CT analysis 
Hematoma volume assessment at baseline and at 24 hours and 7 days is performed by an experienced 
neuroradiologist. The assessment will be assisted using an automated stroke volume assessment software 
(e.g. COMBAT stroke APS, Aarhus University Hospital, Denmark) or using the formula ABC/2 where A is the 
greatest hematoma diameter by CT, B is the diameter perpendicular to A, and C is the number of CT slices 
with hematoma multiplied by slice thickness43. 
Magnetic resonance imaging (MRI) protocol 
Diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC), T2* gradient-recalled echo 
(T2*GRE), and T2 fluid-attenuated inverse recovery (T2-FLAIR). MR angiography time-of-flight (MRA-TOF) is 
performed according to hospital standard operating procedures (SOP). 
The 24-hour MRI is performed on the same MRI scanner used at baseline, if possible. This protocol 
includes: DWI, T2*, T2 and T2-FLAIR. MRA-TOF at 24 hours is obtained if the baseline CT-angiography or 
MRA-TOF demonstrated vessel occlusion.  
The total acquisition time for this protocol is approximately 7-10 mins (MRI)/10-15 min (MRI + MRA-TOF), 
depending on the MRI equipment. 
MRI analysis 
Acute (baseline) and 24-hour follow-up (DWI lesion will be outlined, representing irreversibly damaged 
tissue (substudy at Aarhus University Hospital). 
Infarct growth is defined as the difference between baseline DWI and the 24-hour MRI-DWI lesion. 
Infarct volume assessment at baseline and at 24 hours is performed by an experienced neuroradiologist. 
The assessment will be assisted using an automated stroke volume assessment software (e.g. COMBAT 
stroke APS, Aarhus University Hospital, Denmark) or using the formula ABC/2 where A is the greatest 
hematoma diameter by CT, B is the diameter perpendicular to A, and C is the number of CT slices with 
hematoma multiplied by slice thickness43 
Vascular patency and reperfusion are assessed using the Thrombolysis in Cerebral Infarction Perfusion 
Scale (TICI) criteria44  
• 
No perfusion (TICI 0) 
• 
Perfusion past the initial occlusion, but no distal branch filling (TICI 1) 
• 
Perfusion with incomplete or slow distal branch filling (TICI 2) 
• 
Full perfusion with filling of all distal branches, including M3 and M4 (TICI 3) 

Page 43 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
Supplement B – Baseline data 
 
Age 
Platelet inhibitor treatment 
Male/female 
Anticoagulation therapy 
Medical History 
New oral anticoagulation treatment (NOAC) 
Hypertension 
Opioid treatment 
Smoking 
SSRI treatment 
Alcohol 
Clinical and physiological data 
Hyperlipidemia 
Prehospital Stroke Score (PreSS) 
Diabetes 
Modified Rankin Scale prestroke 
Previous myocardial infarction 
Yes: within 3 months, yes: more than 3 months, no, unknown 
NIHSS (baseline) 
Angina pectoris 
Symptom onset (time) 
             Recent angina pectoris (< 4 weeks)             
If yes, date for latest episode 
Time of admission 
Atrial fibrillation 
Completed prehospital RIC/sham cycles 
Previous ischemic stroke 
           = 5, 4, 3, 1-2, 0 
             Stroke < 3 month 
If yes, date 
Time (start/stop) for each RIC/sham cycle 
Previous TIA 
NIHSS (t = 24 hours) 
             Recent TIA < 4 weeks 
If yes, date for latest episode 
Stroke etiology (TOAST) 
Previous ICH 
Admission blood pressure 
Peripheral artery disease 
IV tPA/EVT treated AIS  
Physical activity (PASE interview) 
Substudy at Aarhus University Hospital 
Treatment initiation (time) 
Medication on admission 
Quality indicators (Danish Stroke Registry) 
Statins 
WHO-5 
Substudy at Aarhus University 
Calcium channel blockers 
 
ACE inhibitors/angiotensin receptor blockers 
 
Beta-blockers 
 
Baseline data obtained from treating physician, database of Danish stroke center (ddsc.dk), Danish stroke registry 
and electronic health records.  
 
 
 
 

Page 44 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
References 
 
1.  
Astrup J, Siesjo BK, Symon L. Thresholds in cerebral ischemia - the ischemic penumbra. Stroke. 
1981;12(6):723-725. 
2.  
Group N study. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24). 
3.  
Hacke W, Kaste M, Bluhmki E. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic 
stroke. … Engl J …. 2008:1317-1330. http://www.nejm.org/doi/full/10.1056/NEJMoa0804656. 
Accessed October 21, 2014. 
4.  
Berkhemer OA, Fransen PSS, Beumer D, et al. A randomized trial of intraarterial treatment for acute 
ischemic stroke. N Engl J Med. 2015;372(1):11-20. doi:10.1056/NEJMoa1411587 
5.  
Touma L, Filion KB, Sterling LH, Atallah R, Windle SB, Eisenberg MJ. Stent Retrievers for the 
Treatment of Acute Ischemic Stroke: A Systematic Review  and Meta-analysis of Randomized Clinical 
Trials. JAMA Neurol. January 2016. doi:10.1001/jamaneurol.2015.4441 
6.  
Prior A, Laursen TM, Larsen KK, et al. Post-Stroke Mortality , Stroke Severity , and Preadmission 
Antipsychotic Medicine Use – A Population-Based Cohort Study. 2014;9(1). 
doi:10.1371/journal.pone.0084103 
7.  
Ren C, Gao M, Dornbos D, et al. Remote ischemic post-conditioning reduced brain damage in 
experimental ischemia/reperfusion injury. Neurol Res. 2011;33(5):514-519. 
doi:10.1179/016164111X13007856084241 
8.  
Hougaard KD, Hjort N, Zeidler D, et al. Remote ischemic perconditioning in thrombolysed stroke 
patients: randomized study of activating endogenous neuroprotection - design and MRI 
measurements. Int J Stroke. 2013;8(2):141-146. doi:10.1111/j.1747-4949.2012.00786.x 
9.  
Khatri R, McKinney AM, Swenson B, Janardhan V. Blood-brain barrier, reperfusion injury, and 
hemorrhagic transformation in acute  ischemic stroke. Neurology. 2012;79(13 Suppl 1):S52-7. 
doi:10.1212/WNL.0b013e3182697e70 
10.  
Campbell BC V, Christensen S, Tress BM, et al. Failure of collateral blood flow is associated with 
infarct growth in ischemic stroke. J Cereb Blood Flow Metab. 2013;33(8):1168-1172. 
doi:10.1038/jcbfm.2013.77 
11.  
Ip HL, Liebeskind DS. The future of ischemic stroke: flow from prehospital neuroprotection to 
definitive reperfusion. Interv Neurol. 2014;2(3):105-117. doi:10.1159/000357164 
12.  
Giles MF, Albers GW, Kim AS, Sciolla R. Early stroke risk and ABCD2 score performance in tissue- vs 
time-defined TIA A multicenter study. Neurology. 2011. 
13.  
Kellner CP, Connolly ES. Neuroprotective Strategies for Intracerebral Hemorrhage Trials and 
Translation. 2010. doi:10.1161/STROKEAHA.110.597476 
14.  
Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute 
intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365. doi:10.1056/NEJMoa1214609 
15.  
Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in 
ischemic myocardium. Circulation. 1986;74(5):1124-1136. 
16.  
Hahn CD, Manlhiot C, Schmidt MR, Nielsen TT, Redington AN. Remote ischemic per-conditioning: a 
novel therapy for acute stroke? Stroke. 2011;42(10):2960-2962. 
doi:10.1161/STROKEAHA.111.622340 

Page 45 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
17.  
Hess DC, Hoda MN, Bhatia K. Remote limb perconditioning [corrected] and postconditioning: will it 
translate into a promising treatment for acute stroke? Stroke. 2013;44(4):1191-1197. 
doi:10.1161/STROKEAHA.112.678482 
18.  
Schmidt MR, Pryds K, Bøtker HE. Novel adjunctive treatments of myocardial infarction. World J 
Cardiol. 2014;6(6):434-443. doi:10.4330/wjc.v6.i6.434 
19.  
Li J, Rohailla S, Gelber N, et al. MicroRNA-144 is a circulating effector of remote ischemic 
preconditioning. Basic Res Cardiol. 2014;109(5):423. doi:10.1007/s00395-014-0423-z 
20.  
Schmidt MR, Redington A, Bøtker HE. Remote conditioning the heart overview - translatability and 
mechanism. Br J Pharmacol. September 2014:1-37. doi:10.1111/bph.12933 
21.  
Hoda MN, Bhatia K, Hafez SS, et al. Remote ischemic perconditioning is effective after embolic 
stroke in ovariectomized female mice. Transl Stroke Res. 2014;5(4):484-490. doi:10.1007/s12975-
013-0318-6 
22.  
Lim SY, Hausenloy DJ. Remote ischemic conditioning: from bench to bedside. Front Physiol. 
2012;3(February):27. doi:10.3389/fphys.2012.00027 
23.  
Hougaard KD, Hjort N, Zeidler D, et al. Remote ischemic perconditioning as an adjunct therapy to 
thrombolysis in patients with acute ischemic stroke: a randomized trial. Stroke. 2014;45(1):159-167. 
doi:10.1161/STROKEAHA.113.001346 
24.  
Meng R, Asmaro K, Meng L, et al. Upper limb ischemic preconditioning prevents recurrent stroke in 
intracranial arterial stenosis. Neurology. 2012;79(18):1853-1861. 
doi:10.1212/WNL.0b013e318271f76a 
25.  
Meng R, Ding Y, Asmaro K, et al. Ischemic Conditioning Is Safe and Effective for Octo- and 
Nonagenarians in Stroke Prevention and Treatment. Neurotherapeutics. 2015;12(3):667-677. 
doi:10.1007/s13311-015-0358-6 
26.  
Vaibhav K, Braun M, Khan MB, et al. Remote Ischemic post-conditioning promotes hematoma 
resolution via AMPK-dependent immune regulation. Journal of experimental medicine. 2018. 6 sept 
(online). doi.10.1084/jem.20171905 
27.  
Le Page S, Bejan-Angoulvant T, Angoulvant D, Prunier F. Remote ischemic conditioning and 
cardioprotection: a systematic review and meta-analysis of randomized clinical trials. Basic Res 
Cardiol. 2015;110(2):11. doi:10.1007/s00395-015-0467-8 
28.  
Bøtker HE, Kharbanda R, Schmidt MR, et al. Remote ischaemic conditioning before hospital 
admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute 
myocardial infarction: a randomised trial. Lancet. 2010;375(9716):727-734. doi:10.1016/S0140-
6736(09)62001-8 
29.  
Hausenloy DJ, Candilio L, Evans R, et al. Remote Ischemic Preconditioning and Outcomes of Cardiac 
Surgery. N Engl J Med. 2015;373(15):1408-1417. doi:10.1056/NEJMoa1413534 
30.  
Laiwalla AN, Ooi YC, Liou R, Gonzalez NR. Matched Cohort Analysis of the Effects of Limb Remote 
Ischemic Conditioning in Patients with Aneurysmal Subarachnoid Hemorrhage. Transl Stroke Res. 
2016;7(1):42-48. doi:10.1007/s12975-015-0437-3 
31.  
Hess DC, Blauenfeldt RA, Andersen G, et al. Remote ischaemic conditioning-a new paradigm of self-
protection in the brain. Nat Rev Neurol. 2015;11(12):698-710. doi:10.1038/nrneurol.2015.223 
32.  
Hastrup S, Damgaard D, Johnsen SP, Andersen G. Prehospital Acute Stroke Severity Scale to Predict 
Large Artery Occlusion: Design and Comparison With Other Scales. Stroke. 2016;47(7):1772-1776. 
doi:10.1161/STROKEAHA.115.012482 

Page 46 of 46 
 
RESIST trial 
Clinical investigation plan  
version 8.0 (29 Nov 2018) 
Danish Medicines Agency jr nr: 2017114177              EUDAMED CIV-ID: CIV-17-11-022324 
Regional research ethics committee ID: 1-10-72-97-17 
33.  
Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati Prehospital Stroke Scale: reproducibility 
and validity. Ann Emerg Med. 1999;33(4):373-378. 
34.  
Sivakumar L, Kate M, Jeerakathil T, Camicioli R, Buck B, Butcher K. Serial montreal cognitive 
assessments demonstrate reversible cognitive impairment in patients with acute transient ischemic 
attack and minor stroke. Stroke. 2014;45(6):1709-1715. doi:10.1161/STROKEAHA.114.004726 
35.  
Riepe MW, Riss S, Bittner D, Huber R. Screening for cognitive impairment in patients with acute 
stroke. Dement Geriatr Cogn Disord. 2004;17(1-2):49-53. doi:10.1159/000074082 
36.  
Bruno A, Akinwuntan AE, Lin C, et al. Simplified modified rankin scale questionnaire: reproducibility 
over the telephone and validation with quality of life. Stroke. 2011;42(8):2276-2279. 
doi:10.1161/STROKEAHA.111.613273 
37.  
Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life 
measures: literature  review and proposed guidelines. J Clin Epidemiol. 1993;46(12):1417-1432. 
38.  
Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural 
adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-3191. 
39.  
Demchuk AM, Dowlatshahi D, Rodriguez-Luna D, et al. Prediction of haematoma growth and 
outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): 
a prospective observational study. Lancet Neurol. 2012;11(4):307-314. doi:10.1016/S1474-
4422(12)70038-8 
40.  
Kappetein AP, Head SJ, Genereux P, et al. Updated standardized endpoint definitions for 
transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus 
document. Eur Heart J. 2012;33(19):2403-2418. doi:10.1093/eurheartj/ehs255 
41.  
Schuit AJ, Schouten EG, Westerterp KR, Saris WH. Validity of the Physical Activity Scale for the 
Elderly (PASE): according to energy expenditure assessed by the doubly labeled water method. J Clin 
Epidemiol. 1997;50(5):541-546.  
42.  
Washburn RA, McAuley E, Katula J, Mihalko SL, Boileau RA. The physical activity scale for the elderly 
(PASE): evidence for validity. J Clin Epidemiol. 1999;52(7):643-651.  
43.  
Kothari RU, Brott T, Broderick JP, et al. The ABCs of measuring intracerebral hemorrhage volumes. 
Stroke. 1996;27(8):1304-1305. 
44.  
Khatri P, Neff J, Broderick JP, Khoury JC, Carrozzella J, Tomsick T. Revascularization end points in 
stroke interventional trials: recanalization versus reperfusion in IMS-I. Stroke. 2005;36(11):2400-
2403. doi:10.1161/01.STR.0000185698.45720.58